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Flashcards in Med Surg HESI Deck (123):
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.

 

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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

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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

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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

31

Drug therapy (AIDS)

  • A common respiratory infection among people with HIV disease is P. jiroveci pneumonia (PCP).
    • trimethoprim with sulfamethoxazole (Apo-Sulfatrim , Bactrim, Cotrim, Septra)
    • Pentamidine isethionate (Pentacarinat , Pentam), usually given IV or IM
    • Other drug therapies include bronchodilators to improve airflow, as well as dapsone (Avlosulfon) and atovaquone (Mepron), which can be used as alternative therapies to trimethoprim-sulfamethoxazole for existing PCP or as prophylaxis.

32

Rest and activity changes (AIDS)

  • Most patients with HIV/AIDS have fatigue, especially when respiratory problems also are present. 
  • Consult with the patient to pace activities to conserve energy.
    • Guide the patient in active and passive range-of-motion (ROM) exercises.
    • Schedule non–time-critical activities, such as bathing, so that he or she is not fatigued at mealtime.

33

Major complications of arterial pressure monitoring

  • thrombosis
  • embolism
  • blood loss
  • infection

Determine the presence of adequate collateral circulation with the Allen’s test before drawing ABGs

If pinkness does not return to hand within 6-7 secs after releasing pressure on ulnar artery, choose another arterial puncture site

34

Women - MI

Women do not experience pain in the chest but, instead, feel discomfort or indigestion.

  • Indigestion or feeling of abdominal fullness
  • chronic fatigue despite adequate rest and feelings of an “inability to catch my breath” (dyspnea)
  • sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike

Age is the most important risk factor for developing CAD in women. The older a woman is, the more likely she will have the disease

35

Nursing Assessment: serum cardiac markers

  • Troponin T and I are myocardial muscle proteins released after MI or injury with greater sensitivity and specificity for myocardial damage than CK-MB. Increase 3-12 hours, peak at 10-24, and return 5-14 days later.
  • Normal: 0-0.10

36

Barotrauma

  • includes pneumothorax, subcutaneous emphysema, and pneumomediastinum
  • highest risk for barotrauma have chronic airflow limitation (CAL), have blebs or bullae, are on PEEP, have dynamic hyperinflation, or require high pressures to ventilate the lungs (because of “stiff” lungs, as seen in acute respiratory distress syndrome [ARDS]).
  • Ventilator-induced lung injury can be prevented by using low tidal volumes combined with moderate levels of PEEP, especially in patients with acute lung injury (ALI) or ARDS.

37

Pneumothorax occurs

  • Alert the health care provider or Rapid Response Team about a new onset of decreased breath sounds or unequal chest excursion, which may be due to pneumothorax.
  • Auscultate breath sounds.

38

tension pneumothorax

  • When tension pneumothorax occurs, pressurized air enters the pleural space. Air is unable to exit the pleural space and continues to accumulate.
  • Treatment consists of immediate insertion of a chest tube or a needle thoracostomy.
  • Whenever a pneumothorax is suspected in a patient receiving mechanical ventilation, the patient should be removed from the ventilator and ventilated with a bag-valve device until a needle thoracostomy is performed or a chest tube is inserted.

39

 Asystole

Nonshockable rhythm (DO NOT DEFIB)

  1. Continue CPR for 2 minutes
  2. Obtain intravenous (IV)/intraosseous (IO) access
  3. Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2)
  4. 5. Administer vasopressor (epinephrine q3-5min)

    6. Check pulse and rhythm (every 2 minutes)

40

MODS- Hypergylcemia

  • The continued stress response triggers the continued release of glucose from the liver and causes hyperglycemia.
  • The more severe the response, the higher the blood glucose level 
  • Hyperglycemia and insulin resistance are common in the patient with sepsis
  • Suggest that the target be less than 180 mg/dL. On the basis of those results, normal blood glucose levels may not be the clinical goal
  • Insulin therapy is used to maintain blood glucose levels between 110 mg/dL and 150 mg/dL.

41

ICU/Sepsis Med

  • a drug regimen may indicate a disorder or problem that can contribute to sepsis. These drugs include aspirin, corticosteroids, antibiotics, and cancer therapy drugs.
  • Drug therapy to enhance cardiac output and restore vascular volume is essentially the same as that used in hypovolemic shock
  • IV antibiotics with known activity against gram-negative bacteria are given before organisms are identified, preferably within 1 hour of a sepsis diagnosis (After blood cultures are taken)

42

adrenal insufficiency (Sepsis)

  • The stress of severe sepsis can cause adrenal insufficiency.
  • Adrenal support may involve providing the patient with low-dose corticosteroids during the treatment period.
    • Drugs used for this purpose are IV hydrocortisone and oral fludrocortisone (Florinef

43

High Pressure Alarm

  • sounds when peak inspiratory pressure reaches the set alarm limit :usually set 10-20 mm Hg above the patient's baseline PIP
  1. Increase secreations
  2. Pt coughs, gags, bites tube
  3. Anxious, fights ventilator
  4. Airway size decreases
  5. Pneumothorax occurs
  6. The artificial airway is displaced; the ET tube may have slipped into the right mainstem bronchus.
  7. Kink in tube

44

Low exhaled volume

  • sounds when there is a disconnection or leak in the ventilator circuit or a leak in the patient's artificial airway cuff
  1. Leak in ventilator
  2. Pt stops breathing
  3. Leak in cuff occurs

ASSESS PT

45

Electrical Burn

  • Deep muscle injury may be present even when superficial muscles appear normal or uninjured.
  1. ​Thermal burns occur when clothes ignite from heat or flames produced by electrical sparks.
  2. External burn injuries can occur when the electrical current jumps, or “arcs,” between two body surfaces. These injuries usually are severe and deep.
  3. True electrical injury occurs when direct contact is made with an electrical source. Internal damage results and can be devastating

 

46

Immediate treatment of electrical injuries

involves prompt removal of the patient from the electrical source while protecting the rescuer

  • course of flow is defined by the locations of the “contact sites,” which are the entrance and exit wound
  • All patients with electrical injury are monitored closely for cardiac dysrhythmias.
  • If present, continuous cardiac monitoring or serial electrocardiographic evaluations continue for at least 24 hours after injury
  • Tea-colored urine indicates the presence of hemochromogens (myoglobin), released as a result of severe deep tissue damage in a process called rhabdomyolysis

47

ET tube verification

  1. The most accurate ways to verify placement are by checking end-tidal carbon dioxide levels and by chest x-ray
  2. Assess for breath sounds bilaterally, sounds over the gastric area, symmetric chest movement, and air emerging from the ET tube

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48

Medical treatment for shock 

  • Correct decreased tissue perfusion and restore cardiac output

1. oxygenation and ventilation 
2. Fluid resuscitation 
3. Drug therapy 
4. Monitor closely

49

Medical treatment interventions: drugs that increase preload (2)

1. blood products 
2. crystalloids

50

Medical treatment interventions: drugs that increase after load (2)

1. vasopressors 
2. dopamine

51

SHOCK: when administering vasopressors or adrenergic stimulators (epinephrine, dopamine, dobutamine, norepinephrine, isoproterenol) (4)

1. administer thru volume-controlled pump
2. monitor hemodynamic status q 5-15 min 
3. site site: tissue damage 
4. ask HCP for targeted mean systolic BP (usually 80-90)

52

Acute respiratory distress syndrome (ARDS)

Abnormal lung sounds are not heard on auscultation because the edema occurs first in the interstitial spaces and not in the airways

acute respiratory failure with these features:

• Hypoxemia that persists even when 100% oxygen is given (refractory hypoxemia, a cardinal feature)

• Decreased pulmonary compliance

• Dyspnea

• Noncardiac-associated bilateral pulmonary edema

• Dense pulmonary infiltrates on x-ray (ground-glass appearance)

Cyanosis is a late sign of hypoxemia and should not be relied on as an early warning of distress

53

Noninvasive positive-pressure ventilation (NPPV)

  • the delivery of mechanical ventilation without an ETT or tracheostomy tube.
  • is indicated for the treatment of acute exacerbations of COPD

54

ARDS and COPD can cause

RIGHT SIDED HEART FAILURE

55

The diagnosis of ARDS is established by

  1. lowered partial pressure of arterial oxygen (Pao2) value (decreased gas exchange and oxygenation), determined by arterial blood gas (ABG) measurements

56

A premature atrial contraction (PAC)

  • is a single ectopic beat arising from atrial tissue, not the sinus node.
  • The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm.
  • The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat.

57

Bigeminy

exists when normal complexes and premature complexes occur alternately in a repetitive two-beat pattern, with a pause occurring after each premature complex so that complexes occur in pairs.

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58

PAC Symptoms and treatment

The patient usually has no symptoms except for possible heart palpitations. No intervention is needed except to treat causes such as heart failure

59

Beta-Blockers

60

Once-a-day beta-adrenergic blocking agents

  • decrease the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in patients with MI.
  • The physician usually prescribes a cardioselective beta-blocking agent within the first 1 to 2 hours after an MI if the patient is hemodynamically stable.
  • Beta blockers slow the heart rate and decrease the force of cardiac contraction

61

Central venous pressure (CVP)

  • is the pressure within the superior vena cava; it reflects the pressure under which blood is returned to the superior vena cava and right atrium.
  • The CVP is measured with a central venous line in the superior vena cava.
  • Normal CVP pressure is about 2 to 6 mm Hg.
  • An elevated CVP indicates an increase in blood volume as a result of sodium and water retention, excessive IV fluids, alterations in fluid balance, or kidney failure

62

Measuring CVP

  1. The right atrium is located at the midaxillary line at the fourth intercostal space; the zero point on the transducer needs to be at the level of the right atrium.
  2. The client needs to be supine, with the head of the bed at 45 degrees.
  3. The client needs to be relaxed; note that activity that increases intrathoracic pressure, such as coughing or straining, will cause false increases in the readings.
  4. If the client is on a ventilator, the reading should be taken at the point of end-expiration.
  5. To maintain patency of the line, a continuous small amount of fluid is delivered under pressure.

63

Elevated CVP

  • hypervolemia (seen with aggressive administration of intravenous fluids)
  • severe vasoconstriction
  • mechanical ventilation (additional positive pressure increases RAP).
  • Conditions causing RAP increase include
    • pulmonary hypertension
    • right-sided heart failure (often seen in cardiac ischemia of the right heart, causing a backup of blood into the right side of the heart).

64

Four major components for validating the accuracy of hemodynamic monitoring systems are

(1) patient positioning,

(2) zeroing the transducer

(3) leveling the air-fluid interface (zeroing stopcock) to the phlebostatic axis

(4) assessing dynamic responsiveness (performing the square wave test).

65

pulmonary artery catheter

  • is a multi-lumen catheter with the capacity to measure right atrial and indirect left atrial pressures or pulmonary artery wedge pressure (PAWP), also known as the pulmonary artery occlusive pressure (PAOP). 
  • The PAWP is a mean pressure and normally ranges between 8 and 12 mm Hg.
  • Elevated PAWP measurements may indicate
    • left ventricular failure
    • hypervolemia
    • mitral regurgitation
    • intracardiac shunt.
  • A decreased PAWP is seen with hypovolemia or afterload reduction. Individual values may be less important than the trend in values.

66

PA cath proximal port

lies in the right atrium and measures RAP; it is also used to administer fluids and electrolytes and to obtain intermittent thermodilution CO measurements

Normal RAP - 2-6

 

67

Distal PA Cath port

port measures PAP and PA occlusion pressure (PAOP); mixed venous blood samples are also drawn from this port

Normal PAP 10-20

Normal POAP 8-12

68

PA cath requires

Infromed consent

69

How to insert a PA cath

1.bed is placed in Trendelenburg position to promote venous filling in the upper body for easier insertion of the catheter, unless the patient has respiratory distress or increased intracranial pressure. This position can also prevent air embolism during insertion.

If Trendelenburg position is contraindicated, a blanket roll can be placed between the patient's shoulder blades to facilitate insertion.

The skin is cleaned and draped and is then injected with a local anaesthetic.

A needled syringe is used to puncture the vessel and to confirm placement by backward flow of blood into the syringe.

The syringe is removed, and a guidewire is threaded through the needle into the vessel.

70

The PAOP waveform signals

the end of insertion, at which time the balloon is deflated. Once the balloon is deflated, the tip of the catheter falls back into position in the PA.

Nursing priorities are to accurately interpret PA catheter waveforms, recognize effect of respiratory variations, prevent complications, and document hemodynamic values. Graphing the pressure waveforms and ECG tracing is also recommended

71

Position of pulmonary artery (PA) catheter and associated waveforms.

1.Dual-channel tracing of cardiac rhythm with pressure waveforms obtained as the PA catheter is inserted into the right atrium (RA) and right ventricle (RV). 

2.Dual-channel tracing of cardiac rhythm with PA, and pulmonary artery occlusion pressure (PAOP) waveforms as the catheter is floated into proper position.

72

Several pressures and parameters are measured and/or calculated by the PA catheter:

RAP; PA systolic (PAS), PA diastolic (PAD), and PA mean pressures (PAPm); PAOP; pulmonary and systemic vascular resistance (PVR and SVR); and CO

73

The PAOP is obtained when the balloon of the PA catheter is inflated to

  • wedge the catheter from the PA into a small capillary.
  • The resulting pressure reflects the left atrial pressure and left ventricular end-diastolic pressure when the mitral valve is open.
  • When properly assessed, the PAOP is a reliable indicator of left ventricular function.
  • Normal PAOP is 8 to 12 mm Hg.
  • The PAOP is measured at regular intervals as ordered by the provider, or in accordance with unit protocols.
  • The measurement is obtained by inflating the balloon with no more than 1.5 mL of air, for no longer than 8 to 10 seconds, while noting the waveform change from the PAP to the PAOP.
  • To obtain accurate measurement of the PAOP, the critical care nurse must print the PAOP waveform simultaneously with the ECG waveform and respiratory patterns.
  • Similar to RAP, PAP and PAOP measurements must be obtained at end expiration.  

74

PAWP (PAOP) Measurement 

If the PAOP is obtained with a much smaller amount of air, the catheter may have migrated further into the PA.

The nurse should never force the balloon to inflate if resistance is met.

If the PAOP is not noted with inflation of 1.5 mL of air, the catheter may have been pulled out of position, or the balloon may have ruptured.

In both of these situations, verification of proper positioning by a chest x-ray and observation of the PAP waveform are important interventions

75

How to recognize an inferior STEMI

  • ST elevation in leads II, III and aVF
  • Progressive development of Q waves in II, III and aVF
  • Reciprocal ST depression in aVL (± lead I)
  • Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction. These patients may develop severe hypotension in response to nitrates and generally have a worse prognosis
  • A displacement in the ST segment can indicate myocardial ischemia or injury. 
    • If ST displacement is noted and is a new finding, a 12-lead ECG is performed and the provider notified.
    • The patient is assessed for signs and symptoms of myocardial ischemia

76

ST elevation and Depression

ST elevation or depression is significant if displacement is 1 mm (one small box) or more above or below the line and is seen in two or more leads.

ST elevation may indicate problems such as myocardial infarction, pericarditis, and hyperkalemia.

ST depression is associated with hypokalemia, myocardial infarction, or ventricular hypertrophy.

77

Ventricular tachycardia

  • is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles.
  • It is characterized by at least three PVCs in a row.
  • VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute.

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78

VT s/s

Symptoms include chest pain, fainting, dizziness, and shortness of breath.

  • Assess the patient's airway, breathing, circulation, level of consciousness, and oxygenation level.
  • For the stable patient with sustained VT, administer oxygen and confirm the rhythm via a 12-lead ECG. Amiodarone (Cordarone), lidocaine, or magnesium sulfate may be given.

79

Drug therapy for burns

  • requires opioid analgesics (e.g., morphine sulfate, hydromorphone [Dilaudid], fentanyl) and non-opioid analgesics
  • During the resuscitation phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach.
  • When given IM or subcutaneously, these drugs remain in the tissue spaces and do not relieve pain.
  • In addition, when edema is present, all the doses are rapidly absorbed at once when the fluid shift is resolving.
  • This delayed but rapid absorption can result in lethal blood levels of opioids.
  • Morphine is the drug of choice, and IV administration is the route of choice

80

Vasoconstrictors (Dopamine)

  • Improve mean arterial pressure by increasing peripheral resistance, increasing venous return, and increasing myocardial contractility.
  • Monitor urine output hourly.

    Assess blood pressure every 15 min.

    Assess the patient for headache.

    Assess every 30 min for extravasation; check extremities for color and perfusion.

    Assess for chest pain.

Used in low CO states or vasodilatory states (distributive shock) to restore vascular tone Dose-dependent effect

At 2-10 mcg/kg/min 

81

Barotrauma

  • includes pneumothorax, subcutaneous emphysema, and pneumomediastinum.
  • Patients at highest risk for barotrauma have chronic airflow limitation (CAL), have blebs or bullae, are on PEEP, have dynamic hyperinflation, or require high pressures to ventilate the lungs (because of “stiff” lungs, as seen in acute respiratory distress syndrome [ARDS]).
  • Ventilator-induced lung injury can be prevented by using low tidal volumes combined with moderate levels of PEEP, especially in patients with acute lung injury (ALI) or ARDS.

82

Because one of the side effects of PEEP is tension pneumothorax, assess

  • lung sounds hourly and suction as often as needed to maintain a patent airway.

83

Open and closed pneumothorax

  • The pneumothorax can be open (pleural cavity is exposed to outside air, as through an open wound in the chest wall)
  • closed (such as when a patient with chronic obstructive pulmonary disease [COPD] experiences a spontaneous pneumothorax). Assessment findings commonly include:

• Reduced breath sounds on auscultation

• Hyperresonance on percussion

• Prominence of the involved side of the chest, which moves poorly with respirations

• Deviation of the trachea away from the side of injury (tension pneumothorax)

84

Treatment of pneumothorax

  • Treatment consists of immediate insertion of a chest tube or a needle thoracostomy.
  • Whenever a pneumothorax is suspected in a patient receiving mechanical ventilation, the patient should be removed from the ventilator and ventilated with a bag-valve device until a needle thoracostomy is performed or a chest tube is inserted.

85

Rule of nines

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86

Tylenol OD

  • causes liver damage which causes the liver to release metabolites and enzymes into the body…leading to MODS.

87

End-of-life care/ Corneal Dryness

  • Tear production is reduced, in aging resulting in dry eyes, discomfort, and increased risk for corneal damage or eye infections.   
    • Teach about the use of saline eyedrops to reduce dryness.
  • Teach patient to increase humidity in the home.
  • If patient is an organ donor be sure to clean eyes with saline asap and place gauze soaked with saline over eyes and elevate head.

88

Heat Stroke

  • a true medical emergency in which body temperature may exceed 104° F (40° C).
  • It has a high mortality rate if not treated in a timely manner.
  • The victim's thermoregulation mechanisms fail and cannot adjust for a critical elevation in body temperature.
  • If the condition is not treated or the patient does not respond to treatment, organ dysfunction and death can result.

89

Heat Stroke S/S

  • Body temperature more than 104° F (40° C)
  • Hot and dry skin; may or may not perspire
  • Mental status changes, such as:
    •  Acute confusion
    •  Bizarre behavior
    •  Anxiety
    •  Loss of coordination
    •  Hallucinations
    •  Agitation
    •  Seizures
    •  Coma

• Vital sign changes, including:

  •  Hypotension
  •  Tachycardia
  •  Tachypnea (increased respiratory rate)
  • Electrolyte imbalances, especially sodium and potassium
  • Decreased renal function (oliguria)
  • Coagulopathy (abnormal clotting)
  • Pulmonary edema (crackles)

90

At the Scene the scene of Heat Stroke

• Ensure a patent airway.

• Remove the patient from the hot environment (into air-conditioning or into the shade).

• Remove the patient's clothing.

• Pour or spray cold water on the patient's body and scalp.

• Fan the patient (not only the person providing care, but all surrounding people should fan the patient with newspapers or whatever is available).

• If ice is available, place ice in cloth or bags and position the packs on the patient's scalp, in the groin area, behind the neck, and in the armpits.

• Contact emergency medical services to transport the patient to the emergency department.

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Labs

Serum creatinine 0.5-1.2mg/dL

Blood urea nitrogen 10-20 mg/dL

Serum sodium 136-145 mEq/L

Serum potassium 3.5-5.0 mEq/

Serum phosphorus (phosphate) 3.0-4.5 mg/dL;

Serum calcium 9.0-10.5 mg/dL;

Serum magnesium 1.3-2.1 mEq/L;

Serum chloride98-106meq/dl

Arterial blood pH 7.35-7.45

Arterial blood bicarbonate HCO3: 21-28 mEq/L

Arterial blood Paco2 35-45 mm Hg

Arterial SPO295%-100%

Arterial Pa02- 80-100

CO2 23-30meq/dl

Hemoglobin 12-18g/dL

Hematocrit Female: 37%-52%

RBC 4.2-6.1

WBC 5000-10000

PT 11-12.5 sec

INR 0.7-1.8

APTT 30-40 sec

92

At the hosptial with Heat Stroke

  • Give oxygen by mask or nasal cannula; be prepared for endotracheal intubation.
  • Start at least one IV with a large-bore needle or cannula.
  • Administer normal saline (0.9% sodium chloride) as prescribed, using cooled solutions if available.
  • Use a cooling blanket.
  • Do not give aspirin or any other antipyretics.
  • Insert a rectal probe to measure core body temperature continuously, or use a rectal thermometer and assess temperature every 15 minutes.
  • Insert an indwelling urinary drainage catheter.
  • Monitor vital signs frequently as clinically indicated.
  • Obtain baseline laboratory tests as quickly as possible: serum electrolytes, cardiac enzymes, liver enzymes, and complete blood count (CBC).
  • Assess arterial blood gases.
  • Administer muscle relaxants (benzodiazepines) if the patient begins to shiver.
  • Measure urine output and specific gravity to determine fluid needs.
  • Stop cooling interventions when core body temperature is reduced to 102° F (39° C).
  • Obtain urinalysis, and monitor urine output.

 

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Methods for Rapid cooling

Removing clothing

• Placing ice packs on the neck, axillae, chest, and groin

• Immersing the victim in cold water

• Wetting the patient's body with cold water and then fanning rapidly to aid in cooling by evaporation

  • Drenching the victim with large amounts of icy water may be the fastest, most effective means to reduce core body temperature.

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hypovolemic shock

a loss of blood volume from the vascular space, resulting in a decreased mean arterial pressure (MAP) and a loss of oxygen-carrying capacity from the loss of circulating red blood cells (RBCs).

  • lead to anaerobic (without oxygen) cellular metabolism.

95

Treatment for hypovolemia 

  • Isotonic crystalloids such as normal saline are generally used first, although blood and blood products may be administered if the patient is bleeding.

96

Vasoconstrictors for hypovolemia

  • Improve mean arterial pressure by increasing peripheral resistance, increasing venous return, and increasing myocardial contractility.
    • Dopamine (Intropin, Revimine )
      Norepinephrine (Levophed)
      Phenylephrine HCl
      • Asses chest pain
      • Monitor urine output
      • Asses BP q15mins
      • Asses headache
      • Assess every 30 min for extravasation; check extremities for color and perfusion.

97

Inotropic Agents for hypovolemia

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

98

Agents Enhancing Myocardial Perfusion for Hypovolemia

  • Improve myocardial perfusion by dilating coronary arteries rapidly for a short time.
    • Sodium nitroprusside (Nitropress, Nipride)
      • Protect drug container from light.
      • Assess BP

99

STEMI treatment

  • Thrombolytic therapy is given in a unit where the patient can be continuously monitored.I
  • t is indicated for chest pain of longer than 30 minutes' duration that is unrelieved by nitroglycerin, with indications of STEMI by the ECG. 
  • It is not indicated for the NSTEMI patient population.
  • The goal is to start the infusion of fibrinolytics within 30 minutes of ED admission.
  • Contraindications include recent abdominal surgery or stroke, because bleeding may occur when fresh clots are lysed (broken down or dissolved).
  • (For treatment to be considered, the patient must be symptomatic for less than 6 hours, have pain for 20 minutes that was unrelieved by NTG, and have a 12-lead ECG with an ST-segment elevation of 1 mm or greater in two or more contiguous ECG leads or an ST-segment depression of 0.5 mm or greater.)

100

torsades de pointes

  • is a type of VT that is caused by a prolonged QT interval
  • Hypomagnesemia prolongs the QT interval, causing this specific type of ventricular tachycardia.
  • This lethal dysrhythmia is treated as pulseless VT.
  • Magnesium administered IV may terminate or prevent recurrent torsades de pointes in patients who have a prolonged QT interval
  • When VF/pulseless VT cardiac arrest is associated with torsades de pointes, 1 to 2 g of magnesium sulfate diluted in 10 mL of D5W is given IV/IO over 5 to 20 minutes.
  • In nonarrest situations, a loading dose of 1 to 2 g mixed in 50 to 100 mL of D5W is given over 5 to 60 minutes

101

Tension Pneumothorax

  • a rapidly developing and life-threatening complication of blunt chest trauma, results from an air leak in the lung or chest wall.
  • Air forced into the chest cavity causes complete collapse of the affected lung.
  • Air that enters the pleural space during inspiration does not exit during expiration
  • If not promptly detected and treated, tension pneumothorax is quickly fatal

102

Assessment findings with tension pneumothorax include

  • Asymmetry of the thorax
  • Tracheal movement away from midline toward the unaffected side
  • Extreme respiratory distress
  • Absence of breath sounds on one side
  • Distended neck veins
  • Cyanosis
  • Hypertympanic sound on percussion over the affected side
  • Hemodynamic instability

103

Managment of tension pneumothorax

  • Initial management is an immediate needle thoracostomy, with a large-bore needle inserted by the health care provider into the second intercostal space in the midclavicular line of the affected side.
  • Then a chest tube is placed into the fourth intercostal space and the other end is attached to a water seal drainage system until the lung re-inflates.

104

Hemothorax

  • a common problem occurring after blunt chest trauma or penetrating injuries
  • With a large hemothorax, the patient may have respiratory distress with breath sounds reduced on auscultation.
  • Percussion on the involved side produces a dull sound.
    • Blood in the pleural space is visible on a chest x-ray and is confirmed by thoracentesis.

105

Hemothorax interventions

  • focus on removing the blood in the pleural space to normalize breathing and to prevent infection.
  • Chest tubes are inserted to empty the pleural space; multiple chest tubes may be needed.
  • An open thoracotomy is needed when there is initial blood loss of 1000 mL from the chest or persistent bleeding at the rate of 150 to 200 mL/hr over 3 to 4 hours

106

Myocardial Infarction VS Angina

107

Hypovolemic Shock (Category) 

Total body fluid decreased (in all fluid compartments).

  • Hemmorage
  • Trauma
  • Vomiting

108

Cardiogenic Shock (Category)

Direct pump failure (fluid volume not affected).

• Myocardial infarction

• Cardiac arrest

• Ventricular dysrhythmias

109

Distributive Shock

Fluid shifted from central vascular space (total body fluid volume normal or increased).​

  • Spinal cord injury​
  • Pain
  • Head trauma
  • Burns

110

Obstructive Shock

  • Cardiac function decreased by noncardiac factor (indirect pump failure). Total body fluid is not affected although central volume is decreased.

• Cardiac tamponade

• Arterial stenosis

• Pulmonary embolus

• Pulmonary hypertension

111

HIV and CD4 cell count

  • HIV is a parasite looking for a way into a cell, to take over the cell, and to force the cell into making more copies of the virus (viral particles).
    • These new viral particles then look for additional cells to infect, repeating the cycle as long as there are new host cells to infect.
  • A healthy adult usually has at least 800 to 1000 CD4+ T-cells per cubic millimeter (mm3) of blood.
  • A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection.
  • Once AIDS is diagnosed, even if the patient's T-cell count goes higher than 200 cells/mm3 or if the percentage rises above 14%, or the infection is successfully treated, the AIDS diagnosis remains and the patient does not revert to being just HIV positive.

112

Stage 1 CDC Case Definition (HIV/AIDS)

  • describes a patient with a CD4+ T-cell count of greater than 500 cells/mm3 or a percentage of 29% or greater.
  • A person at this stage has no AIDS-defining illnesses.

113

Stage 2 CDC Case Definition (HIV/AIDS)

  • describes a patient with a CD4+ T-cell count between 200 and 499 cells/mm3 or a percentage between 14% and 28%.
  • A person at this stage has no AIDS-defining illnesses.

114

Stage 3 CDC Case Definition (HIV/AIDS)

  • describes any patient with a CD4+ T-cell count of less than 200 cells/mm3 or a percentage of less than 14%.
  • A person who has higher CD4+ T-cell counts or percentages but who also has an AIDS-defining illness meets the Stage 3 CDC Case Definition.

115

Stage 4 CDC Case Definition 

is used to describe any patient with a confirmed HIV infection but no information regarding CD4+ T-cell counts, CD4+ T-cell percentages, and AIDS-defining illnesses is available.

116

Burn- first 8 hours

  • the Parkland Formula (4 mL/kg/%TBSA burn of crystalloid solution).
  • recommend that half of the calculated fluid volume for 24 hours be given in the first 8 hours after injury. The other half is given over the next 16 hours for a total of 24 hours.
  • LR
  • During 2nd 24 hrs, dextrose in water, plus K.

117

Gentamicin

Dosage For Patients With Normal Renal Function. Children: 6 to 7.5 mg/kg/day. (2 to 2.5 mg/kg administered every 8 hours.)

Which toxicity is specific to gentamicin?
1. Hepatatoxicity.
2. Ototoxicity.
3. Myocardial toxicity.
4. Neurotoxicity.

118

Withholding or stopping extraordinary resuscitation efforts

is ethically and legally appropriate if patients or surrogates have previously made their preferences known through advance directives.

119

Burns and Culture

Drug therapy with antibiotics is used when pneumonia or other pulmonary infections impair breathing.

Drug selection is based on known culture and sensitivity reports or on the specific organisms common to that burn unit.

120

DABDA

denial, anger, bargaining, depressionand acceptance

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