1
Q
Establishing priorities
A
Maslow’s, A.B.C.D., Trends before Isolated events, Actual before Potential, Systemic before Local, Least stable before Most stable, Acute before Chronic. Also take into account Time management and infection control.
2
Q
pH high, CO2 normal, HCO3 high
A
Metabolic Alkalosis
3
Q
pH high, CO2 low, HCO3 normal
A
Respiratory Alkalosis
4
Q
pH low, CO2 normal, HCO3 low
A
Metabolic Acidosis
5
Q
pH low CO2 high, HCO3 normal
A
Respiratory Acidosis
6
Q
ABG: Compensation
A
- Respiratory system can compensate in minutes, metabolic system takes hours/days.
- If all three numbers are abnormal, you have partial compensation.
- If pH is normal, but CO2 and HCO3 are abnormal, you have full compensation.
7
Q
ABG: Hypoxemia scale
A
Normal 80-100, Mild hypoxemia 70-79, Moderate hypoxemia 60-69, anything less is severe.
8
Q
Mechanical Ventilation: AC/ACV
A
- Assist Control Ventilation
- Most common
- Preset RR and Vt
- Pt “triggers” breath and vent takes over (no work of breathing)
- *If pt suddenly declines, they may have aspirated or vomited
9
Q
Mechanical Ventilation: Synchronized Intermittent Mechanical Ventilation (SIMV)
A
- Synchronized Intermittent Mechanical Ventilation
- Preset RR and Vt
- Pt must do some of the work of breathing (more than with AC)
- Pt may spontaneously breathe
10
Q
Mechanical Ventilation: CPAP
A
- Continuous Positive Airway Pressure
- Prevent alveolar collapse
- Pt does all the work of breathing
11
Q
Mechanical Ventilation: BiPAP
A
- Bi-level Positive Airway Pressure
- Two levels for pts who unable to exhale against the higher pressure.
- Example setting: 12/5, 12 is the IPAP (inspiratory) and 5 is the EPAP (expiratory)
- If pt declines from here, prepare for intubation
12
Q
Mechanical Ventilation: Pressure Regulated Volume Control (PRVC)
A
- Pressure Regulated Volume Control
- Used on pts w/ ARDS
- Delivers pre-set Vt at the lowest possible pressure.
- Used when lungs are stiff
13
Q
Mechanical Ventilation: Airway Pressure Release Ventilation (APRV)
A
- Airway Pressure Release Ventilation
- Used for pts w/ O2 issues, not ventilation issues
- Pt must spontaneously breathe
- Do not want pt heavily sedated.
14
Q
PaO2:FiO2 Ratio: PaO2 is 90, FiO2 is 21%
A
Answer: 90 / 0.21 = 429
15
Q
Ventilator Pt Care
A
- Ambu-bag at bedside
- Oral care Q 4 hrs
- Frequent turning/positioning
- *Nutrition
- Sedation Vacation
16
Q
High Pressure (Pressure) Alarms
A
Line is occluded in some way: kink, pt “bucking” vent, coughing, pulmonary edema, or Pneumothorax.
17
Q
Low Pressure (Volume) Alarms
A
Lack of good seal somewhere in line: accidental extubation, cuff leak, or circuit leak.
18
Q
Acute Respiratory Failure
A
Failure of pulmonary system to maintain adequate gas exchange
19
Q
Acute Respiratory Failure: Hallmark Signs
A
- Hypoxemia, due to different lung disorders that interfere w/ transfer of O2 to the blood
- Hypercapnia, due to insufficient O2 removal, drug OD (cocaine), Neuromuscular diseases, CNS trauma, Respiratory Acidosis *(Pt will have inability to compensate and must be put on vent)
20
Q
Good lung up or down?
A
DOWN!!!
If disease is bilateral, place Rt lung down
21
Q
ARF: management
A
- 1st promote adequate gas exchange: NC/PEEP/Vent, keep O2 >90 (also helps prevent ischemic-anoxic encephalopathy [brain damage] )
- Give NAHCO3 for if needed to reverse Acidosis
- Nutritional support must be started w/in 1-3 days of Vent depending on nutritional state pre-vent.
- Promote secretion clearance
22
Q
ARF: Meds
A
- Give NAHCO3 to reverse Acidosis
- Give Bronchodilator, Steroid, and Mucolytics in that order
23
Q
ARF: Positioning
A
- Good lung down if unilateral, Rt lung down if bilat
- Non-recumbent positioning for pt w/ alveolar hypoventilation
24
Q
PE: Diagnostic Procedures
A
- *Spiral CT
- V/Q scan: will show difference in Ventilation and Perfusion
- Pulmonary Angiogram: can give a better view of where the embolus may be
- D-Dimer: asses thrombin and plasmin activity
25
PE: S/S
- *Impending Doom
- Acute onset dyspnea, pleuritic chest pain, hemoptysis, tachycardia
- ABG shows low O2, and low-early/high-late CO2
26
PE: Meds
- O2 for vasoconstriction (keeps clot from going deeper)
- Dobutamine: Pulmonary vasodilator (to avoid infarction)
- Morphine/Sedatives: relieve anxiety and improve tolerance of ETT
- TPA: clot-buster (if uncontrolled bleeding occurs give FFP)
27
ARDS: Hallmark S/S
- *Pulmonary Edema in the absence of cardiac failure
- *Characterized by acute lung inflammation due to direct/indirect injury
- If chronic, heart will be hypertrophied
28
ARDS: Exudative phase
- Chemical mediators increase capillary permeability
- Fluid leaks into pulmonary interstitium
- Fluid forced from interstitial space into alveoli (alveolar edema)
- Damaged to type 1 alveolar cells and decreased surfactant
- Collapse of alveoli and decreased lung compliance
29
ARDS: Exudative phase S/S
- Restlessness, apprehension, progressive dyspnea and tachypnea, moderate use of accessory muscles
- Breath sounds usually clear
- ABG: mild Resp. Alk.
30
ARDS: Proliferative phase
- Starts 7-10 days after exudative phase
- Decreased surfactant, causes collapse of alveoli and decreased compliance
- Compression, collapse, and edema of alveoli and small airways, pulm. shunting
- Hypoxemia
- Increased airway resistance, decreased compliance, increased work of breathing, pt fatigues which leads to hypoventilation
- Hypoventilation and increased dead space worsen hypoxemia
- Pulm. HTN, increased RV, decreased CO
31
ARDS: Proliferative phase S/S
- Agitation, increased resp. distress and accessory muscle use, fatigue
- Breath sounds: fine crackles
- ABG: Resp. Acid.
- CXR shows "white out"
32
ARDS: Fibrotic phase
- Cellular granulation, membrane pulm. fibrosis
- Structural/vascular remodeling
- Further stiffening of lungs, increasing pulm. HTN, worsening hypoxemia, MODS, decreased LOC and urine output
- Recovery: resolution of fibrosis and restoration of alveolo-capillary membrane
33
ARDS: Survival
- Directly related to presence of MODS/Sepsis
| - Recovery lasts from weeks-months
34
ARDS: Management
- Treat underlying cause
- AC ventilation (*repeated opening/closing of alveoli releases chemical mediators and worsens ARDS)
- PEEP, low Vt, or PCV (PEEP should not be used until healing has begun)
- Maintain SaO2 >90 using lowest level of FiO2
- Encourage fluids to help circulation
- Nutritional support
35
ARDS: Pt Care
- *Turn pt
- Good lung down
- Monitor Hgb
- Vent care
36
Pulmonary Contusion: S/S
- Interstitial/alveolar hemorrhage, alveolar edema, atelectasis
- Breath sounds initially clear, crackles later
- Hypoxia
- ABG: Resp. Acid. and hypoxemia
- CXR: initially clear for first 1-2 days, later shows infiltrates
37
Pulmonary Contusion: Management
- Adequate O2, vent, secretion removal
- Antimicrobial Rx
- Avoid hypervolemia
38
Tension Pneumothorax: S/S
- Mediastinum shifts to UNaffected side
- Low PaO2, high PaCO2
- Breath sounds diminished on affected side
- Percussion is hyperresonant
- CXR shows "dead space"
39
Tension Pneumothorax: Management
-Emergency: insert tube/needle into 2nd intercostal space at mid-clavicular line to release trapped air, insert chest tube in 4th or 5th intercostal space and mid-axillary line to release hemothorax.
40
PaO2:FiO2 Lung Injury Scale
- Normal Lung: 300-500
- Acute Lung Injury: 200-300
- ARDS:
41
H and H
- 1 unit PRBC increases Hb by 1 gm
- 1 unit PRBC increases Hct by 3-4%
- Typically a late sign (6-12 hours), and actual H and H may be worse than results as bleeding may still be going
42
External v. Internal Hemorrhage
- External: Fe stores are depleted
| - Internal: Fe is recovered
43
Acute Viral Infections: Lab Findings
- ESR :elevated
- Albumin: decreases
- C-Reactive Protein: Increases
44
Bacterial Infection: Lab Findings
- Acute infection: WBCs increased (Segs and Bands up)
- Sepsis: WBCs decreased (your body has nothing left to fight with. (Segs down, Bands up)
- Pt is considered to be in recovery when lab values begin to trend towards normal (Segs up, Bands down)
45
Degenerative Shift to the Left
- Increase in Bands with no leukocytosis (no bone marrow response)
- Poor Prognosis
46
Regenerative Shift to the Left
- Increased Bands with Leukocytosis (shows bone marrow response)
- Good prognosis
47
Shift to the Right
- Decrease in Band cells and an increase in Segs
| - Body is recovering
48
SIRS Criteria
- Temp: 100.4
- HR: > 90
- RR: >20 or Pa CO2 12,000 (or >10% bands)
- 2 of these plus current or recent infection = SEPSIS
49
Sepsis: Labs
- CBC and WBC: high, then drop
- Culture: should be positivie
- ABG: Met. Acid./Hypoxemia
- Normal Lactate: 0.5 - 2 (tx elevated numbers with fluids)
- Glucose: should be closely monitored (pt may be put on an insulin drip)
50
Thrombocytosis
- Increased risk of clotting
| - Risk factors: Renal failure, splenectomy, CA
51
Thrombocytopenia
- Increased risk of bleeding
| - Risk factors: CA, massive blood transfusion, bypass machine
52
Heparin Induced Thrombocytopenia (HIT)
Pt develops antibodies to Heparin (Heparin-PF4) which cause to kick off the clotting cascade whenever Heparin is introduced to the system.
53
HIT: Tx
- Avoid use of Heparin or any derivatives
- Monitor plt counts
- Monitor for thrombosis
54
Prothrombin Time: Coumadin effectiveness
- If effective, PT should be 2-2.5 times the normal range
- If prolonged, decrease meds
- If shortened, Increase meds
55
Fibrinogen
- Important coagulation protein
- Normal: 200-400
- Decrease could indicate: liver disease, DIC, or CA
- If 700 risk for MI/CVA
56
D-Dimer
- Very general test
| - Normal:
57
Fibrin Degradation Products (FDP)
- Fibrin is split by plasmin and creates FDPs
- Normal: 0-10
- Critical if > 40
- Increased value could indicate: DVT, cardiac/thoracic surgery, liver disease, CA, or MI
58
Protein C
- Anticoagulant produced by liver
- Prevents thrombosis/enhances fibrinolysis
- Decreases w/ age, DIC, liver disease, and ARDS
59
DIC: S/S
- Bleeding: *Petichiae, bleeding/oozing from various sites, hematuria,
- Clotting: *Altered LOC, thrombosis, gangrene, PE, bowel ischemia/infarction, ARF
60
DIC Labs: Plt count, Fibrinogen, PT, Protein C, FDPs, D-Dimer, Serum Bilirubin, BUN
- Plt count: down
- Fibrinogen: down
- PT: prolonged
- Protein C: down
- FDPs: up
- D-Dimer: up
- Serum Bilirubin: up (RBCs are breaking down)
- BUN: up (RBC fragments [schistocytes] clog kidneys)
61
DIC: Tx
- Treat underlying cause
- Correct Imbalances: O2, replace fluids/electrolytes, give vasopressors
- Severe Bleeding: Cryoprecipitate, FFP, plt transfusion
62
Albumin
- Indicator of nutritional status
- Normal: 3.4-5
- If low, pt has been malnourished for awhile and there will be more problems as well
63
Calculating Osmolality
- Normal Serum Osmolality: 280-303
- Normal Urine Osmolality: 300-900
- Calculated: 2Na + BUN/3 + Glucose/18
64
Albuterol (Proventil)
- Class: Beta2-Andrenergic Agonist
- AE: Tachycardia, palpitations, tremors
- Teaching:Take Beta2's before inhaled glucocorticoids
65
Terbutaline (Brethine)
Class: Long-acting Beta2-Andrenergic Agonist (*Oral)
| -AE:tachycardia, palpitations, tremors
66
Midazolam (Versed)
- Class: Benzodiazepine
- AE: CNS depression, Respiratory depression
- D/D interactions: Any CNS depressant
67
Diphenhydramine (Benadryl)
- Class: H 1 Blocker (antihistamine)
- AE: Sedation, Anticholinergic Effects, GI discomfort, Hallucination
- Contraindicated in 3rd trimester
- Caution in children/older adults, asthma, urinary retention, HTN, open-angle glaucoma
68
Insulin: Rapid Acting
- Humalog or Novalog
| - Onset
69
Insulin: Short Acting
- Regular Insulin, Humulin-R, or Novolin-R
- Onset: 30 min.-1 hr
- Peak: 2-3 hr
- Duration: 5-7 hr
- *Always draw short acting first
- *Don't admin if cloudy
70
Insulin: Intermediate Acting
- NPH, Humulin-N, or Novolin-N
- Onset: 1-2 hr
- Peak: 4-12 hr
- Duration: 18-24 hr
71
Insulin: Long Acting
- Glargine (Lantus)
- Onset: 1 hr
- Peak: none
- Duration: 10-24 hr
- *Do not mix with any other insulin
401
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