ICU Medical Core Mets

Hemodynamics & Cardiac Parameters

1. Normal SVR: 900–1200 dynes·sec/cm⁵

2. Normal PAWP: 8–12 mmHg

3. Normal CVP: 2–6 mmHg / 5–10 cm H₂O

4. Normal MAP: 60–80 mmHg

5. Normal CO: 4–8 L/min

6. Normal CI: 2.8–3.6 L/min/m²

7. Normal PAS: 25–30 mmHg

8. Normal PAD: 6–12 mmHg

9. Normal SvO₂: 70–75%

10. Normal PVR: 80–180 dynes·sec/cm⁵

Treatments Based on Hemodynamics

11. CVP >8: Diuretics, nitroglycerin, morphine, lisinopril, losartan

12. CVP <2: Fluids, blood, blood products

13. PAWP >12: Diuretics, nitroprusside

14. PAWP <8: Fluids, blood, blood products

15. SVR >1200: Nitroprusside, nitroglycerin, hydralazine, lisinopril, losartan, IABP

16. SVR <900: Phenylephrine, norepinephrine, epinephrine, vasopressin

17. PVR >180: Epoprostenol (Flolan)

18. EF <40%: Milrinone, dobutamine, digoxin, AICD

19. Elevated contractility: Metoprolol, amlodipine

Formulas

20. Cardiac Output (CO): SV × HR

Complex Scenarios / Combined Parameters

21. CVP >8 & PAWP <12: Nitroglycerin, nitroprusside, epoprostenol

22. MAP <60 & HR >100: Phenylephrine, vasopressin

23. MAP <60 & HR <100: Norepinephrine, dopamine

24. MAP >80 & HR >100: Nitroglycerin, nitroprusside, nicardipine, metoprolol

25. CO <4 & MAP <60: Epinephrine

26. CO <4, MAP <60, HR <60: Epinephrine, dopamine

27. CO <4, MAP >60: Dobutamine, epinephrine, dopamine, milrinone

Medication Safety & Receptors

28. Six Rights: Patient, dose, route, amount, time, documentation

29. Alpha-1 receptors: Vessels

30. Beta-1 receptors: Heart

31. Beta-2 receptors: Lungs

32. Do NOT give in RV MI/failure: Nitroglycerin

33. Check thiocyanate levels: Nitroprusside

34. Pure alpha-1 agonist: Phenylephrine

35. Alpha-1 meds: Phenylephrine, vasopressin

36. Beta-1 meds: Epinephrine, norepinephrine, dobutamine, dopamine

37. Beta-2 meds: Albuterol, dobutamine (mild-moderate), milrinone

38. Inoconstrictors: Norepinephrine, dopamine, epinephrine

39. Vasoconstrictors: Phenylephrine, vasopressin

40. HR >100 meds: Metoprolol, amiodarone, diltiazem

41. Norepinephrine side effect: Abdominal pain due to vasoconstriction

NG Tube

42. Placement check: Chest X-ray

43. Normal post-op secretions: Serosanguinous → serous → clear/yellow/green over 2–3 days

44. Abnormal secretions: Coffee grounds, hemolyzed blood, dark brown granular; >500–1000 mL/24h → notify MD

Neurologic / ICP

45. Early increased ICP: Headache, change in LOC

46. Late increased ICP: Pupil changes, HTN with wide pulse pressure, bradycardia, abnormal respirations

47. Normal CPP: MAP – ICP

48. CPP function: Maintain cerebral perfusion

49. Normal ICP: 0–15 mmHg

50. Post-neuro positioning: HOB up, head midline, neutral

51. ICP monitoring: No pressure bag; transduce to tragus; drain or monitor—not both

52. ICP goal: <20 mmHg, maintain perfusion, prevent herniation

53. Early CNS decline: Headache, fever, vomiting, nuchal rigidity

Liver / Renal / Pulmonary

54. Liver disease labs: Clotting issues, DIC (elevated D-dimer)

55. Pulmonary edema (renal pt): HTN, JVD, frothy sputum, tachypnea, tachycardia, hypoxia

56. Pulmonary edema tx (renal pt): Hemodialysis, morphine, NTG, furosemide

57. Anemia tx (renal pt): Epoetin alfa

58. Assess bowel function: Last BM and flatus

Hemodynamic Waveforms & Lines

59. Normal CVP/RA waveform

60. Normal RV waveform

61. Normal PA waveform

62. Normal PAOP waveform

63. PA catheter out of place: Notify MD

64. D/C Central Line: Supine, HOB flat, hold breath, apply direct pressure 5–10 min

65. D/C arterial line: Hold pressure 5–10 min

Hemodynamic Measures

66. Preload (L side): PAWP

67. Preload (R side): CVP

68. Afterload (R side): PVR

69. Afterload (L side): SVR

70. Vasoactive drips causing dysrhythmias: Dobutamine, dopamine

71. SvO₂: Oxygen delivery vs. consumption

72. Normal SvO₂: 60–75%

73. SvO₂ 85%: Tissues unable to extract oxygen

74. SvO₂ 40%: Oxygen demand > delivery

75. Mechanical ventilation effect on CO: ↑ intrathoracic pressure → ↓ venous return → ↓ CO

76. Mechanical ventilation effect on BP: ↓ venous return → ↓ RV output → hypotension

Cardiac Emergencies

77. Cardiac tamponade s/s: Muffled heart sounds, equalized PA/CVP/PAOP, hypotension

78. Cardiac tamponade patho: Fluid compresses atria/vena cava/pulmonary veins → ↓ RV filling → ↓ SV, CO → RV collapse

79. Cardiac tamponade tx: Pericardiocentesis, may need 24h drain

Angina & MI

80. Stable angina: Fixed stenosis, demand ischemia, chronic exertion, T-wave inversion; tx: rest, NTG

81. Unstable angina: Thrombus, supply ischemia, frequent/severe pain, ST elevation; tx: rest, NTG, revascularization

82. Variant angina (Prinzmetal): Vasospasm, ST elevation, tx: Ca²⁺ channel blocker

83. MI s/s (women): N/V, arm/back/neck/jaw/stomach pain, sweating, fatigue

84. MI s/s (men): Crushing chest pain, sweating, pale, dyspnea, tachypnea, dysrhythmias

Pericarditis

85. Patho: Inflammation of pericardium from infection, MI, post-op CABG

86. S/s: Sharp chest pain, SOB, tachycardia, friction rub, EKG changes (ST elev, T wave inversion)

87. Tx: HOB up, pain management, pericardiocentesis; may lead to tamponade

MI Locations

88. Inferior MI: II, III, aVF

89. Septal MI: V1, V2

90. Anterior MI: V2–V4

91. Lateral MI: I, aVL, V5–V6

92. RV MI: V3R, V4R

93. Acute MI tx: Reperfusion (cath lab door-to-balloon ≤90 min), thrombolytics if no cath (6h window)

94. Thrombolytic criteria: No abd surgery, CVA, ICH; caution: severe HTN, anticoagulation

95. Acute MI meds: Morphine, NTG, O₂, ASA, beta blockers, diuretics

96. Cath lab considerations: Dye nephrotoxicity, fluids post-procedure, monitor pulses, bleeding, hematoma, retroperitoneal bleed

97. Renal function: May have ↓ UOP due to ↓ perfusion/CO

Heart Failure

98. RV HF s/s: JVD, edema, ascites, ↑ CVP, liver engorgement

99. LV HF s/s: Pulmonary edema, rhonchi, dyspnea, cough, hyperventilation, ↑ LA/LV/PA/PAWP

100. First compensatory mechanism: SNS → ↑ HR → ↑ CO

101. Later compensatory mechanism: RAAS → Na/H₂O retention → dilutional hyponatremia

102. Pulmonary edema tx: Diuretics, Na/H₂O restriction, O₂ therapy less effective

Dysrhythmias

103. 1st AVB

104. 2nd AVB type 1: Lengthening PR → drop QRS; may dec CO; atropine 0.5 mg

105. 2nd AVB type 2: Fixed PR; more P’s than QRS; atropine 0.5 mg or pacing

106. 3rd AVB: P waves not assoc. with QRS; HR <40; needs pacemaker; no atropine

107. SVT: Adenosine, beta blockers, vagal maneuvers, electrolyte replacement

108. VT: Check pulse; 150J, epinephrine

109. Torsades de pointes: Magnesium

Cardiac Arrest / Dysrhythmias

110. VF (Ventricular Fibrillation): Defibrillate 150J, give epinephrine

Therapeutic Hypothermia

111. Indications: Comatose patient after ROSC to promote neurological healing

112. Tx: Target temp 32–36°C, maintain for 24h, rewarm slowly (risk: vasodilation, electrolyte abnormalities). Use sedatives, paralytics

Mechanical Ventilation

113. Goal of PEEP: Open collapsed alveoli

114. PEEP Settings: Low PEEP generally 5–10 cm H₂O. Risks: ↓ CO, ↓ venous return, barotrauma (pneumothorax, tension pneumo)

Chest Tubes

115. Management: Tidaling = normal; bubbling = air leak. Use hemostats to locate; manage pain before ambulation

116. Problems: Tracheal deviation, ↑ dyspnea, O₂ <90%, no drainage or >70 mL/hr → notify MD

117. CT Falls Out: Cover with gauze, 3-sided dressing

118. CT Disconnection: Place end in sterile water below chest level

Pneumothorax

119. S/s: Pain, diminished/absent breath sounds, dyspnea, cyanosis, tracheal deviation (tension)

120. Causes: Trauma, misplaced CT, bleb rupture

121. Tx: Thoracentesis, thoracotomy, chest tube to restore negative pleural pressure

Tracheostomy

122. Emergency Supplies: Obturator + spare trach (1 size smaller) at bedside

123. Communication: Patient can speak only with PMV, not while on ventilator

Oxygen Therapy

124. COPD Consideration: O₂ is respiratory drive; too much → ↓ RR → resp acidosis. Goal SpO₂: 88–92%

Pulmonary Embolism

125. S/s: Chest pain on inspiration, dyspnea, tachycardia, cough, hypoxia

126. Tx: Thrombolytics, heparin, O₂, embolectomy, IVC filter

Acid-Base Disorders

127. Respiratory Acidosis: pH <7.4, CO₂ >45 mmHg (hypoventilation, COPD, sedation, overdose)

128. Metabolic Acidosis: pH <7.4, HCO₃ <22 (loss of bicarb from lactic acidosis, sepsis, DKA, shock)

129. Respiratory Alkalosis: pH >7.4, CO₂ <35 (hyperventilation)

130. Metabolic Alkalosis: pH >7.4, HCO₃ >26 (loss of acids: vomiting, NG suction, diuretics)

131. Respiratory Compensation: ↑ RR to remove CO₂ or ↓ RR to retain CO₂

132. Metabolic Compensation: Retain or excrete HCO₃

133. Complete Compensation: pH normal, CO₂ & HCO₃ abnormal in same direction

134. Partial Compensation: pH abnormal, CO₂ & HCO₃ abnormal in same direction

SIRS / Sepsis / Shock

135. SIRS s/s: Tachycardia, tachypnea, fever

136. SIRS tx: Antibiotics, remove infection source, replace fluids

137. Early Sepsis: SBP <90, UOP <30 mL ×2 hr, lactate >2, WBC <4 or >12, ↑ O₂ requirement

138. Late Septic Shock (Hypodynamic): Tachycardia, weak pulses, hypotension, narrow pulse pressure, cool skin, bradypnea/tachypnea, lethargy, hypothermia

139. Early Septic Shock (Hyperdynamic): Tachycardia, bounding pulses, normal BP, wide pulse pressure, warm skin, irritability/confusion, oliguria, hyperthermia

140. Distributive Shock: Volume displaced (septic, neurogenic, anaphylactic)

141. Obstructive Shock: Physical obstruction (PE, cardiac tamponade)

142. Cardiogenic Shock: Pump failure, ↑ PAWP

143. Hypovolemic Shock: Low volume, ↓ PAWP

144. Common Feature: Inadequate perfusion

145. Early Shock Tx: Labs (Pancx, lactate, CBC, CMP, coag), antibiotics within 1 hr, IVF 30 mL/kg

146. Anaphylactic Shock Tx: Remove agent, epinephrine, benadryl, IVF

147. Cardiogenic Shock Tx: Diuretics, NTG, nitroprusside, IABP, dopamine, dobutamine, norepinephrine

148. Hypovolemic Shock Tx: Blood, blood products, IVF, massive transfusion

Diabetes Emergencies

149. DKA: Type 1 DM, BG >400, +ketones

150. HHS: Type 2 DM, N/V, ↑ UOP, hunger/thirst, BG >800, ↑ serum osm, electrolyte abnormalities

151. Tx DKA/HHS: IVF for hypovolemia (until K ≥3.3), then insulin gtt

DIC (Disseminated Intravascular Coagulation)

152. S/s: Easy bruising, bleeding, occult blood in stool/urine/emesis, ↑ HR, ↓ BP, labs: ↑ D-dimer, fibrin degradation, PT, aPTT, thrombin; ↓ platelets, fibrinogen, H/H

153. Tx: Correct cause, give blood/products, possible heparin, RN assess for shock, MODS, circulation

154. Patho: Coag cascade disorder → microclots → systemic hemorrhage due to depleted clotting factors

155. Causes: Infection, trauma, OB complications, hematologic/oncologic disorders