ICU Q & A


Source is in blue, just click on it to get to the original article.

Patient is having rhabdomyolysis, CK is 8,000 but the tropoinin I is 2.5. Is she having a heart attack? There are nonspecific changes on EKG and she is SOB.

There is no hard and fast answer. Troponin can be elevated in rhabdomyolysis. But this usualy happens when CK is more than 30,000 and high troponin was defined as more than 0.6 only. The patient in question should be treated as an AMI until ruled out for sure.
Source: Int J Cardiol

What is the dose of steroids in septic shock?
Hydrocortisone (a 50-mg intravenous bolus four times per day) and Fludrocortisone (50 mcg PO per day) for seven days.
Source: NEJM

Patient ingested unknown amount of Tylenol 3 hours ago. Tylenol level is 148. Should we start N-ACC?
Probably yes. Check the level 4 hours after the ingestion. If more than 150 the liver toxicity is likely and you should treat.
Source: Iowa University - VH, NEJM

Patient is on vent with AC. He is breating at 20/min and the vent rate is 14/min. Is the vent going to give him any breaths?
Sure. The vent with the AC setting will give him 14 breaths no matter what. In addition all his
spontaneous breaths will be "pumped in" with the preset vent volume. That's why you can probably try CPAP for some patients with an intact respiratory drive. Just don't forget the apnea backup.
Source: eMedicine

Patient got Coumadin 7.5 mg yesterday and today's INR is 6.7. There is no bleeding. Should I give her Vit.K?
There are 2 approaches. First is simple - just hold Coumadin for a day or two and check INR in AM. Second - give a small dose of Vit.K like 0.5 mg PO x 1 in addition to holding Coumadin.Don't give Vit.K SQ or IV unless there is bleeding or INR >10.
Source: AFP, there is a nice flowchart.

Patient's IBW (ideal body weight) is 78 kg but his actual weight is just 52 kg. Which one should I take into account when I calculate his TV on the vent?

That's a difficult one. I think you pick a number somewhere in the middle between the IBW and the actual body weight (if the weight is below IBW) and you use it for the calculations - mainly TV (6-8 cc/kg).
Source: Dr.Wolfson

Patient's body weight is 70 kg. How to estimate his required minute ventilation (MV) so that I can adjust TV and RR setting on the vent?

MV = 130 cc x Weight in kg (IBW)

You already know that his TV should be 6-8 cc/kg, don't you? Now that you know his MV you can calculate his vent. RR.

9100 (MV) / 490 (TV) = 18 (RR)

His vent. RR should be set at 18 / min. And of course you are going to check ABG.
Source: Dr.Sopko

What is the ratio suggestive of ARDS? What about ALI?

The ratio is PaO2 / FiO2. If the PaO2/FIO2 is less than 200 this is suggestive of ARDS, less 300 - of ALI.
Source: Critical Care Tutorials

Patient is having a Non-ST elevation AMI confirmed with positive troponins. Should she go to the cath. lab?

Yes. Contrary to the old belief that Non-ST AMI patients don't need cath. right away, the new studies show that PTCA reduces mortality as compared to the conservative strategy.

TACTICS-2001: In patients with unstable angina and myocardial infarction without ST-segment elevation who were treated with the glycoprotein IIb/IIIa inhibitor tirofiban, the use of an early invasive strategy significantly reduced the incidence of major cardiac events. These data support a policy involving broader use of the early inhibition of glycoprotein IIb/IIIa in combination with an early invasive strategy in such patients.
NEJM

Yet according to the ultimate resource the Clinical Eidence the routine early invasive treatment has uknown effectiveness with contradictory trials (you need to register to view)

I think your best bet to solve the issue is to review the official guideline algorithm on Guideline.gov which recommeds urgent cath. when the patient is:
-Hemodynamically unstable
-Has ongoing chest pain

Recent trials (collectively FRISC II and TACTICS-TIMI) suggest an early aggressive/invasive approach (early diagnostic coronary angiography and appropriate PCI or CABG) within 48 hours of presentation, in non-STE ACS (with ST segment deviation, elevated cardiac markers or TIMI Risk Score greater than 3), significantly reduces the risk of major cardiac events.
Guideline.gov

Patient is having an asymptomatic thoracic aneurysm on CXR. CT chest confirms a size of 4.8 cm. Should he have a surgical repair?

No, thoracic aneurysms generally should be resected if >= 6 cm.

What about AAA? When should they be resected?

The natural history of AAAs is closely related to size. Rupture is uncommon if aneurysms are <> 6 cm. Thus, elective surgical repair is usually recommended for all aneurysms > 6 cm unless surgery is contraindicated. In patients who are good surgical risks, elective repair is generally recommended for aneurysms between 5 and 6 cm (mortality 2 to 5%).
Source: Merck

Patient had an ischemic stroke and she is having a new onset Afib. She is already taking ASA and we started Coumadin. Does she really need both?

No, Coumadin alone is good enough. Actually for patients with Afib Coumadin is preferred over ASA for stroke prevention. There is no benefit form double treatment with ASA + Coumadin.
Source: AFP, Clinical Evidence (you need to register, it's free)

I have another patient with Afib with unknown duration. We started Heparin and did a TEE. There was no thrombus and he was converted to NSR.
Does he really need Coumadin?

Yes, he does. Coumadin for 3 weeks if NSR.
TEE has been used to exclude LA/LAA thrombus before elective cardioversion. In a multicenter observational study, however, 17 cases of thromboembolism in AF patients were reported after conversion to sinus rhythm even after TEE showed no LA/LAA thrombus.
Source: ACC

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