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Flashcards in Med Surg HESI Deck (123)
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1

Emergency Community Disaster Plan

2

Red tag triage

  • Immediate care, Emergent
  • Example: a major hemorrhagic wound/internal bleeding, airway compromise, shock, facture with no distal pulse
  • trauma victims, clients with chest pain, clients with severe respiratory distress or cardiac arrest, clients with limb amputation, clients with acute neurological deficits, and clients who have sustained chemical splashes to the eyes.

 

3

Yellow Tag Triage

  • major injuries, need treatment within 30 minutes to 2 hours.
  • open fractures with a distal pulse and large wounds

4

Green Tag Triage

  • minor injuries that can be managed in a delayed fashion, generally more than 2 hours.
  • Examples include closed fractures, sprains, strains, abrasions, and contusions

5

Black Tag Triage

  • The victim is either deceased or is not expected to live.
  • open fracture of cranium with brain damage, multiple penetrating chest wounds

6

Multiple Organ Dysfunction

  • the progressive dysfunction of two or more organ systems as a result of an uncontrolled inflammatory response to severe illness or injury

7

Refractory stage of shock

  • Occurs when too much cell death and tissue damage result from too little oxygen reaching the tissues.
  • The sequence of cell damage caused by massive release of toxic metabolites and enzymes is termed multiple organ dysfunction syndrome (MODS).
  • Once the damage has started, the sequence becomes a vicious cycle as more dead and dying cells open and release metabolites.
    • These trigger small clots (microthrombi) to form, which block tissue perfusion and damage more cells, continuing the devastating cycle.
    • Liver, heart, brain, and kidney function are lost first.

8

Trauma Priority 

1. Airway/cervical spine

  • Establish a patent airway by positioning, suctioning, and oxygen as needed.
  • Protect the cervical spine by maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury.

2. Breathing

  • Assess breath sounds and respiratory effort.

9

Sepsis Care Bundle (First 3 hours)

1. Measure serum lactate levels.

2. Obtain blood cultures before administering antibiotics.

3. Administer broad-spectrum antibiotics.

4. If either hypotension or a serum lactate level greater than 4 mmol/L (36 mg/dL) is present, administer 30 mL/kg crystalloids intravenously.
 

10

Sepsis Care Bundle (3 hours after 1st 3 hours)

5. Administer prescribed vasopressors for hypotension that does not respond to initial fluid resuscitation measures to maintain MAP ≥65 mm Hg.

6. If arterial hypotension persists despite fluid volume resuscitation (indicating septic shock) or lactic acid remains ≥4 mmol/L (36 mg/dL), institute these assessments:

• Measure central venous pressure.

• Measure central venous oxygen saturation.

7. Re-measure lactic acid (lactate) level if initial value was elevated.

11

Hypovolemic Shock (Sepsis meds)

Vasoconstrictors​
 

  • Improve mean arterial pressure by increasing peripheral resistance, increasing venous return, and increasing myocardial contractility.
    • Dopamine (Intropin, Revimine image)
    • Norepinephrine (Levophed)
    • Phenylephrine HCl

1. Assess patient for chest pain.

2.Drugs increase myocardial oxygen consumption.

3.Monitor urine output hourly.

4.Higher doses decrease kidney perfusion and urine output.

12

Hypovolemic Shock (Sepsis meds)

Inotropic Agents

  • Directly stimulate beta adrenergic receptors on the heart muscle, improving contractility
    • Dobutamine (Dobutrex)
    • Milrinone (Primacor)

13

Hypovolemic Shock (Sepsis meds)

Agents Enhancing Myocardial Perfusion

  • Improve myocardial perfusion by dilating coronary arteries rapidly for a short time.
    • Sodium nitroprusside (Nitropress)

14

Hemodynamic monitoring 

  • The primary goal of hemodynamic monitoring is to assess and trend adequacy of tissue perfusion, rather than to compare a patient's values to so-called normal parameters.

15

The invasive catheter

  • The catheter can be placed into an artery, a vein, or the heart.
  • An arterial catheter consists of a relatively small-gauge, short, pliable catheter that is placed over a guidewire or in a catheter-over-needle system.
  • CVP or central venous oxygen saturation (ScvO2) monitoring is obtained through a central venous catheter (CVC), most commonly placed in the subclavian or internal jugular veins
  • Pulmonary artery (PA) pressure and mixed venous oxygen saturation (SvO2) monitoring requires a longer catheter that is placed into the PA

16

Noncompliant pressure tubing

  • designed specifically for hemodynamic monitoring is used to minimize artifact and increase the accuracy of the data transmission.
  • .In order to maintain the most accurate pressure readings the tubing should be no longer than 36 to 48 inches, with a minimum number of additional stopcocks

17

The transducer

  • translates intravascular pressure changes into waveforms and numeric data. To ensure that the data are accurate, the system must be calibrated to atmospheric pressure by zeroing the transducer.
    • A three-way stopcock attached to the transducer is generally used as the reference point for zeroing and leveling the system.
    • This is referred to as the air-fluid interface or the zeroing stopcock

18

The flush system

  • maintains patency of the pressure tubing and catheter.
  • A solution of 0.9% normal saline is recommended for the flush system.
    • The flush solution is placed in a pressure bag that is inflated to 300 mm Hg to ensure a constant flow of fluid through the pressure tubing.
    • The rate of fluid administration varies from 2 to 5 mL/hr per lumen.

19

Patient positioning (cath)

  • HOB elevated up to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis

20

Zero referencing 

  • the zeroing stopcock of the transducer is opened to air (closed to the patient), and the monitoring system is calibrated to read a pressure of 0 mm Hg.
  • Clinical protocols determine when it is necessary to zero the system, but in general zero referencing is done when:

1. The catheter is inserted

2.At the beginning of each shift

3.when the patient is disconnected or moving the patient

4. When there are significant changes in hemodynamic status

21

Leveling the air-fluid interface

  • The zeroing stopcock of the transducer system must be positioned at the level of the atria and PA for accurate readings.
    • This external anatomical location is termed the phlebostatic axis.
    • located by identifying the fourth intercostal space at the midway point of the anterior-posterior diameter of the chest wall.
    • Once the level of the phlebostatic axis is identified, the transducer and zeroing stopcock can be secured to the chest wall or to a standard intravenous pole positioned near the patient.
      • assess skin integrity to prevent skin breakdown
    • Variations in the height of the transducer system by as little as 1 cm below the phlebostatic axis can result in a false elevation by as much as 0.73 mm Hg
      • must be regularly monitored and releveled with each change in the patient's position

22

Square wave test

  • To verify that the transducer system can accurately represent cardiovascular pressures
    • done by recording the pressure waveform while activating the fast flush valve/actuator on the pressure tubing system for at least 1 second
    • The resulting graph should depict a rapid upstroke from the baseline with a plateau before returning to the baseline.
    • Upon the return of the pressure tracing to the baseline, a small undershoot should occur below the baseline, along with one or two oscillations, within 0.12 seconds before resuming the pressure waveform.
      • should be performed after catheter insertion, at least once per shift, and after opening the system

23

Mechanical ventilation

  • purpose of mechanical ventilation is to support the respiratory system until the underlying cause of respiratory failure can be corrected.

24

A clinical definition of respiratory failure is as follows:

  1. PaO2 ≤60 mm Hg on a FiO2 greater than 0.5 (oxygenation)
  2. PaCO2 ≥50 mm Hg, with a pH of 7.25 or less (ventilation)
  3. rapid, shallow breathing
  4. increase in the WOB as evidenced by increased use of the accessory muscles of ventilation
  5. abnormal breathing patterns
  6. complaints of dyspnea

25

Nasotracheal intubation

  • used when there is no time to obtain radiographs of the cervical spine but it is contraindicated if there is any sign of facial trauma
  • Suspect spinal cord injury= no oral airway

26

Cricothyrotomy

  • may be necessary as surgical airway for patients with maxillofacial trauma, laryngeal fractures, upper airway burns, airway edema or hemorrhage

27

cardiogenic shock

  • necrosis of more than 40% of the left ventricle occurs. Most patients have a stuttering pattern of chest pain.
  • Signs:
  1. Tachycardia
  2. Hypotension
  3. Systolic BP less than 90 mm Hg or 30 mm Hg less than the patient's baseline
  4. Urine output less than 0.5-1 mL/kg/hr
  5. Cold, clammy skin with poor peripheral pulses

  6. Agitation, restlessness, or confusion

  7. Pulmonary congestion

  8. Continuing chest discomfort

28

clinical presentation of cardiogenic shock

  • left ventricular failure
    • S3 heart sound, crackles, dyspnea, hypoxemia
  • right ventricular failure
    • jugular venous distention, peripheral edema, hepatomegaly

29

Pressures in cardiogenic shock

  • cardiac output and cardiac index decrease
    • Normal CO 4-8
    • Normal CI 2.5-4.2
  • RAP, pulmonary artery pressure (PAP), and PAOP increase as pressure and volume back up into the pulmonary circulation and the right side of the heart
    • RAP 2-6
    • PAP Systolic 15-25
    • PAP Diastolic 8-15
    • POAP 8-12

30

Managment for Cardiogenic shock

  1. Improve contactility with inotropic medications
    1. Dopamine and dobutamine
  2. Mechanical support
  3. Emergency Revascularization
  4. Reduce preload and afterload
  5. Prevent/treat dysrhythmias