Respiratory Accs

ACCS: ADULT CRITICAL CARE SPECIALTY
REVIEW & KEYPOINTS

Version 2
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MARK VARGAS MSRC,RRT,RRT-ACCS, RRT-NPS

DISCLAIMER AND COPYRIGHT © 2016- 2024 RESPIRATORY CARE PREPBOARD , LCC.
COPYRIGHT ALL RIGHTS RESERVED.
NOTICE THE ADULT CRITICAL CARE SPECIALTY POWERPOINT MATERIAL
WAS DEVELOPED BY MARK VARGAS.
NO PART OF THE MATERIAL PROTECTED BY THIS COPYRIGHT MAY

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BE REPRODUCED OR UTILIZED IN ANY FORM, ELECTRONIC, OR
MECHANICAL, INCLUDING PHOTOCOPYING, RECORDING OR BY
ANY INFORMATION STORAGE AND RETRIEVAL SYSTEM, WITHOUT
WRITTEN PERMISSION FROM THE COPYRIGHT OWNER(S).
COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

IF PHARMACOLOGY IS NOT YOUR STRONG
SUBJECT, PLEASE MAKE IT A POINT TO REVIEW
PHARMACOLOGY THE DRUGS AND INDICATIONS GIVEN HERE.
THIS IS A SPECIALITY EXAM THEREFORE;

MAINSTREAM RESPIRATORY CARE
3 PHARMACOLOGY IS FAR MORE ADVANCED
THAN WHAT YOU ARE USED TO.
THINK OUTSIDE THE BOX AND BE ON GUARD!

CARDIOVASCULAR DRUGS:
 NITROGLYCERIN: DECREASES PVR, BP, PAP, RELAXES CARDIAC

SMOOTH MUSCLE.
 PROPANOLOL: LOWERS HEART RATE, BETA 1 BLOCKER
(EFFECTIVE IN PATIENTS WITH SUSTAINED TACHYCARDIA).
PHARMACOLOGY
4  LIDOCAINE: VASODILATOR, DECREASES HEART RATE, TREATS
PVC’S.
 DIGITALIS: TREATS CHF, USE FOR PATIENTS WITH RIGHT HEART
FAILURE, WATCH FOR CLUES SUCH AS INCREASED CVP
(HEMODYNAMCS INDICATING RIGHT HEART ISSUES). MAY
CAUSE HYPERKALEMIA.

LABETATOL: MECHANISM OF ACTION TO
DECREASE BP AND HR (BETA BLOCKER).
EPINEPHRINE: CARDIAC ARREST, ASYSTOLE,

INCREASES HR, WIDELY USED DURING CPR.
5 PHARMACOLOGY
ATROPINE: TREATS BRADYCARDIA, ALSO
USED FOR REVERSAL OF ANTICHOLINERIC
MG CRISIS.
ADENOSINE: TREATS SUPRAVENTRICULAR

TACHYCARDIA.

PULMONARY VASODILATORS (MAINLY UTILIZED FOR PULMONARY
HYPERTENSION)
• NITRIC OXIDE (iNO): IMPROVES OXYGENATION AND ACTS AS A PA

VASODILATOR, STARTING DOSE 20-40 ppm OR YOU MAY SEE A QUESTION
IN WHICH STARTING POINT IS AT 40 ppm.
• SILDENAFIL: ALSO KNOWN AS REVATIO OR VIAGRA -DECREASES PAP, PVR.

TYPICALLY, NOT USED IN THE ICU SETTING.
• FLOLAN (EPOPROSTENOL SODIUM): INDICATIONS: ARDS, REFRACTORY

6 PHARMACOLOGY HYPOXEMIA, CARDIAC SURGERY ASSOCIATED PULMONARY HYPERTENSION
(QUESTION ON EXAM TO CHOOSE FLOLAN INSTEAD OF iNO). MAY CAUSE
HYPOTENSION AND TACHYCARDIA. MAYBE TERMED PROSTACYCLIN OR
PGI2 (TERMS FOR THIS MED ARE INTERCHANGEABLE) BE ON GUARD. DRUG
GIVEN AEROSOLIZED OR IV.
• KEYPOINT TO WATCH FOR: LOW CVP, ANURIA PARTICULARLY ON VENTED

PATIENTS, FALLING HEMODYNAMICS (BP, CVP).

SEDATION/HYPTONICS
• DEXMEDETOMIDINE (PRESEDEX): EXCELLENT SEDATIVE, SHORT ACTING. SIDE
EFFECTS HYPERTENSION AND HYPOTENSION , A-FIB
• PROPOFOL (DIPRAVAN): INDUCTION AGENT IN RSI (RAPID SEQUENCE
INTUBATION) USED WIDELY ON THE ACCS. BE ON GUARD! HAS SHORT HALF
LIFE, LOWERS BP– AGAIN WATCH FOR FALLING HEMODYNAMICS CHOOSE
ANOTHER SHORT ACTING. GOOD DRUG FOR VACATION SEDATION WHILE
WEANING PATIENTS OFF MECHANICAL VENTILATION.USE SEDATIVE LIKE
ETOMIDATE AS AN ALTERNATIVE TO SEDATE– DOES NOT AFFECT
HEMODYNAMICS.
7 PHARMACOLOGY • NEMBUTAL (PENTOBARBITAL): STRONG SEDATIVE, HAS MULTIPLE USES BESIDES
SEDATION. LOWERS ICP. USED IN INCREASING ICP’S > 26, THIS WILL BE
ANOTHER CHOICE BESIDES MANNITOL. BE ON GUARD
PARALYTICS
• ANECTINE (SUCCINYLCHOLINE): DEPOLARAZING AGENT. BE CAREFUL WHEN
CHOOSING THIS DRUG AS AN ANSWER! POTENTIAL SIDE EFFECTS: INCREASES
POTASSIUM (IF PATIENT IS HYPERKALEMIC DO NOT USE THIS PARALYTIC
AGENT OR BURN PATIENTS). PATIENTS WITH A MALLAMPATI SCORE > 3 DO
NOT USE! CONTRAINDICATED IN ACUTE BRAIN INJURIES. OTHER CHOICES
ARE ROCURONIUM OR PAVULON (NON –DEPOLARIZING AGENTS).

BACK DOOR NON-DEPOLARIZING AGENTS (BACK DOOR AGENTS)
• ROCURONIUM: BEST CHOICE WHEN SUCCINYLCHOLINE IS
CONTRAINDICATED WHEN PATIENT PRESENT WITH THESE FACTORS:
HYPERKALEMIA, BURNED PATIENTS, BRADYCARDIA , INCREASED
ICP’S.
• CISATRACURIUM
• VECURONIUM
• CURARE
8
PHARMACOLOGY • REVERSAL AGENTS ARE: EDROPHONIUM, PYRIDOSTIGMINE THESE
ARE CONSIDERED ANTICHOLINESTERASE AGENTS.
• ANTICHOLINERGIC AGENTS: ATROPINE AND GLYCOPYRROLATE
• NEW ANTICHOLINERGIC (NEW ON EXAM): SUGAMMADEX
(BRIDON) REVERSES ROCURONIUM AND VECORONUIM BASED ON
ACTUAL BODY WEIGHT. SIDE EFFECTS: BRADYCARDIA AND IS NOT
RECOMMENDED FOR PATIENT WITH RENAL FAILURE REQUIRING
DIALYSIS.

NARCOTIC/OPOID REVERSAL AGENT: NARCAN ( NALAXONE)
SIDE EFFECTS: HYPERTENSION, TACHYCARDIA (QUESTION ON

EXAM) CLUES: PATIENT ON MORPHINE PCA, FENTANYL, ANY
OPIODS, OD (PINPOINT PUPILS) ARE INDICATIONS TO USE
NARCAN.
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PHARMACOLOGY
BENZODIAZEPINES REVERSAL AGENT: FLUMAZENIL
(ROMAZICON)
SIDE EFFECTS: RESPIRATORY DEPRESSION, SOMNOLENCE,

HYPOTENSION. PATIENTS STATUS POST SURGERY PLACED ON
ATIVAN, LORAZEPAM, VERSED DRIP WILL NEED FLUMAZENIL TO
REVERSE THE EFFECT. DO NOT INTUBATE UNLESS THE PATIENT IS
SHOWING RESPIRATORY DISTRESS.

TWO COMMON VASODILATORS FOR THE EXAM:
• DOBUTAMINE: THIS DRUG HAS MULTIPLE USES SUCH AS:

MAY TREAT LEFT VENTRICULAR DYSFUNCTION, INCREASES
CARDIAC OUTPUT AND HR. USED AS A SYSTEMIC
VASODILATOR TO HYPERTENSIVE STATES.
• PROSTACYCLIN (FLOLAN): TREATS PULMONARY
PHARMACOLOGY HYPERTENSION, LOWERS PAP.
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VASOPRESSOR ACTING:
• DOPAMINE: ACTION: INCREASES HR, BP. WATCH FOR
SHOCKS.
•

• LEVOPHED: TREATS HYPOTENSIVE STATE, WATCH FOR THOSE
QUESTIONS IN WHICH IVF HAS BEEN INITIATED AND STILL
HYPOTENSIVE. CHOOSE LEVOPHED TO INCREASE BP. IN CASE OF
DOPAMINE FAILS PLEASE KEEP IN MIND LEVOPHED!
• VASOPRESSIN(EPI): WIDELY USED WITH EPI DURING CPR.

HYPOTENSIVE STATE. MAY BE USED TO STOP HEMOPTYSIS DURING
PHARMACOLOGY BRONCHS.
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• KEYPOINT:
• NOTE: VASODILATORS DILATES THE VASCULAR SYSTEM TO ALLOW

BLOOD TO BE TRANSPORTED EASILY THROUGHOUT THE BODY,
TISSUES AND CELLS. VASOPRESSORS ACTS AS ANTIDIURECTIC IN
ORDER TO CONTROL BODY FLUIDS. KNOW THE DIFFERENCE
ESPECIALLY FOR CARDIAC QUESTIONS!

ANTIBIOTICS/ANTIFECTIVES
• PENICILLIN (AMOXICILLIN, AMPICILLIN ETC.) TREATS GRAM
POSTIVE ORGANISMS.
• PENICILLIN RESISTANT (OXACILLIN, NAFACILLIN) CHOOSE WHEN
PATIENT IS GRAM POSTIVE RESISTANT.
• BACTRIM (SULFA BASED ANTIBIOTIC) TREATS UTI, HIV-PCP AND
UPPER RESPIRATORY INFECTION (NOT FIRST LINE ANTIBIOTIC FOR
URI/SINUSITIS).
• LEVAQUIN (LEVOFLOXIN) TREATS A WIDE RANGE OF
PHARMACOLOGY PULMONARY INFECTIONS, LOOK FOR SIGNS OF SEPSIS,
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INCREASED WBC, FEBRILE ILLNESS, CXR SHOWING OPACITIES.
(QUESTION ON EXAM).
• MYCINS: TOBI, GENTAMYCIN, VANCOMYCIN ETC- TREATS
GRAM NEGATIVE ORGANISMS.
• NOTE: IF PATIENT IS SEPTIC THERE’S A SPECIFIC ANTIBIOTIC USED:
MAXCEF (CEFEPIME) WIDELY USED IN PATIENT WITH INCREASED
WBC. BE ON GUARD!

PATIENTS WITH PENICILLIN ALLERGY: GRAM + ORGANISMS IN
CULTURES SELECT THESE TYPE OF BACK DOOR ANTIBIOTCS:
• KEFLEX
PHARMACOLOGY • KEFLIN
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• ERYTHROMYCIN
• CEPHALORIDINE OR ANY THIRD GENERATION
CEPHALOSPORIN

ANXIETY CONTROL/ BENZODIAZEPINES
VALIUM (DIAZEPAM): TREATS ALCOHOL WITHDRAWAL SYMPTOMS AND

ANXIETY. WIDELY USED IN ICU VENTED PATIENTS.
VERSED (MIDAZOLAM): MOST COMMON AGENT TO TREAT ANXIETY (IV

PUSH OR GIVEN AS A DRIP.
PHARMACOLOGY BENZODIAZEPINES AND BENZO REVERSAL DRUGS:

14
ATIVAN (LORAZEPAM): GOOD SEDATIVE CHOICE FOR PATIENTS ON
MECHANICAL VENTILATION AND ALCOHOL WITHDRAWAL SYMPTOMS.
FLUMAZENIL (ROMAZICON) SEEN AS A CHOICE ON THE EXAM:

REVERSES BENZOS POTENTIAL SIDE EFFECT: SEIZURES.
AROUSAL AGENT: PHYSOSTIGMINE USED FOR NEUROGOLICAL

PATHOLOGIES

ANTICOAGULANT THERAPEUTICS/BLOOD CLOT REMOVAL:
• PLAVIX (CLOPIDROGEL): NOT AN ANTICOAGULANT – THIS WILL BE ONE OF THE

CHOICES IN SOME QUESTIONS ON THE EXAM! THIS DRUG IS ONLY USED TO
PREVENT CVA AND MI’S. ALSO INHIBITS PLATELET AGGREGATION. DO NOT
CHOOSE IN ACUTE PULMONARY EMBOLISM.
• IF YOU HAVE QUESTION IN WHICH PATIENT IS BEDRIDDEN, SUDDEN SYMPTOMS

OF CHEST PAIN THIS IS NOT THE DRUG TO USE. PATIENT MAY BE PRESENTING
WITH A PE.
PHARMACOLOGY
15 • THE TREATMENT OF CHOICE WILL BE EITHER HEPARIN OR LOVENOX.
• COUMDIN (WARFARIN): USE FOR MAINTENACE S/P BLOOD CLOTS, BLOCKS

FORMATION OF VITAMIN K DRUG OF CHOICE AFTER PATIENT HAS BEEN
HEPIRINIZED WITH EITHER LOVENOX OR HEPARIN.
• HEPARIN – WILL TREAT PE. KNOW THE DIFFERENCE IN THESE DRUGS! DO NOT USE
RTPA IN THOSE PATIENTS THAT ARE STABLE OR POST SURGICAL! RECALL PT/INR
NORMALS.

ANALGESICS AND PAIN CONTROL:
• FENTANYL (SUBLIMAZE): LONG TERM USE FOR CHRONIC PAIN. PATIENT WILL
PRESENT WITH ERRATIC VITAL SIGNS, S/P MVA, SPINAL CORD INJURIES, VENT
ASYNCHRONY THIS IS WILL BE THE DRUG TO USE. ANSWER FOR A SMALL
NUMBER OF QUESTIONS ON THE EXAM.
• DILAUDID (HYDROMORPHONE): POWERFUL NARCOTIC
• DEMEROL: THERE WAS A QUESTION PRESENTED ON THE EXAM: TERMINAL

CANCER PATIENT AND YOU HAVE TRIED MORPHINE, FENTANYL AND PATIENT
PHARMACOLOGY
16 REMAINS IN PAIN; THIS WAS THE ONLY CHOICE AS A NARCOTIC FOR PAIN
RELIEF.
• MORPHINE: POWERFUL NARCOTIC WITH POTENTIAL SIDE EFFECTS. LOWERS

RR, BP, CARDIOVASCULAR HEMODYNAMICS. TREATS DYSPNEA
(HOSPICE,PALLATIVE CARE-END OF LIFE SITUATIONS) INHALED MORPHINE
HAS LESS POTENTIAL SIDE EFFECTS THAN THE IV ROUTE. USE NARCAN TO
REVERSE OPIODS OR MORPHINE. FEW QUESTIONS ON THE EXAM.

RESPIRATORY DRUGS: (BETA-2, ANTICHOLINERGICS, MUCOLYTICS, CORTICOSTERIODS)
• XOPENEX (LEVALBUTEROL): SHORT ACTING BRONCHODILATOR (1.25MG/3ML) ADULT

DOSE GIVEN.
• ALBUTEROL: SHORT ACTING, MAY REDUCE K+ WHEN HIGH DOSE >10MG NEBULIZED
GIVEN.
• ATROVENT (IPRATROPIUM BROMIDE): ANTICHOLINERGIC, USED IN COMBINATION WITH
ALBUTEROL OR LEVALBUTEROL.
• SPIRIVA (TIOTROPIUM BR): LONG ACTING, MAINTENANCE DPI. NOT A RESCUE DRUG.
PHARMACOLOGY
17 • PREDINSONE: USED SYSTEMICALLY TO REDUCE INFLAMMATORY PROCESS.
• SOLU-MEDROL (METHYL-PREDNISOLONE): A GLUCORTICOSTERIOD USED IN IV USED FOR
PATIENT IN STATUS ASTHMATICUS, COPD, AMONG OTHER COMORBID STATES.
• PULMOZYME (DORNASE ALPHA): USE FOR CF PATIENT WITH COPIOUS THICK
SECRETIONS.
• MUCOMYST (ACETYLCYSTEINE): BREAKS DISULFIDE BONDS IN PULMONARY SECRETIONS.
• DOPRAM: RESPIRATORY STIMULANT TREATS CENTRAL SLEEP APNEA.

DIURETICS:
• LASIX (FUROSEMIDE): BEST DRUG FOR THOSE IN PULMONARY EDEMA,

LOWERS POTASSIUM (HYERKALEMIA), IF PATIENT IS 3RD SPACING DO
NOT USE LASIX!
• ALDACTONE: WILL CAUSE EXCRETION OF SODIUM AND POTASSIUM,

PHARMACOLOGY ALSO INCREASES URINE OUTPUT. RETAINS WATER IN PATIENTS IN
18
HYPOTENSIVE STATE. ALDACTONE ALSO TREATS FLUI OVERLOAD IN
PATIENTS WITH CHF, LIVER CIHRROSIS OR NEPHROTIC SYNDROME.
• MANNITOL: USED WIDELY ON HEAD TRAUMAS TO DECREASE SWELLING

OR FREE CEREBRAL FLUID. ALSO, IF YOU SEE A PATIENT THAT HAS
INCREASING ICP’S DESPITE HYPERVENTILATION TECHNIQUES THIS WILL
BE YOUR DRUG OF CHOICE!

MISC DRUGS PRESENTED IN THE EXAM:
• KETAMINE: ANESTHETIC, MAY CAUSE HYPERTENSION.
• FLUCONAZOLE: ANTIFUNGAL (SELECT IF PATIENT HAS A PULMONARY FUNGAL

INFECTION).
• PROTONIX: PROTON PUMP INHIBITOR-USE WITH PATIENTS WITH GI DISTURBANCES EX:

EROSIVE GASTRITIS. (EXAM QUESTION)
• SODIUM BICARB: USED TO TREAT DKA, INDICATED WHEN HC03 IS LOW.
PHARMACOLOGY • INSULIN: DIABETES CONTROL OF HYPERGLYCEMIA. IF YOU ENCOUNTER A QUESTION

19 WITH A LOW BICARB AND HIGH GLUCOSE , TREAT WITH INSULIN STAT.
• ACETOMINOPHEN: TREATS FEBRILE ILLNESS. PATIENT WILL BE EXHIBITING INCREASED

WOB AND FEBRILE ILLESS. THIS WILL BE THE ANSWER IN FEW QUESTIONS
• DILANTIN (PHENYTOIN): TREATS SEIZURES AND TONIC-CLONIC SEIZURES.
• METHYLENE BLUE: TREATS METHEMOGLOBINEMIA (PATIENTS ON iNO, NITROGLYCERIN,

DAPSONE, BENZOCAINE).

COMMON PATHOLOGIES:(RECALL FOR EXAM-KEYPOINTS)
• EMPHYSEMA: CXR SHOWS DIMINISHED MARKINGS,
FLATTENED DIAPHRAMS, HYPERLUCENCY. DECREASED
PULMONARY FLOWS, ABG-COMPENSATED RESPIRATORY
ACIDOSIS. IN CASE OF EMERGENCY TREAT WITH 100% FiO2
DUE TO THE IMPENDING HYPOXIC STATE OF THE PATIENT.
ACCS- OTHERWISE, LOW FLOW O2 AT HOME.
20 PATHOLOGY • CHF/PULMONARY EDEMA: CXR: BATWING/BUTTERFLY
REVIEW PATTERN, WATCH FOR INCREASING HEMODYNAMICS SUCH

AS PCWP, PAP, CVP. ALWAYS TREAT RIGHT A AWAY!! 100%
FiO2, NPPV, DIRUETICS, INOTRPICS (DIGOXIN). PINK
FROTHY SECRETIONS. DISTINGUSH BETWEEN CARDIOGENIC
VS. NON-CARDIOGENIC. BE ON GUARD!

ARDS (ACUTE RESPIRATORY DISTRESS SYNDROME): USE
ARDS.NET AS REFERENCE FOR ARDS PROTOCOLS. LUNG
PROTECTIVE STRATEGIES TO VENTILATE THESE PATIENTS.
CXR: GROUNDGLASS, DIFFUSE BILATERAL INFILTRATES,

DIFFUSE PATTERN, RETICULOGRANULAR OR HONEYCOMB
PATTERNS. USE PEEP WISELY FOR THESE PATIENTS TO
CORRECT REFRACTORY HYPOXEMIA.
21 PATHOLOGY
WATCH FOR FALLING HEMODYNAMICS SUCH AS CARDIAC
OUTPUT AND HIGH PEEP LEVELS. RETURN TO PREVIOUS
SETTINGS TO MAINTAIN FAIRLY NORMAL HEMODYNAMICS.
PATIENTS WITH ARDS WILL HAVE INCREASED CVP AND PAP.
ALI (ACUTE LUNG INJURY): EARLY STAGES OF ARDS –LESS

SEVERE. RECALL P/F FORMULA. USE LUNG PROTECTION,
LOW VT 4-6mL/Kg. START AT 6ml/Kg AND MAY INCREASE
UP TO 8ml/Kg.

22
OLD SCHOOL - ACUTE LUNG INJURY ARDS P/F RATIO <
ATS/ERS CRITERIA P/F RATIO < 300 200
PATHOLOGY
NEW SCHOOL-
BERLIN CRITERIA – MILD ARDS P/F MODERATE ARDS
EVERYTHING IS RATIO < 200-300 P/F RATIO < 100-200
ARDS!
CXR: WILL APPEAR

WITH DIFFUSE NORMAL P/F RATIO:
SEVERE ARDS P/F
BILATERAL 380 TORR OR
RATIO < 100
OPACITIES AND GREATER.
INFILTRATES

CHRONIC BRONCHITIS: USE AGGRESSIVE PULMONARY TOILET, OXYGEN
THERAPY, ANTIBIOTICS. CXR: HYPERLUCENT FIELDS AND MAY PRESENT
NORMAL. DECREASED PFT’S (MID FLOWS FEF 25%-75%). ABG’S:
RESPIRATORY ACIDOSIS PRESENT.
ASTHMA: O2 THERAPY, CORTICOSTEROIDS, PULMONARY TOILET,

BRONCHODILATOR THERAPY. EDUCATION AND PEAK FLOW
23 PATHOLOGY MONTIORING. CXR: FLATTENED DIAPHRAGMS, SCATTERED INFILTRATES

AND HYPERINFLATION. ABG: RESPIRATORY ACIDOSIS OR ALKALOSIS. PFT:
DECREASED FLOWS.
STATUS ASTHMATICUS: THESE PATIENTS ARE REFRACTORY TO MOST

BRONCHODILATORS IN WHICH THEY MAY BE INTUBATED IF DISEASE
PROCESS IS NOT REVERSED. USE LOW VT STRATEGY. GIVE EPI SUBQ AT
LEAST 1ML Q 20 MINS X 3 DOSES. SUGGEST HELIOX THERAPY. THE EXAM
WILL TEST YOUR KNOWLEDGE IN HOW TO AVOID VENTILATORY FAILURE
FOR THESE TYPE OF PATIENTS. BE ON GUARD! WATCH FOR EARLY SIGNS
OF RESPIRATORY FAILURE. CXR: SAME AS ASTHMA AS WELL AS ABG BUT
PATIENT WILL BE HYPOXIC. USE INHALED ANESTHETICS SUCH AS
HALOTHANE, ENFLURANE, ISOFLURANE (ANYTHING WITH THE “ANE”
ENDING).
PULMONARY EMBOLISM: BE ON GUARD FOR THOSE SCENARIOS IN WHICH STATES SUDDELY
PATIENT HAS BECOME DYSPNEIC, INCREASED WOB, CHEST PAIN ETC. ABG: HYPOXEMIA,
ABNORMAL V/Q SCAN. MONITOR WITH CAPNOGRAPHY- DECREASED PETCO2. GIVE
HEPARIN OR LOVENOX RIGHT AWAY. MONITOR PT/APTT. THESE PATIENTS MAY REQUIRE
STREPTOKINASE AND A IVC FILTER IF PATIENT HAS CONTRAINDICATING FACTORS
(SUBARACHNOID HEMORRHAGE & MONITOR CLOSELY).
PULMONARY HYPERTENSION: WATCHT FOR ABNORMAL HEMODYNAMICS: PAP > 25/8,

mPAP>14 mmHg. PATIENTS MAY PRESENT WITH COR PULMONALE, PFO, COPD- BE ON
24 PATHOLOGY GUARD! LOOK FOR PATHOLOGIES ASSOCIATED WITH THE RIGHT HEART. (TRICUSPID VALVE
PATHOLOGY).
PNEUMONIA: INCREASED WBC, FEBRILE ILLNESS, CXR: SCATTERED INFILTRATES, TREAT WITH
ANTIBIOTICS–MYCIN FAMILY.
PULMONARY TUBERCULOSIS: WATCH FOR SIGNS OF NIGHT SWEATS, HEMOPTYSIS, CXR:

CAVITATIONS IN UPPER LOBES. TREATMENT: ISOLATION, INH, ETHAMBUTOL, STREPTOMYCIN
AND RIFAMPIN.

• CYSTIC FIBROSIS: SWEAT CHOLORIDE TEST > 60mEq/L TO DIAGNOSE CF.
AGGRESSIVE PULMONARY TOILET. ANTIBIOTIC THERAPY: RECALL TOBI – DRUG
OF CHOICE. ALSO, PULMOZYME AND MUCOMYST FOR INSASSEPATED
SECRETIONS. REMEMBER CF IS NOT JUST A LUNG ISSUE, IT ALSO AFFECTS THE
LOWER GI TRACT- PANCREAS. CXR: HYPERINFLATED FIELDS.
CYSTIC/CAVITARY PATTERN FOR ADVANCED STAGES CF. KEYPOINT:
COMMON PATHOGEN CAUSING PNEUMONIA : PSEUDOMONAS
AERUGINOSA, FOLLOWED BY H. FLU, STAPH A.
• PLEURAL EFFUSION: FLUID ACCUMLATION AT LUNG BASES. SELECT

25 PATHOLOGY THORACENTESIS TO REMOVE FLUID. IF LARGE PLEURAL EFFUSION >20% IS
PRESENT THEN PLACE CHEST TUBE. RECOMMEND A LATERAL DECUBITUS CXR
FOR PROPER DIAGNOSIS. COMPLETE BLUNTING OF COSTOPHRENIC ANGLES.
KEYPOINT: SERUM PROTEIN > 0.5 EXUDATE- PLACE CHEST TUBE, < 0.5
TRANSUDATE- CONTINUE TO MONITOR.
• METHEMOGLOBINEMIA: BLOOD APPEARS DARK CHOCOLATE CAUSED BY

NITRATES AND OTHER SPECIFIC MEDICATIONS SUCH AS BENZOCAINE,
DAPSONE, NITROPRESSIDE. TREATMENT OF CHOICE: METHYLENE BLUE OR
ASCORBIC ACID. WEANING OF NITRIC OXIDE CAN CAUSE REBOUND
PULMONARY HYPERTENSION, IF OCCURS RETURN NO TO PREVIOUS DOSE.
• MYSTHENIA GRAVIS: RECALL THAT TENSILON (DIAGNOSTIC USE
ONLY) IMPROVES MG AND THERE ARE 2 OTHER DRUGS TO KEEP MG
CRISIS STABLE: MESTION (PYRIDOSTIGMINE) AND NEOSTIGMINE
(PROSTIGMINE) BE FAMILIAR WITH THESE DRUGS. NOTE IF PATIENT
HAS CHOLINERGIC CRISIS, THEN ADMINISTER ATROPINE FOR
ANTICHOLINESTERASE REVERSAL. MONITOR AND WATCH FOR
DECREASING VC, MIP, VT. MONITOR VC, IF VC FALLS <1.0 PREPARE
FOR INTUBATION. DO NOT WAIT UNTIL PULMONARY MECHANICS ARE
26 PATHOLOGY
BELOW NORMAL TO INTUBATE. REMEMBER MIND TO GROUND.
• GUILLAIN BARRE SYNDROME: REMEMBER THIS PATHOLOGY STARTS

WITH FLU LIKE SYMPTOMS IN MOST PATIENTS. SLOW ONSET, GROUND
TO MIND. MONITOR FOR FALLING PULMONARY MECHANICS,
TREATMENTS: O2, SMI,PULMONARY HYGIENE, ANTICOAGULANT
THERAPY, PLASMAPHERESIS AND PHYSICAL THERAPY.

• TBI-HEAD TRAUMA: YOU WILL BE TESTED IN HOW TO MONITOR FOR INCREASING ICP’S
AND MEAN AIRWAY PRESSURES WHILE VENTILATING THESE PATIENTS. MINIMIZE USE OF
PEEP AND SUCTIONING. SUCTION ONLY IF PIP’S ARE INCREASING. HYPERVENTILATE TO
KEEP PaCO2 25-30mmHg AS INITIAL RECUE TECHNIQUE AND ICP’S <20cm H2O. MAY
GIVE DILANTIN IF SEIZURE OCCURS. WATCH FOR CASES INVOLVING NARCOTIC OD. BE
ON GUARD!
• PULMONARY CONTUSION: S/P MVA, MOTORCYCLE ACCIDENT ETC. CXR: MULTIPLE

FRACTURES. WATCH FOR KEY TERMS SUCH AS PARADOXICAL CHEST WALL MOVEMENT,
BRUSING OVER THE CHEST (PETECHIAE) WATCH FOR POTENTIAL PNEUMOTHROAX OR
27 PATHOLOGY HEMOTHORAX. DISTINGUISH THE DIFFERENCE IN HOW TO TREAT EACH PATHOLOGY. IF

YOU ARE INTUBATING THESE PATIENTS DUE TO VENTILATORY FAILURE USE VT 6-7mL/kg,
USE PEEP AROUND 5-10cmH20.
• CERVICAL/SPINAL INJURIES: FIRST THING TO INSTITUTE IS TO PLACE PATIENT ON C-

COLLAR. WATCH FOR DETERORATING PULMONARY MECHANICS. DEPENDING ON
SITUATION YOU MAY INTUBATE THIS PATIENT- USE MODIFIED JAW THRUST OR FLEXIBLE
BRONCHOSCOPE DUE TO THE SEVERITY OF INJURY. PATIENTS WITH INJURIES BELOW C4
MAY SPONTANEOUSLY BREATHE, BUT EVENTUALLY WILL BE ON MECHANICAL
VENTILATION. THE EXAM IS TRYING TO TEST YOUR KNOWLEDGE IN INTUBATION
TECHNQUES !
• ARRHYTHMIAS/MI: ECG SHOWS Q WAVES, AND S-T SEGMENT ELEVATIONS. LOOK
FOR SIGNS OF HYPOXEMIA IN THESE PATIENTS ALSO PRIOR TO MI ECG MAY SHOW
FLIPPED T-WAVES. CHECK CARDIAC ENZYMES: TROPONIN > 0.1, TREAT WITH 100%
Fi02, MORPHINE, NITROGLYCERIN, ASA.
• PVC’S: O2/LIDOCAINE, AMIODORONE, BRADYCARDIA: 02/ATROPINE, V-FIB:

DEFIB 360J REPEAT, PULSELESS VENTRICULAR TACHYCARDIA: COMPRESSION AND
28 PATHOLOGY DEFIB. A-FIB: SYNCHRONIZED CARDIOVERSION BEGIN WITH 50J.
• TAKE HOME MESSAGE FOR ARRHYTHMIAS IS TO KNOW TREATMENT AND

PHARMACOLOGY!
• THORACIC SURGERY: QUESTIONS WILL BE BASED ON HOW TO TROUBLESHOOT

CHEST TUBES AND MECHANICAL VENTILATION. IF YOU ENCOUNTER A QUESTION
WITH A PATIENT THAT HAS BEEN INTUBATED S/P PNEUMONECTOMY OR
LOBECTOMY USE ½ VT. IDENTIFY ANATOMICAL PLACEMENT OF A CHEST TUBE.

• THERMAL INJURIES: RECALL “CHERRY RED” COLOR FACE WITH THOSE EXPOSED TO
CO. LOOK FOR SIGNS OF CONFUSION, HOARSE VOICE AND STRIDOR. CO
POISONING MAY LEAD INTO PULMONARY EDEMA. NOTE: COHb (HEMOXIMETRY)
>20%. INTUBATE AND INSTITUTE MECHANICAL VENTILATION TO PROTECT AIRWAY
FOR PATIENTS IN RESPIRATORY SISTRESS. CO EXPOSURE TREAT WITH 100% FiO2.
MAY ALSO BE TREATED WITH HBO, BE ON GUARD.
• FOR BURN PATIENTS AVOID USING SUCCINYLCHOLINE, SELECT ROCURONIUM OR

OTHER PARALYZING AGENT-ONE SIDE EFFECT OF SUCCINOLYCHOLINE IS
29 PATHOLOGY HYPERKALEMIA IN THESE PATIENTS AND HAS A POTENTIAL OF TRIGGERING
MALIGNAT HYPERTHERMIA.
• TREATMENT FOR MALIGNAT HYPERTHERMIA: DATROLENE OR SODIUM BICARB.
• SHOCKS: ESTABLISH IV ACCESS RIGHT AWAY, PUSH FLUIDS STAT! AIRWAY AS

SOON AS POSSIBLE. EACH TYPE OF SHOCK REQUIRES DIFFERENT MANAGEMENT.
WATCH FOR FALLING VALUES IN PCWP, CVP, CO AND PAP. THESE PATIENTS ARE
QUITE ILL AND WILL EXPRESS SIGNS THAT MAY LEAD INTO INTUBATION.

• HIV/AIDS: RECALL KEYPOINTS: ELISA TEST FOR DIAGNOSIS. PATIENT WITH ADVANCED
HIV/AIDS MAY PRESENT WITH PCP (PNEUMOCYSTIS CARINII) TREAT WITH PENTAMADINE
(NEBUPENT) MONTH-USE ONE WAY VALVE / FILTERS WHEN ADMINISTERING THIS
MEDICATION VIA RESPIRGARD II.
• DRUG OVERDOSE: NUMBER ONE PRIORITY IS TO ESTABLISH AN AIRWAY IF PATIENT IS
DETERIORATING. RECALL PINPOINT PUPILS. GIVE NARCAN IF SUSPECTED DRUG
OVERDOSE. POTENTIAL SIDE EFFECT: HYPERTENSION AND TACHYCARDIA (ON THE EXAM)
30 PATHOLOGY
• DIABETES: THESE TYPE OF QUESTIONS MAY LEAD WITH A PATIENT WITH A HISTORY OF
DIABETES AND RENAL FAILURE. HAS ALL CLASSIC SIGNS: ELEVATED GLUCOSE, PEDAL
EDEMA, DECREASED URINE OUTPUT, METABOLIC ACIDOSIS. GIVE ELECTROLYTES IV AND
IVF STAT. WATCH FOR VENTILATORY FAILURE DUE TO RENAL INSUFFICIENCY THAT MAY
LEAD INTO RESPIRATORY KETOACIDOSIS. IF PATIENT ON DKA- GIVE INSULIN. GLUCOSE >
140, IF PATIENT HYPOGLYCEMIC THEN ADMINISTER GLUCOSE. BE ON GUARD WITH THESE
QUESTIONS!
• BARIATRIC: OSA, INCREASED BMI> 30kg/m2. POST SURGICAL PATIENTS MAY
REQUIRE CPAP OR NIPPV. DELAYED RESPONSE AFTER SURGERY. MAY HAVE HIGH
PaCO2. DURING MECHANICAL VENTILATION, THESE PATIENTS WILL REQUIRE HIGH
PEEP LEVELS, WILL HAVE HIGHER AIRWAY PRESSURES, DECREASED PULMONARY
COMPLIANCE, NORMAL AIRWAY RESISTANCE, MARKED DECREASED TOTAL LUNG
CAPACITY DUE TO ADIPOSE TISSUE SURROUNDING THE THORAX. INTUBATION:
POSSIBLE MALLAMPATTI CLASS 3 OR 4 AND PREPARE FOR DIFFICULT INTUBATION.
• PSYCHIATRIC: (NEW ON EXAM) BE FAMILIAR WITH THE DIFFERENCE BETWEEN

HYPOACTIVE DELIRUM VS. HYPERACTIVE DELIRUM.
31 PATHOLOGY
• COGNITIVE IMPAREMENT: PATIENT WITH CHRONIC DISEASES WILL HAVE
CHRONIC COGNITVE IMPAREMENT.
• HYPOACTIVE: DECREASED MENTAL ACTIVITY, NOT ABLE TO FOCUS
• HYPERACTIVE: COMBATIVE STATUS, ANXIOUS, WATCH FOR SELF EXTUBATION,

PULLING AT LINES ETC.
• ICU PSYCHOSIS OR DELIRUM FOR MOST PATIENTS IS TEMPORARY.

MASSIVE HEMOPTYSIS:
• FIRST ESTABLISHED WHICH SIDE IS BLEEDING (RIGHT OR LEFT LUNG)
• PATIENT MUST BE THEN POSITIONED ON RIGHT OR LEFT DEPENDENT

POSITION. RIGHT SIDE DOWN DECUBITUS POSITION OR LEFT SIDE
DECUBITUS POSITION.
• ESTABLISH AIRWAY: INTUBATE WITH ENDOBRONCHIAL (DOUBLE

32 PATHOLOGY
LUMEN ETT), INSTITUTE ILV (INDEPENDENT LUNG VENTILATION).
• PERFORM BRONCHIAL ARTERY EMBOLIZATION- NON-SURGICAL

PROCEDURE IN WHICH A CATHETER IS INSERTED INTO THE
BRONCHIAL ARTERY AND CREATES A CLOT TO STOP THE BLEEDING.
WATCH FOR CLUES IN EXAM: PATIENT UNDERGOING A
BRONCHOSCOPY OR DURING INTUBATION.
LUNG TRANSPLANTATION (NEW ON EXAM)
• AGE LIMITS : HEART AND LUNG TRANSPLANT ~ 55 YEARS OLD,
SINGLE LUNG ~ 65 YEARS OLD, BILATERAL LUNG TRANSPLANT ~
60 YEARS OLD.
GENERAL COMORBIDITIES THAT WILL IMPACT TRANSPLANTATION:
1. SYSTEMIC CORTICOSTERIODS
2. PROGRESSIVE NEUROMUSCULAR DISEASE (ABSOLUTE
CONTRAINDICATION).
33
PATHOLOGY 3. SYMPTOMATIC OSTEOSPOROSIS.
4. IBW < 70% OR 130%- PATIENT MAY BE REQUIRED TO GAIN OR
LOOSE WEIGHT.
5. PSYCHOLOGICAL-MENTAL ILLNESS
6. BACTERIAL OR FUNGAL LUNG INFECTIONS

LUNG TRANSPLANTATION CONTRAINDICATIONS
• HIV INFECTION
• CORONARY ARTERY DISEASE
• LEFT VENTRICULAR DYSFUNCTION
• HEPATITIS B+ ANTIGEN
• HEPATITIS C (ACTIVE LIVER DISEASE)
• DIABETES MELLITUS
• COLLAGEN VASCULAR DISEASE
34 PATHOLOGY
SPECIFIC DISEASES FOR TRANSPLANTATION
• COPD – FEV1 < 25% OF PREDICTED, PaCO2 > 55
• CYSTIC FIBROSIS
• SEVERE BRONCHIECTATSIS
• PULMONARY HYPERTENSION WITHOUT CONGENITAL HEART
DISEASE
• EISENMENGER’S SYNDROME

• MALLAMPATTI SCORE SYSTEM IS WIDELY USED ON THE
35 EXAM: IT WILL TEST YOUR ABILITY FOR THE SPECIALIST TO
RECOGNIZE UPPER AIRWAY PATENCY.
CRITICAL CARE • SCORE 1: FULL VISULIZATION OF UVULA, SOFT PALATE,

TONSILS, AIRWAY FULL OPEN
• SCORE 2: MAY BE ABLE TO VISUALIZE UVULA, SOFT

PALATE, AND UPPER PORTIONS OF TONSILS.
• SCORE 3: SOFT AND HARD PALATE VISIBLE AND BASE OF

VALLECULA. MAY PRESENT DIFFICULTIES TO INTUBATE
THESE PATIENTS.
• SCORE 4: ONLY THE HARD PALATE IS VISIBLE. WHICH

INDICATES DIFFICULT INTUBATION.

CRITICAL CARE-
MALLAMPATI VISUALS
36
THYROMENTAL DISTANCE IS ANOTHER TECHNIQUE USED FOR
ASSESS FOR DIFFICULT INTUBATION. NOT THE BEST METHOD TO
USE. MALLAMPATTI IS BETTER TO ASESS FOR DIFFICULT INTUBATION.
TD IS DETERMINED BY THE MEASUREMENT OF THE THYROID
CARTILAGE TO CHIN WHILE NECK IS HYPEREXTENDED.
SCORING SYSTEM: 6.5-7CM DETERMINES- NON-PROBLEMATIC /

EASY INTUBATION
37
CRITICAL CARE <5CM DETERMINES- PROBLEMATIC INTUBATION
THIS MAY BE SEEN ON THE EXAM AS FAR AS KNOWING THE

DIFFERENCE OF THE 2 SCORING SYSTEM AND WHICH ONE IS
MORE EFFECTIVE FOR DIFFICULT INTUBATION ASSESSMENT!

38 COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS
01/01/2024
DIAGNOSTIC RADIOLOGY
• MRI- RECALL TO USE FLUIDIC VENTILATORS OR NON-FERROUS ITEMS DURING

TRANSPORT.
CRITICAL CARE
• V/Q SCAN- IF PATIENT PRESENTS WITH SYMPTOMS IN WHICH ARE LEADING TO RULE
OUT A PULMONARY EMBOLUS THIS IS YOUR SECOND-BEST ANSWER. SPIRAL CT IS THE
BEST CHOICE. SYMPTOMS OR PATHOLOGIES INCLUDE: SHORTNESS OF BREATH, “ALL
OF THE SUDDEN”- CHEST PAIN, TACHYCARDIA, PLEURAL EFFUSION, OR EMPHYSEMA.
• KNOW THE DIFFERENCE TYPE OF CHEST XRAYS THAT WILL BE USEFUL FOR
39 DIAGNOSING LUNG PATHOLOGIES!
• LATERAL DECUBITUS- DX: PLEURAL EFFUSION
• ANTERIOR POSTERIOR: TO DETERMINE SMALL PNEUMOTHORAX, USE FOR PROPER

PLACEMENT STATUS POST INTUBATION- RECALL ANATOMICAL MARKINGS, THE EXAM
WILL NOT GIVE YOU THE MOST COMMON ANSWERS SUCH AS 2-5 CM ABOVE THE
CARINA.
• LOOK FOR LEVEL WITH T-4 OR 4TH RIB, LEVEL WITH AORTIC KNOB OR NOTCH.

• CENTRAL VENOUS CATHETER TIP SHOULD BE IN THE RIGHT
ATRIUM OR VENA CAVA. ON THE EXAM IT MAY ASK YOU HOW
TO TROUBLESHOOT THE DISTANCE OF THE CATHETER .
• NG TUBES SHOULD BE IN THE STOMACH A KUB OR
40 CHEST/ABDOMINAL X-RAY MUST BE ORDERED TO DETERMINE
PROPER PLACEMENT PRIOR TO START PARENTERAL FEEDING.
CRITICAL CARE TROUBLESHOOTING: IF PATIENT WAS TRANSFERRED OR MOVED
NASOGASTRIC TUBE MAY HAVE MIGRATED UPWARDS AND
PATIENT IS ASPIRATING TUBE FEEDS, FIRST ACTION TO TAKE IS
STOP THE FEEDING THEN OBTAIN CXR. WATCH FOR CLUES HEAD
OF THE BED WAS MOVED 40 DEGREES.
• PULMONARY ARTERY CATHETER TIP MUST BE IN THE RIGHT
LOWER OR BASE OF THE LUNG REGION ON THE XRAY.
TROUBLESSHOOTING: IF PAC IS > 50cm IN DEPTH, CATH IS
CURLING IN RA OR RV: ANSWER IS TO DEFLATE AND WITHDRAW
CATHETER.
• ULTRASOUND: USE TO RULE OUT PLEURAL EFFUSION (THORACIC
ULTRASOUND). USE ON PATIENTS THAT ARE UNSTABLE, NOT ABLE
TO BE TRANSPORTED TO CT.
• ECHO: R/O EJECTION FRACTION, PULMONARY ARTERIAL
PRESSURE OR VALVE FUNCTIONS (TRICUPID OR MITRAL). TEE –
TRANSESOPHAGEAL IS BETTER OPTION.
• PET SCAN: (POSITRON EMISSION TOMOGRAPHY) USE TO RULE
OUT CANCER.
CAPNOGRAPHY
KNOW THE DIFFERENCE BETWEEN

NORMAL, RESPIRATORY FAILURE,
41 CRITICAL PULMONARY EMBOLUS AND
DISCONNECTION.
CARE
ONE OF THESE WAVEFORMS WILL BE

IN YOUR EXAM BE ON GUARD! SEE
WAVEFORMS

42 COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024
44

45

KEYPOINTS
• ETCO2 CAN BE EXPRESSED A NORMAL VALUE AS 3-5% OR

PETCO2 3.4-3.6 TORR. QUESTION ON THE EXAM.
• DURING CARDIOPULMONARY ARREST PETCO2 WILL INCREASE-

IMPROVED CIRCULATION.
47
CAPNOGRAPHY • IF YOU ARE PRESENTED WITH A QUESTION IN WHICH SECRETIONS
–ETCO2, PETCO2
OR MOISTURE ARE OBTRUCTING THE LINE THE ANSWER IS : PETCO2
WILL READ ZERO.
• IF ARE PRESENTED WITH THESE VALUES : C(a-v)O2 (NORMAL 4-

5%) INCREASING, CvO2 (NORMAL 12-14 VOL%) AND SvO2 THE
CARDIAC OUTPUT IS DECREASING.

• STROKES: KNOW THE DIFFERENCE BETWEEN HEMORRAHAGIC (BLEED)
VS. ISCHEMIC STROKE (DUE TO CLOT). USE CT HEAD TO DIAGNOSE.
YOU MAY SEE THE TERM HEMIPARETIC WHEN IS USED TO DESCRIBE
THE ACTUAL LOCATION OF THE STROKE (RIGHT OR LEFT BRAIN)
TREATMENT FOR ISCHEMIC STROKES: USE THROMBOLYTICS STAT!,

48 CRITICAL •
UNFORNUTELY THE TREATMENT CHOICE FOR HEMORRHAGIC STROKE
CARE IS LIMITED. A QUESTION MAY COME UP IF YOU CAN GIVE HEPARIN
OR ASPIRIN TO A PATIENT WITH A HEMORRAHAGIC STROKE: THE
ANSWER IS NO! IS ONLY GIVEN TO PATIENTS WITH ISCHEMIC
STROKES.

STUDY THE TABLE PROVIDED, YOU WILL BE
ASKED ON THE EXAM IN REGARD TO THE
SCORING SYSTEM AND WHICH ACTION TO
TAKE.
50 CRITICAL
CARE NOTE: A GCS OF < 8 INTUBATE PATIENT. IF A
PATIENT HAS A TOTAL GCS OF 3 IT WILL
INDICATE PATIENT IS IN A DEEP COMA, IF
GCS IS 15 INDICATES PATIENT IS FULLY
AWAKE.

CARDIOVASCULAR MEDICINE:
• HEART SOUNDS: S1,S2 ARE NORMAL SOUNDS. S3, S4 ARE
ABNORMAL-CONSIDER ECHO. VALVE ISSUES-REGURGITATION S3-
INDICATES CHF, S4 INDICATES-MI OR CARDIOMEGALY.
• HOLTER 24 HR MONITOR: MONITORS CARDIAC EVENTS WITH
LIFESTYLE FOR 24 HOURS.
• ECHOCARDIOGRAM: KNOW THE NORMAL VALUES OBTAINED
51 CRITICAL FROM ECHOS- EF 50-70%, CARDIAC OUTPUT 4-8L/MIN, STROKE
VOLUME 50-100ML.CARDIAC INDEX IS ½ OF THE C.O.
CARE • CO= HR X SV
• SV= EDV- EDV: NORMAL IS 120-50= 70ML
• EJ= SV/EDV: NORMAL 70/120=58%
• ANGIOGRAPHY: RULE OUT NARROWING OF THE CORONARY
ARTERIES, USED UNDER FLUOROSCOPY.

CRITICAL CARE

53 CRITICAL CARE

CRITICAL CARE

CRITICAL CARE

LEARN THE HEART BLOCKS:
CRITICAL CARE • 1ST DEGREE HEART BLOCK : TREATMENT
OF CHOICE ATROPINE (P-R INTERVAL)
IS > 0.20 SECONDS
• 2ND DEGREE HEART BLOCK:
56 TREATMENT: ATROPINE/PACING. P
WAVE PRESENT WITH OCCASIONAL
“MISSING” QRS COMPLEX
• 3RD DEGREE HEARTBLOCK: TREATMENT:
PACEMAKER (FOR MOST PATIENTS)
MISSING P WAVE AND QRS COMPLEX.

CRITICAL CARE

CRITICAL CARE

CRITICAL CARE
59

60 CARDIAC DISEASES
• HYPERTENSION: PHARMACOLOGIC AGENTS

CRITICAL CARE USED TO INCREASE CONTRACTILITY CHOOSE
DIGOXIN.
• VASODILATION: CHOOSE PROSTACYCLIN,
DOBUTAMINE.
• BLOOD VOLUME REDUCTION: CHOOSE
FUROSEMIDE (LASIX).
• CONGESTIVE HEART FAILURE: USE LASIX, 100%
02, DIGOXIN. WATCH FOR TERMS SUCH AS JVD.
• PULMONARY HYPERTENSION: TREATMENT OF
CHOICE FLOLAN, iNO (20 ppm- 40 ppm-TO
START)

TACHYCARDIA TREAT WITH LABETALOL, PRONESTYL, PROPRANOLOL, ESMOLOL.
BRADYCARDIA TREAT WITH ATROPINE OR EPI.

61 KNOW YOUR HEMODYNAMICS AND NORMALS
CVP 2-6mmHg NORMAL VALUE
CRITICAL CARE • CVP <2 -DEHYDRATION PRESENT–GIVE IVF’S (HYPOVOLEMIA PRESENT)
• CVP > 6-FLUID OVERLOAD – GIVE DIURETIC (HYPERVOLEMIA PRESENT)
• PAP 14mmHg (MEAN) OTHERWISE IT MAY PRESENT IN FORM OF BP (25/8)

REMEMBER THE DIASTOLIC PORTION OF PAP IS AN ESTIMATED PORTION TO
DETERMINE PCWP.
• PCWP 8mmHg (4-12mmHg) IF ELEVATED IT RELATES TO LEFT HEART FUNCTION

ONLY. SWAN GANZ ALSO IS KNOWN AS BALLON TIPPED FLOW DIRECTED
PULMONARY ARTERY CATHETER. BE ON GUARD FOR INTERCHANGEABLE
TERMS ON THE EXAM! WATCH FOR PRESSURE DAMPENING –QUESTION MAY
ASK FOR YOU TO TROUBLESHOOT PRESSURE DOME FOR AIR BUBBLES.
• RECALL: ASPIRATE FIRST, FLUSH AND THEN ROTATE CATHETER.

TYPES OF SHOCKS
• ANAPHYLACTIC SHOCK: CAUSED BY ALLERGIC REACTION (BEE STING, FOOD

ETC) TREAT WITH IVF, STEROIDS, ANTIHISTMINES AND EPI.
62
• SEPTIC SHOCK: TREAT WITH IVF, BROAD SPECTRUM ANTIBIOTICS, SUGGEST
BLOOD CULTURES AND GRAM STAIN (TO DETERMINE GRAM+ OR -BACTERIA
FOR FAST RESULTS), ELEVATED WBC > 10K. BE ON GUARD WITH AIDS/
CANCER PATIENTS WITH NEUTROPENIA IN DIFFERENT SCENARIOS.
CRITICAL CARE • CARDIOGENIC SHOCK- SHORT TERM: IVF, DOPAMINE, DOBUTAMINE,

LEVOPHED, EPI. HINT FOR THE EXAM: GUN SHOT WOUND (GSW), POSSIBLE
HEMORRHAGE.
• HYPOVOLEMIC SHOCK (OLIGEMIC SHOCK) (CVP <2)- IVF, TRANSFUSIONS,

WATCH FOR PATIENTS THAT MIGHT BE DEHYDRATED (URINE LOSS, VOMITING,
DIARRHEA).
• NEUROGENIC SHOCK (DISTRIBUTIVE SHOCK) -IVF, COMMON IN PATIENT WITH

SEPSIS,SPINAL CORD INJURIES (S/P MVA).
WHAT IS THE COMMON DENOMINATOR: IVF! PUSH FLUIDS IN ALL SHOCKS!!!

KNOW THE DIFFERENCE BETWEEN OBSTRUCTIVE SLEEP
APNEA VS. CENTRAL SLEEP APNEA AND TREATMENT.
KNOW AHI (APNEA-HYPOPNEA INDEX) <5 IS
CONSIDERED NORMAL, > 5-15 MILD DISORDER, 15-30
MODERATE DISORDER, >30 SEVERE SLEEP APNEA.
OSA TREATMENT: CPAP/ NIPPV- USE FOR POST OP

PATIENTS, ANALGESICS MAY TRIGGER PATIENT TO
63 CRITICAL CARE BECOME SOMNOLENT, DECREASED MINUTE

VENTILATION, INCREASING PaCO2, WATCH FOR THESE
HINTS ON THE EXAM.
CSA TREATMENT: DOPRAM – RESPIRATORY ESTIMULANT,

MAY REQUIRE MECHANICAL VENTILATION.

KEYPOINT: PATIENTS EXPOSED TO CHEMICALS, NEAR
DROWNING, HIGH ALTITUDES AND INCREASED PEAK
PRESSURE WHILE ON MECHANICAL VENTILATION MAY
DEVELOP A CONDITON CALLED DAH (DIFFUSE ALVEOLAR
HEMORRHAGE).
KEYPOINT: RECALL THE MOST ACCURATE IMAGE OF

RENAL FUNCTON IS CREATININE NOT BUN. NORMAL
CREATININE IS 0.6-1.2mg/dL. WATCH FOR
64 TERMINOLOGY: THIRD SPACING/FLUID SHIFTING IN THESE
PATIENTS.
CRITICAL CARE
KEYPOINT: TRALI (TRANFUSION RELATED LUNG INJURY)
VERY COMMON IN PATIENTS GETTING TRANSFUSIONS OR
PLASMA DEVELOPING PULMONARY EDEMA. TREATMENT:
STOP THE TRANSFUSION FIRST, ASSESS PULMONARY
STATUS-USE CPAP OR NIPPV, DIURECTICS.

METABOLISM AND NUTRITION:
RESPIRATORY QUOTIENT( RQ) : NORMAL 0.67-1.3 RQ= VCO2/VO2
• FOOD METABOLISM BY RQ : CARBOHYDRATES 1.00, FATS (LIPIDS) 0.71,

PROTEINS 0.82. THIS WILL COME UP ON THE EXAM. CARBOHYDRATES HAVE A
HIGH YIELD AND WILL PRODUCE MORE CO2 INCREASING WOB, DIET
SHOULD BE CHANGE TO HIGH LIPS AND PROTEIN IF PATIENT IS FAILING TO
WEAN OFF MECHANICAL VENTILATION.
RER (RESPIRATORY EXCHANGE RATIO): NORMAL = 0.8 INCREASES WITH

65 CRITICAL CARE EXERCISE DUE TO C02 PRODUCTION AND MORE OXYGEN IS CONSUMED.
• NORMAL ADULT CONSUMES ABOUT 1300-1500 Kcals PER DAY. PATIENT ON

MECHANICAL VENTILATION WILL NEED AROUND 1750 Kcals/day. ANYTHING
GREATER THAN 1750 Kcals/day MUST BE REDUCED.
BMR (BASIC METABOLIC RATE): IS DESCRIBED AT THE TOTAL ENERGY NEEDED IN

ONE DAY. IN HOSPITALS THIS IS USED FOR CALORIC INTAKE FOR PATIENTS
RECEIVING TPN.

• TOTAL PROTEIN LEVEL: 6.0-8.5g/dL DECREASED LEVEL CAN BE
ASSOCIATED WITH ON GOING INFECTION,TB, DIARRHEA AMONG
OTHER ISSUES.
• ALBUMIN LEVEL: 3.5-5.5 d/dL (BLOOD), URINE 10-100 mg/24h OF
URINE. HIGH LEVELS CAN BE LINK TO LIVER FAILURE, DEHYDRATION
AND SHOCK. LOW LEVELS – DIARRHEA, MALNUTRITION, 3RD DEGREE
BURNS, FEVER, INFECTION, EDEMA -NEW FOR THE EXAM
66 CRITICAL CARE
GI TRACT COMPLICATIONS:
• GI BLEED: LOOK FOR TERMS “COFFEE GROUND” APPERANCE –
TREATMENT: IVF, TRANSFUSE.
• ILEUS: SYMPTOMS CONSIST OF: FLATULENCE, CONSPITATION,
NAUSEA. TREAMENT: STOOL SOFTNERS.

NUTRITIONAL CARE AND STATUS
• HYPOGLYCEMIA NORMAL LEVEL 70-125 mg/dL

• GIVE DEXTROSE IV STAT OR GLUCOSE IN CRITICAL CONDITION
PROTEIN WASTING
• SEEN IN PATIENTS WITH SHORT BOWEL SYNDROME
67 • CROHN’S DISEASE
• ALSO ENCOUNTER THE TERM: PROTEIN LOOSING ENTEROPATHY
CRITICAL CARE ENTERAL VS PARENTERAL ROUTE: BE AWARE OF THE
DIFFERENCE
• ENTERAL: NORMAL WAY TO CONSUME FOOD
• PARENTERAL: IV ROUTE – EXAMPLE : TPN, PEG TUBE,
NASOGASTRIC TUBE.

CRITICAL CARE
COMPLICATIONS OF NUTRITIONAL SUPPORT
• REFEEDING SYNDROME (NEW ON EXAM): COMPRISE ON A SEQUALE OF

METABOLIC DYSFUNCTIONS AND DISTURBANCES WHICH OCCUR WHEN
INTRODUCING NUTRITION TO PATIENTS THAT HAVE BEEN STARVING OR
SEVERELY MALNOURISHED.
68
• THESE PATIENTS WILL HAVE DEFICIENCIES IN POTASSIUM, ESSENTIAL VITAMINS,
SODIUM AND MAY LEAD INTO ARRHYTHMIAS, CARDIAC ARREST (MOST
COMMON CAUSE OF DEATH FROM REFEEDING SYNDROME), ANEMIA, SEIZURES,
DELIRUM. COMMON IS PATIENTS WITH ANOREXIA NERVOSA.
• SIGNS OF REFEEDING SYNDROME: ATAXIA, TACHYCARDIA NEUROPATHY,

EMESIS, HYPERVOLEMIA (INCREASED CVP).

RHABDOMYLOSIS
• WATCH FOR KEY TERMS: URINE LOOKS LIKE “DARK TEA” THIS IS DUE TO THE MUSCLE
TISSUE BREAKDOWN. MYOGLOBIN IS EVENTUALLY FILTERED BY THE KIDNEYS CAUSING
DAMAGE TO KIDNEY CELLS AND PASSED INTO THE URINE. SCENARIOS : TRAPPED IN A
COLLAPSED BUILDING, HOUSE, EXTRENOUS EXERCISE. PATIENT MAY DEVELOP
COMPARTMENT SYNDROME. CHECK LABS: POTASSIUM , PHOSPHORUS, BUN AND
CREATININE.
• TREATMENT: IVF AND IN SEVERE CASES PATIENTS MAY NEED HEMODIALYSIS.
69 CRITICAL CARE IT IS ESSENTIAL FOR YOU TO KNOW THE LAB NORMALS FOR THE EXAM! SOME OF THE KEY
LAB VALUES ARE:
• BNP (B-TYPE NATRIURETIC PEPTIDE) > 100pg/mL INDICATES CHF,< 100 COPD
EXACERBATION
• TROPONIN: >0.1ug/L INDICATES MYOCARDIAL INFARCTION
• INR (INTERNATIONAL NORMALIZED RATIO) NORMAL 0.8-1.3 (OFF ANTICOAGULANT

THERAPY). (ON ANTICOAGULANT THERAPY: 2.0-3.0), HIGHER IN SOME CASES WITH
ARTIFICIAL VALVES.

CRITICAL CARE
RISK FOR DEEP VEIN THROMBOSIS (DVT)
• HEART FAILURE
• CANCER
• OBESITY
• POST TRAUMA
• NON-AMBULATORY
70
• POST SURGERY
• HISTORY OF DVT’S
IMAGING FOR DVT
• LEG ULTRASOUND
• PROXIMAL COMPRESSION ULTRASOUND
• DOPPLER ULTRASOUND

• CBC: NORMAL 5-10K INCREASED WBC > 16K (LEUKOCYTOSIS) MAY INDICATE
PATIENT IS SEPTIC OR HAS UNDERGOING INFECTION. (COMMON LAB VALUE ON
EXAM) LOOK FOR FEBRILE ILLNESS. WBC < 5 IS CONSIRED LEUKOPENIA (VIRAL)
• RBC: NORMAL 4-6 MILL/CU MM
• HEMOGLOBIN: 12-16gm/dL. WATCH FOR LOW HB LEVEL BE ON GUARD: MAY
CRITICAL CARE NEED TO BE TRANSFUSED BUT MAY NOT THE SOLE ISSUE FOR THIS PATIENT. SAME
RULE APPLIES TO RBC/HCT. PATIENT MAY NEED IVF, LOOK FOR FALLING
HEMODYNAMICS-CORRECT THAT FIRST THEN GIVE IVF. THERE WAS A QUESTION IN
REGARD TO A PATIENT WITH ELEVATED Hb > 16- THE CORRECT ANSWER IS
71
POLYCYTHEMIA- SEEN WITH COPD PATIENTS.
• RULES OF 3’S: ESTIMATE HCT BY: HB X 3= HCT COUNT, SAME APPLIES TO RBC X 3=
HB
• WATCH FOR THE TERM NEUTROPENIA ON THE EXAM- PATIENT MIGHT BE

SUSCEPTIBLE TO INFECTIONS- AIDS, CANCER, TERMINALLY ILL PATIENTS. IF
NEUTROPHIL COUNT IS ELEVATED INDICATES AN INFECTION. INCREASED
LYMPHOCYTES ARE ASSOCIATED WITH VIRAL INFECTIONS.

ELECTROLYTES
• SODIUM LEVEL: 135-145 mEq/L: SIGNS OF HYPERNATREMIA OR

HYPONATREMIA. INSENSIBLE VS SENSIBLE WATER LOSS, PATIENT
DEHYDRATED OR VOLUME OVERLOAD, VOMITING, DIAAHREA.
• MAGNESIUM: 1.4-2.0 mEq/L: EVALUATES KIDNEY ISSUES, ALSO IT

CRITICAL CARE MIGHT BE DECREASED ON THOSE PATIENT GETTING CONTINOUS
ALBUTEROL NEBS.
72 • POTASSIUM 3.5-4.5 mEq/L : HYPOKALEMIA– LEADS INTO

METABOLIC ALKALOSIS AND FLATTENED T WAVES. REMEMBER WITH
HYPERKALEMIA IS THE OPPOSITE YOU WILL SEE SPIKED T WAVES.
IMPERATIVE TO REMEMBER FOR EXAM.
• ANION GAP NORMAL 3-11 mEq/L (QUESTION ON EXAM):

DETERMINES CAUSES OF METABOLIC ACIDOSIS IF ANION GAP >
11mEq/L

METHEMOGLOBINEMIA:
SIGNS “DARK CHOCOLATE COLOR” IN ARTERIAL BLOOD
CRITICAL CARE •
• LEADS TO HYPOXEMIA- GIVE 0XYGEN IMMEDIATELY (MAY
HELP)
73 • HIGH LEVELS CAN LEAD TO DEATH IF NOT TREATED

QUICKLY
• CAUSING AGENTS: NITRIC OXIDE, BENZOCAINE,
LIDOCAINE, DAPSONE, NITROPRUSSIDE
• TREATMENT: METHYLENE BLUE IV OR ASCORBIC ACID

NON-CARDIAC BIOMAKERS:
CRITICAL CARE
D-DIMER: USEFFUL TO RULE OUT PULMONARY EMOBOLISM, DO NOT CHOOSE D-
DIMER IN PATIENT HAS BEEN HOSPITLIZED.
74
LACTATE: NORMAL LEVEL 0.5-2.2 mmol/L OR 4.5 -19.8 mg/dL USED AS A
GOOD INDICATOR OF OXYGEN DELIVERY TO THE CELL, ELEVATED DURING
SHOCKS AND CARDIAC ARREST.
PROCALCITONIN: (NEW ON EXAM) NORMAL LEVEL 0.01ug/L IF > 0.5ng/dL

POSSIBLE SEPSIS. PROCALCITONIN IS PROPEPTIDE OF CALCITONIN WHICH
ASSIST THE CLINICIAN OF INITATION OF ANTIBIOTICS OR CESSATION OF
ANTIOBIOTICS. HIGH LEVELS SHOULD BE CONSIDERED AN EMERGENCY.

ENDOCRINE ASSESSMENTS (NEW ON EXAM)
CORTISOL : NORMAL LEVEL 10-20ug/dL EARLY IN A.M. CLASSIFIED AS A
GLUCORTICOSTERIOD HORMONE. REGULATES METABOLISM, IMMUNE RESPONSE AND
STRESSFUL SITUATIONS.
SYMPTOMS OF HIGH CORTISOL LEVELS
CRITICAL CARE
• HYPERTENSION
• OSTEOSPOROSIS
• SKIN CHANGES
• WEIGHT GAIN
75
• MOOD SWINGS
THYROID FUNCTION TESTS (NEW ON EXAM)
T4 TEST AND TSH ARE THE TWO MOST COMMON THYROID FUNCTION TESTS. T4 TEST IS KNOWN
AS THYROXINE TEST A HIGH LEVEL OF T4 LEVEL INDICATED AN OVERACTIVE THYROID
(HYPERTHYROIDISM).
THESE SYMPTOMS INCLUDE ANXIETY, UNPLANNED WEIGH LOSS , TREMORS AND DIARRHEA.
TSH MEASURES THE LEVEL OF THRYOID STIMULATING HORMONE IN BLOOD. TSH NORMAL
RANGE IS BETWEEN 0.4-4.0mIU/L

LIVER FUNCTION (NEW ON EXAM)
• BILIRUBIN: NORMAL LEVEL 0.2-1.2mg/dL TEST USED TO RULE OUT CONDITIONS OF

LIVER, JAUNDICE, ANEMIA, GALLSTONES AND OTHER CONDITIONS SUCH AS SICKLE
CELL ANEMIA AND HEMOLYTIC ANEMIA. HIGH LEVELS OF BILIRUBIN CAN ATTRIBUTED
TO HEPATITIS.
CRITICAL CARE • SIGN AND SYMPTOMS INCLUDE FATIGUE, NAUSEA, VOMITING, FATIGUE, ABDOMINAL
PAIN AND DARK URINE.
• TOTAL BILIRUBIN 0.2-1.2mg/dL
76 • DIRECT BILIRUBIN 0-0.4mg/dL
KEYPOINT: THEOPHYILLINE, PHENOBARBITAL AND HIGH LEVELS OF VITAMIN C CAN

DECREASE LEVELS OF BILIRUBIN.
• AST (ASPARTATE AMINOTRANSFERASE) NORMAL LEVEL 5-40U/L
• ALT (ALALINE AMINOTRANFERASE) NORMAL LEVEL 7-56U/L
• THESE LEVELS ARE GOOD INDICATORS OF INJURY TO THE LIVER AS WELL AS OTHER
CONDITION.

AMMONIA LEVELS (NH3) (NEW ON EXAM) NORMAL LEVELS : LOWER
LIMIT 10-20mol/L AND UPPER LIMIT 35-64mol/L.
• CONSIDERED A WASTE PRODUCT OF BACTERIA IN INTESTINES DURING

THE DIGESTION ON PROTEIN. INCREASED LEVELS OF AMMONIA CAN
BE TOXIC TO BRAIN PARTICULARLY WITH PATIENTS WITH UNDERLYING
CRITICAL CARE LIVER DISEASE SUCH AS CIRRHOSIS, AMMONIA CAN ACCUMULATE IN
BRAIN CELLS AND CAUSE DISORIENTATION, SLEEPINESS AND
CONFUSION IN SOME PATIENTS. DIFFERENTIAL DIAGNOSIS
77
HYPERCARBIA VS. INCREASED AMMONIA LEVELS.
• INCREASED LEVELS SEEN IN PATIENTS WITH LIVER DISEASE, RENAL

FAILURE, CHANGES IN BEHAVIOR. COULD ALSO SUPPORT THE
DIAGNOSIS OF HEPATIC ENCEPHALOPATHY OR REYE’S SYNDROME.
• TREATMENT: DIET CHANGES, LACTULOSE, ENEMAS, ANTIBIOTICS

(RIFAXIMIN).

PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA KEY FACTORS
• BED POSITION-SEMI FOWLER’S POSTION, HOB >30 DEGREE ANGLE, THIS WILL
MINIMIZE ASPIRATION.
CRITICAL CARE • ORAL CARE- VERY IMPORTANT-REDUCES COLONIZATION OF OTHER ORGANISMS

IN THE ORAL MUCOSA AND RESPIRATORY TRACT. DONE Q6 OR Q12. ON THE EXAM
APPEARED QD – WRONG ANSWER. BE ON GUARD
• INTUBATION AVOIDANCE-TRY CPAP, NIPPV FIRST BEFORE INTUBATING. IF

INTUBATION TAKES PLACE THINK OF EXTUBATING PATIENT ASAP- EXTUBATE TO
78 PLACE NIPPV ESPECIALLY COPD PATIENTS. (EXAM QUESTION)
• USE HEATED WIRES INSTEAD OF HME’S. HME’S CAN LEAD INTO HIGHER PEAK
PRESSURES IF NOT CHANGE OFTEN. DO NOT USE IN PATIENTS WITH COPIOUS
SECRETIONS.
• CONTINOUS SUBGLOTTIC SUCTION.
• GASTRIC PROPHYLAXIS-REGLAN, PEPCID.
• WEANING PROTOCOLS

RECOGNIZE SIGNS OF INFECTION WHILE ANSWERING QUESTIONS ON THE EXAM
KEY WORDS: FEBRILE ILLNESS, CHILLS, RASH, DELIRIUM
THESE PATIENT WILL FULL SEPSIS WORK UP: LABS, BLOOD CULTURES, SPUTUM CULTURE, CXR
TO RULE OUT PNEUMONIA ETC. LOOK FOR PATIENTS THAT ARE BEDRIDDEN, AIDS, CANCER,
CRITICAL CARE SEVERAL CO MORBID STATES.
CATHETERS LEADING TO SEPSIS: LOOK FOR SIGNS OF REDNESS, INFLAMMATION AT SITE-

ESPECIALLY IF THEY WERE PLACED BY CUT DOWN PROCEDURE OR IN THE EMERGENCY DEPT.
• ARTERIAL LINES
79
• IV LINES
• URINE CATHS
• CENTRAL VENOUS
• PULMONARY CATHETERS
• PICC
ON WORD OF CAUTION IF CATHETER IS NOT IN USE: DC IMMEDIATELY!!

IMAGING (CHEST XRAY) TERMINOLOGY: (BIG TICKET ITEM FOR
THE ACCS)
TYPES OF XRAYS:
CRITICAL CARE • PA (POSTERIOR ANTERIOR): STANDING, BETTER THAN AP
• AP(ANTERIOR POSTERIOR): USED FOR BEDRIDDEN PATIENTS,
80 USE TO DETECT SMALL PNEUMOTHORAX AT MAXIMAL
EXHALATION.
• LATERAL DECUBITUS-CXR USED TO DETERMINE PLEURAL
EFFUSIONS
• OBLIQUE-USED TO DETERMINE MASSES, PULMONARY LESIONS
OR BLEBS.

TRANSPULMONARY PRESSURE MONITORING (NEW ON EXAM)
• TRANPULMONARY PRESSURE IS THE DIFFERENCE BETWEEN ALVEOLAR PRESSURE AND

THE INTERPLEURAL PRESSURE IN PLEURAL CAVITY.
CRITICAL CARE • CONTRAINDICATIONS FOR ESOPHAGEAL BALLON CATHETER ARE: EPITAXIS,

NASOPHARYGEAL SURGERY, DIVERTICULITIS, TUMORS, ESOPHAGEAL ULCERATIONS,
AND GASTRIC SURGERY.
• TRANSPULMONARY PRESSURE (TPP) IS KNOWN AS THE DISTENDING PRESSURE

APPLIED TO THE LUNG BY CONTRACTION OF THE INSPIRATORY MUSCLES OR
81 POSITVE PRESSURE VENTILATION.
• TPP IS THE DIFFERENCE BETWEEN THE ALVEOLAR PRESSURE (Palv) AND PLEURAL
PRESSURE (Ppl); i.e., FORMULA : TPP = Palv – Ppl
• ESOPHAGEAL PRESSURE [Pes] IS USED AS A SURROGATE FOR Ppl, THEREFORE TPP

CAN BE MEASURED BY PERFORMING ESOPHAGEAL MANOMETRY DURING AN END-
INSPIRATORY AND END-EXPIRATORY OCCLUSSION TECHNIQUE ; i.e., FORMUL; TPP
= Palv – Pes

CRITICAL CARE INCREASED Pes MEANS EXTRA-PULMONARY/CHEST WALL
COMPLIANCE IS DECREASING FACTORS FOR THESE ISSUES
ARE:
• PLEURAL EFFUSIONS
82 • TRAUMA TO CHEST
• INTRABDOMINAL HYPERTENSION
• ASCITES

TROUBLESHOOTING
• ESOPHAGEAL AND AIRWAY PRESSURE ARE SIMILAR IN
NATURE WHEN THEY ARE MEASURED. METHOD OF
MEASUREMENTS ARE AT END INSPIRATORY AND END
EXPIRATORY CYCLE USING END INSPIRATORY AND END
EXPIRATORY OCCULSION.
CRITICAL CARE • IF ESOPHAGEAL CATHETER IS INSTERTED IN TRACHEA DEFLATE
BALLON IMMEDIATELY AND REMOVE.
• NO PRESSURE WAVEFORM INDICATES RT TO RECHECK THE
CONNECTIONS. CHECK FOR CATHETER POSITION TOO FAR
83
INTO THE ESOPHEGUS OR POSSIBLE KINK. ANSWER:
WITHDRAW CATHETER.
• PRESSURE WAVEFORM DAMPNENED RULE OUT IF BALLON HAS
TOO MUCH AIR.
• PRESSURE WAVEFORM FLAT RULE OUT IF THERE IS NOT
ENOUGH AIR IN THE BALLON.

PLEURAL EFFUSION
84

PULMONARY EDEMA-BATWING PATTERN
85

PNEUMONIA
86

PLEURAL EFFUSION-
LATERAL DECUBITUS
87

ARDS-ADULT
RESPIRATORY DISTRESS
SYNDROME
88

PULMONARY EMBOLUS
(WEDGED INFILTRATE)

PNEUMOTHORAX

SPIRAL CT-
PNEUMOTHORAX

ON THE PREVIOUS SLIDE IS SHOWING A SPIRAL
CT OF THE THORAX INDICATING A RIGHT
PNEUMOTHORAX. THERE IS A SIMILAR IMAGE ON
THE EXAM ASKING YOU FOR YOUR
RECOMMENDATION BASED ON THE CT RESULTS.
92
CRITICAL CARE THE CORRECT ANSWER IS : INSERT A CHEST TUBE

–RIGHT CHEST.

CRITICAL CARE
93
LEARN YOUR CHEST XRAY TERMINOLOGY FOR THE EXAM. THIS WAS
PRESENTED ON THE EXAM AS QUESTION NOT AS AN IMAGE.

MOST COMMON RADIOLOGICAL DESCRIPTIONS AND PATHOLOGIES:
BE ON GUARD WITH THESE TERMS!!
• PLEURAL EFFUSION- CONCAVE SUPERIOR INFERFACE, OBLITERATED /
BLUNTED COSTOPHERNIC ANGLES
• PNEUMOTHORAX-ABSENT VASCULAR MARKINGS, TRACHEAL SHIFT
OR DEEP SULCUS SIGN (ON THE EXAM)
• ARDS-RETICULOGRANULAR PATTERN, GROUNDGLASS, HONEYCOMB
PATTERN. SCATTERED BILATERAL INFILTRATE, OR PATCHY
94 CRITICAL INFILTRATES,DIFFUSE PATTERN (COMMON IN MOST QUESTIONS)
• PULMONARY EDEMA- BATWING AND BUTTERFLY PATTERN.
CARE • PULMONARY EMBOLUS- WEDGE SHAPED INFILTRATES
• PNEUMONIA- AIR BRONCHOGRAMS
• RECALL: RADIOLUCENT STATES: CXR IS NORMAL

DISASTER PREPARENESS:
• FOLLOW HOSPITAL PROCEDURES FOR DISASTERS AND PROTOCOLS
• TRIAGE– PRIORITIZE CRITICAL VS. NON-CRITICAL PATIENTS, PATIENTS COME FIRST

AND THEIR HEALTH. A QUESTION IN THE EXAM WAS IN REGARD TO PLACE PATIENTS
OF SIMILAR SYMPTOMS IN SAME AREA.
• MEDICAL / RESPIRATORY EQUIPMENT- IV POLES, O2 H-TANKS, MECHANICAL

VENTILATORS, AMBU BAGS, ETC. PROPER FUNCTION OF EACH EQUIPMENT MUST BE
95 TAKEN CARE OF PRIOR TO PATIENT ARRIVAL. USE H-TANKS IN CASE THAT MAIN O2
SUPPLY IS DOWN FOR LONG PERIOD- (QUESTION ON THE EXAM)
CRITICAL CARE • AS THE RRT-ACCS YOU WILL BE RESPONSIBLE FOR INTUBATIONS, MECHANICAL
VENTILATION, MODIFYING THERAPIES, INSTITUTE RESPIRATORY CARE PROTOCOLS
AND TEACHING OTHER ALLIED HEALTH IN BASIC RESPIRATORY CARE MODALITIES.
• MULTIDISCIPLINARY PROTOCOLS IN PLACE WITH MD, RN, RRT-ACCS, SPEECH,

PHARMACISTS, PT ETC. MUST BE IN PLACE. EFFECTIVE COMMUNICATION WITH TEAM
IS THE SIGNIFICANT ISSUE CONTINUE CARE.
96 CRITICAL CARE
01 02 03
DISASTER PLAN: PROCEDURE IN HOW TO USE THE
RACE AND PASS CASE OF FIRE : EXTINGUISHER:
RESCUE, ALARM, PULL, AIM,
CONTAIN, SQUEEZE, SWEEP
EXTINGUISH

SYSTEM TROUBLESHOOTING: RESPIRATORY CARE EQUIPMENT
• NITRIC OXIDE (iNO) – CHECK ALARMS, CALIBRATE PROPERLY, TROUBLESHOOT

SENSORS. NOTE: TRANSFERING PATIENTS TO OR/CT –KEEP SAME VENT BEING USED.
CHECK INJECTOR MODULE FAILURE, FLOW ALARM. CHECK FOR LEAKS. IF USING A
DIFFERENT VENTILATOR IN THE OR, iNOVent MUST BE CALIBRATED BEFORE PLACING
PATIENT BACK ON iNO THERAPY.
• ART LINES – BE ON GUARD WITH QUESTIONS PERTAINING TO ART LINES, THE EXAM WILL
WANT YOU TO RECOGNIZE COMPLICATIONS AND TROUBLESHOOTING AN ART LINE.
97 CRITICAL EXAMPLES: WATCH FOR PRESSURE DAMPENING, AIR BUBBLES IN TRANSDUCER DOME,
CARE KINKED LINES, NOT ENOUGH PRESSURE IN BAG. PLACEMENT AND LOCATION OF
TRANSDUCER.
• CHEST TUBES MONITORING- THERE ARE SEVERAL QUESTIONS ON 3 CHAMBER SYSTEM

AND TROUBLESHOOTING. IF LEAK SUSPECTED: GET CXR STAT! R/O
BRONCHOPULMONARY FISTULA. IF FISTULA IS CONFIRMED SURGERY WILL BE REQUIRED.
VENTILATE PATIENT WITH ILV DOUBLE LUMEN ETT OR HFV.

BRONCHOSCOPY
• RISK OF BLEEDING IS EMMINENT DURING BRONCHS, IF

WERE TO OCCUR INSTILL EPI OR ICE SALINE, THEN APPLY
PRESSURE TO SITE WITH BRONCHOSCOPY RIGHT AWAY TO
98 CRITICAL
STOP BLEEDING. USE A FOGARTY CATH TO CREATE AND
CARE KEEP PRESSURE APPLIED TO SITE.
• (THIS IS ONE OF THE QUESTIONS ON THE EXAM)

PRONING- KEYPOINT FOR THE EXAM (IF PATIENT IS PRONE
WATCH FOR FACIAL ULCERS)- QUESTION ON THE EXAM.
BEST POSITION TO PREVENT ASPIRATION IS LATERAL FLAT.
99 RESPIRATORY
CRITICAL CARE REMEMBER FOR UNILATERAL CONSOLIDATION USE THE
AFFECTED LUNG UP TO INCREASE PERFUSION TO THE
UNAFFECTED LUNG.
NUMBER ONE HAZARD OF SUCTIONING IS TRAUMA TO

MUCOSA, IT MAY LEAD TO BLEEDING AND OTHER ISSUES.
FOLLOWED WITH CONTAMINATION –HEALTH CARE PERSONNEL
NOT JUST RT, NOT USING STERILE TECHNIQUE, LAST HYPOXEMIA.

AIRWAY CARE KEYPOINTS
RECALL TUBE MARKINGS: MALES 7.5-8.5mm, FEMALES 6.5-8.0mm
TROUBLESHOOTING ETT OR TRACHEOSTOMY TUBES (WILL COME
UP IN YOUR EXAM) LEARN THESE IN ORDER GIVEN. ONE OF THE
OTHER WILL BE A CHOICE ON THE EXAM. (4 POSSIBLE ANSWERS)
1. PLACE STOPCOCK IN BALLON VALVE
2. INSERT BLUNT NEEDLE INTO PILOT LINE
100 3. CLAMP THE PILOT LINE
4. REPLACE THE TUBE
RESPIRATORY FOR PUNCTURED CUFF AND NOT ABLE TO SEAL THE CUFF THEN
CRITICAL CARE YOU MUST REPLACE THE ETT OR TRACHEOSTOMY TUBE.
 QUESTION IN THE EXAM: UNABLE TO PASS CATHETHER –
ACTION: REPLACE TUBE AND INSERT AND NEW ONE.

AIRWAY CARE KEYPOINTS AND HIGHLIGHTS
• POLYURETHANE CUFFED ETT (QUESTION ON EXAM): ETT THAT MAY PREVENT TO REDUCE
VAP (VENTILATOR ACQUIRED PNEUMONIA) ALSO PREVENTS CUFF CHANNEL FORMATION.
• CASS (CONTINUOUS ASPIRATION OF SUBGLOTTIC SECRETIONS (CASS): KEYPOINTS TO

REMEMBER FOR THE EXAM IS VACCUM PRESSURE 20mmHg, MINIMIZES
MICROASPIRATION. QUESTION ON EXAM RELATED TO THIS: COPD PATIENT S/P SURGERY
REQUIRING EXTENTED DAYS ON MECHANICAL VENTILATION A GOOD CHOICE TO PLACE
A CASS ETT INSTEAD OF A REGULAR ETT.
101
RESPIRATORY • DOUBLE-LUMEN, ENDOBRONCHIAL OR CARLEN’S TUBE (STUDYALL 3 NAMES) ANY OF THE
NAMES WILL APPEAR ON THE EXAM. PURPOSE OF THIS ETT IS TO VENTILATE EACH LUNG
CRITICAL CARE SEPARATELY DUE TO MASSIVE HEMOPTYSIS, BRONCHOPLEURAL FISTULAS,
PNEUMONECTOMY, LOBECTOMY, PNEUMOTHRORAX. “ ANYTHING UNILATERAL”.
• KEYPOINT: USE ½ THE VT TO VENTILATE EACH LUNG.

AIRWAY CARE KEYPOINTS AND HIGHLIGHTS
BE ON GUARD IN REGARD TO QUESTIONS ON ASSESSMENT
FOLLOWING INTUBATION
• CHEST X-RAY IS THE BEST ASSESSMENT FOR TUBE POSITION
FOLLOWING INTUBATION.
• VISUALIZATION
• AUSCULTATION
102 • CAPNOGRAPH, COLOMETRIC END TIDAL CO2 MONITOR
USE SELLICK MANUEVER FOR PATIENTS THAT MAY RECENTLY
COLLAPSE AND HAVE SONOROUS SOUNDS IN UPPER AIRWAY-
RESPIRATORY THIS WILL PREVENT GASTRIC ASPIRATION.
CRITICAL CARE GIVE H2 ANTAGONIST SUCH AS REGLAN, PEPCID, ZANTAC S/P
INTUBATION TO MINIMIZE GASTRIC CONTENTS AND REDUCE
GASTRIC ASPIRATION.

RESPIRATORY THERAPY SPECIALTY GASES AND THERAPUTICS
• HELIOX : USE IN UPPER AIRWAY OBSTRUCTION, GOOD FOR PATIENTS WITH

COPD, ARDS, REFRACTORY ASTHMA EXACERBATION (ANSWER TO ONE OF
THE QUESTIONS IN THE EXAM). CONCENTRATIONS 80% / 20%, 70% / 30%
(COMMONLY USED), 60% / 40% USE NRB FOR DELIVERY. RECALL FACTORS:
70 / 30- 1.6 (COMMON).
• NITRIC OXIDE: WEAN SLOWLY, REDUCE 10ppm Q2H, WHEN YOU REACH
10ppm THEN REDUCE 2.5ppm Q2H UNTIL REACHES 0. GIVE PATIENT 100%
103
FiO2. WATCH FOR DEVELOPMENT OF METHB AND REBOUND PULMONARY
HYPERTENSION, IF REBOUND OCCURS PLACE BACK TO ORIGINAL DOSE.
RESPIRATORY
CRITICAL CARE
• PROSTAGLANDIN E1 (FLOLAN)- TREATS PULMONARY HYPERTENSION.
WATCH FOR PATIENTS WITH CARDIOVASCULAR COMPROMISE ESPECIALLY
LEFT VENTRICULAR FUNCTION.

RESPIRATORY CRITICAL CARE
MECHANICAL VENTILATION: THIS SECTION WILL GO OVER NEW MODES OF

VENTILATION AND SETTINGS.
• MODES: ANY MODE WILL ACTUALLY WORK!, DO NOT BE FOOLED BY THE
MODE ALONE.
104 • VT 6-10ml/Kg (7-8ml/Kg) IS BEST FOR MOST PULMONARY DISEASES
EXCEPT ALI AND ARDS.
• RR 10-14 FOR MOST DISEASES (WATCH FOR EXCEPTIONS ARDS,ALI,
HYERCARBIA)
• PEEP 5-10 cmH20
• FiO2 30-60% IF PATIENT IN MARKED DISTRESS USE 100%

105 RESPIRATORY CRITICAL CARE
STEPS TO CALCULATE VT
• LOOK AT THE IBW (IDEAL BODY WEIGHT)
• CALCULATE (EXAMPLE): 5’ 5”
• 50 KG + (2.3 X INCHES OVER 5 FEET) FOR MALES ADD 2 AND FOR FEMALE -2
• CALCULATE HIGH AND LOW VT: PICK THE CLOSEST VT THAT MATCHES YOUR
CALCULATION FOR THE EXAM.

PRESSURE CONTROL VENTILATION (PCV)
• SETTINGS: INSPIRATORY PRESSURE: GOOD STARTING POINT AT 20

cmH20. MAKE CHANGES ACCORDING TO THE ABG RESULTS GIVEN
(PaC02). RECALL IF PATIENT ON PCV USE PRESSURE THAT WILL MATCH
A VT 4-6ml/Kg. RECALL IF YOU ARE SWITCHING TO PCV IS DUE TO
106 RESPIRATORY ARDS / ALI IN WHICH PATIENT WILL REQUIRE A LOW VT.
CRITICAL CARE • RR 12-24BPM
• FiO2 60% OR BELOW- LOOK AT THE ABG FIRST.
• PEEP 10 cmH20 OR GREATER

HIGH FREQUENCY VENTILATION SETTINGS
START WITH 4-8 HZ: RECALL 1HZ = 60 CYCLES (FREQUENCY)
AMPLITUDE =VT, IF YOU NEED CORRECT A HIGH CO2 CHANGE

THE AMPLITUDE NOT FREQUENCY. “CHEST WIGGLE”
I-TIME % INITIAL AT 33%

107
PAW START AT 40 cmH20 – ADJUST FOR PaO2

RESPIRATORY
CRITICAL CARE FiO2 START AT 100% AND TITRATE
BIAS FLOW START AT 30L/MIN

PRESSURE REGULATED VOLUME CONTROL (PRVC)
• GREAT MODE: KEEPS PRESSURE CONSTANT, HELPS WITH

DISTRIBUTION OF GASES, ADJUSTS VT BREATH BY BREATH, DO NOT
CHOOSE THIS MODE FOR SEVERE ASTHMATICS OR COPD PATIENTS.
IT MAY WORSEN AIR TRAPPING IN THESE DISEASE STATES.
108 PAV (PROPORTIONAL ASSIST VENTILATION) (NOT TESTED ON THE EXAM)
• PAV WORK AS PS BUT DOES A BETTER JOB TO MAINTAIN VT AND

RESPIRATORY DECREASED WOB. CUSTOMIZES EACH BREATH FOR PATIENT, LOWERS
CRITICAL CARE MEAN AND PEAK PRESSURES, COMFORT AND WELL TOLERATED BY
MOST PATIENTS. CHOOSE THIS MODE FOR COPD PATIENTS. (NOT
TESTED ON EXAM).

VS (VOLUME SUPPORT VENTILATION) ****NOT ON THE EXAM****

• BETTER VERSION OF PS GUARANTEES THE SET VT BEING DELIVERED TO
PATIENT
• PRESSURE DOES NOT FLUCTUATE LIKE IN PS, PRESSURE IS DELIVER AND
109 SET BREATH BY BREATH
• MECHANICAL VENTILATOR TITRATES PS AUTOMATICALLY
ASV (ADAPTIVE SUPPORT VENTILATION) ****NOT ON THE EXAM****
• GREAT MODE FOR COPD AND S/P CARDIAC SURGICAL PATIENTS
• SETS A TARGET MAX PLATEAU PRESSURE AND NOT EXCEED THAT
PRESSURE

INVERSE I:E RATIO VENTILATION (IRV)
• NOT AN ACTUAL MODE TO VENTILATE PATIENTS. RRT MUST
CHANGE I:E RATIO 3:2,3:1 ETC.
• USE FOR ARDS, RESTRICTIVE LUNG DISEASES, SEVERE
PULMONARY FIBROSIS
• LIMITS THE INSPIRATORY CYCLE AND MAY LEAD INTO AUTO-
PEEP IN WHICH IS BENEFICIAL FOR THESE PATHOLOGIES
LISTED.
• IMPROVES OXYENATION AND PULMONARY COMPLIANC
• USE SEDATION DURING IRV
110
NAVA (NEURALLY ADJUSTED VENTILATORY ASSIST) – NEW ON
EXAM
RESPIRATORY • NOT USE AS A CONVENTIONAL MODE
CRITICAL CARE • DETECTS AN ELECTRICAL MUSCULAR ACTIVITY IN DIAPHRAGM
AND SUPPORTS SYNCHRONY WITH PATIENT
• SENSOR MUST BE PLACE IN THE ESOPHAGUS
• THE ELECTRICAL SIGNAL IS CALLED Edi OR EAdi (ELECTRICAL
ACTIVITY OF THE DIAPHRAGM)

APRV (AIRWAY PRESSURE RELEASE VENTILATION)
• INITIAL SETTINGS: P-HIGH KEEP BELOW 35 cmH20 (BEST STARTING
POINT)
• T-HIGH 4.5 TO 6.0 SECONDS (INSPIRATORY PHASE)
• P-LOW BEGIN AT 0-3 cmH20 (BASELINE PRESSURE)
• T-LOW 0.5 TO 0.8 SECONDS (EXPIRATORY PHASE)
• PATHOLOGIES: ARDS,ALI,T-E FISTULA, DIFFUSE PNEUMONIA
111 • IMPLEMENT IN EARLY STAGES OF ALI/ARDS
• WEANING METHOD: DROP AND STRETCH, ALTHOUGH THERE ARE
SEVERAL CHANGES MADE NOW TO STRETCH AND DROP.
RESPIRATORY • MAKE CHANGES ACCORDING TO VENTILATORY PATTERN OF PATIENT:
PATIENT EXHALING TOO FAST: DECREASE P-HIGH BY 1-2cmH20
CRITICAL CARE
• IF INHALING TOO FAST AND USING ACCESSORY MUSCLES INCREASE
P-HIGH.

SCALAR WAVEFORMS AND LOOPS
• FEW OF THESE WAVEFORMS WILL BE

112 PRESENTED ON THE EXAM.
• SEE NEXT FEW SLIDES PRESENTED, I WILL
RESPIRATORY EXPLAIN EACH AND TROUBLESHOOT EACH
CRITICAL CARE ONE.


RESPIRATORY
CRITICAL CARE

RESPIRATORY
CRITICAL CARE


RESPIRATORY
CRITICAL CARE

RESPIRATORY
CRITICAL CARE

RESPIRATORY
CRITICAL CARE

ECMO (EXTRACORPOREAL MEMBRANE OXYGENATOR) (NEW ON
EXAM)
UTILIZES EXTRACORPOREAL CIRCULATION AND GAS EXCHANGE
TO PROVIDE TEMPORARY ESSENTIAL LIFE SUPPORT FOR THE
CARDIOPULMONARY SYSTEM AFTER AN INSULT.
• USED IN SEVERE CASES OF ARDS/FAILED OTHER THERAPIES,
PATIENT IN SEVERE REFRACTORY HYPOXEMIA.
• SHOWS IMPROVED OUTCOME, BUT CREDIBLE EVIDENCE
SUPPORTING MORTALITY BENEFIT IS LACKING.
120 • FURTHER STUDIES AND RESEARCH (ECMO CENTERS).
ECMO CONTRAINDICATIONS
• AGE : < 34 WEEK GESTATION OR > 75 YEARS OF AGE
RESPIRATORY
• SEVERE CHRONIC ORGAN FAILURE (ESRD, LIVER CIRRHOSIS)
CRITICAL CARE • INFANTS WEIGHING < 2000 GRAMS
• UNRESOLVED OR ONGOING COAGULOPATHIES
• NEUROLOGICAL DEFICITS PRESENT

• ECMO CONSISTS PLACING PATIENT ON ARTERIO-VENOUS (A-V)- HEART LUNG
BYPASS OR VENO-VENOUS (V-V) ACTS A 3RD LUNG INTERFACE.
• DISEASES FOR V-A ECMO IN ADULTS
• CARDIOMYOPATHIES
• POST CARDIAC ARREST
• PERIOPERATIVE CARDIAC SURGERY
• SEPSIS
• DISEASES FOR V-V ECMO IN ADULTS
• SEPSIS
121 • ASPIRATION PNEUMONIA
RESPIRATORY • DROWNING
CRITICAL • TRAUMA
CARE •
•
PNEUMONIA
RESPIRATORY FAILURE
• ARDS
• RECALL THE OXYGEN INDEX FORMULA: OI= FiO2 X MAP/PaO2 X 100. TYPICALLY,
AN OXYGEN INDEX AROUND 40 DETERMINES PATIENT IS A GOOD CANDITATE FOR
ECMO.


RECALL STATIC AND DYNAMIC LUNG COMPLIANCE FORMULAS
• CSTAT = VT/ PLATEAU-PEEP
• CDYN = VT/ PIP-PEEP
CORRECTING AUTO PEEP (DYNAMIC HYPERINFLATION)

123 RESPIRATORY
• DECREASE MANDATORY RATE
CRITICAL
• INCREASE FLOW RATE
CARE
• DECREASE I-TIME
• INCREASE E-TIME

ALVEOLAR RECRUITMENT OR RECRUITMENT MANUEVER (FEW
QUESTIONS ON THE EXAM)
• TARGET PATHOLOGIES: ALI, ARDS, SEVERE ATELECTASIS (BE ON

GUARD).
• LOOK FOR: GOOD VT’S, A-aDO2 DECREASES, QS/QT %

DECREASES, P/F RATIO INCREASES.
124
• ON SEVERE CASES OF ALI/ARDS THE EXAM WILL WANT YOU TO
RESPIRATORY PRONE PATIENT, THIS IS USED AS A LAST RESORT TO IMPROVE GAS
CRITICAL CARE EXCHANGE (OXYGENATION) IMPROVES THE DORSAL REGIONS OF
THE LUNGS. WATCH FOR PATIENTS WITH FiO2 >60% AND PEEP> 12
cmH20.

MECHANICAL VENTILATION/SBT, SAT PARAMETERS (BE ON
GUARD)
RECALL THE BEST METHOD OF WEANING IS SAT OR SBT
• A-aDO2 <300mmHg
• RSBI < 106 (RSBI = RR/VT)
• VC 10mL/Kg
• Vd/VT 60% or LESS (DO NOT CONFUSED WITH 20%-25% OFF
VENT)
125 • QS/QT <20%
• MIP/NIF > 20cmH20
RESPIRATORY • ABG’S WITH A STABLE pH, VITAL SIGNS AND UNDERLYING
CRITICAL CARE PATHOLOGY RESOLVED.
• IF YOU ENCOUNTER ONE OF THESE PARAMETERS OFF: DO
NOT LIBERATE PATIENT.

NOTE: FEW QUESTIONS WITH SIMV MAY OMIT PSV TO
THROW YOU OFF. THE PATIENT MIGHT BE IN MODERATE
DISTRESS, INCREASED WOB, VT <5mL/Kg ETC. THE
ANSWER WILL BE TO ADD PSV.. REMEMBER THE PURPOSE
OF PSV AND SHOULD ALWAYS BE USED IN
CONJUCTION WITH SIMV.
126
RESPIRATORY PLEASE REFER TO: ARDS.NET FOR EXCUSIVE WEANING

STRATEGIES FOR WEANING
CRITICAL CARE

• SWITCH TO PCV DURING ALVEOLAR RECRUITMENT MANUEVERS TO DECREASE
THE CHANCES OF BAROTRAUMA DURING TRIALS.
• GOOD POSITION TO OPTIMIZE V/Q MATCHING IS GOOD LUNG DOWN OR

RIGHT LATERAL DECUBITUS POSITION.
• IF YOU ARE PRESENTED WITH AIRWAY PRESSURE DATA IN WHICH SHOWS

INCREASED PEAK AND PLATEAU PRESSURES CHOOSE: CHEST X-RAY, DO NOT
127
CHOOSE SUCTIONING OR INCREASE PEEP- THESE OPTIONS WILL NOT BE
BENEFICIAL.
ACCS KEYPOINTS
• A DIFFICULT INTUBATION (MALLAPATTI SCORE 4) AND PATIENT NOW BEING
MECHANICALLY VENTILATED DISCONNECTION OCCURS THE LOW PEEP ALARM
IS THE MOST IMPORTANT AND MOST SENSITIVE FROM ALL THE CHOICES GIVEN
IN THE EXAM.

CHOOSE He/O2 ASTHMA EXACERBATION PATIENT IS NOT REVERSING
SYMPTOMS REGARDLESS OF ALBUTEROL 10MG CONTINIOUS, IV PREDNISONE.
He/02 WILL DECREASE THE WOB AND AIRWAY RESISTANCE. ADD
SUPPLEMENTAL 02 FOR THESE PATIENTS.
WATCH FOR FEBRILE ILLNESS (TEMP > 39 C OR 100 F) IN S/P SURGICAL PATIENTS
THEY TEND TO HAVE DECREASED HEMODYNAMICS (CVP, PAP, PCWP) BE ON
GUARD,
IF FLOW AND I-TIME REMAIN CONSTANT THE PATIENT WILL EXPERIENCE

INCREASED VT INSPIRATORY PRESSURE IS INCREASED.
128
ACCS KEYPOINTS RECALL FOR ARDS –MINUMUM STRETCH AND USE PEEP.
IF A-aDO2 >300, QS/QT >20 PATIENT ON MECHANICAL VENTILATION STOP

WEANING TRIALS IMMEDIATELY. QS/QT IS THE NUMBER ONE INDICATOR IN THE
QUESTION GIVEN WITH THESE PARAMETERS.

• OBSERVE AND LOOK AT THE HEMODYMICS FIRST PRIOR TO
CORRECTING AN ABG, RESOLVE CARDIOVASCULAR ISSUES FIRST.
• PRESSURE DAMPENING CAN CAUSE FLUCTUATIONS IN BLOOD

PRESSURE/HR DUE TO AIR BUBBLE IN THE TRANSDUCER DOME.
• HFV- 1HZ= 60 CYCLES , THEREFORE IF THE PATIENT IS ON 5 HZ THE

ANSWER IS 300 CYCLES
129
• APRV: VT = DIFFERENCE BETWEEN P-HIGH AND P-LOW, DELIVERED VT
ACCS KEYPOINTS CAN BE DECREASED BY LOWERING THE P-HIGH.
• REMEMBER LUNG PROTECTIVE STRATEGIES: WATCH FOR CXR TERMS

IN THESE QUESTIONS SUCH AS : S/P BONE FRACTURES MVA, TRAUMA,
CXR REVEALING BILAT PULMONARY INFILTRATES THIS IS SUGGESTIVE
OF EARLY ALI/ARDS.

• PROVIDE MANUAL VENTILATION ON THE FIRST REACTION OF ANY VENTILATOR
ALARM, TROUBLESHOOT VENTILATOR BUT ALWAYS MAINTAIN VENTILATION AND
SAFETY OF PATIENT FIRST.
• BE ON GUARD WHEN A LOT OF DATA IS GIVEN: ABG, HEMODYNAMICS, DISEASE

STATE, LABS ETC. PRIORITIZE WHAT NEEDS TO BE ADDRESSED FIRST. FOR EXAMPLE, IF
PATIENT IS MAX OUT OF O2 THE QUESTION MAY WANT YOU TO INCEASE PEEP. DO
NOT PANIC IF YOU SEE PEEP LEVELS +20,+22, +24 cmH20.
130
• FEW QUESTION MAY WANT YOU TO TROUBLESHOOT I-TIME, IF PRESENT IN QUESTION
ACCS KEYPOINTS
THE ANSWER MIGHT BE TO CORRECT IT.
• IF I-TIME IS 1:3 OR GREATER IT CAN CAUSE INCREASE MAP AND EVENTUALLY AUTO
PEEP, DECREASE I-TIME BY INCREASING PEAK INSPIRATORY FLOW RATE.

A SMALL NUMBER OF QUESTIONS WILL HAVE HIDDEN P/F RATIOS
INDICATION AND LEADING TOWARDS ALI/ARDS. THE QUESTION
WILL INDICATE FiO2 OF 60% ,HIGH PEEP LEVELS OR GREATER
WITH A LOW PaO2. PLEASE USE ARDS VENTILATING PROTOCOLS.
PLEURAL FLUID: EXUDATE OR TRANSUDATE THIS IS CLEARLY AN

INDICATION OF PROTEIN NOT TRIGLYCERIDES OR LEUKOCYTES.
131
PATIENTS WITH S/P BARIATRIC SURGERY/MORBID OBESITY ON
MECHANICAL VENTILATION EXPECT HIGHER PEAK PRESSURES TO
OVERCOME POOR LUNG COMPLIANCE DUE TO EXCESS
ACCS KEYPOINTS ADIPOSE TISSUE IN THORACIC REGION.
CHOOSE PAV (PROPORTIONAL ASSIST VENTILATION) IF YOU

ENCOUNTER A QUESTION IN WHICH WEANING ATTEMPTS ON
SIMV PSV HAVE FAILED, REMEMBER PAV IS LIKE PSV BUT
PROVIDES A BETTER LEVEL OF VENTILATION AND EASY TO WEAN
PATIENT OFF VENT.

• APRV-WATCH FOR FALLING HEMODYNAMICS MAINLY IF CARDIAC OUTPUT IS NOT
GIVEN IN THE QUESTION, IT MAY APPEAR AS C(a-v) 02 THIS VALUE CAN DETERMINE IF
PATIENT HAS A LOW C.O. / LOW BP AND INCREASED MAP. NORMAL C(a-v) O2 IS 5% IF
deltaP IS GIVEN IN AN APRV QUESTION AND HEMODYNAMICS ARE FALLING OR
INCREASING: DECREASE THE P-HIGH SETTING.
• PNEUMOTHORAX / EXCESSIVE BUBBLING ON THE WATER SEAL CHAMBER, LOW VT THESE

132 SIGNS ARE INDICATIVE OF A LEAK. CHOOSE ILV FOR THIS PATIENT, THIS WILL ALLOW
LOW VT/PRESSURE UNTIL “LEAK” (FISTULA) IS SURGICALLY REPAIRED.
ACCS KEYPOINTS • DO NOT CHOOSE NAVA (NEURALLY ADJUSTED VENTILATORY ASSIST) WITH PATIENTS
WITH MYASTHENIA GRAVIS, THIS IS A CONTRAINDICATION FOR THESE PATHOLOGY. USE
VOLUME VENTILATION. NAVA WILL NOT BE TOLERATED BY PATIENTS WITH MG DUE TO
DIAPHAGMATIC PARALYSIS.

APRV IF deltaP IS INCREASED IT WILL RESULT IN EXPANSION
OF THE ALVEOLAR CAPILLARY SURFACE IN WHICH WILL
LEAD TO INCREASE GAS EXCHANGE SURFACE RESULTING
IN A-aDO2 TO DECREASE PULMONARY SHUNTING.
CHOOSE N-95 MASK DURING A TRANSPORT WITH AN

IMMUNOCOMPROMISED PATIENT, THIS WILL PROTECT THE
PATIENT FROM ORGANISMS AND PATHOGENS AROUND
THE HOSPITAL AND THE ONES YOU CAN TRANSMIT TO
THEM. KEEP HEAD OF THE BED > 30 DEGREES DURING
TRANPORT TO DECREASE MICROASPIRATION.
133
A SILVER COATED ETT WILL DECREASE VAP BY REDUCING
ACCS KEYPOINTS BIOFILM COLONIZATION.
PLATELETS: NORMAL COUNT IS 150,000-400,000 u/ml ,

<50,000 RISK OF BLEEDING, <30,000 CRITICAL PLATELET
COUNT. IF PLATELETS ARE LOW: CHOOSE TO TRANFUSE
PLATELETS.

• INTUBATION/ETT SIZE HAS TO BE GREATER THAN 7.0 IN ORDER TO PERFORM A
BRONCHOSCOPY, IF ETT IF <7.0, TUBE MUST BE EXCHANGED PRIOR TO BRONCHOSCOPY.
• TROUBLESHOOTING: DURING BRONCHOSCOPY AND PATIENT RECEIVING MECHANICAL

VENTILATION THE BRONCHOSCOPE WILL INCREASE AIRWAY RESISTANCE AS IT ENTERS THE
ETT, ACTION TO TAKE: INCREASE HIGH PRESSURE LIMIT ALARM AND PLACE ON 100% FiO2.
DISCONTINUE PROCEDURE IF HEMODYNAMIC VALUES FALL.
• RECALL THE TYPES OF AIRWAY DEVICES: BOUGIE IN WHICH VERY HELPFUL WHEN
134 VISUALIZATION IS IMPARED PRIOR TO INTUBATION BUT IT DOES NOT PROVIDE

VENTILATION OR OXYGENATION. ALSO, CAN BE USED TO INITIALLY INSERT AN ETT OR
ACCS KEYPOINTS REMOVE THE EXISTING ONE. LMA-USED IN FOR SURGICAL PROCEDURES NOT LONG TERM.
AIRWAY EXCHANGER CATHETER CAN BE USED TO CHANGE ETT ON THOSE PATIENTS WITH
DIFFICULT AND TRAUMATIC INTUBATIONS.
• TRACHEOSTOMY TUBE CUFF OR PILOT VALVE: TROUBLESHOOT BY PLACING STOPCOCK

ON THE PILOT VALVE.

CORRECT VENTILATION FIRST BY: 1ST INCREASING RATE, 2ND
INCREASE VT, AND LAST REMOVE DEADSPACE. CHOOSE
VT IF PaCO2 IS OFF BY 3-5mmHg, CHOOSE RATE IF PaCO2
IS > 49, 50mmHg. DECREASE VT IF PaCO2 IS AROUND 32-
34 mmHg, DECREASE RATE IF PaCO2 IS AROUND 30, AND
ADD DEADSPACE IF PaCO2 IS OFF BY 1 OR 2mmHg.
ABRUPT WITHDRAWAL FROM iNO WILL INCREASE

PULMONARY ARTERIAL SYSTOLIC PRESSURE FIRST THEN IT
WILL CAUSE METHB.
135
BRONCHOPULMONARY FISTULA, POST LOBECTOMY WILL
BENEFIT FROM INDEPENDENT LUNG VENTILATION WITH A
DOUBLE LUMEN ET TUBE AND HFOV.
ACCS KEYPOINTS
RECALL YOUR NEUROLOGICAL PATHOLOGIES AND
ETIOLOGIES: FOR GUILLIAN BARRE PATIENT PRESENTS WITH
EARLY SYMPTOMS OF INFLUENZA.

ALWAYS MODIFY THERAPY- FOR EXAMPLE : IF PATIENT CAN NOT
TOLERATE POSTURAL DRAINAGE, THEN CHOOSE CPT VEST
(HFCWO). IF PATIENT INTUBATED EXPERIENCES PVC’S,
DECREASED SATURATIONS ETC AND NEEDS SUCTIONING THEN
DECREASE AMOUNT OF TIME SPENT IN THE AIRWAY.
DO NOT CHOOSE TRENDELENGBURG POSITION WITH PATIENTS

WITH INCREASED ICP’S.
136
TRANSPORT: IF VENTILATOR IS MALFUNCTIONING IN WHICH RR
AND VT ARE DECREASING TROUBLESHOOT THE GAS SOURCE
ACCS KEYPOINTS
RIGHT AWAY, CHANGE THE TANK. DO NOT CALIBRATE OR
REPLACE VENTILATOR / VENTILATOR BATTERY.
TRANSPORT WITH SWAN GANZ (PAC) MONITOR PAP AT ALL

TIMES ESPECIALLY IF MOVED FROM ORIGINAL POSITION, IT CAN
GIVE FALSE READINGS AND CAN BE A HIGH RISK.

LUNG RECRUITMENT STRATEGY- IF PATIENT’S VITAL SIGNS OR
HEMODYNAMICS ARE FALLING THEN STOP THE MANUEVER,
WATCH FOR DECREASED CARDIAC OUTPUT, BLOOD PRESSURE
OR SPO2.
IF PCV, APRV, RECRUITMENT MANUEVERS, PRONING HAVE

FAILED THEN THE BEST ANSWER IS TO RECOMMEND HIGH
FREQUENCY VENTILATION. IF HFV FAILS THEN ECMO IS THE LAST
RESORT.
137 VAP (VENTILATOR ASSOCIATED PNEUMONIA) BE PREPARED TO

ANSWER ABOUT 5 QUESTIONS IN REGARD TO VAP. RECALL
WHAT IS NECESSARY TO PREVENT VAP: HOB> 30 DEGRESS,
ACCS KEYPOINTS HEATED WIRES, H2 ANTAGONISTS, RT WEANING PROTOCOLS,

ORAL CARE Q6-Q12H.
ON TRANSPORT REMEMBER YOUR DISTANCES LEARN 80-150

MILES: ROTATY WING AIRCRAFT, > 150 MILES FIXED WING
AIRCRAFT.

IF PATIENT IS HEMODYNIMICALLY UNSTABLE AND REQUIRES A
PROCEDURE CHOOSE A BEDSIDE TOOL OR ALERNATIVE METHOD
NOT TO TRANSPORT PATIENT.
READ QUESTIONS CAREFULLY INVOLVING PHARMACOLOGY,

READ THE FACTS THAT ARE PRESENTED IN THE QUESTION, DO NOT
OVER THINK. IF QUESTION GIVEN INVOLVES MEDICATION I.E.
VERSED, LORAZEPAM CAUSING DECREASED RESPIRATION,
SOMNOLENCE THEN CHOOSE THE REVERSAL AGENT.
138 OVERSEDATED PATIENT MAY REQUIRE NIPPV, CHECK ALL FACTS

FIRST. PATIENT ASSESSMENT VOCABULARY COMES IN HANDY.
WATCH FOR KEY WORDS SUCH AS: OBTUNDTED, NO GAG
REFLEX, UNCONCIOUS, UNABLE TO AROUSE. KNOW YOUR RASS,
ACCS KEYPOINTS
OR RICHMOND AGITATION SCALES.
BODY MASS INDICES (BMI) INTERPRETATION WILL BE ON YOUR

EXAM. <18 UNDERWEIGHT, > 25 OVERWEIGHT, > 30 OBESE. YOU
WILL HAVE SEVERAL QUESTIONS WITH BARIATRIC PATHOLOGIES.
BE ON GUARD.

THE EXAM WILL TEST YOUR KNOWLEDGE ON THE GLASCOW COMA SCALE,
REVIEW TABLE AND LEARN THE MIDDLE OF EACH CATEGORY. FOR EXAMPLE:
EYE : RESPONSE TO PAIN SCORE : 2, VERBAL: INAPROPIATE WORDS SCORE: 3,
MOTOR (ARM) WITHDRAWS FROM PAIN SCORE 4. IF A TOTAL GCS IS < 8
INTUBATE PATIENT.
PROPOFOL IS THE BEST CHOICE IF YOU ARE WEANING A PATIENT, DRUG HAS A
SHORT HALF LIFE AND PATIENT WILL BE ABLE TO PERFORM SAT/SBT. GOOD
CHOICE FOR THIS TYPE OF SCENARIOS. RECALL THAT PROPOFOL CAN CAUSE
HYPOTENSION, YOU WILL HAVE QUESTIONS IN WHICH YOU WILL RECOMMEND
TO DISCONTINUE THE INFUSION.
140
THERE WAS A QUESTION ABOUT SEVERAL BRONCHIAL SPECIMENS SENT TO THE
LAB, BUT WERE CONTAMINATED, YOUR RECOMMENDATION FOR THIS
ACCS KEYPOINTS SCENARIO IS PERFORM A MINI-BAL FOR A NON-CONTAMINATED SPECIMEN.
FOR NEUROLOGICAL PATHOLOGIES BE ON GUARD OF YOUR PULMONARY

MECHANICS. LEARN AND REVIEW YOUR NORMALS. IF VC <1L, FALLING MIP
(LOW TEENS), SPONTENOUS VT < 5ml/kg, THEN PREPARE TO INTUBATE.

• BE ON GUARD WHEN GIVEN A PATIENT IN DKA THE CHOICES WILL BE TO GIVE
BICARB, INSULIN. THE ANSWER IS TO GIVE INSULIN. DO NOT OVERLOOK THE
HIGH GLUCOSE LEVEL.
• A QUESTION ABOUT MORPHINE SIDE EFFECTS: DECREASED CARDIAC WORK,

RESPIRATORY DEPRESSION, HYPOTENSION. ANY OF THOSE CHOICES WILL BE THE
ANSWER ON THE EXAM. MORPHINE IS ALSO USED FOR TERMINAL PATIENTS GIVEN
INHALED, IF NO IV ACESS AND PATIENT IS INTUBATED THE INSTILL DOWN THE ETT.
140 • REMEMBER NARCAN REVERSES OPIOIDS: WATCH FOR OD PATIENTS OR PATIENTS

THAT ARE STATUS POST SURGERY OR EXTREME PAIN USING A PCA PUMP, VITALS
ACCS KEYPOINTS ARE BEING IMPARED DUE TO MANY OPIODS THE ANSWER IS NARCAN.
• ARTERIAL LINE- IF PRESENTED WITH AN ELEVATED BP FROM ART LINE AND A

NORMAL BP CUFF PRESSURE, THE CORRECT BP IS THE CUFFED BP. THE ART LINE
MAY HAVE AIR BUBBLES WHICH CAN CAUSE PRESSURE DAMPENING, CLOTS,
KINKED LINE. BE ON GUARD.

TRAUMATIC BRAIN INJURY – BIG TICKET ITEM ON THE EXAM. FACTS TO KNOW:
POLYURIA/DIABETES INSIPIDUS IS A MAJOR FACTOR WITH PATIENTS WITH TBI,
AND TREAT WITH DESMOPRESSING THIS WAS ASKED ON THE EXAM.
A SMALL NUMBER OF QUESTIONS AND CHEST XRAYS TO DETERMINE PATIENT

DIAGNOSED WITH PNEUMONIA; FACTORS GIVEN- FEBRILE ILLNESS,
LEUKOCYTOSIS, CHOOSE AN ANTIBIOTIC, THE ONE GIVEN ON THE EXAM WAS
LEVAQUIN.
PULMONARY EDEMA CXR WAS PRESENTED WITH FEW KEY FACTORS SUCH AS
PITTING EDEMA 3+, CVP > 6, THE CORRECT ANSWER WAS FUROSEMIDE (LASIX).
141
ACCS KEYPOINTS FOR EROSIVE GASTRITIS TREAT WITH PROTONIX- SEEN ON THE EXAM
BE ON GUARD FOR QUESTIONS WITH PATIENTS THAT ARE FEBRILE WITH

VARIABLE VITAL SIGNS, THE ANSWER IS TO TREAT THE FEVER WITH
ACETOMINOPHEN. UNLESS THE QUESTION GIVES YOU THE FACTORS OF AN
ACTIVE INFECTION THEN TREAT WITH ANTIBIOTICS.

KNOW THE DIFFERENCE BETWEEN EXUDATE AND
TRANSUDATE, HOW TO TREAT EACH PATHOLOGY. THIS
WAS ASKED ON THE EXAM. REMEMBER SERUM PROTEIN
WILL DETERMINE ONE FROM THE OTHER. EXUDATE WITH
A SERUM PROTEIN > 0.5 ( POSSILBE MALIGNACY) AND
TRANSUDATE < 0.5.(SEEN IN CHF PATIENTS).
ICP (INTRACRANIAL PRESSURES) NORMAL VALUE 5-15

mmHg TREAT WITH MANNITOL OR DIAMOX, FOR
INCREASING ICP’S UPPER 20’S TREAT WITH
142 PENTOBARBITAL. KEEP HOB > 30 DEGREES, MINIMAL
STIMULATION. CPP FORMULA CPP=(MAP-ICP) NORMAL
60-100 mmHg, CRITICAL VALUE 20-40 mmHg.
ACCS KEYPOINTS APNEA TESTING (FEW QUESTIONS SEEN) THE EXAM WILL
TEST YOU ON THE ABLITY ON RECALLING IMPORTANT
FACTS. PATIENT MUST BE NORMOTHERMIC TO PERFORM
APNEA TEST, SYSTOLIC BP > 90mmHg, HAVE A NORMAL
PaCO2. IF ANY HEMODYNAMICALLY ADVERSE EVENTS
OCCUR DURING THE TEST, MUST RETURN PATIENT BACK
TO MECHANICAL VENTILATION.

THE ONLY WAY TO DIAGNOSE AND CONFIRMATION OF BRAIN DEATH IS NOT APNEA TEST, OR
EEG, THE CORRECT ANSWER IS BRAIN PERFUSION SCAN. THIS WAS A QUESTION ON THE EXAM.
THIS IS THE ONLY TEST TO RULE OUT BRAIN DEATH. IF PATIENT ON MECHANICAL VENTILATION
LOOK FOR AUTO TRIGGERING.
RECALL ORGAN DONATION CRITERIA TO MAINTAIN VIABLE ORGANS.
PATIENTS WITH SUBARCHNOID HEMORRAGHE ARE NOT GOOD CANDIDATES FOR

ANTICOAGULANT THERAPY WITH SUSPECTED PULMONARY EMBOLISM THE BEST CHOICE IS TO
143 PLACE AN IVC FILTER.
ACCS KEYPOINTS IF SUSPECTED PATIENT WITH A PE CHOOSE SPIRAL CT SCAN AS A FIRST CHOICE IF NOT GIVEN ON
THE EXAM, THEN CHOOSE VQ SCAN.
SEVERAL QUESTIONS SEEN IN REGARD TO PULMONARY CONTUSION ON THE EXAM ( CXR GIVEN)
MOST LIKELY THE ANSWER WILL BE TO “ CONTINUE TO MONITOR” IF PATIENT IS STABLE OR IF AN
ABG IS GIVEN PATIENT MOST LIKELY WILL BE HYPOXIC THEN PLACE ON HIGH FLOW NASAL
CANNULA. IN SEVERE CASES PULMONARY CONTUSIONS CAN LEAD TO ARDS. BE ON GUARD
WITH INFO GIVEN.
• BE ON GUARD WITH PATIENT WITH ELEVATED BUN, CREATININE AND A
HIGH POSITIVE FLUID BALANCE- THIS PATIENT IS CLEARLY ON ACUTE
RENAL FAILURE.
• RECOMMEND A CHEST XRAY IF YOU ARE PRESENTED WITH A QUESTION

IN HOW TO TROUBLESHOOT A CHEST TUBE: FACTORS SEEN ON THE EXAM
SUCH AS NO BUBBLING,FLUCTUATION IN WATER SEAL CHAMBER OR
“MARKED BUBBLING”- KEY WORD MARKED. IF PATIENT IS ON
144 MECHANICAL VENTILATION DECREASE THE PEEP.
• IF PATIENT DURING TRANPORT AND CHEST TUBE EXTUBATION OCCURS
ACCS KEYPOINTS THEN PLACE GUAZE AND VASELINE TO THE AREA. DO NOT ATTEMPT TO
INTRODUCE CHEST TUBE BACK INTO THE CHEST.
• RECALL YOUR PT/INR, PLATELET COUNT NORMALS AND INDICATIONS.
• MAIN REASON TO KEEP HOB > 30 DEGREES IS TO MINIMIZE ASPIRATION

QUESTION ON EXAM: PATIENTS THAT ARE NOT ABLE TO TAKE BLOOD
DUE TO RELIGIOUS BELIEFS AND THEY ARE ANEMIC RECOMMEND
100% NRB OR CPAP.
THE BEST METHOD TO KEEP YOUR HANDS CLEAN IS SOAP AND WATER.
THERE WAS A QUESTION ON THE EXAM WITH A PATIENT WITH C. DIFF.
REMEMBER YOUR HEART BLOCKS, LOOK BACK ON THE POWER POINT

FOR THE SLIDES.
145 RECALL THE DIFFERENCE IN PALLATIVE CARE, AND HOSPICE.

PALLATIVE CARE DEALS WITH CONTROLLING PAIN, DYSNEA AND
ACCS KEYPOINTS OTHER SYMPTOMS. HOSPICE SUPPORT THE TERMINALLY ILL PATIENT.
INTERACTIONS WITH INTERDISCIPLINARY TEAM –CONFLICTS CAN BE

GOOD IT OFTEN LEADS TO THE BEST OUTCOMES FOR PATIENT CARE.
POOR COMMUNICATION AMONG HEALTHCARE TEAMS CAN LEAD TO

FALLS, INCREASED INFECTIONS, MEDICATION ERRORS AND POOR
PATIENT OUTCOMES.

ACCS PRACTICE
146
QUESTIONS

A 65-YEAR-OLD MALE PATIENT REMAINS INTUBATED ETT SECURED AT
25cm AT LIP IN ICU ON APRV MODE. CURRENT LABS ARE:
WBC 5,300K BUN 15
RBC 4.5 TROPONIN: PENDING
K+ 3.5
SETTINGS AND VITAL SIGNS
DELTA P 32 Qs/Qt 18%
PEEP 3cmH20 TEMP: 100.1
BP 92/60mmHg
147 C(a-v)02 12vol%
RESIDENT IS ASKING YOU FOR RECOMMENDATION, AS THE SPECIALIST
ACCS PRACTICE FOR THIS PATIENT YOU RECOMMEND:
QUESTION #1 A. REVATIO
B. INCREASE T-HIGH
C. DECREASE P-HIGH
D. ADMINISTER ACETOMINOPHEN

THE CORRECT ANSWER IS C:
• BY DECREASING THE P-HIGH WHICH FOR THIS PATIENT IS

SIGNIFICANTLY HIGH. PATIENT REMAINS HYPOTENSIVE
AND BY OBSERVING AT C(a-v)O2 DETERMINES THAT THE
CARDIAC OUTPUT IS DECREASING. RECALL YOUR
QUESTION #1 NORMAL VALUES C(a-v)O2 NORMAL IS 4-5%. IF YOU SEE

148
EXPLANATION A C(a-v)O2 THAT IS ELEVATED BE ON GUARD. MEAN
AIRWAY PRESSURE INCREASED AND THE BEST WAY TO
NORMALIZE SYSTEMIC CIRCULATION THE ACTION TO TAKE
IS TO DECREASE THE P-HIGH.
• REMEMBER LIFE FUNCTIONS.

A 34-YEAR-OLD FEMALE STATUS POST MVA ARRIVES IN THE
ED AND PLACED ON VC AC. PATIENT SUSTAINED BILATERAL
FEMUR FRACTURES. AFTER DAY 3 CHEST XRAY SHOWS DIFFUSE
INFILTRATES AND CHEST ASSESSMENT SHOWS DIFFUSE
PETECHIAE. WHAT WOULD BE YOUR RECOMMENDATION?
A. ADMINSTER PLAVIX
149 B. VENTILATE WITH LOW TIDAL VOLUMES
C. INVERSE I:E VENTILATION
ACCS PRACTICE D. ADMINISTER LOW MOLECULAR WEIGHT HEPARIN
QUESTION #2

THE CORRECT ANSWER IS B:
• VENTILATE WITH LOW TIDAL VOLUMES. LUNG PROTECTIVE

STRATEGY MUST BE EMPLOYED WITH THE INFORMATION GIVEN
150 QUESTION #2 IN THIS SCENARIO. PATIENT WITH PULMONARY CONTUSIONS
EXPLANATION MIGHT LEAD INTO POSSIBLE ACUTE LING INJURY. LONG BONE
FRACTURES, DIFFUSE INFILTRATES AND DIFFUSE PETECHIAE ARE
THE MAIN FACTORS FOR THIS QUESITON. HEPARIN AND
PLAVIX ARE CONTRAINDICATED AT THIS TIME.

A 76-year-old female intubated in ICU, currently on VC-AC.
Possible massive MI.
EKG: Elevated S-T segments, Q waves present
Lytes: Na : 136, K: 5.1 CL: 103
BUN : 178
CXR : Bilateral pleural effusions and Pulmonary venous
congestion
Which of the follow is most helpful to preserve cardiac
151
tissue?
A. Osmotic Diuresis
ACCS PRACTICE B. Hemodialysis
C. Furosemide IV / Levophed
QUESTION # 3 D. Therapeutic Hypothermic Protocol

THE CORRECT ANSWER IS D.
• THERAPEUTIC HYPOTHERMIA PROBLEM. THIS METHOD FROM ALL
THE CHOICES GIVEN FOR THIS QUESTION THE MOST
APPROPRIATE ACTION TO PRESERVE CARDIAC MUSCLE.
152 QUESTION #3 COOLING DOWN CARDIAC TISSUE WILL PREVENT FURTHER
DAMAGE TO HEART MUSCLE AND CELLS. DO NOT BE FOOLED
EXPLANATION BY THE DISTRACTORS GIVEN IN THE QUESTION. MAIN FACTOR IS
ELEVATED S-T SEGMENT, Q WAVES = MYOCARDIAL
INFARCTION.

Which of the following would be most indicative of patient’s
readiness to wean from mechanical ventilation?
A. MIP -20 or greater
B. SBT
153 C. RSBI <106
D. VC >1L / VE <10 L/min
ACCS PRACTICE
QUESTION # 4

THE CORRECT ANSWER IS B.
• SBT: SPONTANEOUS BREATHING TRIAL. THIS CONSIDERED THE
EFFECTIVE STRATEGY FOR RAPID REMOVAL FROM MECHANICAL
VENTILATION. THE SUCCESS DURING SBT IS USED AS A
154 QUESTION #4 PREDICTABLE MEASUREMENT IF THEY ARE READY FOR
EXTUBATION. SBT MINIUM TRIAL IS 30 MINS AND MAX IS 120
EXPLANATION MINUTES. RSBI , VC, VE ARE PARAMETERS. IF THE QUESTION
HAVE STATED PARAMETERS, THEN RSBI IS THE BEST, FOLLOWED
BY MIP AND VC, VE.

You just nasally intubated a patient in respiratory distress.
Currently on PC-AC FiO2 100%
CXR : Diffuse alveolar infiltrates.
ABG : pH 7.34, PaCO2 78 PaO2 67 HCO3 34
ETT currently at 24 cm mark at the patient nare. What must you
do?
155
A. Leave ETT in place
B. Withdraw ETT 2 cm to 22 cm mark
ACCS PRACTICE C. Advance ETT to 26 cm mark
D. Withdraw ETT to 24 cm mark
QUESTION #5

THE CORRECT ANSWER IS C.
• THE CURRENT DEPTH OF THE ETT IS NOT NORMAL. FOR NASALLY
INTUBATED PATIENTS THE DEPTH SHOULD BE APPROXIMATELY 26-
29CMTO ACCOUNT FOR THE DEADSPACE IN UPPER AIRWAY. FOR
156 QUESTION #5 ORAL INTUBATION 21-25 CM APPROXIMATELY. REMEMBER THERE
EXPLANATION ARE ALOT OF DISTRACTORS FOR THIS QUESTION THEREFORE
FOCUS ON WHAT THEY ARE ASKING YOU. DISTRACTORS CAN GET
YOU IN TROUBLE.

ACCS PRACTICE
QUESTION #6
A 33-year-old in ICU was recently
diagnosed with Influenza. Over the last 2
days patient have deteriorated and
required intubation.
Data: WBC 17K, RBC 6K, K 4.0, Na+ 145,
Blood cultures : pending
Gram stain: gram - rods
CXR: Right lung :Diffuse alveolar
infiltrates and Left lung: opacity in LLL
Which of the following strategies is most
appropriate for this patient?
A. Inverse Ratio Ventilation 3:1

B. Set VT 6ml/kg IBW
C. AC- PCV 35cm H20
D. Start PCV 40cm H20

• BASED ON THE INFORMATION GIVEN HERE THIS PATIENT IS
LEADING TO ALI/ ARDS. CXR SHOWING DIFFUSE ALVEOLAR
INFILTRATES GIVES ENOUGH INFORMATION TO VENTILATE THIS
PATIENT WITH LUNG PROTECTIVE STRATEGIES. ALSO, PATIENT
158 QUESTION # 6 MAY BENEFIT FROM STEROIDS, ANTIBIOTICS DUE TO ELEVATED
WBC’S AND ADVANCING THE ETT CLOSER TO THE CARINA.
EXPLANATION INVERSE IS A GOOD START BUT NOT TYPICAL FOR ALI USING
LOW VT WILL IMPROVE THE SURVIVAL FOR THIS PATIENT. HIGH
PRESSURES WILL CAUSE FURTHER INJURIES. BEST WAY TO TREAT
THIS PATIENT WOULD BE WITH A LOW VT.

According to the Berlin Criteria a patient with a
PF (PaO2/FiO2)ratio of 180 has :
A. Moderate ARDS
159
B. Mild ARDS
C. Severe ARDS
ACCS PRACTICE D. Normal
QUESTION # 7

THE CORRECT ANSWER IS A.
• MODERATE ARDS ACCORDING THE BERLIN CRITERIA. SEVERE
ARDS < 100 WITH DIFFUSE BILATERAL OPACITIES
160 QUESTION #7 MILD 300-200, MODERATE 100 -200.
EXPLANATION
• THE ATS ERS CRITERIA CONTAINS ALI AND ARDS

Following intubation of a 33-year female in the
ED. Which of the following offers the best
assessment in tube placement post intubation?
A. Colometric monitoring
161 B. Auscultation
C. Visualization
ACCS PRACTICE D. Chest Radiograph
QUESTION #8

• CHEST RADIOGRAPH WILL BE THE BEST ASSESSMENT TOOL TO
CONFIRM. FOLLOWING COLOMETRIC MONITORING. BE CAREFUL
WITH WORDING ON THE EXAM. IF I WOULD HAVE ASKED WHICH OF
162 QUESTION #8 THE FOLLOWING ACTIONS YOU DO “FIRST” THEN VISUALIZATION
EXPLANATION WOULD BE THE ANSWER. CONFIRMING ETT PLACE HAS TO BE
CONFIRMED BY A SCIENTIFIC OR TECHNICAL ASSESSMENT.
• KEY WORD: BEST ASSESSMENT.

A 55-year-old male patient in the ED which sustained a 3-story
fall, SpO2 on room air is 96%, but has slowing dropping in the last
few hours.
Labs: WBC 4.5 uL, Platelets 90,000 K ,
K+ 3.6 BUN 15, Creatinine 0.7
ABG: pH 7.36
PaCO2 47
PaO2 56
163 Total CO2 Content 26
Which of the following treatments would you recommend at this
time based on clinical info and chest radiograph?
ACCS PRACTICE A. Thoracic Ultrasound
B. Lateral decubitus chest radiograph
QUESTION #9 C. High flow nasal cannula
D. Administration of frozen plasma

• CXR WILL REVEAL PULMONARY CONTUSION S/P FALL. PATIENT IS
STABLE WITH MODERATE HYPOXEMIA. PATIENT IS FULLY
COMPENSATED AT THIS TIME. PROVIDING HIGH FLOW NC WILL
PROVIDE A LEVEL OF CPAP AND INCREASE FRC. THORACIC
164 QUESTION #9 ULTRSOUND AND LATERAL DECUBITUS X-RAY IS NOT INDICATED
EXPLANATION HERE. PLATELETS ARE MARGINALLY LOW (NORMAL 150-400K) BUT
NO NEED TO ADMINISTER FROZEN PLASMA.
• REMEMBER YOUR PATHOLOGIES AND LIFE FUNCTIONS FOR THESE
TYPE OF QUESTIONS.

A 54-year-old male patient status post open-heart surgery in ICU.
Upon assessment patient has a productive cough and a temp of
100.2. Patient currently on 2L NC with a SpO2 94%. Incentive
spirometry has been ordered per resident. Prior to surgery
spirometry was performed.
Spirometry data:
SVC 4.4L
FEV1 3.4L
165 FVC 3.5L
IC 1.8L
What would you recommend for this patient?
ACCS PRACTICE A. Switch to flow type spirometer
B. Perform nasotracheal suctioning
QUESTION #10 C. Give bronchodilator q4hrs and IC after each treatment
D. Set the incentive spirometer goal at 900-1000mL

THE CORRECT IS D.
• FIRST YOU MUST LOOK AT THE SPIROMETRY DATA GIVEN PRIOR
TO SURGERY, ESPECIALLY THE INSPIRATORY CAPACITY.
166 QUESTION #10 ADDING INCENTIVE SPIROMETER TO A PATIENT S/P SURGERY
WILL HELP PREVENT POST SURGICAL COMPLICATIONS. SINCE
EXPLANATION THE INITIAL IC WAS 1.8L (1800mL) , TAKE 1/2 OF THE IC AND
SET A GOAL OF 900-1000mL FOR THIS PATIENT.

An 80 kg patient in ICU on mechanical ventilation unable
to wean off in the last 3 days. Patient is currently receiving
enteral nutrition via PEG tube at 30 kcal/kg/day.
According to this intake what is the current kcal/day for
this patient?
167 ACCS A. 2,700 kcal/ day
B. 2,400 kcal/ day
PRACTICE C. 1,000 kcal/ day
QUESTION D. 1,500 kcal /day
# 11

• 2400 kcal/ day. NORMAL TARGET INTAKE IS 25kcal/day.
THEREFORE, CALCULATE 80kg x 30 kcal/kg/day = ROUND TO
2,400 kcal/ day. THIS PATIENT IS OVEFED MAKING IT DIFFICULT
TO WEAN OFF THE VENT. ENTERIC FEED SHOULD BE DECREASED
168 QUESTION #11 SUBSTANTIALLY TO ALSO DECREASE CO2 PRODUCTION.
EXPLANATION ADDING LIPIDS TO PATIENTS DIET IS HIGHLY BENEFICIAL FOR
THOSE PATIENTS THAT DIFFICULT TO WEAN. REMEMBER
EXCESSIVE CARBOHYDRATE INTAKE WILL LEAD TO INCREASED
CO2 PRODUCTION (VCO2).

After confirmation of brain death by brain perfusion scan
and apnea test, family would like to donate organs. Prior
to transplantation which criteria must be met to
maximize and maintain organs?
A. MAP > 60, Glucose 192, Temp 35.7C
169
B. MAP < 60, Hemoglobin 11, Glucose 180
C. MAP 65, Urine Output 150ml/hr., CVP 5mmHg
ACCS PRACTICE D. MAP 60, C.O. 3.5, Hematocrit <30%
QUESTION #12

• MAP > 60 , UO 100-200ml/hr. AND CVP 4-10mmHg GLUCOSE
120-180, HEMOGLOBIN >10gdL, HEMATOCRIT >30%, C.O. >
170 QUESTION #12 3.8L/min , C.I. 2.4 , SYSTOLIC BP> 90, NORMAL LYTES AND
PATIENT MUST BE NORMOTHERMIC TO SUSTAIN ORGAN
EXPLANATION VIABILITY FOR TRANSPLANTATION.

A 34-year-old male status post traumatic brain injury in ICU is
requiring intubation.
ABG: pH 7.21
PaCO2 65
PaO2 60
Total CO2 Content 33
Vital signs:
RR 32
BP : 88/50
171 ACCS HR 120
PRACTICE Physician is asking for your expertise to use a sedative hypnotic

agent for rapid sequence induction. Which agent is best for this
QUESTION patient?
A. Succinylcholine (Anectine)
# 13 B. Propofol
C. Lorazepam
D. Etomidate

• ETOMIDATE.
• SEVERAL CONTRAINDICATIONS WITH THE ANSWERS GIVEN HERE.
ANECTINE FIRST OFF IS A DEPOLARIZING AGENT AND INCREASES
ICP, THE QUESTION ASKED FOR SEDATIVE HYPNOTIC. PROPOFOL IS
CONTRAINDICATED DUE SYSTEMIC HYPOTENSION WHICH ALSO
CAN DECREASE SV, SVR AND BY LOOKING AT THE BP ALONE YOU
MAY DETERMINE A LOW CARDIAC OUTPUT. LORAZEPAM IS A
172 QUESTION #13 BENZODIAZEPINE WHICH IS NOT FIRST LINE FOR RSI THERAPEUTIC
EXPLANATION USES IS TO COMBAT ANXIETY AND LAST ETOMIDATE IS USED AS A
BACKDOOR AGENT FOR THOSE HYPOTENSIVE PATIENTS. IT HAS A
RAPID ONSET AND RECOVERY. HOWEVER, IT MAINTAINS
HEMODYNAMICS. THE MAJOR SIDE EFFECT FROM ETOMIDATE IS
ADRENAL SUPPRESSION. PATIENTS WITH ADRENAL INSUFFICIENCY
MAY NOT BE THE RIGHT MEDICATION TO GIVE SINCE IT CAN
DECREASE STEROID PRODUCTION.

A 73-year-old female patient with COPD currently in MICU with
moderate bilateral pneumonia. Vitals are:
SpO2 91% on 2L
HR 120 bpm
BP 210/100
Temp 99.0
MD orders RN to give Nipride IV STAT. Which of the follow would
173 you expect to increase?
A. Mean PAP
ACCS PRACTICE B. V/Q mismatch
QUESTION #14 C. Pulmonary shunting
D. Gas distribution

• V/Q MISMATCH WILL INCREASE. NIPRIDE WILL DILATE PULMONARY
VASCULATURE WHICH WILL LEAD TO AN INCREASE IN PULMONARY
BLOOD FLOW AROUND THE ALVEOLI IN THIS CASE PERFUSION, BUT
SINCE THIS PATIENT HAS A PNEUMONIA, THIS PATHOLOGY
174 QUESTION #14 WILL DECREASE THE AMOUNT OF GAS REACHING THE ALVEOLI
EXPLANATION (VENTILATION).
• BE ON GUARD WHEN PATHOLOGIES ARE GIVEN IN A QUESTION.
DONT FOCUS JUST ON ONE FACT LIKE IN THIS CASE THE DRUG
WHEN IN FACT IS THE DRUG AND THE PATHOLOGY.

A 67-year-old male in SICU with a recent
diagnosis of pulmonary fibrosis. The initial
assessment you notice only the hard palate at
maximal mouth opening. Which Mallampati
score would you classify this patient?
175 A. 3
B. 2
ACCS PRACTICE C. 4
QUESTION #15 D. 1

• MALLAMPATTI SCORE OF 4 WILL ALLOW THE PRACTITIONER TO
ONLY VISUALIZE THE HARD PALATE.
MALLAMPATTI CLASS 1 FULL VISIBILITY OF ALL ANATOMICAL
STRUCTURES UPON MAXIMAL MOUTH OPENING WHICH
DETERMINES EASY INTUBATION.
176 QUESTION #15 • CLASS 2 HARD AND SOFT PALATE, UPPER PORTIONS OF THE
EXPLANATION TONSILS AND UVULA CAN BE SEEN.
• CLASS 3 AND 4 ARE CONSIDERED DIFFICULT INTUBATIONS
WHICH WILL REQUIRE ESPECIAL EQUIPMENT SUCH AS FLEX
BRONCHOSCOPE, OR VIDEO ASSISTED DEVICE
(GLIDEOSCOPE) FOR OPTIMAL VISUALIZATION.

A Physician ask for your assistance with a patient in
the ER. CXR shows a deep sulcus sign. Which
pathology must you conclude based on the
information given by physician?
177 ACCS A. Pleural effusion

B. Pneumomediastinum
PRACTICE C. Severe lobar consolidation
QUESTION D. Pneumothorax
# 16

THE CORRECT ANSWER IS D
• PNEUMOTHORAX.
QUESTION #16 • DEEP SULCUS SIGN IS ANOTHER SYNONYM

178
RADIOLOGIST MAY USE TO DETERMINE AND
EXPLANATION
DIAGNOSE THE PRESENCE OF A
PNEUMOTHORAX.

A Patient in ICU is showing signs of malignant
hyperthermia and fasciculations. Which drug can
cause these potential side effects?
A. Methylene Blue
179 B. Propofol
C. Dobutrex
ACCS PRACTICE D. Succinylcholine
QUESTION # 17

• ANECTINE WILL CAUSE POTENTIAL SIDE EFFECTS. ALSO,
PATIENTS THAT ARE HYPERKALEMIC SUCX SHOULD NOY BE
ADMINISTERED. USE ONE OF THE BACKDOOR NON
180 QUESTION #17 DEPOLARIZATING NEUROMUSCULAR AGENTS LIKE
EXPLANATION ROCURONIUM, PANCURONIUM ETC. ALSO IS
CONTRAINDICATED IN BURN PATIENTS, AND CAN CAUSE
INCREASED ICP’S. PERFECT DRUG TO USE FOR RSI.

A 56-year-old male patient intubated on mechanical ventilation with the following
data on AC-PC
Mandatory rate 22
Set pressure limit 35cmH20
PEEP 16
FiO2 100%
Delta P 20cmH20
CXR: Diffuse bilateral alveolar infiltrates R > L
ABG: pH 7.33
PaCO2 54
PaO2 52
Total CO2 content 25
BE 1
181 ACCS His total RR now is 26. Fellow would like to place patient on APRV
PRACTICE P-high 28 cmH20

P-low 2 cmH20
I:E 4:1
QUESTION Which of the following will be expected to decrease ?
# 18 A. Dynamic Hyperinflation
B. FRC
C. Qs/Qt
D. Mean airway pressure

• APRV HELPS INCREASE MEAN AIRWAY PRESSURE AND FRC NOT
DECREASE MEAN AIRWAY PRESSURE. ALSO HELPS TO
DECREASE THE EFFECTS BAROTRAUMA AND VOLUTRAUMA.
APRV HELPS WITH ALVEOLAR RECRUITMENT AND DECREASING
182 QUESTION #18 VQ MISTMATCH WHICH OCCURS IN ARDS. BY CORRECTING
EXPLANATION THIS ISSUE, YOU WILL SEE AN IMPROVEMENT IN CaO2 AS WELL.
PRONING WILL ALSO PROMOTE A DECREASE IN YOUR PERCENT
SHUNT. PLEASE FOLLOW AND LEARN
THE ARDS.NET GUIDELINES.

A 66-year-old male 168 cm (5 ft 6 in) 65 kg (142 lbs.) patient had a
recent right-side pneumonectomy and currently on mechanical
ventilation in VC- AC.
Mechanical ventilation settings are :
Mandatory rate 14
PEEP 3 cmH20
VT 300 ml
FiO2 60%
ABG:
pH 7.34
PaCO2 48
183 PaO2 76
Total CO2 content 24
BE -1
ACCS PRACTICE Based on the data above what would you do first?
QUESTION #19 A. Increase VT to 600 ml
B. Increase rate to 16
C. Increase PEEP to 5
D. Increase FiO2 to 70%

• INCREASE THE RESPIRATORY RATE TO 16. THE ABG SHOWS
HYPOVENTILATION AND MILD HYPOXEMIA. LIFE FUNCTIONS
STATES VENTILATION SHOULD BE CORRECTED FIRST AND THE
BEST APPROACH MOST OF THE TIME IS TO INCREASE THE VT
FOR THIS MINOR CHANGE IN VENTILATION. A VT OF 600 ml
184 QUESTION #19 SEEMS TO BE PERFECT FOR THIS SCENARIO BUT THE PATIENT
UNDERWENT A RIGHT PNEUMONECTOMY THEREFORE YOU
EXPLANATION SHOULD USE 1/2 THE VT ONLY, 600 ML WILL BE EXCESSIVE AT
THIS POINT S/P SURGERY. THE MAIN FOCUS AND FACTOR FOR
THIS QUESTION IS THE PNEUMONECTOMY. BE ON GUARD.
• REVISE YOUR PATHOLOGIES.

A 44-year female status post bus crash with sustained traumatic
brain injury. Currently patient is in SICU on mechanical ventilation.
PAC and A-line in place.
Data:
RR: 25 bpm
ICP18 mmHg
HR 68
BP 96/60
PAP 25/9
PCWP 8
185 ACCS C.I. 3
CXR: Moderate cardiomegaly with mild bilateral pleural effusions.
PRACTICE What is the CPP (Cerebral Perfusion Pressure) for this patient ?
QUESTION A. 70mmHg
B. 54mmHg
# 20 C. 62mmHg
D. 75mmHg

• IN ORDER TO FIND MAP WHEN IS NOT GIVEN IN THE DATA YOU
MUST CALCULATE TO OBTAIN THE MAP
FORMULA
MAP= 2 x DIASTOLIC + SYSTOLIC/3
THEREFORE,
186 QUESTION #20 MAP =60 x 2 + 96 /3 = 72mmHg
EXPLANATION • CPP= (MAP – ICP)
• CPP = (72-18)
• CPP = 54mmHg
REMEMBER THE HEART SPENDS MORE TIME OF DIASTOLE THAN

SYSTOLE.

BLOOD PRESSURE
SYSTOLIC 90-140 URINE OUTPUT 40 HEART RATE 60-
CaO2 17-20 vol %
mmHg/DIASTOLIC ml/hr 100 bpm
60-90 mmHg
APTT 24-32
CvO2 12-16 vol% C.O, 4-8 L/min P/F RATIO > 380 SECONDS/ PT 12-
15 SECONDS
CREATININE 0.7- mPAP 14mmHg or

ICP 5-10 mmHg BUN 6-24 mg/dL
1.3 mg/dL 25/8 mmHg
187
ACCS- SEVERAL PCWP 7-9mmHg SVR 1400 DYNES PVR 200 DYNES MAP 93 mmHg
NORMAL VALUES
LACTATE LEVEL
0.7-2.0 mmol or
4.5-20 mg/dL

GOOD LUCK ON YOUR ACCS
EXAM AND STUDY DAILY

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ACCS: ADULT CRITICAL CARE SPECIALTY

REVIEW & KEYPOINTS

MARK VARGAS MSRC,RRT,RRT-ACCS, RRT-NPS

NO PART OF THE MATERIAL PROTECTED BY THIS COPYRIGHT MAY

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

THIS IS A SPECIALITY EXAM THEREFORE;

THINK OUTSIDE THE BOX AND BE ON GUARD!

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

 NITROGLYCERIN: DECREASES PVR, BP, PAP, RELAXES CARDIAC

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

EPINEPHRINE: CARDIAC ARREST, ASYSTOLE,

ADENOSINE: TREATS SUPRAVENTRICULAR

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• NITRIC OXIDE (iNO): IMPROVES OXYGENATION AND ACTS AS A PA

• SILDENAFIL: ALSO KNOWN AS REVATIO OR VIAGRA -DECREASES PAP, PVR.

• FLOLAN (EPOPROSTENOL SODIUM): INDICATIONS: ARDS, REFRACTORY

• KEYPOINT TO WATCH FOR: LOW CVP, ANURIA PARTICULARLY ON VENTED

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

SIDE EFFECTS: HYPERTENSION, TACHYCARDIA (QUESTION ON

SIDE EFFECTS: RESPIRATORY DEPRESSION, SOMNOLENCE,

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• DOBUTAMINE: THIS DRUG HAS MULTIPLE USES SUCH AS:

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• VASOPRESSIN(EPI): WIDELY USED WITH EPI DURING CPR.

• NOTE: VASODILATORS DILATES THE VASCULAR SYSTEM TO ALLOW

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

VALIUM (DIAZEPAM): TREATS ALCOHOL WITHDRAWAL SYMPTOMS AND

VERSED (MIDAZOLAM): MOST COMMON AGENT TO TREAT ANXIETY (IV

PHARMACOLOGY BENZODIAZEPINES AND BENZO REVERSAL DRUGS:

FLUMAZENIL (ROMAZICON) SEEN AS A CHOICE ON THE EXAM:

AROUSAL AGENT: PHYSOSTIGMINE USED FOR NEUROGOLICAL

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• PLAVIX (CLOPIDROGEL): NOT AN ANTICOAGULANT – THIS WILL BE ONE OF THE

• IF YOU HAVE QUESTION IN WHICH PATIENT IS BEDRIDDEN, SUDDEN SYMPTOMS

• COUMDIN (WARFARIN): USE FOR MAINTENACE S/P BLOOD CLOTS, BLOCKS

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• DILAUDID (HYDROMORPHONE): POWERFUL NARCOTIC

• DEMEROL: THERE WAS A QUESTION PRESENTED ON THE EXAM: TERMINAL

• MORPHINE: POWERFUL NARCOTIC WITH POTENTIAL SIDE EFFECTS. LOWERS

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• XOPENEX (LEVALBUTEROL): SHORT ACTING BRONCHODILATOR (1.25MG/3ML) ADULT

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• LASIX (FUROSEMIDE): BEST DRUG FOR THOSE IN PULMONARY EDEMA,

• ALDACTONE: WILL CAUSE EXCRETION OF SODIUM AND POTASSIUM,

• MANNITOL: USED WIDELY ON HEAD TRAUMAS TO DECREASE SWELLING

COPYRIGHT©2024 MARK VARGAS MSRC,RRT,RRT-ACCS,RRT-NPS 01/01/2024

• KETAMINE: ANESTHETIC, MAY CAUSE HYPERTENSION.

• FLUCONAZOLE: ANTIFUNGAL (SELECT IF PATIENT HAS A PULMONARY FUNGAL

• PROTONIX: PROTON PUMP INHIBITOR-USE WITH PATIENTS WITH GI DISTURBANCES EX:

• SODIUM BICARB: USED TO TREAT DKA, INDICATED WHEN HC03 IS LOW.

PHARMACOLOGY • INSULIN: DIABETES CONTROL OF HYPERGLYCEMIA. IF YOU ENCOUNTER A QUESTION

• ACETOMINOPHEN: TREATS FEBRILE ILLNESS. PATIENT WILL BE EXHIBITING INCREASED

• DILANTIN (PHENYTOIN): TREATS SEIZURES AND TONIC-CLONIC SEIZURES.

• METHYLENE BLUE: TREATS METHEMOGLOBINEMIA (PATIENTS ON iNO, NITROGLYCERIN,