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3250 Final > Cardio > Flashcards

Cardio Flashcards

1
Q

Peri-post complications

A
  • Changes to planned procedure
  • Large blood loss  low Hb post-op
  • Cardiac complications
  • Labile BP, intra-operative CVA
  • Contamination of the field
  • Other tissue damage
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2
Q

Mobilisation limited by

A
  • Pain, incision
  • Anxiety
  • Drowsiness
  • Medications
  • Attachments
  • Blood pressure, syncope
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3
Q

Thoracic post-op complications

A

Pulmonary Oedema
Post-pneumonecotmy syndrome
Pleural space problems

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4
Q

Pathogenesis of post-op pulmonary complications

A
  • Anaesthesia  decreased ventilatory drive, monotonous breathing, decreased gas exchange
  • Restrictive reduction in lung volume drowsiness, pain, altered chest wall dynamics
  • Decreased FRC
  • Atelectasis
  • Slowing of mucociliary clearance
  • Secretion retention/painful cough
  • Abnormalities in gaseous exchange
  • Impaired surfactant production and sign mechanism
  • Diaphragmatic dysfunction
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5
Q

Common medical complication post- thoracic surgery

A 
	Post-operative bleeding – if severe re-open
	Respiratory failure
	Bronchopleural fistula
	Emphysema
	Pulmonary embolus
	Pneumonia
	Myocardial infarction
	Cardiac arrhythmias (especially atrial fibrillation)
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6
Q

Thoracic: Pulmonary complications Amendable by physio

A 
Sputum retention 
Attachments
Respiratory failure
Respiratory infection
Exacerbation of underlying chronic lung condition
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7
Q

Thoracic: Pulmonary complication not amendable by physiotherapy

A

Pulmonary embolus
Pulmonary oedema
Pleural effusion
Pneumothorax

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8
Q

Objective assessment

A
  • Vital signs
  • Attachments
  • Surgical incision
  • Access breathing pattern
  • Auscultations
  • Huffing/cough ability
  • Bed mobility & positioning
  • transfers and mobility
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9
Q

Discharge planning

A
  1. Safe on stairs
  2. Home exercise program
  3. Discuss return to activity
  4. Referral to community services
  5. require referral to pulmonary rehab
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10
Q

Post of challenges of lung transplant

A
  • Deinnervation
  • Impaired mucociliary clearance
  • Location-exposure to inhaled material
  • Chronic lung allograft dysfunction
  • Higher immunosuppression
  • Impaired lympathic drainage
  • Poor cough reflex
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11
Q

Precaution of sternal wires

A
  • Avoid reaching behind back
  • minimise pressure through UL
  • Bilateral rather than uni UL activities
  • no weight for 1 month
  • no heavy lifting 3 months, no driving 6 wks
  • sternal support when coughing
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12
Q

Thoracic: Respiratory complications

A
  • Atelectasis: CPB causes surfactant washout and alveolar collapse, resorption type from bronchial secretions, compressive from pleural effusion
  • Fluid: Consolidation, pleural effusion
  • Pneumonia
  • Pulmonary oedema
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13
Q

Thoracic: circulatory complications

+ predisposing factors

A

-Venous thromboembolism

  • Major surgery
  • Increasing age
  • Venous stasis from immobility
  • Cardiac failure
  • Obesity
  • Blood disorders
  • Prolonged hospital stay
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14
Q

Thoracic: cardiovascular complications

A
  • Rhythm disturbance
  • hyper/hypotension
  • Fluid overload
  • Cardiac failure
  • AF: 90-120 care with mob, >120 breathing and bed exercises only
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15
Q

Thoracic: neurological complication

A

3% strokes

-delirium, anxiety, PTSD, memory loss, depression

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16
Q

Thoracic: Sternal complications

A
  • Superficial sternal wound infection
  • Sternal dehiscence
  • Deep sternal wound infection
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17
Q

Thoracic: Sternal risk factors

A
  • Obesity
  • Diabetes
  • COPD
  • IMA
  • Re-sternotomy
  • severe coughing. PVD, delirium, prolong duration of surgery
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18
Q

Thoracic Post-op mobility Contraindications

A
  • PVC>5 at rest
  • Rapid AF >100
  • iniotropic support to maintain resting BP usually if Dopamine is >5mics/kg
  • IABP: 4-6 hrs after removal
  • Low Hb requiring transfusion
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19
Q

thoracic Post-op mobility precautions

A
  • Rest HR> 100bpm
  • AF > 100bpm for >24hrs
  • Systolic >160 or <80, Diastolic > 90
  • PVC < 5 at rest
  • Low Hb not requiring transfusion
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20
Q

Aims of NIV

A
  • enhance airway clearance, atelectasis management and exercise with physiotherapy
  • offlaod resp muscles, reduce WOB, relieve dyspnoea
  • Maximise QoL and function
  • improve sleep duration and quality
  • improve gas exchange
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21
Q

How bilevel works

A
  • Increase PS for increased tidal volume
  • EPAP=PEEP=CPAP
  • CPAP= sustained pressure needed to keep airways open
  • PEEP= positive end expiratory pressure
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22
Q

Explain IPAP

A

Inspiratory positive airway pressure

  • augmenting pressure by supporting inspiratory efforts
  • Increase TV, MV and reduces CO2
  • Rest respiratory muscles and decrease work of breathing
  • IPAP> EPAP (at least 4cm)
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23
Q

Explain EPAP

A

Expiratory positive airway pressure

  • acts as a splint pressure to prevent airways closure at end-expiration
  • positive pressure also assists secretion removal
  • recuit atelectatic regions of lung via collateral ventilation therefore improving ventilation/perfusion matching
  • increases FRC: improves oxygenation, reduce diaphragmatic effort
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24
Q

BIPAP modes

A

Spontaneous: I & E level set independently

  • Triggering EPAP and IPAP reliant on patient effort and flow
  • RR and cycle determined by patient

Spontaneous/Timed
-Augments breaths indicated by patient + delivers additional breaths if spontaneous efforts fall below the ‘back up’ rate set

Timed: Clinician set cycle, all breaths machine generated

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25
Q

CPAP

A
  • Single level of continuous positive pressure throughout respiratory cycle
  • CPAP=EPAP (alone)
  • Patietn controls all aspects of the respiratory cycle including RR and inspiratory time
  • effective in pulmonary oedema and post-op atelectasis
  • Useful for Obstrution sleep apnoea
  • ARF T1
  • Cardiopulmonary oedema
  • post-op atelectasis
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26
Q

Contraindications for NIV

A
  • Undrained pneumothorax
  • Severe haemoptysis
  • Cardiovascular instability
  • Airway obstruction
  • Respiratory or facial trauma
  • Severely depressed level of consciousness
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27
Q

Precautions of NIV

A
  • Bullae/cystic disease
  • GCS< 9, unprotected airways
  • Inability to clear secretions
  • Facial pressure areas
  • GOR
  • Persistant air leaks
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28
Q

NIV complications

A 
Pressure: 
-SInus pain
-Gastric insufflaation
-pneumothorax
Airflow:
-dryness
-nasal congestion
-eye irritation
  • Severe hypoxaemia
  • Aspiration
  • Hypotension
  • Mucous plugging
  • Pressure sores at nasal bridge
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29
Q

Indication for full face mask

A
  • Acute respiratory failure
  • Mouth breather
  • Extremely breathless
  • Naive patient
  • Facial weakness
  • High Bilevel pressure
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30
Q

Indication for nasal mask

A
  • Claustrophobia
  • Able to maintain closed system with mouth closure
  • Airway clearance and regular expectoration
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31
Q

Indication for humidification

A

thick secretions
Supplemental O2
Mouth dryness

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32
Q

NIV help CF

A
  • reduced respiratory muscle fatigue, increased tolerance to treatment
  • Prevent airway closure during techniques (EPAP)
  • Additional humidification assists MCC, oxygen aids hypoxaemia
  • Noctural use: improve gas exchange
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33
Q

NIV positives

A
  • Airways clearance easier
  • may help exercise tolerance
  • fatigue lower with NIV compared to CPT
  • RR lower with NIV
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34
Q

NIV negatives

A
  • no long-term effects

- no diff pre/post lung function

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35
Q

Physio app NIV

A
  • Sputum clearance
  • decrease WOB
  • Increase patient tolerance to airway clearance techniques
  • Enhanced collateral ventilation
  • Ventilatory support exercise
  • Overcome pain limitation post #
36
Q

Signs of inadequate airway

A
  • voice alteration, Hoarse
  • tachycardia, tachypnoea, sweating
  • Anxiety, confusion, lethargy
  • gurgling
  • drooling
  • choking, gagging
  • inspiratory stridor
  • Hypercarbia and hypoxaemia
37
Q

Methods of maintaining clear airways

A
  • Positioning
  • jaw position
  • Nebulised adrenaline
  • Suctioning
  • Intubation
  • Tracheostomy
38
Q

Indications or intubations

A
  • Airway obstruction
  • Inadequate oxygenation
  • Inadequate ventilation
  • elevated work of breathing
  • Airway protection
  • Facilition of tracheobronchial suctioning
  • Facilitation of mech ventilation
39
Q

Endotracheal considerations

A
  • larger tube
  • less tolerated by patient
  • tube occlusion by biting
  • damage to patient teeth
40
Q

Nasotracheal considerations

A
  • Oral hygiene
  • easier to insert
  • Smaller tube, easier to block with secretion
  • Sinus infections, nose bleeds
41
Q

Indication for tracheostomy

A
  • Long term intubation >7 days
  • reduced anatomical dead space
  • prevent laryngeal damage from ETT
  • ETT not well tolerated
  • Head and neck injuries
  • Facilitation of suctioning
  • Bypass obstruction or tumour
42
Q

Tracheostomy Complications

A
  • Risks of operation procedure
  • Placement in pre-tracheal tissues
  • Haemorrhage of innominate artery
  • Trachealstenosis
  • Surgical emphysema
  • Blockage of secretions
43
Q

Cuffed tube

Indication

Adv

A
  • Unconscious
  • Unable to swallow
  • Required full mech ventilation
  • Can potentially cause trauma to vocal cord
  • Prevents aspiration GTI
  • Provides good seal
  • Prevents movement
  • Low pressure, high volume
44
Q

Uncuffed tube indications

A
  • Awake or able to swallow
  • Paediatric use
  • patients able to speak

May cause increased secretions

45
Q

Complications due to intubation

A

-Trauma: teeth, insertion, movement
-Malposition
-Obstruction: biting, kinking, increased secretion
Physiology disorders:
-increased secretion
-Decrease ciliary activity
-inability to cough
-tendency towards infection
-Inability to talk or swallow
-Lack of humidification
-Sinus infections from nasal intubation

46
Q

Indications for suctioning

A
  • Artificial airways
  • Unconscious
  • Inability to cough & expectorate effectively with retained secretions
47
Q

Precautions for suctioning

A
  • Hypotension
  • High PEEP level
  • head injuries
  • Pulmonary oedema
  • Severe infection
  • respiratory burns: soft catheter
  • Haemoptysis
48
Q

Side effects of Suctioning

A
  • Hypoxaemia: drop O2 turn up prior to suctioning
  • Cardiac arrhythmia: quick
  • Haemodynamic alterations: may increase ICP
  • Gastric aspiration: turn on side
  • Trauma: damage to larynx
  • Distress: reassurance
  • Atelectasis: hyperinflation
  • Infection: sterile technique
49
Q

Indications for mechanical ventilation

A
  • Respiratory failure
  • Patient at risk of respiratory failure: unsustainable level of cardiac work or WOB
  • Major insult to body
  • Airway protection or large secretion load
  • Condition must be reversible
50
Q

Indications or ventilation

A
  • Spontaneous ventilation inadequate to maintain gas exchange: PaO2< 60 and PaCO2 >49
  • Increased WOB, accessory muscle use, Sweating, increase HR, increase RR, increase BP, confusion, aggression
51
Q

Effects of mech ventilation

A

Hypoxaemia= increase gas exchange, decreased WOB
Improve cardiac function= decrease preload and afterload
Allows oxygen to be used by other organs= multi organ failure, sepsis, burns
Hypercarbia= Improves thoracic stability, improves alveolar ventilation

52
Q

Methods of ventilatory support

A

CMV
SIMV
A-C
PS + PEEP

53
Q

Explain CMV

A

Controlled mandatory ventilation

  • machine takes all breaths
  • requires heavy sedation and causes weakened respiratory muscles
54
Q

Explain SIMV

Indications

Advantages

A

Synchronised intermittent mandatory ventilation

  1. Controlled breathes
  2. Assisted breathes- triggered by Pt, assisted by ventilator looks same as controlled breath
  3. Spontaneous breaths - assisted by ventilator (PS) but volume not controlled

Indications

  • weaning from mechanical ventilation
  • used for most patients

Advantages

  • Improves comfort
  • No breath stacking
  • Reduced respiratory muscle atrophy
55
Q

Explain A-C

A

Assisted controlled

  • May receive assisted or controlled breaths
  • When patient triggers ventilator, breath of identical duration and magnitude as mandatory breath
56
Q

Explain PS + PEEP

Adv and Dis

A

Total spontaneous supported by ventilator

Advantages

  • Reduced bronchiolar and alveolar collapse as PEEP holds open
  • Increases FRC
  • Allows lower FiO2
  • Reduces shunting

Dis

  • Reduced CO
  • Increases airways pressure
57
Q

Why spontaneous breathing better

A
  • Less disuse atrophy
  • less sedation required= exercise and mob more
  • reduced weaning time
  • Less infection
58
Q

Explain pressure support

A

Augments pressure during spontaneous breath to decrease WOB and increase TV
-Patietn regulates own TV and RR

59
Q

Explain Flow-by

A

Continuous baseline flow

  • Reduces dead space
  • reduces WOB to trigger a breath
60
Q

Explain Peak flow

A
  • how quickly air enters the lungs

- COPD high flow

61
Q

Explain volume vs pressure controlled (SIMV)

A

Volume (CMV, SIMV)

  • TV and RR pre set
  • Airway pressure variable

Pressure controlled

  • Inspiratory pressure and RR pre set
  • TV variable
  • Improves recruitment : long time constant so beneficial for lung with uneven atelectasis
  • Better high flow reqd or where lungs can be easily damaged by high pressure
  • asthma or COPD
62
Q

Side effects of ventilation

A

Pulmonary

  • Maldistribution of ventilation
  • Progressive atelectasis
  • Hyperinflation
  • V/Q mismatch
  • decreased surfactant

Ventilator induced lung injury
-Barotrauma, atelectrauma, volumtraums, biotrauma

  • Ventilator associated pneumonia
  • Haemodynamic effect: Decreased CO
  • DVT
  • Gastric ulcerations
  • Disuse atrophy of diaphragm,
63
Q

Ventilator: Prevent Ventilator acquired Pneumonia

A 
Humidification
Position
Percussion/vibs + MHI 
Hand washing 
NIV 
Aspiration of subglottic secretions 
Early tracheostomy
64
Q

Prevent DVT

A

Leg exercises
Passive movements
TED’s
SCD’s

65
Q

Prevent ventilator induced disuse weakness

A

Provide exercises
Mobilise while still ventilated
Prevent ICU psychosis

66
Q

Cause and prevention Hypoxaemia in ventilation

A

Causes

  • Incorrect setting
  • Secretions
  • Malposition
  • Pneumothorax
  • Medications

Prevention

  • check settings
  • suction tube
  • auscultations
  • increase FiO2
67
Q

Process of weaning

A
  • Decrease rate of SIMV
  • Change to PS/PEEP ASAP
  • If tracheostomy: T-Piece
  • Extubate: high flow nasal prongs or NIV
68
Q

Parameters for weaning

A

• Original cause of admission resolved or improved
• Adequate gas exchange  SaO2 >90%, FiO2 ≤ 0.4, PaO2/FiO2 >200, PEEP ≤ 8 cmH20
o MIP5ml/kg,VC>10ml/kg
o RR/TV < 105 breaths/L 

• Absence of fever 

• Normal Hb (for ICU) 

• Stable cardiovascular function 

• Appropriate neurological and muscular status 

• Correction of metabolic and/or electrolytes disorders 

• Adequacy of sleep, no sedation, adequate mentation

69
Q

Physio role in weaning

A
  • Early exercise, mobilise to prevent weakness
  • monitor while weaning for signs of not coping
  • avoid exercise when just placed on lower level ventilation
70
Q

Sign of not coping weaning

A
  • Patient anxiety, discomfort or progressive obtunbation
  • High RR, shallow breaths, high HR, low SpO2
  • Laboured breathing
  • Accessory muscle recruitment
  • Rapid shallow breathing
71
Q

Purpose MHI

A
  • Secretion removal and cilliary function decreased because of intubation, immobility and mech ventilation & PEEP
  • Prevent or reverse atelectasis
  • Improve compliance’
72
Q

Complications of MHI and VHI

A
  • pneumothorax
  • barotrauma, volutrauma
  • desaturation

Decreased venous return
Decreased CO

73
Q

Contraindication for MHI

A
  • Pulmonary oedema
  • Severe haemoptysis
  • Undrained pneumothorax
  • Nitric oxide
  • Severe broncho spasms
  • Acute septic shock
  • Low BP
74
Q

Precautions with MHI

A
  • Bullae
  • PEEP >10
  • FiO2 >0.7
  • low lung compliance
75
Q

ARDS and cause

A

Syndrome of inflammation and increased lung permeability

Mild= PaO2/FiO2 <300
Moderate= <200
Severe= < 100
  • Multitrauma
  • Blood loss >3L
  • Head injury
  • Burns
  • Pneumonia
  • Pancreatitis
  • Near drowning
76
Q

Management of ARDS

A

-concept of baby lung
-limit volume and pressure
-Open lung tech
TV <8ml/kg
Low IP <32 mmHg
PEEP- 5-15cm H2O

  • prone positioning
  • High levels of PEEP
77
Q

Physio ARDS

A
  • disconnecting from vent, may reduce FRC
  • MHI may cause trauma
  • need to prevent secretion retention: Positions, perks and vibe, closed scution
78
Q

Intrapulmonary ARDS

A

Consolidation

Stiff lung

79
Q

Extrapulmonary

A

Atelectasis

Compliant lung

80
Q

benefits of prone positioning for ARDS

A
  • Recruit dorsal lung
  • V/Q improves
  • Imporves compliance on return to supine
  • Improves in oxygenation maintained when returned to supine
  • Improves even distribution of ventilation and perfusion
81
Q

Explain SIRS

A

Systemic inflammatory response syndrome
-Response to release of exotoxins

  • Increase RR>20
  • Increase WCC >12
  • Increase HR> 90 bpm
  • Temp >38 after Day 1
82
Q

Explain Sepsis

A

Life threatening organ dysfunction due to dysregulated host response to infection

  • RR >22
  • GCS >13
  • Systolic <100

-NO HI

83
Q

Septic shock

A

Persistant hypotension requiring vasopressors to maintain MAP >65

84
Q

Cranial perfusion pressure

A

CPP=MAP-ICP

if <40 tissue perfusion fails

85
Q

Medical management of head injury

A
  • Paralysis and sedation
  • Optimal ABG (Co2 30-35)
  • Ensuring CPP>70
86
Q

Implication for physio head injury

A
  • Intubated, ventilated, sedated, paralysis to rest brain and ensure optimal ABG’s (CO2 30-35, CPP>70)
  • Rx short and frequent
  • SAP and MAP stable
  • head midline, 30 deg head up

3250 Final (3 decks)

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