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Icm > Equipment > Flashcards

Equipment Flashcards

1
Q

What are the key components of an arterial line

A

500/1000mls pressurised bag of saline, stiff non compliant tubing, a transducer, a cable connecting it to the monitor and the arterial canula

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2
Q

How does an arterial line work

A

Changes in blood pressure are transmitted via the fluid filled rigid tubing to the pressure transducer. The diaphragm in the transducer responds to these pressure changes which are changed into an electrical signal via the Wheatstone bridge. The electric signal is transmitted via the cable to a microprocessor, amplified and processed to display on the monitor

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3
Q

What level do you zero an arterial line to

A

4th intercostal space, mid clavicular line

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4
Q

If the art line trace looks like a hump, what is wrong and what causes this

A

It is over damped.

Causes by air bubbles, Long thin tubing, kinks in the line, clots, vasospasm

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5
Q

What is resonance and damping

A

Resonance: the natural frequency of a system is the frequency at which it will ocsilate freely. Resonance is the amplification of a signal when it’s frequency is too close to that of the natural frequency of a system

Damping: is the process of the system absorbing the energy or amplification of the oscillations.

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6
Q

How does a passey muir work

A

This is a speaking valve attached to a cuffed or uncuffed tracheostomy tube. This involves a one way valve attached to the ventilator / high flow or nothing that during inspiration opens but closes on expiration. Therefore air is forced around the tube and through the larynx.

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7
Q

What should the cuff pressure be limited to in a trache

A

20-25

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8
Q

Talk me through the bronchial tree

A

Right main bronchus splits into right upper lobar bronchus (leading to the apical segment of the right upper lobe), and the bronchus intermedius. Off the BI is the right middle and the right lower lobe bronchus.

Off the left main bronchus is the left upper which subdivides into the lingular, and the left lower lobe bronchus.

2 upper lobes, 3 middle lobes, 5 lower lobes

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9
Q

Main risks of bronchoscopy

A

Hypoxia, difficult to ventilate, bronchospasm, hyperinflation (barrotrauma and pneumothorax) , raising the ICP, tachycardia, hypertension, bleeding/ damage to the airway.

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10
Q

How does therapeutic hypothermia work

A

Decreased the metabolic rate of the brain which reduces the release of harmful molecules (e.g. free radicals) which stabilises cell membranes

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11
Q

Which patients should be considered for TTM

A

TTM trial 2013

  1. Cardiac arrest with rosc
  2. <15mins between collapse and attempted rosc
  3. < 60mins between collapse and rosc
  4. Comatose and intubated
  5. Systolic > 90 with or without Inotropes
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12
Q

Exclusions for TTM

A

Coma due to a neurological event
Sepsis
Not suitable for ITU
Bleeding / coagulopathy

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13
Q

Complications from cooling

A

Arterial spasm
Bradycardia
Shivering
Hypokalaemia

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14
Q

Effect of cooling on an abg

A

Reduction in measured pco2

Lower k, mg and phosphate

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15
Q

How do we re-warm

A

0.2 -0.5 degrees each hour

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16
Q

How does a PA catheter work ?

A

It is used to measure cardiac output based on the principle of thermodilution.
10mls of cold saline is injected at the proximal and the change in temperature is measured by a thermistor at the distal end. As per the Stuart Hamilton equation the cardiac output is inversely proportional to the change in temperature over time.

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17
Q

Can you talk me through the pressures at each stage of the PA Catheters placement

A

Right atrial pressure 0-6mm
Right ventricular pressure 15-30/ 2-8 diastolic
Pulmonary artery 15-30/ 8-15 diastolic
Pulmonary Capillary wedge pressure 8-15

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18
Q

Contraindications to an NG

A

Base of skull fracture
Oesophageal varicies
Coagulopathy
Nasal surgery

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19
Q

How to estimate the length of an NG

A

Ear lobe to xiphisternum

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20
Q

How far is an NJ inserted

A

100cm

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21
Q

What are the physiological effects of NIV

A 
Larger tidal volumes 
Reduces atelectasis 
Aids recruitment 
Reduces work of breathing 
Decreased left ventricular after load
Reduces left and right ventricular preload
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22
Q

What does the equipment for HFNC consist of

A 
Nasal canula
Face strap 
Heated circuit
Oxygen air blender
Heated humidifier
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23
Q

What flow rates are delivered to the patient on HFNC

A

70l /min

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24
Q

What inspiratory flow rates can a patient generate on HFNC

A

Up to 100l /min

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25
Q

Benefits of HFNC

A

Humidified and heated
Meets the inspiratory needs of the patient - Generate higher flow rates therefore exceed the patients peak inspiratory flow rates
Increase functional residual capacity of the patient
Lightweight
Oxygen dilution is reduced as you don’t entrain air
Wash out of deadspace- high flow rates wash out co2 in deadspace

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26
Q

What are ABCD in the arterial waveform

A

A peak systolic pressure
B diacrotic notch - closure of aortic valve
C map
D diastolic pressure

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27
Q

What is pulse pressure variation.

A

In a mechanically ventilated patient there will be changes in the arterial pressure due to respiration. PP variation is the maximum -minimum / mean of the 2 values and it is expressed as a %

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28
Q

What is pulse contour analysis

A

A measurement of stroke volume variation with each beat using the artierial waveform
It assumes vessel diameter changes are due to cardiac output.

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29
Q

Explain the fick principle

A

Blood flow to an organs can be calculated using a marker substance if the following info is know
The amount of substance taken up in unit/ time
The affluent concentration of marker substance
The effluent concentration of marker substance

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30
Q

What is an ultrasound wave

A

Sound at frequency greater than 20 k hz

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31
Q

What is the relationship between frequency velocity and wavelength

A

Velocity = wave length x frequency

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32
Q

How can you distinguish pericardial from pleural fluid on ECHO

A

Pericardial fluid lies in front of the descending aorta

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33
Q

What is the difference between a Minnesota and S-B tube

A

SB has 3 ports where as Minnesota tube has a 4th port for oesophageal suctioning

The Minnesota tube has 450-500mls in the gastric ballon whereas the SB has 250-300mls

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34
Q

How would you inserted a Minnesota tube

A

Test the ballon integrity and verify the volume with a manometer

Measure from Angle of the mouth to xiphisternum for an estimated depth

Insert the tube to the estimated length under direct Vision

Inflate the gastric ballon 50mls and X-ray to confirm position

Inflate the ballon in increments of 50mls to 450 and check pressure with manometer

Clamp and withdraw the tube and attach traction 500mls bag saline

Oesophageal ballon inflation to 40mmhg if required

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35
Q

What are the complications of a SBT or Minnesota tube

A 
Migration of ballon resulting in via us perforation
Necrosis or oesophagus
Aspiration pneumonia 
Mouth or nose pressure damage
Cardiac arrhythmia
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36
Q

What are the effects on the respiratory system from using cold dry gas

A 
Mucosal dysfunction
Mucosal or epithelium lesions
Decreased compliance
Decreased frc 
Increased energy expenditure
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37
Q

In what situations might a heat and moisture exchanger not perform as well as normal

A

Expired volume is less than inspired (BP fistula)
Hypothermia
High minute ventilation.

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38
Q

What are the risks associated with the use of an Heat and moisture exchanger

A

Obstruction due to secretions blood or vomit
Increased dead space
Increased expiratory resistance

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39
Q

How can condensation in the ventilation tubing circuit cause problems when using active humidification

A

Obstruction of the ventilator circuit
Auto trigger the ventilator
Increased risk of Infection

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40
Q

How can you reduce the risk of condensation in the circuit during active humidification

A

Heat the circuit distal to the humidifier
Add a heated expiratory filter to the circuit
Add a water trap

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41
Q

What is the Doppler effect

A

When a wave strikes a moving object the reflected wave undergoes a proportional change in frequency depending on the velocity of the object.

Increase in frequency when it comes towards and decrease when it moves away

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42
Q

How does tcd work

A

Vasospasm developed due to narrowing of the inter cranial arteries causing a reduction in blood flow and increase in mean blood velocity. Tcd uses Doppler to measure the increase in velocity of blood

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43
Q

What is the lingaard ratio

A

Ratio of blood velocity in MCA to the velocity in the intercranial artery on the same side

Helps to distinguish hyperaemia from vasospasm
> 3 mild / mod vasospasm
> 6 severe

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44
Q

When are patients at greatest risk of vasospasm following an SAH

A

3-14 days

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45
Q

What are the uses of capnography in critical care

A

Et tube placement
Adequate ventilation
Identify bronchospasm
Identify low cardiac output states

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46
Q

How is partial pressure ofco2 measures on critical care

A

Infrared spectrography

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47
Q

How can the absorption of IR light be used to measure the partial pressure of co2

A

The absorption of ir light at 4.3 is proportional to the concentration of pco2
By measuring the degree of absorption and comparing it to references the partial pressure can be determined

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48
Q

2 methods of IR capnography

A

Main stream

Side stream analysers

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49
Q

What do the four phases of capnography waveform represent

A

Phase 1: expiration of co2 from the anatomical dead space

Phase 2: mixed gas from airways and alveoli

Phase 3: gas leaving the alveoli

Phase 0: inspiration

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50
Q

What is the difference between end tidal and arterial partial pressure of co2 and why

A

End tidal usually 2-5 lower due to effect of alveolar dead space (ventilated but not perfused)

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51
Q

Indications for RRT

A 
Severe metabolic acidosis
Symptomatic uraemia 
Fluid overload resistant medical mx 
Hyperkalaemia resistant to medical mx
Poisoning
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52
Q

What is the definition of dose with regards to RrT

A

The volume of blood purified per unit time

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53
Q

What medications are used for RrT anticoagulants

A

Citrate
UF heparin
LMWH
Prostacyclin

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54
Q

What are the risk factors for citrate toxicity with citrate RrT

A 
Hepatic dysfunction 
Hypocalcaemia
Hypoalbuminaemia
Hupothermia
Low cardiac output
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55
Q

What ph range is used for correct ng placement

A

1- 5.5

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56
Q

Describe how to perform a nex measurement for ngt placement

A

Hold exit port to top of nose
Extend length to earlobe
Extend length to xiphisternum

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57
Q

Five questions for correct NG placement

A

Most recent X-ray
Contours of the oesophagus bisect carina
Cross diaphragm in midline
Visible below HD

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58
Q

Causes of damped aerial line trace

A 
Narrow tube
Bubbles
Kinked
Arterial spasm
Clot
Poor flush bag pressure
Over compliant tubing
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59
Q

What changes are seen on an art line when a patient has vasodilation

A

Wide pulse pressure
Low systolic and diastolic bp
Delayed dicrotic notch

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60
Q

What drugs can be used to maintain distal perfusion after accidental injection of a drug

A 
Heparin
Steroids
NSAIDs
Prostacyclin
 thrombolysis 
Ca Chanel blockers
61
Q

Indications for tracheostomy

A 
Upper airway obstruction 
Airway protection 
Wean from mechanical support
Secretion management 
Long term ventilation in neuro msk injury
62
Q

What is the appropriate size of a trache tube

A

No larger 3/4 size of the internal diameter

63
Q

How often measure cuff pressure

Of a trache

A

8 hourly

64
Q

Maximum cuff pressure of a trache

A

25 cm h20

65
Q

How frequently should an established trache’s inner canula be changed

A

30 days

66
Q

Which patients benefit from an adjustable flange

A

Obese
Large neck
Anatomical - mediastinal mass or burns
Low lying trache

67
Q

What was the outcome of Tracman study

A

Compared trache early (around day 4) vs late (at 10days )
All cause mortality at 30 days same (30%)
No effect on critical care LOS
No effect hospital LOS
Decrease in sedation with early

68
Q

What are the benefits of work place based assessments

A

The learner takes ownership of the assessment- promoting active learning
The assessment has high construct and content validity
The assessment is timely
The assessment is structured
The assessment is formative and promotes future learning and development

69
Q

Which canulation configurations are used for Ecmo

A

Venous venous
Central
Venous arterial

70
Q

What are the disadvantages of va Ecmo compared to vv

A

Risk of arterial canulation
Arterial embolisation
Impaired pulmonary / coronary/ cerebral perfusion
Increased lv afterload

71
Q

What are the potential canula options for VV Ecmo

A

IJ to femoral
Femoral to femoral
Single dual lumen in IJ or femoral

72
Q

What are the key components of Ecmo

A 
Cannula 
Blender 
Oxygenator
Heat exchanger
Centrifugal pump
Interface/ console
73
Q

How to reduce recirculation of oxygenated blood within the Ecmo circuit

A

Adjust cannula position
use dual lumen cannula
Change to VA Ecmo

74
Q

Contraindications to an Intraosseous needle

A 
Bone injury at or proximal to site 
Acute ischaemic limb or compartment syndrome 
Burn 
skin or bone infection 
Osteoporosis/ bone fragility
75
Q

Sites for IO insertion

A 
Proximal tibia
Proximal humerus 
Distal tibia 
Distal femur 
Iliac crest
76
Q

Confirmation of positioning of io needle

A

Loss of resistance
Stability of the needle
Aspiration of bone marrow
2mls flush without swelling or resistance

77
Q

Complications of io insertion

A 
Malposition
Pain 
Extravisation
Compartment syndrome
Infection 
Damage to surrounding structures
Disruption of growth plate
78
Q

Which blood tests poorly correlate when taken IO

A 
White cell count
Platelet 
Sodium 
Potassium
Calcium 
Co2
79
Q

What view drains the proximal tibia, the distal tibia and the proximal humerus

A

PT- popliteal vein
DT- great saphenous
Proximal h- axillary

80
Q

What material is an ET tube made from

A

Polyvinyl chloride

81
Q

What is murphy’s eye and what is it for

A

Side hole near tip of ET

Allows gas flow should the end become occluded

82
Q

What is the diameter of the connection at the proximal end of the ET

A

15 mm

83
Q

What is the significance of the code IT in reference to an ET tube

A

Denotes it has been tested to confirm tissue compatibility

84
Q

Indications for a double lumen tube

A

Massive pulmonary haemorrhage
Bronchopleural fistula
Protection of transplanted lung from high pressures
Whole lung lavage

85
Q

How does a right differ from a left Double lumen tube

A

The right sided tube has a ventilation slot to allow for ventilation of the right upper lobe

86
Q

Describe the insertion technique for a blind left sided double lumen tube

A

Insert a stylet into the DLT and perform direct laryngoscopy
Insert the dlt through laryngeal inlet with curved tip facing up
Remove the stylet rotate dlt 90 degrees anti-clockwise and advance to resistance
Inflate tracheal cuff
Confirm etco2
Clamp proximaly to the tracheal cap and inflate the bronchial cuff so that left lung is ventilated. Release clamp and replace cap.
Confirm position with fibre optic bronch

87
Q

What are the risks of a blood transfusion.

A 
Incorrect administration 
Viral infection 1:1.3 million 
Bacterial contamination 
Allergy 
Taco
Trali 
Febrile reaction 1:75
Urticaria 1:100
No longer give blood
88
Q

How to optimise view on direct laryngoscopy

A 
Optimise head and neck position 
Adequate neuromuscular blockade
Attempt with different blade or size 
Video laryngoscopy 
External laryngeal manipulation 
Remove cricoid
89
Q

Recommended max attempts at

Laryngoscopy

A

3 plus 1 expert

90
Q

What is the purpose of a ventricular assist device

A

Supports or replaces the right and left ventricular function

91
Q

How can you classify a VAD

A
  • ventricle supported: right, left, both
  • type of pump; pulsitile , axial flow (impella) centrifugal
  • extra corporeal or Intracorporeal
92
Q

Where does an lvad and RVad take blood from and to

A

Left ventricle to the aorta

Right ventricle to the pulmonary artery

93
Q

Indications for a VAD

A

Bridge to recovery - myocarditis, post transplant
Bridge to transplant- heart failure
Permanent

94
Q

What is the x descent

A

Atrial relaxation

95
Q

What is an A C V wave

A

A is atrial contraction
C closure of TV
V atrial filling prior to TV opening

96
Q

What would be seen on the CVP wave form with significant Tricuspid regurgitation

A

Enlarge V wave with no clear x decent

97
Q

Causes of cannon A waves

A

Complete HB
VT
Junctional rhythm
Avnrt

(When atrial and ventricle contract simultaneously)

98
Q

How is pulmonary hypertension defined

A

Mean pulmonary pressure > 25

At rest on right heart catheterisation

99
Q

What factors affect the fraction of Inspired oxygen via a standard face mask

A

Peak inspiratory flow rate
RR
OXygen flow rate
Mask fit

100
Q

Why do masks have side holes

A

To entrain ambient air when the inspiratory flow exceeds oxygen flow
Alows expired gasses to be flushed out

101
Q

How does a venturi mask provide a fixed fraction of inspired oxygen

A

The oxygen flows through a restriction in the nozzle. The size of the constriction determines the final concentration of oxygen for a given gas flow.

As the flow of oxygen passes through the constriction, a negative pressure is created.

The smaller the orifice is, the greater the negative pressure generated, so the more ambient air entrained, the lower the FiO2.

102
Q

Which adult diseases could worsen with hyperoxic therapy

A

Stroke, copd, mi, head injury, acute lung injury, pulmonary fibrosis,

103
Q

Primary function of an intra aortic balloon pump

A

Increase myocardial oxygen supply
Reduce afterload
Decrease myocardial oxygen demand

104
Q

Why is the balloon of an IABP filled with helium

A

Helium has a low viscosity therefore travels quicker within the tubing and the risk of embolism is lower

105
Q

Where should the tip of an IABp lie

A

2 cm distal to the origin of the left subcalavian

106
Q

What are the absolute and relative contraindications of an IABp

A

Severe AR
Dissection
Aortic stents
No recovery

Severe pvd
Aortic aneurysm
Sepsis
Tachyarrythmias

107
Q

What is lamberts law

A

The absorption of radiation by a substance is directly proportional to the thickness of the absorbing layer

108
Q

What is an isosbestic point in pulse oximetry

A

590 and 805

Wavelengths where absorption of light is equal for oxyhaemoglobin and deoxyhaemoglobin

109
Q

Wave length of the two sources of light in a pulse oximetry

A

660

940

110
Q

How does amyl nitrates cause methhaemoglobinaemia

A

Nitrates oxidise Haem from ferrous 2+ state to ferric 3+ state
Methaemoglobin increases the oxygen carrying capacity of the blood and prevents offloading in the peripheries

111
Q

What shifts the oxygen dissociation curve left

A

Increase ph
Decreased temp, 23 DPG pco2
Presence of methaemoglobin

112
Q

Treatment for amylnitrate poisioning

A

Methylene blue

Oxygen

113
Q

What distance should the pa catheter be inserted to be in the pulmonary artery occlusion pressure the pa and the rv

A

Rv 25
Pa 35
Paop 45

114
Q

How to do an ssep

A

An electrical stimuli is delivered to a peripheral nerve
Scalp electrodes and positioned over the corresponding cortex
The eeg is then recorded to see if the amplitude changes

115
Q

What are the different types of evoked potential measures

A

Brain stem Auditory EP- demyelinating or brain stem lesions

Visual EP- optic neuritis

Somatosensory and motor EP - prognostication

116
Q

What depth place an oesophageal Doppler

A

Nasal - 40-45

Mouth - 35-40

117
Q

What does oesophageal Doppler measure

A

Velocity of blood flow in the descending aorta

118
Q

What assumptions are made when deriving data from the oesophageal Doppler

A

The probe placement is optimal
The aorta is cylindrical
The normogram accurate calculates cross sectional area
No diastolic flow

119
Q 
On an oesophageal Doppler
What is the peak of the triangle 
What is the area under the triangle 
What is the upstroke of the triangle 
What is the base of the triangle
A

Peak -peak velocity ( contractility)
Area - stroke distance(stroke vol)
Upstroke- mean acceleration
Base- flow time

120
Q

Risks of a trache

A 
Bleeding 
Collapsed lung
Scaring windpipe 
Oxygen / bp problems
Wound healing
Death 
Change to voice
121
Q

How is an image generated using a single bronchoscope

A

Led and distal camera

122
Q

What is the difference between cleaning disinfecting and sterilising

A

Cleaning - removal of visible contamination

Disinfecting - removal of organisms able to cause infection

Sterilising - removal of all microbials

123
Q

Methods of sterilising

A

Dry heat
Moist heat
Chemical
Irradiation.

124
Q

What is the relationship between delivered current and thoracic impedance h

A

Delivered current = 1/ thoracic impedance

125
Q

Components of a defib circuit

A 
Transformer 
Switch
Capacitor 
Diode
Inductor coil
126
Q

What is activated clotting time

A

Blood is added to a tube containing a surface activator which triggers the intrinsic pathways and the end point of clot formation is recorded.
Used on bypass or Ecmo - heparin is Troy rated to an act 400-600

127
Q

How does teg work

A 
Blood is inserted into 2 cups
Heated
A pin or torsion wire is inserted 
Cups are rotated 
As the clot forms the pin moves and forms a trace generated by a transducer

Uses kaolin as an activator to accelerate clotting

128
Q

How does rotem work

A

Blood is placed into a cup
Sensory pin is inserted
Pin is attached to a mirror which triggers an LED and detector to generate trace

Extem extrinsic pathway
Intem intrinsic pathway
Fibtem platelet inhibitor - analysed fibrinogen
Aptem detects fibrinolysis

129
Q

What does the r time or clotting time show and what should be given

A

Time until fibrin clot formation

Give ffp or pcc as it indicates if there are clotting factors

130
Q

What does the maximum clot firmness or Ma Time show

And what should be given

A

This is an indication of clot strength

Give platelets or cryoprecipitate

131
Q

What does cryoprecipitate contain

A

Fibrinogen
Factor 7
Factor 8
Vwf

132
Q

What does PCC contain

A

2 7 9 10

Protein c and s

133
Q

What is the k time or the clot formation time, and what should be given

A

Clot kinetics

Give ffp or platelet

134
Q

What is cl30 or clot lysis time

And what should be given

A

Represents fibrinolysis

Give txa

135
Q

What are the benefits of bird

A

Increase lung volumes
Assist sputum clearance
Inspiratory muscle training
Improved oxygenation

136
Q

What is another word for the bird

A

Intermittent positive pressure breathing

137
Q

Tracheostomy approach

A

2 finger breaths above the sternal notch make a transverse incision

Blunt dissect to the tracheal rings

Needle puncture through between 1st and 2nd rings

Insert guide wire then dilate

138
Q

Cricothyroidostomy approach

A

Stabilise thyroid cartilage with left hand

If palp-> horizontal stab, turn 90 then bougie and railroad tube 0.6

If not -> 8cm vertical incision, dissect to membrane, then horizontal -> vertical

139
Q

What blood vessel is often in the way during a tracheostomy

A

Anterior jugular vein

140
Q

How fast can you give fluid via an IO

A

150mls/ min

141
Q

Gauge or IO needle

A

15g

142
Q

Sites of IO access

A 
Proximal humerus 
Proximal tibia
Distal tibia
Femoral
Iliac crest
Sternum
143
Q

Causes of epidural dense motor block

A

Large Bolus anaesthetic
Migration into subarachnoid or extradural
Epidural abscess
Epidural haematoma

144
Q

When does a heat and moisture exchange filter not work optimally

A

Expired vol less than inspired
Hypothermia
High minute ventilation

145
Q

Oxygenated blood wavelengths absorbed on pulse oximetry

A

Absorbs more infra- red (940)

Letting more red (660) pass through

146
Q

How does capnography work

A

Infrared light is passed though gas and falls onto a sensor

The presence of co2 decreases the light reaching the sensor and therefore changes the voltage in the circuit.

147
Q

Which spinal needle has a short bevel cutting tip

A

Quincke type

148
Q

Which spinal needle has an atraumatic pencil tip

A

Whitacre

149
Q

What level does the spinal cord end

A

Typically it becomes the cauda equina l1-2

Icm (16 decks)

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