CCP 106 - Critical Care Skills and Equipment

Question 1

Label 2, 4, 6 and where is mean pressure and pulse pressure

Answer 1

2- peak systolic pressure
4- dicrotic notch
6 end-diastolic pressure
Pulse pressure is from 2-6
MAP is area under curve

Question 2

Define CVC

Answer 2

central venous catheter, Aka central line or CVAD (central venous access device)
Tip must be in SVC at CA junction.
Exps. IJ or subclavian

Question 3

Define cvp

Answer 3

Central venous pressure.
Via CVC, Measures RA pressures, surrogate for RV preload— intravascular volume status and right-sided heart functions
Normal range is 2-6mmHg (mean values), measured at end-expiration.

Question 4

Indications for CVC

Answer 4

Administer large volumes quickly, Rx (hypertonics, chemo, irritants, etc), monitoring CVP, ScVO2 (normal 70), hemodynamics parameters, obtain VBG.
Provides access for transvenous pacing wires (TVP) or pulmonary artery catheter (PAC)

Question 5

Contraindications for CVCs

Answer 5

(Relative) significant coagulopathy, local trauma or infection to site of insertion

Question 6

List complications assoc with CVC

Answer 6

Line dysfunction, catheter occlusion or migration, Infection, Vascular perforation, venous air embolism, pneumo/hemo, arrhythmia, cardiac tamponade

Question 7

Discuss types of CVCs

Answer 7

lumens and tunneled (under skin, for long term use) vs not.

Question 8

Describe the proper method for placement of CVC

Answer 8

Equipment: j-tipped guide wire, dilator, scalpel, catheter, 5 and 10mL syringe, chlorhexidine, sterile drapes, iv tubing and fluid, suture materials, occlusive dressing, tape, local anesthetic.

Most common technique is Seldinger:
- Take standard precautions, prep equip, landmark, prep site (chlorhexidine and local anesthetic)
- Insert needle and syringe and aspirate blood.
- remove syringe and insert guide wire into needle and feed into vein
- remove needle while holding guide wire in place
- pass dilator over guidewire and use scalpel to make incision to facilitate passing dilator.
- remove dilator while holding guidewire in place and insert catheter over guidewire into vessel- remove guidewire as you advance catheter.
- aspirate blood and flush all ports
- secure and dress
- CONFIRM on XRAY

Question 9

Label 1-5

Answer 9

1. A wave- atrial contraction during diastole
2. C wave- tricuspid bulging at start of systole
3. V wave- rise in atrial pressure during during systole
4. X descent due to atrial relaxation
5. Y descent due to atrial emptying

Question 10

Describe routine management of CVC

Answer 10

Confirmed on CXR, confirm placement (depth, secure, dressing), clean up and date on opsite. Note any bleeding, erythema, SC emphysema

Question 11

Define sheath introducer

Answer 11

Aka Cordis. Used as large diameter catheter, place TVP or PAC, rapid volume admin, SLIC to monitor CVP, companion port

Question 12

Define PICC

Answer 12

peripherally inserted central catheter
brachial vein (or other arm veins)- medium-duration, long-term (months) access. Tip sits just outside atrium. Often for drug resistant abx

Question 13

List common complications of PICC

Answer 13

Requires regular flushing, may require low dose warfarin, limited arm mobility and aggressive exertion

Question 14

Define and identify components of a PAC

Answer 14

Pulmonary artery catheter Aka Swan-Ganz. Balloon at the tip allows blood flow to carry it into heart and sits at pulmonary artery. Pulled back to CA junction for transport.

110cm in length, contains multiple lumens that terminate at various points along the length (corresponding to different locations in the heart). Marked q 10cm. May have thermistor at distal end for thermodilution CO measurement and is gold standard for core body temp measurement.

Question 15

Explain common indications and rationale for PACs

Answer 15

Not used as much anymore (high risk, better alternatives US and Doppler), but pulmonary wedge capillary pressure (PCWP) is surrogate for LVEDP and can measure pressure in pulmonary artery, right ventricle, right atrium, CVP and ScVO2.

Exps. Differentiate shock, determine mechanism of pulmonary edema, evaluate/tx of pulmonary HTN, manage complex fluid management, guidance for titration of inotropes or vasopressor/dilator tx, etc.

Question 16

Explain the assessment and management of PACs

Answer 16

Note the cm of the PAC at the introducer. Two of the lumens are connected to pressure transducers (RA pressure- mean and PA pressure- systolic, diastolic, mean). Inflated balloon— PCWP waveform (mean value, normal is 4-12mmHg)

Question 17

Normal values associated with PACs

Answer 17

PA pressure, systemic- 15-30mmHg
PA pressure, diastolic- 8-15mmHg
PCWP- 4-12mmHg
SvO2- 60-80%
Scvo2- 70-90%

Question 18

Explain the purpose of a chest tube

Answer 18

To relieve a pneumo, hemo, chylothorax (lymph) or empyema (pus)

Question 19

Analyze selection of chest tube size related to indication for its insertion

Answer 19

Alveolar-pleural fistula=smaller (8-14Fr)
Broncho-pleural fistula- larger (24-32Fr)

Question 20

Discuss the process of Chest tube insertion

Answer 20

Per Rico:
- Obtain consent and position pt (30deg reverse trendelenberg)
- Sterile fields, ppe, chlorhexidine, anesthetize area
- Equipment: scalpel, chest tube, Kelly clamps, sterile occlusive dressing, suturing material, fluid collection device, tape
- ID site “triangle of safety”- lateral edge of pectoralis major, mid-axillary line and above 5th intercostal (nip in males, inframammary crease in females)
- insert at anterior axillary line at 4-5 intercostal
- fio2 and prophylactic abx (cefazolin 1g)

Other- chest tube direction up for air, down for blood

Question 21

Transport consideration with chest tube in place

Answer 21

• tape connections
• ensure tube and dressings are secure (suture/wire/tape) and occlusive
• mark the depth of the tube
• maintain drainage unit below the level of the chest at all times
  -tubing coiled, not kinked
• document bubbling in water seal (1-7) and output and type to collection chamber

Question 22

Discuss the pros and cons of clamping a chest tube

Answer 22

• Clamping may cause tension pneumo
• If hemothorax is draining too much blood (>2L or too fast), clamping may tamponade and slow bleeding until rescue sx can take place

Question 23

Define transvenous pacing

Answer 23

Temp pacemaker inserted via right IJ or left SC

Question 24

Describe components of TVP

Answer 24

Pacing wire, introducer sheath, cable, pulse generator (rate, output/mA, sensitivity/mV)

Question 25

Discuss possible complications of TVP and actions

Answer 25

Failure to capture, failure to pace/oversensing, failure to sense/undersensing.

Check pt (resus), ID rhythm, follow line back (kinks, disconnections), check settings and lights, change batter, consider pt pathology

Question 26

Indications for ICP monitoring

Answer 26

Critical illness/injury to skull/brain, including prolong intracranial HTN. Should be employed in all salvageable pts with gcs 3-8 after resuscitation and an abnormal CT OR normal CT but severe TBI with 2 or more: >40yo, motor posturing, sbp <90

Question 27

Label p1, p2, p3 of intracranial waveform

Answer 27

P1- percussion
P2- tidal
P3- dicrotic

Question 28

Discuss complications of ICP monitoring

Answer 28

Rare.
Intracranial infection, intracerebral hemorrhage, air or csf leak, over drainage of csf leading to ventricular collapse and herniation, etc

Question 29

Define an EVD

Answer 29

External ventricular drain- used to assess ICP, measures ICP at the lateral horn.

Question 30

Describe the set up for icp monitor and evd drain

Answer 30

Measured in mmHg, can set ICP threshold (10) to spill csf into collection. Transducer levelled at tragus, head of bed 30-45deg. EVD system very tall and mounted to iv pole, usually EVD closed to drain CSF during transport because icp manipulated by environmental conditions