cfrn_20230129231503 Flashcards
(500 cards)
1
Q
normal bicarbonate
A
HCO3 = 22-26
2
Q
normal base deficit/excess
A
-2 to +2
3
Q
what is the pH scale
A
power (logarithmic) scale that shows the inverse relationship of hydrogen ions-low pH/acid =pH lots of H
4
Q
buildup of CO2
A
acid
5
Q
what does high CO2 indicate
A
acid builduplow pHapnea/hypoventilation
6
Q
what is Co2 regulation a function of
A
CO2 regulation is a function of minute folume| minute volume = tidal volume (Vt) x RR (F)
7
Q
Vt on ventilator settings
A
tidal volume
8
Q
tidal volume on ventilator settings
A
Vt
9
Q
RR on ventilator
A
frequency = F
10
Q
F on ventilator settings
A
RR
11
Q
CO2 over 45
A
acid buildup| hypoventilation/apnea
12
Q
CO2 if apnea
A
high Co2 over 45| acidosis
13
Q
CO2 if hypoventilation
A
high Co2 over 45.| acidic
14
Q
CO2 under 35
A
alkalosis| high pH
15
Q
CO2 if alkalosis
A
under 35
16
Q
Vt x R
A
minute ventilatiob = Vt x F| tidal volume x RR
17
Q
how does pH and bicarbonate move
A
opposite directions22 is acidotic26 is alkalosis
18
Q
pH if too much bicarb
A
bicarb is alkalotic| over 26 bicarbonate
19
Q
pH if too little bicarbonate
A
under 22| acidosis
20
Q
under 22 bicarb
A
too little bicarbonatebicarb and pH move in teh same directionalkalosis
21
Q
what is base excess/deficit
A
the amount of excess or deficit amount of base present in blood
22
Q
base deficit of -4
A
indicator for blood transufusion
23
Q
base deficit where you would consider blood transfusion
A
base deficit of
24
Q
base deficit where death is likely
A
over -19
25
replacement formula for bicarbonate
0.1 x (-base excess) x weight in kg = bicarb needed
26
SaO2 at PaO2 90
100%
27
SaO2 at pO2 60
90%
28
SaO2 at pO2 30
60%
29
SaO2 at pO2 27
50%
30
what does pulse ox measure
SaO2
31
left shift affinity
increased
32
left shift mneumonic
Left = LOW| acidosis, temp, 2,3-DPG, pCO2
33
right shift mneumonic
Right = RAISe| alkalosis, temp, 2,3-DPG, PCO2
34
what 5 things change in left/right shift
```LEft = LOWRight = Raise+HtemperaturePCO22,3-DPG```
35
CO2 & pH
Co2 is an acid so it makes ABG more acidotic| left shift
36
Bicarbonate & pH
bicarb is a base so makes ABG more alkalotic| right shift
37
CO2 follows pH
respiratory
38
bicarbotate follows pH
metabolic
39
how to tell if the ABG is compensated
the compensatory mechanism is teh opposite of the primary problem* respiratory acidosis is compensated by bicarb* metabolic alkalosis is compensated by CO2
40
compensated respiratory acidosis
compensated by bicarbonate
41
compensated metabolic alkalosis
compensated by CO2 (acid)
42
partially compensated
pH outside normal range| both resp & metabolic are outside of normal range
43
pH/resp/metabolic are all ouside of normal range
partially compensated
44
pH is normal, resp/metaboliic are ousided normal range
fully compensated
45
fully compensated
abnormal pH| normal CO2/bicarb
46
critical pH for intubation
pH under 7.2
47
pH under 7.2
intubate b/c critical
48
pCO2 over 55
intubate b/c critical
49
critical pCO2 to intubate
over 55
50
critical pO2 to intubate
under 60
51
pO2 under 60
intubate
52
acid/base if vomiting/NG/suction/dieuretics/diamox/antacid poisioning
metabolic alkalosis
53
causes of metabolic alkalosis
vomit/NG/suction/dieuretics/diamox/antacid overdose
54
considered lactic acidosis
lactate over 4
55
causes of m. acidosis
lactic acidosis, ketones, hyperthermia/fever, seizures, rhabdo
56
bicarb in m. alkalosis
over 26
57
bicarb in m. acidosis
under 22
58
acid base in antacid poisioning
m. alkalosis
59
acide base in sepsis
m. acidosis
60
acid base in rhabdo
m. acidosis
61
acid base in hyperthermia
m. acidosis
62
acid base in seizures
m. acidosis
63
Co2 in r. alkalosis
low CO2 under 35
64
acid base if hyperventilating
r. alkalosis
65
acid base in hypoermetabolic staes
resp alkalosis
66
acid base in high altitudes
r. alkalosis
67
acid base in ASA poisioning
r. alkalosis (CO2 less than 35) b/c it is a respiratory system stimulant
68
what happens in ASA poisioning
respiratory system stimulant so r. alkalosis a| hyperventilation
69
hyperventilation
r. alkalosis| Co2 under 35
70
hypoventilation
r. acidosis| CO2 over 45
71
Co2 in hyperventilation
under 35| alkalosis
72
CO2 in hypoventilation
over 45| acidosis
73
when is minute ventilation increased
increased to blow off CO2 (Vt x RR)in hyperthmic states like malignant hyperthermialimited ability to remove by hgb
74
every ___ in pH, expect change in bicarbonate by ___ in ___ direction
0.15 pH10 bicarbsame direction
75
every ___ in pH, expect change in K by ___ in ___
0.1 pHK shifts 0.6oppositr direction
76
physiology of the pH & K relationship
*every 0.1 change in pH, K shifts 0.6 in the opposite direction*as pH lowers, K shifts outside the cell giving a falsely elevated K level. when correct imbalance by raising pH, K shifts intracellulary so life threatening low K
77
every change in ___ ETCO2, expect pH to change by ___ in the ___ direction
10 mm hg ETCO20.08opposite direction
78
every change in ___ CO2, K shifts ___ in teh ___ direction
10 CO2K 0/5same direction
79
pH & K relationshipVERSUSCO2 & K
every change in 0.1 pH, the K shifts 0.6 in the opposite directionevery change in 10 CO2, K shifts 0.5 in the same direction
80
ABG to intubate
7.2 pHCO2 over 55PaO2 <60*intubate even if only 1 is off
81
Pediatric Assessment Triangle
appearancework of breathingcirculation
82
ETT size for pediatrics
16 + age in yearsdivided by4
83
16 + age/4ll
ETT size for pediatrics
84
emergency airway for pediatricsl
needle cric if under 8l
85
difficult airway predictors0+
LEMON, HEAVEN| look, evaluate w/ 3-3-2, Mallampati, obstruction, neck mobility
86
3-3-2
difficult aiwary predictor3 fingers in mouth3 fingers between jaw and hyoid2 fingers between hyoid and thyroid
87
Mallampati 2
tonsillar pillars hidden by tongue
88
Mallampati 3
only base of uvula is seen
89
LEMON
```lookevaluate w/3-3-2mallampatiobstructionneck mobility```
90
HEAVEN
```predictors in difficult emergent airwaysHypoxemia under 93%extreme of size (under 8 or obese)anatomic challengesvomit/blood/fluidexsanguination/anemianeck monility```
91
"E" in HEAVEN
exsanguination/anemia can accelerate decompensation during RSI
92
ramping
ear to sternal notch
93
problem of the supine position during intubation
```ramp instead (ear to sternal notch)decrease functional reserve capacity/tidal volume/preload```
94
posterior pressure on cricoid cartiliage believed to occlude the esophagus
Sellick maneuver
95
External Laryngeal Manipulation
provider brings cords into view the the assistant holds pressure.
96
Macintosh v MIller blade
Macintosh = lifts epiglottis via vallecula| Miller - direct displacement of the epiglottis
97
preferred intubation blade for pediatrics
Miller (direct displacement of the epiglottis)
98
bougie size adult versus kids
```adult = 15 Frkids = 10Fr```
99
problem of supraglittic devices
blind insertion| little protection agaisnt aspiration
100
air inflation into ETT
25mm is standard
101
CXR confirmation of ETT placement
distal tip 2-4 cm above carinalevel of T3-T4confirm by visualizing Murphy's eye where the clavicle meets
102
waveform of the ETCO2
half square| expiration - expiratory plateau- ETCO2- inhalation- baseline
103
where is ETCO2 measured on the ETCO2 waveform?
right side of square
104
what can you do when you are preparing & pretreating a pt for RSI intubation
3-5 min of passive oxygen via NC 10-15L
105
pretreatment for RSI
LOAD
106
position for RSI
ear to sternal notch = ramping| pad behind shoulder for pediatrics
107
reason for RSI pretreatment
LOADb/c manipulation of the hypopharynx, larynx, and trachea may cause a reflex sympathet9c response leading to catecholamine mediated increase in BP/HR/ICP
108
RSI preteatment options
```LOADLidocaine OpiatesAtropineDefssciculating```
109
lidocaine as RSI pretreatment
blunts the cough reflex preventiong ICP increase
110
opiates as RSI pretreatment
blunts the pain response
111
atropine as RSI pretreatment
prevents reflexive bradycardia in infants under 1yo
112
defasciculating rx as RSI pretreatemnt
1/10 dose of Roc or VEc prior to administering Succ
113
Fentanyl as RSI analgesic| dose, onset, duration, complication
1mcg/kgonset 3-5 minduration 30-60 minlow risk of chest wall rigidity
114
RSI for awake sedation
Etomidate
115
dose for Etomidate
0.3mg/kg
116
onset/duration for Etomidate
15-45sec onset| lasts 3-12 min
117
caution w/Etomidate
no analgesicshort duration (3-12 min)use cautiously if hemodyanmically unstablevomit when awakeNOT: if adrenal suppression, shock/Addisions/CODP/asthma
118
RSI not to use if adrenal suppression
ETomidate
119
RSI not to use if in shock
Etomidate = don't use if adrenal suippression/shock/COPD/asthma/Addisions, or if hymedynamically unstable
120
common SE w/Etomidate
common to vomit when awake
121
properties of KEtamine
hypnoticanalgesicAmnesic
122
benefit of Ketamine
has unique ability to preserve laryngeal reflex/help w/airway preotection
123
best RSI for asthma/airway issues
Ketamine b/c preserves laryngeal reflexes/airway protection
124
Ketamine dose for RSI
1-2mg/kg
125
onset and duration of Ketamine
```onse = 40 -60 secduration = 10-20min```
126
best RSI for asthatics w/reactive airway complications
Ketamine is a potent bronchodilator
127
SE of ketamine
may hallucinate| may cause laryngospasms
128
reversal agent for Versed
Flumazenil 02mg
129
SE of Flumazenil
BP
130
good RSI choice if shock
Ketamine
131
what is propofol
hypnotic w/ no analgesic properties| "milk of amnesia"
132
dose of Propofol
1-2mg/kg| 25-50mcg/kg/min maintence
133
onset/duration of propofol
onset 15-45 sec| duration 5-10 minutes
134
RSI decreases MAP/CPP
PRopofol
135
what cannot Propofol do
milk of amnesia - hyponotic BUT NO PAIN RX
136
who should not have Propofol
decreases CPP & MAP so not for HEad INjury or if hemodynamically unstable
137
contraindicatiosn for Propofol
Head injury & hemodynamically unstable| *b/c decreases MAP/CPP
138
RSI rx & their complications
Fentnanyl - chest wall rigidity, hypotensionETomidate - adrenal suppressionKetamine preserves laryngeal function so airway protectPropofol = decreases CPP/MAP so not for head injury or hemodyunamically unstable
139
RSI induction
fentanyl, etomidate, ketamine, propofol
140
what will you see someone on Succ do
fasciculation = muscle twitch
141
SE of SUCC - 2
high K| malignant hyperthermia
142
what is linked to malignant hyperthermia
Succ
143
drug class of Succ
depolarizing neuromuccular agent
144
burns contraindicate dfor Succ
over 24hrs
145
contrainidcation for SUcc
```burns over 24hrrhabdo, high Khx of Malignant hyperthermiacrush or eye injuriesany nervous system injury like G-B or MG```
146
pathophysiology of Malignant Hyperthermia
defect in skeletal muscle sarcoplasmic retiulum| *r/t problem w/Ca removal from the cell
147
treat Malignant Hyperthermia
Dantrolene| NEVER CaChannel blockers (b/c MH is a problem w/sustained Ca removal from teh cell)
148
Rx not to give someone with Maligant Hyperthermia
Ca ChB (b/c probelm with calcium removal from the muscle_
149
s/s of Malignant Hyperthermia
```sustINED TETANIC MUSCLE CONTRACTIONmasseter spasmtrismus (lockjaw)rapid incrase in temp up to 110FHTN/high RRmixed acidosisincreased ETCO2```
150
acid base in Malignant Hyperthermia
mixed acidosisincreased ETCO2tachycardia
151
lockjaw
trismus
152
when do you give Dantrolene
for Malignant Hyperthermia s/p gases or Succ
153
cause of Malignant Hyperthermia
induction gasses or Succ
154
dose of Succ
2.5mg/kg
155
Sugammadex
reverses Roc
156
reverses Roc
Sugammadex
157
drug class of Roc
Non-Depolarizing Neuromuscular BLocking
158
onset/duration of Roc
0.6 - 1.2 mg/kg
159
onset and duration of Roc
onset under 2 min| lduration 30-60 moin
160
important Rx to give if induce w/vec or roc
NO pain management
161
how to dose RSI if pt is hemodynamically unstable/shock and low CO
1/2 induction. less rx is needed due to depleted catecholamine storesdouble paralytic b/c low CO slowws the onset
162
RSI dose of induction agent if pt is shock/hemodynamically unstable w/ low CO
1/2 induction.| less rx is needed due to depleted catacholamine stores
163
RSI dose of paralytic if pt is shock/hemodynamically unstable w/low CO
double paralytic b/c low CO slows the onset
164
SALAD technique
suction assisted laryngoscopy airway decontamination| clear airway w/ suction, plae suction in the esophagus wile the intunation tube is passed.
165
post intubation management
Fentanyl, KEtamine, Versed drip
166
failed airway algorithm
3 attemps of laryngoscopy unsuccessful| can't intubate, ventilatie, oxygenate = CRIC
167
what do you palpate for when you cric
feel for ht ecricothyroid membrane
168
what type of cri to use
surgical cric over 8yo| needle crif if under 8
169
amount of air in normal breath
tidal volume = Vt
170
Vt
tidal volume| amount of air in normal breath
171
problem of too high Vt
tidal volume too high causes Ventilator Induce Lung Injury
172
cause of Ventilator Induced Lung INjury
too high Vt
173
surface of airway not involved in gas exchange
dead space
174
Fick's law of Diffusion
gas travels from high to low concentration
175
gas travels from high to low conetration
ick's Law of DIffusion
176
when do you hear apneuristic posturing
decerebrate postuirng
177
apneuristic breathing
depe gasping inspiration with a pause at full inspiration followed by a brief insufficient release
178
deep gasping inspiration with a pase inspiration followed by brief insufficient relase
apneuristic brathing
179
complete irregular breathing w/irregular pasuses and apnea
ataxic
180
ataxic
complete irregular breathing w/irregular pasues and apnea
181
BIots
quick shallow inspiration followed byrgular/iregular apnea
182
quick shallow inspiration followed by regular/irregular apnea
Biot's
183
respiration in stroke
Biot's
184
respiration if pressure on medula r/t herniation
Biot's
185
cause of BIot's
stroke| pressure on medulla from herniation
186
Cheyne-STokes
progressivelydeeper and faster then decrease to tempoary apnea
187
progressively deeper and faster then decreased to tempary apnea
Cheyne-STokes
188
when do you see Cheyne Stokes
decorticate| cushing's brainstem herniation
189
respiration in Cushing's triad
Cheyne-STokes
190
resp in DKA
Kussmaul's
191
Kussmau's Respirations
resp in DKA| respiration gradulally becomes deeper, labored, and gasping
192
respirations deep and labored
Kussmauls'
193
gold standard for oxygenation
SpO2 = pulse ox
194
gold standard for ventilation
capnography = ETCO2
195
inability to diffuse oxygen
hypoxic respiratory failure
196
respiratory failure in ARDS
hypoxic respiratory failure
197
respiratory failure in pneumonia
hypoxic respiratory failure
198
respiratory failure in CHF
hypoxic respiratory failure
199
dx if pO2 below 60
hypoxic respiratory failure
200
definition of hypoxic respiratory failure
pO2 below 60
201
treatment if hypoxic respiratory failure
increase oxygen concentration (FiO2 and PEEP| *treatment assumes that you have adequate tidal volume and rate)
202
how to increase oxygen saturation
increase FiO2 (oxygen concentration) and PEEP
203
increase FiO2 (oxygen concentration) and PEEP
treatment for hypoxic respiratory failure
204
inability to remove CO2
hypERcarbic respiratory failure
205
cause of hypercarbic respiratory failure
damage to pons/upper medulla from stroke or trauma| respiratory acidosis
206
dx hypercarbic respiratory failure
ETCO2 over 45
207
dx if ETCO2 is over 45
hypercarbic respiratory failure
208
treatment of hypercarbic respiratory failure
incrase tidal volume (pPLAT)then rate increasae(double the minute volume (Ve), normal is 4-8L'min
209
what happens if you exceed __ml/kg of ideal body weight for tidal volume settings
over 8ml/kg for tidal volume settings can cause ventilatior associated lung injuries*slowly increase and reassess every 15min
210
ventilator setting for tidal volume
Vt = 4-8ml/kg ideal body weight| volume of air delivered per breath
211
ventilator setting that is the volume of air delivered per breath
Vt = tidal volume4-8ml/IBWover 8 = ventilator associated lung injury
212
Ve
minute volumehow much air is breathed by the pt in one minuteF x Vt
213
4-8 ml/kg IBW
Vt = tidal volume
214
F x Vt
calculate Ve = minute volume| how much air breatahed by a pt over 1 minute
215
calculate Ve
minute volume = F x Vt (tidal volume)
216
purpose of PEEP
keep alveoli open so oxygen can diffuse
217
3 ventilator settings that keep alveoli open so oxygen can diffuse
adequate peepincreased FRCdriving pressure
218
2 ventilator delivery methods
```volume = preset volume consistent. once tidal volume is delivered, exhalation beginspressure = preset inspiratory pressure. once the pressure is achieved, exhalation begins```
219
max PIP
35
220
PIP
amount of resistance to overcome the ventilator circuit, appliances/ETT, and the main airway
221
pPlat
measurement of the pressure applied during positive pressure ventilation to the samll airways/alveoli.*represents the static end inspiratory recoil pressure of hte respiratory system, lung, and chest wall respectively
222
when is pPlat measured
during an inspiratory pause while on m. ventilator
223
normal pPlat
under 30
224
values for PIP & pPlat
PIP under 35| pPlat under 30
225
CMV
controlled mandatory ventilation
226
who needs CMV
controlled mandatory ventilationsedated/apneic/paralyzedall breaths are trigged, limited, cycled by the ventilatorpt unable to breathe on own
227
best ventilator mode for sedated
CMVall breaths are triggered/limited by ventilatorpt unable to breathe on own
228
best ventilator mode for apneic
CMVventilator does all workpt can't breathe on own
229
best ventilator mode for paralyzed
CMV| ventilator does all the work
230
ventilator setting that does all the work and the pt has no ability to initiate their own breaths
CMV = controlled mandatory ventilation
231
preferred ventilator mode for respiratory distress
Assist COntrol
232
trigger for breath in Assist Control
either the pt or by elapsed time
233
how does Assist Control work
ventilator suipports every breath whether it is initiated by the pt or the ventilator*full tidal volume (Vt) regardless of respiratory effort or drive
234
anxious pt on Assist Control
can cause breath stacking/auto-PEEP
235
what ventilator setting can cause auto-PEEP
Assit COntrol
236
good ventilator setting for ARDS
AC
237
ventilator setting where the ventilator supports every breath even if pt initiates in order to deliver the full Vt
AC
238
auto-PEEP
aka breath stacking*predisposes to barotrauma/hemodynamic comproimisesincreases WOB/effort to trigger the ventilator*diminishes the forces generated by the respiratory muscles
239
SIMV
synchronized intermittent mandatory ventilation
240
how does SIMV work
if pt fails to take a rbeath, the ventilator will provide a breathspontaneous breathing by pt in-between assisted breaths at preset intervals
241
ventilator setting where it can sense pt taking a breath and either support it while also allowing pt to take spontaneous breaths in-between preset interval
SIMV
242
best ventilator setting for intact respiratory drive
SIMV
243
candidate for SIMV
someone with an intact ventilation drive| *able to take their own breaths in-between preset intervals
244
how does Pressure Support Ventilation (PSV) work
pressure support makes it easier to overcome the resistance of the ET tube and is often used during weaning b/c it reduces WOB*supports or provides pressure during inspiration to decrease pt's overall WBO
245
what does pt determine in PSV
pressure support ventilation| *tidal volume and rate
246
PSV
pressure support ventilation
247
ventilator setting that provides pressure during inspiration to decrease pt overall work of breathing
PSV = pressure support ventilation
248
what does pt need to be able to do in order to use PSV
consistent ventilatory effort by pt| pt determines Vt, rate (minute volume)
249
what does BiPAP mean
BiPAP refers to a specific manufacturer, not a vent setting
250
pressure alarm if ventilator is dislodged
low pressure
251
pressure alarm if ventilor is obstructed
high pressure
252
pressure alarm if pneumo
high pressure alarm
253
pressure alarm if stacked breaths
high pressure alarm
254
pressure alarm if pt is hypovolemic and on ventilator
low pressure
255
pressure alarm if ARDS
high pressure
256
pt and ventilator are fighting
pt-ventilator dyssynchrony
257
problem patient-ventilator dyssynchrony
PROBLEM: inadequate sedation or pain control| b/c increased oxygen demand & WOB. increased HR/BP/ICP
258
waveform sign if patient-ventilator dyssynchrony
curare cleft
259
curare cleft
waveform sign of patient-ventilator dyssynchrony
260
interventions for patient-ventilator dyssynchrony
```manage auto-peepadjust rate to pt demand, adjust sensitivity Y minute volumesuctionanalgesia & sedation```
261
what settings does teh algorithm have you look at if sudden acute respiratory deterioration while on a m. ventilator
```PIP (decreased/increased/no change)plateau pressure (no change or increqased)```
262
troubleshooting the ventilator| acute respiratory deterioration and the PIP is decreased
air leakhypoventilationhyperventilation
263
troubleshooting the ventilator| acute respiratory deteroration w/o PIP changes
consider PE
264
troubleshooting the ventilator| acute respiratory deterioration w/PIP increased
next consider if the pPlat is increased or if no change
265
troubleshooting the ventilator| acute respiratory deterioation with increased pPLAT -6
```abd distensionatelectasispneumop. edemaatelectasispleural efflusion```
266
troubleshoot the ventilator| acute respiratory deterioration with no change in pPlat
airway obstruction, bronchospasm, ET tube cuff herniation
267
RASS
Richmond Agitation-Sedation Scale+4 = combative0= alert and calm-4= deeply sedated
268
tool used to monitor m. vented pt for over/undersedation
```RASS = Richmond Agitation-Sedation Scale+4 = combative0= alert and calm-4= deeply sedated```
269
decreased V/Q
ventilation is not keeping up with perfusion| *resp fail/pneumonia/ARDS, low PaO2, high PaCO2
270
formula for V/Q
alveolar ventilation/CO| = ~.08
271
low V/Qnormal V/Qhigh V/Q
normal V/Q = ~0.8. alveoli are ventilated and perfusedlow V/Q = shunted. alveoli are perfused but not ventilatedhigh V/Q= deadspace. alveoli are ventilated but not perfused
272
example of low V/Q
shunt perfusion = alveoli are perfused by not vented| ET in mainstem bronchus
273
example of high V/Q
deadspace| alveoli are ventilated but not perfused
274
what is the problem of asthma
breathing out.| respiatory acidosis due to hypercarbic respiratory failure
275
CXR in asthma
flattened disaphragm on CXR. chest cavity is overexpanded due to air trapping
276
shark fin ETCO2
asthma
277
asthma as reflected on ETCO2
shark fin
278
interventions for asthma -ventilator
increase I:E ration to 1:4 (b/c this is an exhalation problem)zero PEEP or under 5
279
I:E setting on ventilator if asthma attak
increase to 1:4 b/c exhalation problem
280
PEEP if on a ventilator & asthma attack
zero to under 5 PEEP
281
rx for asthma attack
```bronchoDsteroidepiimagnesiumketamine if sedated```
282
cutesy names for COPD
blue bloater - chronic bronchitis| pink puffer = emphysema
283
CXR if COPD
flatted diaphragm. chest cavity is expanded from air trappign
284
problem if COPD
problem is breathing out| respiratory acidosis b/c hypercalrbic respriatory failure
285
benefit of increased I:E ratio
more expiratory time increases CO2 clearance but it does carry a risk of atelectasis(increased I only is uncommon but it may be used to increase oxygen at a cost of CO2 clearence)
286
pleural efflusion
fluid in the pleural space| gravitates to the most dependent space
287
CXR of pneumonia
patchy infiltrates| lobular consolidation
288
what happens = hypoxemia & p. HTNin ARDS
diffuse alveolar injury* increased permeability of the alveolar-capillary barrier* influx of fluid into the alveoliar space
289
CXR of ARDS
ground glass appearencepatchy infiltratesbilateral diffuse infiltrates
290
ground glass appearence on CXR
ARDS
291
Swan-Ganz findings in ARDS
high PAWP (18-20) b/c the right heart is pumping against incresed resistance in the lung vasculature
292
ARDS treatment
focus on oxygenation-increase PEEP & FiO2-lower tidal volume (4)increase rate (F)
293
calculate male predicted body wt
50 + 2.3(height in inches - 60)
294
calculate female predicted body wt
45.5 + 2.3(heigh in inches -60)
295
inclusion criteria for ARDS
1. PaO2/FiO2 under 300 2. bilateral infiltrates consistent w/p. edema3. no clinical evidence of left atrial HTN
296
oxygenation goal for ARDS
minimam PEEP of 5. incremental FiO2/PEEP combos to achieve goal fo PaO2 55-80 & SpO2 88-95%
297
pPlat goal if ARDS
under 30check pPlat q4hrs or after each change in PEEP/Vt*pPlat over 30 = decrease Vt by 1ml/steps*pPlat under 25 and Vt under 6ml/kg = increase Vt by 1ml/kg until pPlat is over 25 or Vt 6ml/kg*pPlat under 30 and breath stacking, incrae Vt in 1ml/kg increaments to 7 or 8
298
3 Stages of Tylenol overdose
1. flu-like (N/V, abd pain, swat, pale)2. liver injury (RUQ pain, LFT elevate)3. peak liver enzymes (hepatic fialure (glucose/lactate/phosphate abnormal), encephalopathy, hypoglyemia, coma, death
299
late stage serious complications of tylenol overdose
```hepatic failureencephalopathyhypoglyvemiacomadeath```
300
abnormal labs in tylenol overdose
LFT elevatedlow glucosephosphate abnormal
301
asprin overdose
N/V| tinnitis
302
acid base in asprin overdose
r. alkalosis| can progress to m. acidosis
303
cause of REye's disease
pediatric asprin overdose
304
complications of asprin overdose
liver & brain damagehigh ICP possible encephalopathyhepatic encephalopathy
305
treatment of asprin overdose
sodium bicarb (b/c liver damage causes high ammonia) and dialysis
306
labs in asprin overdose
r. alkalosis progressing to m. acidosis| high lactate b/c liver damage
307
benzodiazepines
```diazepam = valiumlorazepam = ativanmidazolam = versed```
308
treatment of benzodiazepine overdose
activated charcoal if ingested| flumazenil
309
Fluzemanil
benzo overdose
310
pushing Flumazenil too fast
seizures
311
antidoate for Beta Blocker overdose
glucagon
312
s/s of BB overdose
```low bp/hrconduction delayslow glucosep. edemabronchospams```
313
glucose in BB overdose
low glucose
314
overdose with low glucose
consider BB overdose
315
treat BB overdose
glucagonpacing, atropinerIVF for low bp
316
difference between BB and CaChB overdose s/s
both have low HR/BP/conduction delaysBB = low glucoseCaChab= high glucose
317
s/s CaChB overdose
low BP/HR/conduction delaysm. acidosishigh glucose
318
treatment of CaChB overdose
activated charcoalatropine/pacingIVF for low BP
319
s/s of digoxinoversoe
flu-likeyellow green halosrisk of high Kslurred upstroke on ERS
320
avoid if digoxin overdose
avoid electricity like pacing/cardioversion
321
EKG of digoxin overdose
slurred upstroke on ERS
322
use of phenytoin (DIlantin)q
seizures
323
s/s of phenytoin (Dilantin) overdose
SVT, coma, confusion, tremores| DI-like s/s
324
treat phenytoin (Dilantin) overdose
IVF/O2, supportative| maybe gastric lavage
325
s/s of cocaine overdose
chest pain, HTN, seizures, rhabdo
326
treat cocaine overdose
IVF, benzos
327
treat PCP
sedatives. no ketamine b/c delirum can worsen
328
risk of MDMA
overheadinglow Naserotonin syndrome
329
treat alkalis
copious water
330
treat anticholinergic
phyostigime
331
treat ASA
bicarb
332
treatment BB
glucagon
333
treat CaChB
Calcium gluconate
334
treat cocaine
benzos
335
treat coumadin
vitamin K
336
treat pit viper
CroFab, FabAV
337
treat cyanide
sodium thiosulfate, sodium nitrite/amyl nitrate
338
treat phenytoin
supportative
339
treat ethylene gluycol
IV ethonol or Femepizole
340
treat heparin
protamine sulfate
341
treat hydrocarbons
intubate
342
treat hydrofluoric aicd
calcium gluconate
343
treat INH
pyridoxine (vitamin B6)
344
treat iron
Desferal
345
treat methanol
IV ethanol, Fomenizole
346
treat organophosphates
atropine & 2-PAM
347
atropine & 2-PAM
organophosphates
348
treat alcohol overdose
IV ethanol or Fomepizole
349
Fomepizole
alcohol overdose
350
Desferal
iron overdose
351
amyl nitrite/sodium nitrite/sodium thiosulfate
cyanide
352
glucagon as an antidote
BB
353
what does a tricyclic antidepressant overdose look like
anticholinergic-like
354
EKG of tricyclic antidepressant overdose
widened QRS with prolonged QT
355
treatment of tricyclic antidepressant overdose
bicarb, IVFtarget pH is 7.5-7.55vasopressors if refractory low bp
356
how to give rx for iron overdose
Desferan creates rose colored urine and normal once yellow again
357
Antizole
treat toxic alcohols
358
ABG of toxic alcohols
lethal anion-gap acidosis over 16
359
aka antiffreeze
ethylene glycol
360
ethylene glycol
antifreeze
361
windshield wiper fluid
methanol
362
methanol
windshield wiper fluid
363
treat alcohol overdose
IV ethanol, Antizol, hemodialysis
364
complication of hydrocarbons
chemical pneumonitis. decreaed viscosity causes aspiration| DO NOT induce vomiting
365
toxidrome of pesticides
organophosphate = cholinergic toxidrome
366
s/s of cholinergic toxidrome
SLUDGE/DUMBELSoraganophosphatesneve gases like sarin & Vx
367
SLUDE/DUMBELS
cholinergic toxidrome/organiophosphates| defecation (GI distress/emesiss)
368
nerve gas s/s
cholinergic toxidrome| SLUDGE/DUMBELS
369
Vx s/s
cholinergic toxidrome| SLUDGD/DUBELS
370
DUMBBELS
```diarrheaurinationmiosisbronchorrheabronchospasmemesislacriminationlaxationsweating```
371
other s/s of nerve gas & organophosphates
SLUDGE/DUMBBELS| nicotinic stimulation = tachycardiat, HTN, fasciculations, paralysis of respiratoyr muscles
372
death from nerve gas/organophosphates
paralysis of respirtory muscles
373
treat organophosphate overdose
atropine to decrease aireay secreationspralidoxime2-PAM (crowbar organophophate off of ACh)benzos for seizures
374
how does 2-PAM work
crowbar that takes the organophosphate off of ACh| *for organophosphate/nerve agent/cholinergic
375
atropine overdose
anticholinergic
376
benadryl overdose
anticholinergic
377
tricyclic antidepressant overdose
anticholinergic
378
`mad as a hatter....
anticholinergic overdose
379
anticholinergic toxierome s/s
```mad as a hatter - AMSblind as a bat -mydrisasisred as a beethot as a haredry as a bone```
380
rx for anticholinergic overdose
benadryl/atropine, tricyclic antidpressants...atropine for secreationsphysostigimine pushed 1mg/min
381
most important intervention for poisionings/overdose
revert back to ABC & antidote
382
leveling a-line transducer
phelbostatic axis 4th ICS midaxillary
383
dicrotic notch
notch in a-line that represents aortic valve closure
384
a-line waveform feature that represents aortic valve closure
dicrotic notch
385
how to determine proper pressure in a-line system
determine dampening*no more/less than 3 ossillations before returning to baseline
386
too little dampening
many ossillations. too little dampening that the ossillations won't die and continue to reverberate
387
too much pressure in the a-line system
overdampening
388
obstruction in a-line system
overdampened
389
kinded a-line
overdampened
390
air in a-line
overdampened
391
pressure bag overfilled
overdampened
392
Boyle's law on a-line
overdampened
393
what is overdampening
= obstruction in a-line systemtoo much pressure
394
causes of overdampened a-line
obstruction in aline systemkinked alineair in systempressure bag overfilledBoyle's law
395
underdampening
a-line system is too dynamic & has too little pressure
396
a-line if pressure bag isn't full
underdampened -too little pressure
397
a-line if noncompliant tubing
underdampened - too little pressure
398
what does Swan Ganz measure
aka PUlmonary Artery Catheter*right heart preload/afterload*left heart preload
399
insertion site of a Swan Ganz/Pulmonary Artery catheter
central line into subclavin vein
400
what part of the PA catheter is used to measure pressure
distal tip
401
distal tip of the PA catheter
measure pressure
402
how much ml air to measure pressure via PA catheter
do not exceed 1.5ml
403
how to take wedge pressures
PA catheterno more than 1.5ml into distal portdtake at the end of exhalationdon't take for longer than 15 sec or 3 breaths
404
how long to take a wedge pressure
no longer than 15 sec or 3 breaths
405
when do you take a wedge pressure
at the end of exhalation
406
PA catheter PA port
for monitoring/lab samples only
407
PA catheter port for monitoring/lab samples of blood
PA port
408
PA catheter port for infusions/fluids
proximal ports
409
proximal port on PA catheter
influsions/fluids
410
how to transport a pt with a PA catheter
deflate the balloon to prevent an inadgertent wedge pressure when it advances*balloon size increases at altitude b/c Boyle's Law
411
progression of Swan-Ganz
subclavianR atrium/ventricledestination = pulmonary arteryinflate in pulmonary artery to get wedge pressure
412
site where you get the wedge pressure =
pulmonary arteryq
413
dicrotic notch on the left side of PA catheter waveform
RV waveform = tricuspid valve closing
414
dicrotic notch on the right side of the waveform
PA waveform = pulmonic valve closing
415
measures right heart preload
Central venous pressure2-6 mm hg
416
Central venous pressure
CVP = 2-6mm hgright heart preload
417
2-6mm hg
Central Venous PRessure right heart preload
418
Right ventriclar pressure
systolic = 15 - 25mm hgdiastolic = 0-5 mm hg
419
Pulmonary arty pressure
systolic = 15 - 25 mm hgdiastolic = 8-15
420
systolic pressure of right ventricle
15 - 25
421
diastolic pressure of right ventricle
0 - 5
422
systolic pressure of pulmonary artery
15 - 25 mm hg
423
diastolic pressure of pulmonary artery
8-15 mm hg
424
8-15 mm hg
diastolic pressure of pulmonary artery
425
15 - 25 mm hg
systolic pressure of right ventricle & pulmonary artery
426
PAWP
8-12 mm hg
427
8-12 mm hg
PAWP
428
what does PAWP measure
right heart afterloadleft heart preload
429
how to measure left heart preload
PAWP
430
how to measure right heart afterload
PAWP
431
what is normal coronary perfusion pressure
50 - 60 mm hg
432
calculate coronary perfusion prssure
DBP - PAWP= 50 - 60
433
normal CO
4-8L/min
434
normal cardiac index
2.5 - 5 L/min
435
catheter whip
exaggerated waveforms w/elevated systolic pressure and additional peaks (generally only 2 are found) = result of excessive movemnet of the catheter within the artery
436
how to deal w/catheter whip
inflate cuff w/1.5 ml aircoughlay on right side
437
troubleshooting PA/Swan Ganz catheter
catheter whipinadvertent wedge
438
2 cause of inadvertent wewdge
balloon migrationensure the balloon is deflated (Boyle's law)
439
treatment for inadvertent wedge
you'll see a PAWP waveform* deflate the balloon* cough* position pt*withdraw until you see a PA waveform
440
causes of ireased PA pressure
left ventricular failureliver failure/portal HTNcor pulmonary/increased pulmomnary vascular resistancemitral regurg/stenosis
441
why is MAP decreased in hypovolemia
loss of volume
442
central venous pressure in hypovolemia
decreased
443
SVR in hypovolemia
increased
444
CO in cardiogenic shock
decreased
445
central venous pressure in cardiovenic shock
decreased
446
PCWP
pulmonary capillary wedge pressure
447
indirect estimate of left atrial pressure
PCWP = pulmonary capillary wedge pressure
448
PCWP in hypovolemic shock
decreased
449
PCWP in cardiogenic shock
increased
450
normal SVR
800 - 1200
451
800 - 1200
normal SVR
452
normal PVR
50 - 250
453
50 - 250
PVR
454
SVR in neurogenic shock
decreased
455
HR in neurogenic shock
decreased
456
shock w/low HR
neurogenic
457
skin temp in neurogenic shock
cool/moist abovewarm/dry below
458
central venous pressure in late septic shock
decreased
459
PCWP in late septic shock
decreased
460
SVR in late septic shock
increased
461
CO in anaphylaxis
increased
462
CVP in anaphylasis
decreased
463
PCWP in late anaphylaxis
decreased
464
SVR in anaphylaxis
decreased
465
indications for IABP
acute MI w/cardiogenic shockpost CABGcardiogenic due to HF-PAWP over 18-decreased urine output-SBP under 80
466
PAWP where you may need an IABP
PAWP over 18
467
contraindications to IABP -3
low plt b/c hemolysis of RBC smash during inflationaortic insufficiency/disease, severe peripheral vasuclar disease
468
2 effects of IABP
increase coronary perfusiondecrease workload of the heart
469
IABP balloon during systole
deflated
470
IABP balloon during diastole
inflated
471
insertion of IABP
inserted into femoral artery directed towards the heart
472
where does the IABP sit
in descending aortadistal to left subclavian arteryabove renal artery
473
how do you check IABP placement
left radial pusle (left subclavian blockage causes limb ischemia)adequate UOP b/c renal artery artery decreses UOPCXR
474
intervention for IABP if power failure
manually pump every 3-5 minutes to prevent blood from clotting on the balloon
475
IABP at altitude
dont need to purge air b/c self burge
476
transporting IABP
bring exter helium tanks
477
how to tell if IABP balloon has ruptured
rust/brown flankes in IABP tubing -flakes are clotted RBC's inside the tubing
478
rust brown flakes in IABP tubing
IABP balloon has ruptured
479
what happens in IABP if you have normal timing
decreased workloadincreased coronary perfusion
480
early IABP inflation
inflation before the aortic valve closesforces blood back into LV
481
IABP timing error where blood is forced back into the left ventricle
early IABP inflation
482
when does early iABP inflation occur
inflation before the aortic valve closesso blood is forced back into the LV
483
effect of early inflation
HARMFULaortic regurgdecreased COincreased SVR
484
what does early inflation look like
"U" shape
485
when is late inflation of IABP
inflation after the aortic valve closes
486
IABP error when inflation occurs after the aortic valve closes
late inflation
487
appearence of IABP
W
488
W shape of IABP waveform
late inflation
489
U shape of IABP waveform
early inflation
490
problem of late inflation
suboptimal augmentationdecreased coronary perfusion
491
4 shapes of IABP timing errors
early inflation = Ulate inflation = Wlate inflation = cliff shapelate deflation = widened appearence
492
cliff shape of IABP
late inflation
493
shape of late inflation
cliffe
494
shpe of late deflation
widened appearnce
495
widened appearnence of IABP waveform
late deflation
496
problem s of early deflation
decreaed negative pressuredeflation of balloon beore systoleincreased afterload
497
when does the IABP balloon delfate in the timing error of early deflation
deflation of balloon before systole
498
worst IABP timing error
late deflation
499
what happens in late deflation of IABP
inflation of the balloon during systole
500
problems of late inflation IABP
inflation of the balloon during systooleaincreased afterload & workloadharmful/worst tiing erro
