Module - 4 - Respiratory Emergencies Flashcards

Question

25. Situations that involve a right shift in the oxygen-hemoglobin dissociation curve are all of the following, except A. Alkalosis B. Hypercapnia C. Hyperthermia D. Increased level of 2,3-DPG

Answer 1

25. A: Alkalosis causes a left shift.

Answer 2

26. B: The use of etomidate for continued sedation of critically ill patients has been associated with increased mortality, which is due to suppression of steroid synthesis (both glucocorticoids and mineralocorticoids) in the adrenal cortex, which sometimes leads to death due to an adrenal crisis. There is no evidence that a single induction dose of etomidate has any effect on morbidity or mortality.

Answer 3

27. D: The pH is normal, HCO3 is low (acidosis), and the pCO2 is low (alkalosis). When both HCO3 and pCO2 are turned in opposite directions, the etiology is usually metabolic. The primary mechanism is a metabolic acidosis that has been fully compensated by respiratory alkalosis, making the pH within normal range.

Answer 4

28. C: ARDS, also known as respiratory distress syndrome (RDS); lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma, which leads to impaired gas change, resulting in a severe oxygenation defect (hypoxemia). Their compliance is typically reduced, and their dead space increased. ARDS has gradually shifted to mean acute rather than adult. A less severe form is called acute lung injury (ALI).

Answer 5

29. B: Positive end-expiratory pressure (PEEP) is used in mechanically- ventilated patients with ARDS to improve oxygenation.

Answer 6

30. D: BNP is an amino acid polypeptide released by the ventricles of the heart in response to excessive stretching of the heart muscle cells. BNP is a blood test used to help in the diagnosis of CHF and is typically higher in these patients. For patients with CHF, the BNP levels will generally be \>100 pg/mL. The synthetic version of BNP in medication form is Neseritide (natracor), which reduces systemic vascular resistance and cardiac output.

Answer 7

31. A: Neuromuscular blocking agents (NMBA) binds with cholinergic receptor sites of motor neurons preventing the neurotransmitter from relaying the signal. The interruption in this signal pathway is what causes paralysis. Succinylcholine (anectine) is classified as a noncompetitive depolarizing agent because it binds with the motor end-plate receptor site, causing a continuous depolarization to take place. It is this depolarization that causes the initial fasciculations (irregular muscle contractions produced by depolarization of the muscle membrane before complete cessation of muscle activity). As the acetycholinesterase enzyme breaks down the NMBA, there is a return of fasciculations.

Answer 8

32. B: The administration of a defasiculation dose of a competitivenon depolarizing NMBA, such as vecuronium (Norcuron), can prevent fasciculations that occur when succinylcholine (Anectine) is administered. Administration of 10% of the initial NMBA dose is recommended to prevent this complication, especially in trauma patients who have sustained significant skeletal fractures for the purpose of preventing further injury at the fracture site/s.

Answer 9

33. C: The ABG interpretation of a pH 7.52, pCO2 27 and HCO3 24 is a noncompensated respiratory alkalosis, which is present is early salicylate poisoning. The metabolic changes eventually lead to renal depletion of fluids and electrolytes, hypoglycemia, hypokalemia, and a mixed presentation of respiratory and metabolic alkalosis coupled with metabolic acidosis, which may provoke cardiac dysrhythmias, acute pulmonary edema, renal failure or neurological injury. The clinical presentation of salicylate poisoning can also include gastrointestinal bleeding and an unexplained elevated anion gap (metabolic acidosis). Salicylate levels are obtained four to six hours after ingestion. Earlier samples may be unreliable because the pharmacokinetics is not stable before that time. The most important information in assessing severity, however is the patient’s clinical condition.

Answer 10

34. B: Elevated peak inspiratory pressures (PIP) can be managed by decreasing the flow rate and tidal volume initially. If necessary, increasing the respiratory rate can be done to correct an underlying respiratory acidosis.

Answer 11

35. D: Leaks and/or loose connections are associated with low ventilator alarms. Refer to the tables in questions 19 and 20 for review.

Answer 12

36. C: An elevated anion gap is associated with metabolic acidosis. Refer to the table in question 1 for review of causes for elevated anion gap.

Answer 13

37. C: The average recommended ET tube for an adult male airway is 8.0-9.0 mm (size refers to the internal diameter of the tube). The average adult female airway can accommodate a 7.0-8.0-mm tube. The balloon cuff pressure should be at minimal occluding volume of 5-10 mL. At pressures greater than 25 mmHg, mucosal ischemia begins to occur.

Answer 14

38. B: The administration of succinylcholine (Anectine) is contraindicated in patients with known and/or suspected hyperkalemia. The hyperkalemia associated with succinylcholine, which can approach or exceed life-threatening levels, is of greater consequence in patients who have a history of burns or massive muscle trauma 2 to 3 days prior, and patients may continue to be at risk for hyperkalemia for 2 to 3 months. The two absolute contraindications to use of succinylcholine are situations in which cricothyrotomy would be difficult or impossible to accomplish and the use of the medication by individuals who do not possess a thorough knowledge about the pharmacology of neuromuscular blocking agents, and they do not possess advanced airway skills or an alternative plan if they should encounter a failed airway.

Answer 15

39. C: Midazolam (versed) is classified as a benzodiazepine, schedule II controlled drug. It has potent anxiolytic, amnestic, hypnotic, anticonvulsant, skeletal muscle relaxant, and sedative properties. Major adverse effects include hypotension and respiratory depression and/or arrest. Flumazenil is a benzodiazepine antagonist that can be used to treat an overdose as well to reverse sedation. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (p. 172). Xlibris. Kindle Edition.

Answer 16

40. C: Ketamine (ketalar) is classified as an NMDA receptor antagonist with a wide range of effects that include analgesia, anesthesia, hallucinations, elevated blood pressure, and bronchodilation. Indications include use for pediatric anesthesia and asthmatics or patients with COPD. Ketamine has been useful in managing bronchospasm because it inhibits pro-inflammatory cytokines. The accumulation of pro-inflammatory cytokines causes beta-adrenergic receptor hypofunction.

Answer 17

41. A: Application of positive end-expiratory pressure (PEEP). ARDS lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma. Their compliance is typically reduced, and their dead space is increased. Initiating ventilation of patients with ARDS with A/C ventilation at a tidal volume of 6 mL/kg, with a PEEP of 5 and initial ventilatory rate of 12, titrated up to maintain a pH \> 7.25. Target plateau pressure of

Answer 18

42. B: Chronic obstructive pulmonary disease (COPD) can be considered a continuum with asthma on one end, chronic bronchitis in the middle, and emphysema on the opposite end. It is not unusual for emphysema and chronic bronchitis to coexist in varying degrees. Physical examination may reveal pursed-lip breathing, flaring nostrils, rhonchi and/or expiratory wheezes, hyperresonant to percussion, anterior-posterior diameter of the chest is increased (barrel-chest), and tachycardia. The patient’s mental status is an important component since this is the first sign showing that CO2 level has increased beyond the patient’s normal baseline level. Chronic bronchitis results in mucus-secreting cells of the bronchial walls hypersecreting copious amounts of sputum, which prevents airflow into the alveoli. The alveolar gas exchange is normal, but the alveoli are under-ventilated because of obstruction of airflow. Refer the following tables for review of diagnostic studies, pathophysiology, and management of the COPD patient.

Answer 19

43. A: Hyperinflation of the lungs, narrow elongated heart shadow, increased anterior-posterior diameter, and flattened hemidiaphragms are common findings on the chest radiography of a COPD patient. ARDS can present with widespread infilitrates, with a ground glassy appearance, pneumonia with lobar infiltrates and consolidation, and CHF with cardiomegaly and pulmonary congestion.

Answer 20

44. B: Widespread pulmonary infiltrates that is ground glassy in appearance. ARDS results from a severe alteration in pulmonary vascular permeability, which leads to a change in the lung structure and function. The outstanding characteristic is hypoxemia refractory to oxygen therapy. ARDS is most commonly seen in patients with direct or indirect acute lung injury. Because ARDS is a complication of other illnesses or injuries, the transport team must also consider the pathophysiology of the underlying problem.

Answer 21

45. C: Absence of wheezing may indicate that the patient is not able to ventilate sufficiently to produce breath sounds. The problem with a patient presenting with asthma is a prolonged expiratory phase, which can cause air trapping. These patients are not able to exhale adequately. The physical examination can reveal different degrees of respiratory distress based on the severity of their condition. The transport team should consider the situation emergent if an asthma patient presents in respiratory distress without wheezing and has difficulty in speaking. Acute respiratory failure is defined as a pO2 50 mmHg.

Answer 22

46. D: Perfusion becomes inadequate because of decreased venous return to the heart as a result of the increased intrapleural pressure and shift of mediastinal structures. A narrowing pulse pressure is considered a compensatory response that can occur just prior to the patient becoming hypotensive. The diastolic blood pressure becomes closer to the systolic blood pressure in a narrowing pulse pressure, whereas, the systolic blood pressure increases in a widening pulse pressure as seen with Cushing’s triad (increased intracranial pressure[ICP]).

Answer 23

47. B: Normal range pCO2 is 35-45 mmHg.

Answer 24

48. C: Normal range pH is 7.35-7.45.

Answer 25

49. C: Normal range HCO3 is 22-26.

Answer 26

50. C: Diarrheal dehydration can cause metabolic acidosis, especially in the pediatric patient. Metabolic alkalosis can be caused by loss of hydrogen ions through the kidneys or GI tract. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCL). Renal losses (use of diuretics) of hydrogen ions occur when the distal delivery of sodium increases in the presence of excess aldosterone, resulting in reabsorption of sodium, leading to the secretion of hydrogen ions and potassium ions. The administration of sodium bicarbonate in amounts that exceed the capacity of the kidneys to excrete this excess bicarbonate may cause metabolic alkalosis. Shifting of hydrogen ions into the intracellular space can also occur, which is mainly seen with hypokalemia.

Answer 27

ABG Normal range pH 7.35-7.45 pCO2 35-45 HCO3 22-26 pO2 80-100

Answer 28

1. Evaluate pH. Is it normal? 2. Evaluate the pCO2. Is it acute or chronic for respiratory disorder? 3. Evaluate the HCO3 and calculate the anion gap [Na+] - ([Cl-] + [HCO3-]) for metabolic disorder or delta gap. Check if metabolic acidosis is present. 4. Identify the primary disorder. 5. Determine if compensation is present and the degree of compensation using Winter’s formula. Is there more than one disorder?

Answer 29

Acidosis \< 7.35 - 7.45 \> Alkalosis

Answer 30

Alkalosis \< 35 - 45 \> Acidosis

Answer 31

-drainage of hemothorax or large pleural effusion drainage -large pneumothorax (greater than 25%) -prophylactic placement of chest tubes in a patient, with suspected chest trauma before transport to specialized trauma center -flail chest segment requiring ventilator support and severe pulmonary contusion with effusion

Answer 32

\<750ml) Mild increase in HR & RR

Answer 33

15 - 30% blood loss (750ml - 1,500ml) Moderate tachycardia and begins to narrow the pulse pressure, increasing RR and delayed capillary refill time.

Answer 34

30-40% (1,500-2,000 mL) Compensatory mechanisms begin to fail and hypotension, tachycardia, and low urine output (\<0.5 mL/kg/hr in adults) are seen. Body switches to anaerobic metabolism and lactic acids are produced.

Answer 35

\>40% (2,000-2,500 mL) Profound hypotension, DIC, end-organ damage (MODS), and death.

Answer 36

is caused by drastic increases in intracellular calcium levels and muscle contraction, which is due to a mutation of the ryanodine receptor located in the sarcoplasmic reticulum within the skeletal muscles.

Answer 37

include hypercapnea (rise in CO2, usually assessed with capnography), tachycardia, and muscle rigidity.

Answer 38

A late sign is the increase in body temperature up to 108°F or greater and rhabdomyolosis (muscle breakdown).

Answer 39

Dantrolene sodium is classified as a muscle relaxant and is the only specific and effective treatment of malignant hyperthermia.

Answer 40

An alternate site approach is the fourth or fifth intercostal anterior midaxillary line.

Answer 41

2nd intercostal space, midclavicular line

Answer 42

is the amount of gas that reaches the alveoli for gas exchange in one minute. The formula is VAmin = (VT-VD) × Respiratory Rate.

Answer 43

Anion gap = [Na+] - ([Cl-] + [HCO3-]) * The normal anion gap is 8-12. * An anion gap of greater than 12 is "increased".

Answer 44

* Positive-pressure ventilation is responsible for an overall decline in renal function with decreased urine volume and sodium excretion. * Hepatic function is adversely affected by decreased cardiac output, increased hepatic vascular resistance, and elevated bile duct pressure. * Mucosal ischemia and secondary bleeding may result from decreased cardiac output and increased gastric venous pressure.

Answer 45

* The heart, great vessels, and pulmonary vasculature lie within the chest cavity and are subject to the increased intrathoracic pressures associated with mechanical ventilation. The result is a decrease in cardiac output due to decreased venous return to the right heart (dominant), right ventricular dysfunction, and altered left ventricular distensibility.

Answer 46

* Barotrauma may result in pulmonary interstitial emphysema, pneumomediastinum, pneumoperitoneum, pneumothorax, and/or tension pneumothorax. * High peak inflation pressures \> 40 cm H2O are associated with an increased incidence of barotrauma.

Answer 47

Inhalation proceeds until a set tidal volume (TV) is delivered and is followed by passive exhalation. ## Footnote

Answer 48

A set peak inspiratory pressure (PIP) is applied, and the pressure difference between the ventilator and the lungs results in inflation until the peak pressure is attained and passive exhalation follows. The delivered volume with each respiration is dependent on the pulmonary and thoracic compliance.

Answer 49

ultra-high respiratory rates (180-900 breaths per minute) are coupled with tiny tidal volumes and high airway pressures.

Answer 50

* The ventilator delivers the preset tidal volume once it is triggered regardless of patient effort. * If the patient is apneic or possesses limited respiratory drive, control mode can ensure delivery of appropriate minute ventilation.

Answer 51

* The ventilator provides inspiratory assistance through the use of an assist pressure. The ventilator detects inspiration by the patient and supplies an assist pressure during inspiration. It terminates the assist pressure upon detecting onset of the expiratory phase. * Support mode requires an adequate respiratory drive. * The amount of assist pressure can be dialed in.

Answer 52

* The ventilator delivers preset breaths in coordination with the respiratory effort of the patient. With each inspiratory effort, the ventilator delivers a full assisted tidal volume. * Spontaneous breathing, independent of the ventilator between A/C breaths is not allowed. * A potential drawback of A/C ventilation in the patient, with obstructive airway disease, is worsening of air trapping and breath stacking.

Answer 53

* The ventilator delivers preset breaths in coordination with the respiratory effort of the patient. * Spontaneous breathing is allowed between breaths. * Synchronization attempts to limit barotrauma that may occur with IMV when a preset breath is delivered to a patient who is already maximally inhaled (breath stacking) or is forcefully exhaling.

Answer 54

* The application of mechanical ventilatory support through a mask in place of endotracheal intubation is becoming increasingly accepted and used in the emergency department. * It is most commonly applied as continuous positive airway pressure (CPAP) and biphasic positive airway pressure (BiPAP). BiPAP is a form of CPAP that alternates between high and low positive airway pressures, permitting inspiration (and expiration) throughout.

Answer 55

Initial 5-8 mL/kg * lowest values recommended in the presence of obstructive airway disease and ARDS. * The goal is to adjust the TV so that plateau pressures are less than 35 cm H2O.

Answer 56

8-12 breaths per minute * High rates allow less time for exhalation, increase mean airway pressure, and cause air trapping in patients with obstructive airway disease. * The initial rate may be as low as 5-6 breaths per minute in asthmatic patients when using a permissive hypercapnic technique.

Answer 57

* The lowest FIO2 that produces an arterial oxygen saturation (SaO2) greater than 90% and a PaO2 \> 60 mmHg is recommended.

Answer 58

Normal 1:2 ratio * Obstructive lung disease 1:4 or greater * The normal inspiration/expiration (I/E) ratio to start is 1:2. This is reduced to 1:4 or greater in the presence of obstructive airway disease in order to avoid air-trapping (breath stacking) and auto-PEEP or intrinsic PEEP (iPEEP). * Use of inverse I/E may be appropriate in certain patients with complex compliance problems in the setting of ARDS.

Answer 59

60 mL/minute * Inspiratory flow rates are a function of the TV, I/E ratio, and RR and may be controlled internally by the ventilator via these other settings. * If flow rates are set explicitly, 60 L/minute is typically used. * This may be increased to 100 L/minute to deliver TVs quickly and allow for prolonged expiration in the presence of obstructive airway disease.

Answer 60

Physiologic PEEP 3-5 cm/H2O * Is common to prevent decreases in functional residual capacity in those with normal lungs. * The reasoning for increasing levels of PEEP in critically ill patients is to provide acceptable oxygenation and to reduce the FIiO2 to nontoxic levels (FIO2 \< 0.5). * The level of PEEP must be balanced such that excessive intrathoracic pressure does not occur (preventing barotrauma/decreased venous return).

Answer 61

**Disease/Condition** Obstructive lung disease: Asthma and COPD **Problem** Hypoxia can generally be corrected through a high FIiO2, but patients with airway obstruction are at risk of high airway pressures, breath stacking leading to intrinsic PEEP, barotrauma, and volutrauma **Intervention** * To minimize intrinsic PEEP, it is recommended that expiratory flow time be increased as much as possible. * Permissive hypercapnia enables a low respiratory rate of 6-8 breaths per minute to be used, as well as an increased I:E ratio of 1:1.5 or 1:2. * PEEP may benefit some asthmatic patients by reducing the work of breathing and maintaining open airways during expiration, but its effects are difficult to predict and must be carefully monitored.

Answer 62

**Disease/Condition** Acute respiratory distress syndrome (ARDS) **Problem** * ARDS lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma. * Their compliance is typically reduced, and their dead space is increased. **Intervention** * Initiating ventilation of patients with ARDS with A/C ventilation at a tidal volume of 6 mL/kg, with a PEEP of 5 and initial ventilatory rate of 12, titrated up to maintain a pH \> 7.25. * Target plateau pressure of \< 30 cm H2O.

Answer 63

**Disease/Condition** Congestive heart failure (CHF) **Problem** * Cardiac output can be dependent on preload and such patients may easily develop post-intubation hypotension. **Intervention** * CHF responds very well to positive-pressure ventilation, which serves the dual role of opening alveoli and reducing preload. * Many patients with CHF benefit from a trial of noninvasive CPAP or BiPAP. * PEEP can be increased as tolerated to improve oxygenation and reduce preload.

Answer 64

**Disease/Condition** Traumatic brain injury (TBI) **Problem** * Hyperventilation has demonstrated poor outcomes thought to be secondary to excessive cerebral vasoconstriction and reduced cerebral perfusion **Intervention** * PCO2 should be maintained between 35 and 45 mmHg.

Answer 65

**Metabolic alkalosis** is usually the result of decreased hydrogen ion concentration, leading to increased bicarbonate concentration. * Loss of chloride and hydrogen ions by the alimentary tract (vomiting) or via the kidneys is usually accompanied by volume depletion. * With chloride loss and volume depletion (hypochloremic alkalosis), the kidneys reabsorb sodium and HCO3—instead of chloride, perpetuating the metabolic alkalosis. * Chronic administration of alkali also may result in transient metabolic alkalosis. * Shift of hydrogen ion into the intracellular space is seen with hypokalemia. Due to a low extracellular potassium concentration, potassium shifts out of the cells. In order to maintain electrical neutrality, hydrogen shifts into the cells, raising blood pH. * Compensation for metabolic alkalosis occurs mainly in the lungs, which retain carbon dioxide through hypoventilation. * Management would include analyzing electrolytes frequently and replacing deficiency.

Answer 66

is an ECG alteration of the QRS complex amplitude or axis between heart beats. It is thought to be associated to changes in the ventricular axis due to fluid in the pericardium. Pericardial effusion can lead to cardiac tamponade.

Answer 67

pO2 \< 60 mmHg and a pCO2 \> 50 mmHg Normal pO2 is 80-100 mmHg

Answer 68

Malignant hyperthermia is a rare life-threatening condition that is triggered by certain medications administered during general anesthesia (gas agents) and the neuromuscular blocking agent succinylcholine (anectine). **_Mechanism_** of the condition is caused by drastic increases in intracellular calcium levels and muscle contraction, which is due to a mutation of the ryanodine receptor located in the sarcoplasmic reticulum within the skeletal muscles. **Signs - Early & Late** * Characteristic early signs of malignant hyperthermia include hypercapnea (rise in CO2, usually assessed with capnography), tachycardia, and muscle rigidity. * A late sign is the increase in body temperature up to 108°F or greater and rhabdomyolosis (muscle breakdown). **Treatment** * Treatment with dantrolene sodium (dantrium) is usually initiated. Dantrolene sodium is classified as a muscle relaxant and is the only specific and effective treatment of malignant hyperthermia.

Answer 69

2nd ICS Midclavicular 4/5th ICS Mid Axillary

Answer 70

the total volume of air (gas) moved into and out of the lungs each minute. **VE = Vt × f** VE signifies minute ventilation Vt signifies tidal volume f signifies respiratory rate

Answer 71

the amount of gas that reaches the alveoli for gas exchange in one minute. VAmin = (VT-VD) × Respiratory Rate.

Answer 72

* Volume of air inspired or expired with each normal breath. * Amount 500 mL, which is approximately 5-8 mL/kg.

Answer 73

* Extra volume of air that can be inspired above normal tidal volume. * Amount 3 liters.

Answer 74

* Extra volume of air that can be expired by forceful expiration after the end of a normal tidal expiration. * Amount 1,100 mL.

Answer 75

* Volume of air remaining in the lungs at the end of maximum expiration. * Amount 1,200 mL in a 70-kg patient.

Answer 76

* The amount of gas in the tidal volume that remains in the air passageways unavailable for gas exchange. * Anatomic dead space includes the trachea and bronchi. Physiologic dead space from COPD, obstruction, or atelactesis. * Amount 150 mL.

Answer 77

* TV + IRV * The amount of air a person can breathe beginning at the normal expiratory level and distending the lungs to maximum capacity * Approx. 3,500 mL

Answer 78

* ERV + RV * The amount of air that remains in the lungs at the end of normal expiration

Answer 79

* IRV + TV * The amount of air a person can expel from the lungs after first filling the lungs to their maximum extent and then expiring to the maximum extent.

Answer 80

* VC + RV * The maximum volume to which the lungs can be expanded with the greatest possible inspiratory effort.

Answer 81

* Are triggered when resistance to ventilation is high. * This may occur secondary to reduced lung elasticity or airway obstruction or extrinsic compression.

Answer 82

Pneumothorax, bronchospasm, elevated abdominal pressure, mainstem intubation, tube plugs or kinks, tube biting, dynamic hyperinflation/air trapping, psychomotor agitation, worsening pulmonary compliance, and hypovolemia.

Answer 83

Tube suctioning and adequate patient sedation are recommended after other causes of obstruction are ruled out. ## Footnote

Answer 84

* Are triggered by air leaks. * These are most frequently secondary to ventilatory tubing disconnection from the patient’s tracheal tube but can also occur in the event of balloon deflation or tracheal tube dislodgement.

Answer 85

Oxygen saturation, bradycardia (especially in neonates and pediatric patients), and skin color. ## Footnote

Answer 86

Tube placement, balloon inflation, amount of oxygen in tank and connection to the ventilator should be carefully verified.

Answer 87

Cause May occur secondary to hypoventilation, worsening cardiac shunting, inadequate FIO2, mainstem intubation, aspiration, tube dislodgement, or pulmonary edema Intervention Increasing FIO2 and adjusting ventilatory settings to increase PEEP or respiratory rate are useful first steps after excluding equipment failure and mechanical causes of hypoxia.

Answer 88

Causes * Hypotension after intubation can be caused by diminished central venous blood return to the heart secondary to elevated intrathoracic pressures. * Hypotension may also be secondary to vasovagal reaction to intubation, rapid sequence induction, sedation, and tension pneumothorax. Interventions * This can be treated with fluid infusions and/or adjustment of ventilatory settings to lower intrathoracic pressure (reducing PEEP, tidal volume, and, if air trapping is suspected, respiratory rate).

Answer 89

Causes a decrease in the affinity of hemoglobin to oxygen. This makes it harder for hemoglobin to bind to oxygen, but it makes it easier for hemoglobin to release bound oxygen. **R stands for Raised/Releases Oxygen** * High temperature (hyperthermia) * High 2,3-DPG levels Production increases with hypoxemia, chronic lung disease, anemia, and CHF * High pCO2

Answer 90

Causes an increase in the affinity, making the oxygen easier for hemoglobin to pick up but harder to release. **L stands for Low/Holds onto Oxygen - _{There's an L in Alkalosis}** * Low temperature (hypothermia) * Low 2,3-DPG levels Production decreases with septic shock and hypophosphatemia * Low pCO2

Answer 91

* associated with increased mortality, which is due to suppression of steroid synthesis (both glucocorticoids and mineralocorticoids) in the adrenal cortex, which sometimes leads to death due to an adrenal crisis.

Answer 92

* lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma, which leads to impaired gas change, resulting in a severe oxygenation defect (hypoxemia). * Their compliance is typically reduced, and their dead space increased. * If PaO2:FIO2 \< 300 mmHg (40 kPa) acute lung injury (ALI) is considered to be present. * **If PaO2:FIO2 \< 200 mmHg (26.7 kPa), ARDS is considered to be present.**

Answer 93

an amino acid polypeptide released by the ventricles of the heart in response to excessive stretching of the heart muscle cells. * BNP is a blood test used to help in the diagnosis of CHF and is typically higher in these patients. * For patients with CHF, the BNP levels will generally be \>100 pg/mL. * The synthetic version of BNP in medication form is Neseritide (natracor), which reduces systemic vascular resistance and cardiac output.

Answer 94

**Succinylcholine (anectine)** * Binds with the motor-end plate and causes a continuous depolarization, which results in fasciculations. * Unresponsive to acetycholine causing paralysis * Short onset of action of less than 1 minute and ultra short-acting duration of 4-6 minutes * Potential complications include hyperkalemia, bradycardia, especially in pediatric patients, bronchospasm

Answer 95

**Rocuronium (zemuron)** **Vecuronium (norcuron)** **Pancuronium (pavulon)** * Competitively binds with the motor-end plate and does not cause depolarization. * Blocks acetylcholine causing paralysis * Used to extend the time of neuromuscular blockade after intubation * Longer onset of action and duration

Answer 96

* When administering a defasciculating neuromuscular blockade, the dose recommended is 10% normal RSI dosage of NMBA * The administration of a defasiculation dose of a competitivenon depolarizing NMBA, such as vecuronium (Norcuron), can prevent fasciculations that occur when succinylcholine (Anectine) is administered. * Especially in trauma patients who have sustained significant skeletal fractures for the purpose of preventing further injury at the fracture site/s.

Answer 97

noncompensated respiratory alkalosis. ## Footnote

Answer 98

Flumazenil * can be used to treat an overdose as well to reverse sedation. * Use with caution on patients with seizure history; administration may disable ability to stop seizure

Answer 99

0.1 mg/kg (2-5 mg)

Answer 100

A - 2-10 mg P - 0.2 mg/kg

Answer 101

A - 1-2 mg P - 0.1 mg/kg

Answer 102

* is another sedative medication currently being used in the critical care unit and by anesthesiologists. * It is relatively unique in its ability to provide sedation without causing respiratory depression.

Answer 103

* is a short-acting intravenous anesthestic used for the induction of general anesthesia and sedation for short procedures. * It has hypnotic and amnestic properties but no analgesic properties. * Etomidate is less likely to cause hypotension and respiratory depression. * Average recommended dose as an induction agent is 0.3 mg/kg, which can be repeated once if indicated. Lower doses are recommended for use of short procedures. * Continued administration of etomidate can cause cortisol levels to drop, which sometimes leads to death due to adrenal crisis. Some sources advise administering a prophylactic dose of steroids, if etomidate is used. Lopez, Orchid Lee (2011-02-15). Back To Basics: Critical Care Transport Certification Review (pp. 172-173). Xlibris. Kindle Edition.

Answer 104

* is classified as an NMDA receptor antagonist with a wide range of effects that include analgesia, anesthesia, hallucinations, elevated blood pressure, and bronchodilation. * Indications include use for pediatric anesthesia and asthmatics or patients with COPD. * Ketamine has been useful in managing bronchospasm because it inhibits pro-inflammatory cytokines. The accumulation of pro-inflammatory cytokines causes beta-adrenergic receptor hypofunction.

Answer 105

Asthma Chronic Bronchitis Emphysema

Answer 106

Problem * Airway inflammation and narrowed airway. * The hypoxemia stimulates hyperventilation with a resultant decrease in PaO2. MGMT * Ensure adequate airway, humidified oxygen, adrengeric agents, anticholinergics, corticosteroids. * Intubation/mechanical ventilation is used only in severe cases.

Answer 107

Problem * Obstructive airflow. * Hypersecretion of copious amounts of mucous, which prevents airflow into the alveoli. * Hypoventilation results in hypercapnea and hypoxemia. Ventilation-perfusion (VQ) mismatch. * Pulmonary hypertension and hypertrophy of the right ventricle resulting in cor pulmonale. MGMT * Humidified oxygen to thin secretions, may require endotracheal suctioning, IV fluids should be administered cautiously since there may be some degree of right-sided failure, beta agonists, methylxanthines, corticosteroids, and anticholinergics may be used.

Answer 108

Problem * Destruction of alveoli, loss of elasticity, decrease in gas exchange. * Drive for respiration becomes hypoxemia. * Air is trapped in the lungs, which increases residual volume. * Emphysematous blebs are most often located in the apices of the lungs. * Decrease elastic recoil of the lungs. Over/hyperinflation of the lungs. * The expiratory phase increases as the increased resistance to airflow continues. * Increased RBCs and hematacrit. MGMT * Low flow rate \< 2 L/minute oxygen humidified, unless the patient is a mechanically ventilated (use cautiously since blebs may be present, which may cause a spontaneous pneumothorax to occur), pharmacologic therapy is the same treatment as chronic bronchitis.

Answer 109

**ABGs** Chronic respiratory acidosis compensated by a metabolic alkalosis in the COPD patient **Chest radiography** Hyperinflation of the lungs, narrow elongated heart shadow, increased anterior-posterior diameter, and flattened hemidiaphragms. **12-lead ECG** Low voltage may be present because of the barrel chest, large peaked P waves in the inferior leads, and a right-axis deviation as a result of elongation of the heart, signs of cor pulmonale, such as right ventricular hypertrophy.

Answer 110

Absence of wheezing may indicate that the patient is not able to ventilate sufficiently to produce breath sounds. * The problem with a patient presenting with asthma is a prolonged expiratory phase, which can cause air trapping. These patients are not able to exhale adequately.

Answer 111

* Perfusion becomes inadequate because of decreased venous return to the heart as a result of the increased intrapleural pressure and shift of mediastinal structures. * A narrowing pulse pressure is considered a compensatory response that can occur just prior to the patient becoming hypotensive. * The diastolic blood pressure becomes closer to the systolic blood pressure in a narrowing pulse pressure, whereas, the systolic blood pressure increases in a widening pulse pressure as seen with Cushing’s triad (increased intracranial pressure[ICP]).

Answer 112

* Metabolic acidosis, especially in the pediatric patient. * can be caused by loss of hydrogen ions through the kidneys or GI tract. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid (HCL). * Renal losses (use of diuretics) of hydrogen ions occur when the distal delivery of sodium increases in the presence of excess aldosterone, resulting in reabsorption of sodium, leading to the secretion of hydrogen ions and potassium ions. * The administration of sodium bicarbonate in amounts that exceed the capacity of the kidneys to excrete this excess bicarbonate may cause metabolic alkalosis. * Shifting of hydrogen ions into the intracellular space can also occur, which is mainly seen with hypokalemia.

Answer 113

Derangement **Respiratory acidosis** Problem & Common cause Retention of CO2 Hypoventilation ⇒respiratory arrest.

Answer 114

Derangement **Respiratory alkalosis** Problem & Common cause Blowing off CO2 ⇒ Increased respiratory rate which can be caused by different conditions.

Answer 115

Derangement **Metabolic acidosis** Problem & Common cause Increased production of hydrogen or the inability of the body to form bicarbonate in the kidneys ⇒ Diarrhea and other main causes are best grouped by their influence on the anion gap.

Answer 116

Derangement **Metabolic alkalosis** Problem & Common cause Loss of hydrogen ions ⇒Vomiting, nasogastric suction, diuretics, sodium bicarbonate administration.