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ULTIMATE Critical Care > cfrn_20230129231503 > Flashcards

cfrn_20230129231503 Flashcards

1
Q

normal bicarbonate

A

HCO3 = 22-26

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2
Q

normal base deficit/excess

A

-2 to +2

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3
Q

what is the pH scale

A

power (logarithmic) scale that shows the inverse relationship of hydrogen ions-low pH/acid =pH lots of H

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4
Q

buildup of CO2

A

acid

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5
Q

what does high CO2 indicate

A

acid builduplow pHapnea/hypoventilation

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6
Q

what is Co2 regulation a function of

A

CO2 regulation is a function of minute folume| minute volume = tidal volume (Vt) x RR (F)

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7
Q

Vt on ventilator settings

A

tidal volume

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8
Q

tidal volume on ventilator settings

A

Vt

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9
Q

RR on ventilator

A

frequency = F

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10
Q

F on ventilator settings

A

RR

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11
Q

CO2 over 45

A

acid buildup| hypoventilation/apnea

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12
Q

CO2 if apnea

A

high Co2 over 45| acidosis

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13
Q

CO2 if hypoventilation

A

high Co2 over 45.| acidic

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14
Q

CO2 under 35

A

alkalosis| high pH

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15
Q

CO2 if alkalosis

A

under 35

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16
Q

Vt x R

A

minute ventilatiob = Vt x F| tidal volume x RR

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17
Q

how does pH and bicarbonate move

A

opposite directions22 is acidotic26 is alkalosis

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18
Q

pH if too much bicarb

A

bicarb is alkalotic| over 26 bicarbonate

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19
Q

pH if too little bicarbonate

A

under 22| acidosis

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20
Q

under 22 bicarb

A

too little bicarbonatebicarb and pH move in teh same directionalkalosis

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21
Q

what is base excess/deficit

A

the amount of excess or deficit amount of base present in blood

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22
Q

base deficit of -4

A

indicator for blood transufusion

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23
Q

base deficit where you would consider blood transfusion

A

base deficit of

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24
Q

base deficit where death is likely

A

over -19

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25
Q

replacement formula for bicarbonate

A

0.1 x (-base excess) x weight in kg = bicarb needed

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26
Q

SaO2 at PaO2 90

A

100%

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27
Q

SaO2 at pO2 60

A

90%

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28
Q

SaO2 at pO2 30

A

60%

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29
Q

SaO2 at pO2 27

A

50%

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30
Q

what does pulse ox measure

A

SaO2

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31
Q

left shift affinity

A

increased

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32
Q

left shift mneumonic

A

Left = LOW| acidosis, temp, 2,3-DPG, pCO2

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33
Q

right shift mneumonic

A

Right = RAISe| alkalosis, temp, 2,3-DPG, PCO2

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34
Q

what 5 things change in left/right shift

A 
LEft = LOWRight = Raise+HtemperaturePCO22,3-DPG
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35
Q

CO2 & pH

A

Co2 is an acid so it makes ABG more acidotic| left shift

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36
Q

Bicarbonate & pH

A

bicarb is a base so makes ABG more alkalotic| right shift

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37
Q

CO2 follows pH

A

respiratory

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38
Q

bicarbotate follows pH

A

metabolic

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39
Q

how to tell if the ABG is compensated

A

the compensatory mechanism is teh opposite of the primary problem* respiratory acidosis is compensated by bicarb* metabolic alkalosis is compensated by CO2

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40
Q

compensated respiratory acidosis

A

compensated by bicarbonate

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41
Q

compensated metabolic alkalosis

A

compensated by CO2 (acid)

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42
Q

partially compensated

A

pH outside normal range| both resp & metabolic are outside of normal range

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43
Q

pH/resp/metabolic are all ouside of normal range

A

partially compensated

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44
Q

pH is normal, resp/metaboliic are ousided normal range

A

fully compensated

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45
Q

fully compensated

A

abnormal pH| normal CO2/bicarb

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46
Q

critical pH for intubation

A

pH under 7.2

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47
Q

pH under 7.2

A

intubate b/c critical

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48
Q

pCO2 over 55

A

intubate b/c critical

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49
Q

critical pCO2 to intubate

A

over 55

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50
Q

critical pO2 to intubate

A

under 60

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51
Q

pO2 under 60

A

intubate

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52
Q

acid/base if vomiting/NG/suction/dieuretics/diamox/antacid poisioning

A

metabolic alkalosis

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53
Q

causes of metabolic alkalosis

A

vomit/NG/suction/dieuretics/diamox/antacid overdose

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54
Q

considered lactic acidosis

A

lactate over 4

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55
Q

causes of m. acidosis

A

lactic acidosis, ketones, hyperthermia/fever, seizures, rhabdo

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56
Q

bicarb in m. alkalosis

A

over 26

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57
Q

bicarb in m. acidosis

A

under 22

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58
Q

acid base in antacid poisioning

A

m. alkalosis

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59
Q

acide base in sepsis

A

m. acidosis

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60
Q

acid base in rhabdo

A

m. acidosis

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61
Q

acid base in hyperthermia

A

m. acidosis

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62
Q

acid base in seizures

A

m. acidosis

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63
Q

Co2 in r. alkalosis

A

low CO2 under 35

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64
Q

acid base if hyperventilating

A

r. alkalosis

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65
Q

acid base in hypoermetabolic staes

A

resp alkalosis

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66
Q

acid base in high altitudes

A

r. alkalosis

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67
Q

acid base in ASA poisioning

A

r. alkalosis (CO2 less than 35) b/c it is a respiratory system stimulant

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68
Q

what happens in ASA poisioning

A

respiratory system stimulant so r. alkalosis a| hyperventilation

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69
Q

hyperventilation

A

r. alkalosis| Co2 under 35

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70
Q

hypoventilation

A

r. acidosis| CO2 over 45

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71
Q

Co2 in hyperventilation

A

under 35| alkalosis

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72
Q

CO2 in hypoventilation

A

over 45| acidosis

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73
Q

when is minute ventilation increased

A

increased to blow off CO2 (Vt x RR)in hyperthmic states like malignant hyperthermialimited ability to remove by hgb

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74
Q

every ___ in pH, expect change in bicarbonate by ___ in ___ direction

A

0.15 pH10 bicarbsame direction

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75
Q

every ___ in pH, expect change in K by ___ in ___

A

0.1 pHK shifts 0.6oppositr direction

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76
Q

physiology of the pH & K relationship

A

every 0.1 change in pH, K shifts 0.6 in the opposite directionas pH lowers, K shifts outside the cell giving a falsely elevated K level. when correct imbalance by raising pH, K shifts intracellulary so life threatening low K

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77
Q

every change in ___ ETCO2, expect pH to change by ___ in the ___ direction

A

10 mm hg ETCO20.08opposite direction

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78
Q

every change in ___ CO2, K shifts ___ in teh ___ direction

A

10 CO2K 0/5same direction

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79
Q

pH & K relationshipVERSUSCO2 & K

A

every change in 0.1 pH, the K shifts 0.6 in the opposite directionevery change in 10 CO2, K shifts 0.5 in the same direction

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80
Q

ABG to intubate

A

7.2 pHCO2 over 55PaO2 <60*intubate even if only 1 is off

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81
Q

Pediatric Assessment Triangle

A

appearancework of breathingcirculation

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82
Q

ETT size for pediatrics

A

16 + age in yearsdivided by4

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83
Q

16 + age/4ll

A

ETT size for pediatrics

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84
Q

emergency airway for pediatricsl

A

needle cric if under 8l

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85
Q

difficult airway predictors0+

A

LEMON, HEAVEN| look, evaluate w/ 3-3-2, Mallampati, obstruction, neck mobility

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86
Q

3-3-2

A

difficult aiwary predictor3 fingers in mouth3 fingers between jaw and hyoid2 fingers between hyoid and thyroid

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87
Q

Mallampati 2

A

tonsillar pillars hidden by tongue

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88
Q

Mallampati 3

A

only base of uvula is seen

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89
Q

LEMON

A 
lookevaluate w/3-3-2mallampatiobstructionneck mobility
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90
Q

HEAVEN

A 
predictors in difficult emergent airwaysHypoxemia under 93%extreme of size (under 8 or obese)anatomic challengesvomit/blood/fluidexsanguination/anemianeck monility
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91
Q

“E” in HEAVEN

A

exsanguination/anemia can accelerate decompensation during RSI

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92
Q

ramping

A

ear to sternal notch

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93
Q

problem of the supine position during intubation

A 
ramp instead (ear to sternal notch)decrease functional reserve capacity/tidal volume/preload
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94
Q

posterior pressure on cricoid cartiliage believed to occlude the esophagus

A

Sellick maneuver

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95
Q

External Laryngeal Manipulation

A

provider brings cords into view the the assistant holds pressure.

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96
Q

Macintosh v MIller blade

A

Macintosh = lifts epiglottis via vallecula| Miller - direct displacement of the epiglottis

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97
Q

preferred intubation blade for pediatrics

A

Miller (direct displacement of the epiglottis)

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98
Q

bougie size adult versus kids

A 
adult = 15 Frkids = 10Fr
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99
Q

problem of supraglittic devices

A

blind insertion| little protection agaisnt aspiration

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100
Q

air inflation into ETT

A

25mm is standard

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101
Q

CXR confirmation of ETT placement

A

distal tip 2-4 cm above carinalevel of T3-T4confirm by visualizing Murphy’s eye where the clavicle meets

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102
Q

waveform of the ETCO2

A

half square| expiration - expiratory plateau- ETCO2- inhalation- baseline

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103
Q

where is ETCO2 measured on the ETCO2 waveform?

A

right side of square

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104
Q

what can you do when you are preparing & pretreating a pt for RSI intubation

A

3-5 min of passive oxygen via NC 10-15L

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105
Q

pretreatment for RSI

A

LOAD

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106
Q

position for RSI

A

ear to sternal notch = ramping| pad behind shoulder for pediatrics

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107
Q

reason for RSI pretreatment

A

LOADb/c manipulation of the hypopharynx, larynx, and trachea may cause a reflex sympathet9c response leading to catecholamine mediated increase in BP/HR/ICP

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108
Q

RSI preteatment options

A 
LOADLidocaine OpiatesAtropineDefssciculating
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109
Q

lidocaine as RSI pretreatment

A

blunts the cough reflex preventiong ICP increase

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110
Q

opiates as RSI pretreatment

A

blunts the pain response

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111
Q

atropine as RSI pretreatment

A

prevents reflexive bradycardia in infants under 1yo

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112
Q

defasciculating rx as RSI pretreatemnt

A

1/10 dose of Roc or VEc prior to administering Succ

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113
Q

Fentanyl as RSI analgesic| dose, onset, duration, complication

A

1mcg/kgonset 3-5 minduration 30-60 minlow risk of chest wall rigidity

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114
Q

RSI for awake sedation

A

Etomidate

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115
Q

dose for Etomidate

A

0.3mg/kg

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116
Q

onset/duration for Etomidate

A

15-45sec onset| lasts 3-12 min

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117
Q

caution w/Etomidate

A

no analgesicshort duration (3-12 min)use cautiously if hemodyanmically unstablevomit when awakeNOT: if adrenal suppression, shock/Addisions/CODP/asthma

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118
Q

RSI not to use if adrenal suppression

A

ETomidate

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119
Q

RSI not to use if in shock

A

Etomidate = don’t use if adrenal suippression/shock/COPD/asthma/Addisions, or if hymedynamically unstable

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120
Q

common SE w/Etomidate

A

common to vomit when awake

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121
Q

properties of KEtamine

A

hypnoticanalgesicAmnesic

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122
Q

benefit of Ketamine

A

has unique ability to preserve laryngeal reflex/help w/airway preotection

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123
Q

best RSI for asthma/airway issues

A

Ketamine b/c preserves laryngeal reflexes/airway protection

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124
Q

Ketamine dose for RSI

A

1-2mg/kg

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125
Q

onset and duration of Ketamine

A 
onse = 40 -60 secduration = 10-20min
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126
Q

best RSI for asthatics w/reactive airway complications

A

Ketamine is a potent bronchodilator

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127
Q

SE of ketamine

A

may hallucinate| may cause laryngospasms

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128
Q

reversal agent for Versed

A

Flumazenil 02mg

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129
Q

SE of Flumazenil

A

BP

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130
Q

good RSI choice if shock

A

Ketamine

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131
Q

what is propofol

A

hypnotic w/ no analgesic properties| “milk of amnesia”

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132
Q

dose of Propofol

A

1-2mg/kg| 25-50mcg/kg/min maintence

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133
Q

onset/duration of propofol

A

onset 15-45 sec| duration 5-10 minutes

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134
Q

RSI decreases MAP/CPP

A

PRopofol

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135
Q

what cannot Propofol do

A

milk of amnesia - hyponotic BUT NO PAIN RX

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136
Q

who should not have Propofol

A

decreases CPP & MAP so not for HEad INjury or if hemodynamically unstable

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137
Q

contraindicatiosn for Propofol

A

Head injury & hemodynamically unstable| *b/c decreases MAP/CPP

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138
Q

RSI rx & their complications

A

Fentnanyl - chest wall rigidity, hypotensionETomidate - adrenal suppressionKetamine preserves laryngeal function so airway protectPropofol = decreases CPP/MAP so not for head injury or hemodyunamically unstable

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139
Q

RSI induction

A

fentanyl, etomidate, ketamine, propofol

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140
Q

what will you see someone on Succ do

A

fasciculation = muscle twitch

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141
Q

SE of SUCC - 2

A

high K| malignant hyperthermia

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142
Q

what is linked to malignant hyperthermia

A

Succ

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143
Q

drug class of Succ

A

depolarizing neuromuccular agent

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144
Q

burns contraindicate dfor Succ

A

over 24hrs

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145
Q

contrainidcation for SUcc

A 
burns over 24hrrhabdo, high Khx of Malignant hyperthermiacrush or eye injuriesany nervous system injury like G-B or MG
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146
Q

pathophysiology of Malignant Hyperthermia

A

defect in skeletal muscle sarcoplasmic retiulum| *r/t problem w/Ca removal from the cell

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147
Q

treat Malignant Hyperthermia

A

Dantrolene| NEVER CaChannel blockers (b/c MH is a problem w/sustained Ca removal from teh cell)

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148
Q

Rx not to give someone with Maligant Hyperthermia

A

Ca ChB (b/c probelm with calcium removal from the muscle_

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149
Q

s/s of Malignant Hyperthermia

A 
sustINED TETANIC MUSCLE CONTRACTIONmasseter spasmtrismus (lockjaw)rapid incrase in temp up to 110FHTN/high RRmixed acidosisincreased ETCO2
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150
Q

acid base in Malignant Hyperthermia

A

mixed acidosisincreased ETCO2tachycardia

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151
Q

lockjaw

A

trismus

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152
Q

when do you give Dantrolene

A

for Malignant Hyperthermia s/p gases or Succ

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153
Q

cause of Malignant Hyperthermia

A

induction gasses or Succ

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154
Q

dose of Succ

A

2.5mg/kg

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155
Q

Sugammadex

A

reverses Roc

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156
Q

reverses Roc

A

Sugammadex

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157
Q

drug class of Roc

A

Non-Depolarizing Neuromuscular BLocking

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158
Q

onset/duration of Roc

A

0.6 - 1.2 mg/kg

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159
Q

onset and duration of Roc

A

onset under 2 min| lduration 30-60 moin

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160
Q

important Rx to give if induce w/vec or roc

A

NO pain management

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161
Q

how to dose RSI if pt is hemodynamically unstable/shock and low CO

A

1/2 induction. less rx is needed due to depleted catecholamine storesdouble paralytic b/c low CO slowws the onset

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162
Q

RSI dose of induction agent if pt is shock/hemodynamically unstable w/ low CO

A

1/2 induction.| less rx is needed due to depleted catacholamine stores

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163
Q

RSI dose of paralytic if pt is shock/hemodynamically unstable w/low CO

A

double paralytic b/c low CO slows the onset

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164
Q

SALAD technique

A

suction assisted laryngoscopy airway decontamination| clear airway w/ suction, plae suction in the esophagus wile the intunation tube is passed.

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165
Q

post intubation management

A

Fentanyl, KEtamine, Versed drip

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166
Q

failed airway algorithm

A

3 attemps of laryngoscopy unsuccessful| can’t intubate, ventilatie, oxygenate = CRIC

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167
Q

what do you palpate for when you cric

A

feel for ht ecricothyroid membrane

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168
Q

what type of cri to use

A

surgical cric over 8yo| needle crif if under 8

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169
Q

amount of air in normal breath

A

tidal volume = Vt

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170
Q

Vt

A

tidal volume| amount of air in normal breath

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171
Q

problem of too high Vt

A

tidal volume too high causes Ventilator Induce Lung Injury

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172
Q

cause of Ventilator Induced Lung INjury

A

too high Vt

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173
Q

surface of airway not involved in gas exchange

A

dead space

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174
Q

Fick’s law of Diffusion

A

gas travels from high to low concentration

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175
Q

gas travels from high to low conetration

A

ick’s Law of DIffusion

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176
Q

when do you hear apneuristic posturing

A

decerebrate postuirng

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177
Q

apneuristic breathing

A

depe gasping inspiration with a pause at full inspiration followed by a brief insufficient release

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178
Q

deep gasping inspiration with a pase inspiration followed by brief insufficient relase

A

apneuristic brathing

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179
Q

complete irregular breathing w/irregular pasuses and apnea

A

ataxic

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180
Q

ataxic

A

complete irregular breathing w/irregular pasues and apnea

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181
Q

BIots

A

quick shallow inspiration followed byrgular/iregular apnea

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182
Q

quick shallow inspiration followed by regular/irregular apnea

A

Biot’s

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183
Q

respiration in stroke

A

Biot’s

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184
Q

respiration if pressure on medula r/t herniation

A

Biot’s

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185
Q

cause of BIot’s

A

stroke| pressure on medulla from herniation

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186
Q

Cheyne-STokes

A

progressivelydeeper and faster then decrease to tempoary apnea

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187
Q

progressively deeper and faster then decreased to tempary apnea

A

Cheyne-STokes

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188
Q

when do you see Cheyne Stokes

A

decorticate| cushing’s brainstem herniation

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189
Q

respiration in Cushing’s triad

A

Cheyne-STokes

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190
Q

resp in DKA

A

Kussmaul’s

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191
Q

Kussmau’s Respirations

A

resp in DKA| respiration gradulally becomes deeper, labored, and gasping

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192
Q

respirations deep and labored

A

Kussmauls’

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193
Q

gold standard for oxygenation

A

SpO2 = pulse ox

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194
Q

gold standard for ventilation

A

capnography = ETCO2

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195
Q

inability to diffuse oxygen

A

hypoxic respiratory failure

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196
Q

respiratory failure in ARDS

A

hypoxic respiratory failure

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197
Q

respiratory failure in pneumonia

A

hypoxic respiratory failure

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198
Q

respiratory failure in CHF

A

hypoxic respiratory failure

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199
Q

dx if pO2 below 60

A

hypoxic respiratory failure

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200
Q

definition of hypoxic respiratory failure

A

pO2 below 60

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201
Q

treatment if hypoxic respiratory failure

A

increase oxygen concentration (FiO2 and PEEP| *treatment assumes that you have adequate tidal volume and rate)

202
Q

how to increase oxygen saturation

A

increase FiO2 (oxygen concentration) and PEEP

203
Q

increase FiO2 (oxygen concentration) and PEEP

A

treatment for hypoxic respiratory failure

204
Q

inability to remove CO2

A

hypERcarbic respiratory failure

205
Q

cause of hypercarbic respiratory failure

A

damage to pons/upper medulla from stroke or trauma| respiratory acidosis

206
Q

dx hypercarbic respiratory failure

A

ETCO2 over 45

207
Q

dx if ETCO2 is over 45

A

hypercarbic respiratory failure

208
Q

treatment of hypercarbic respiratory failure

A

incrase tidal volume (pPLAT)then rate increasae(double the minute volume (Ve), normal is 4-8L’min

209
Q

what happens if you exceed __ml/kg of ideal body weight for tidal volume settings

A

over 8ml/kg for tidal volume settings can cause ventilatior associated lung injuries*slowly increase and reassess every 15min

210
Q

ventilator setting for tidal volume

A

Vt = 4-8ml/kg ideal body weight| volume of air delivered per breath

211
Q

ventilator setting that is the volume of air delivered per breath

A

Vt = tidal volume4-8ml/IBWover 8 = ventilator associated lung injury

212
Q

Ve

A

minute volumehow much air is breathed by the pt in one minuteF x Vt

213
Q

4-8 ml/kg IBW

A

Vt = tidal volume

214
Q

F x Vt

A

calculate Ve = minute volume| how much air breatahed by a pt over 1 minute

215
Q

calculate Ve

A

minute volume = F x Vt (tidal volume)

216
Q

purpose of PEEP

A

keep alveoli open so oxygen can diffuse

217
Q

3 ventilator settings that keep alveoli open so oxygen can diffuse

A

adequate peepincreased FRCdriving pressure

218
Q

2 ventilator delivery methods

A 
volume = preset volume consistent. once tidal volume is delivered, exhalation beginspressure = preset inspiratory pressure. once the pressure is achieved, exhalation begins
219
Q

max PIP

A

35

220
Q

PIP

A

amount of resistance to overcome the ventilator circuit, appliances/ETT, and the main airway

221
Q

pPlat

A

measurement of the pressure applied during positive pressure ventilation to the samll airways/alveoli.*represents the static end inspiratory recoil pressure of hte respiratory system, lung, and chest wall respectively

222
Q

when is pPlat measured

A

during an inspiratory pause while on m. ventilator

223
Q

normal pPlat

A

under 30

224
Q

values for PIP & pPlat

A

PIP under 35| pPlat under 30

225
Q

CMV

A

controlled mandatory ventilation

226
Q

who needs CMV

A

controlled mandatory ventilationsedated/apneic/paralyzedall breaths are trigged, limited, cycled by the ventilatorpt unable to breathe on own

227
Q

best ventilator mode for sedated

A

CMVall breaths are triggered/limited by ventilatorpt unable to breathe on own

228
Q

best ventilator mode for apneic

A

CMVventilator does all workpt can’t breathe on own

229
Q

best ventilator mode for paralyzed

A

CMV| ventilator does all the work

230
Q

ventilator setting that does all the work and the pt has no ability to initiate their own breaths

A

CMV = controlled mandatory ventilation

231
Q

preferred ventilator mode for respiratory distress

A

Assist COntrol

232
Q

trigger for breath in Assist Control

A

either the pt or by elapsed time

233
Q

how does Assist Control work

A

ventilator suipports every breath whether it is initiated by the pt or the ventilator*full tidal volume (Vt) regardless of respiratory effort or drive

234
Q

anxious pt on Assist Control

A

can cause breath stacking/auto-PEEP

235
Q

what ventilator setting can cause auto-PEEP

A

Assit COntrol

236
Q

good ventilator setting for ARDS

A

AC

237
Q

ventilator setting where the ventilator supports every breath even if pt initiates in order to deliver the full Vt

A

AC

238
Q

auto-PEEP

A

aka breath stackingpredisposes to barotrauma/hemodynamic comproimisesincreases WOB/effort to trigger the ventilatordiminishes the forces generated by the respiratory muscles

239
Q

SIMV

A

synchronized intermittent mandatory ventilation

240
Q

how does SIMV work

A

if pt fails to take a rbeath, the ventilator will provide a breathspontaneous breathing by pt in-between assisted breaths at preset intervals

241
Q

ventilator setting where it can sense pt taking a breath and either support it while also allowing pt to take spontaneous breaths in-between preset interval

A

SIMV

242
Q

best ventilator setting for intact respiratory drive

A

SIMV

243
Q

candidate for SIMV

A

someone with an intact ventilation drive| *able to take their own breaths in-between preset intervals

244
Q

how does Pressure Support Ventilation (PSV) work

A

pressure support makes it easier to overcome the resistance of the ET tube and is often used during weaning b/c it reduces WOB*supports or provides pressure during inspiration to decrease pt’s overall WBO

245
Q

what does pt determine in PSV

A

pressure support ventilation| *tidal volume and rate

246
Q

PSV

A

pressure support ventilation

247
Q

ventilator setting that provides pressure during inspiration to decrease pt overall work of breathing

A

PSV = pressure support ventilation

248
Q

what does pt need to be able to do in order to use PSV

A

consistent ventilatory effort by pt| pt determines Vt, rate (minute volume)

249
Q

what does BiPAP mean

A

BiPAP refers to a specific manufacturer, not a vent setting

250
Q

pressure alarm if ventilator is dislodged

A

low pressure

251
Q

pressure alarm if ventilor is obstructed

A

high pressure

252
Q

pressure alarm if pneumo

A

high pressure alarm

253
Q

pressure alarm if stacked breaths

A

high pressure alarm

254
Q

pressure alarm if pt is hypovolemic and on ventilator

A

low pressure

255
Q

pressure alarm if ARDS

A

high pressure

256
Q

pt and ventilator are fighting

A

pt-ventilator dyssynchrony

257
Q

problem patient-ventilator dyssynchrony

A

PROBLEM: inadequate sedation or pain control| b/c increased oxygen demand & WOB. increased HR/BP/ICP

258
Q

waveform sign if patient-ventilator dyssynchrony

A

curare cleft

259
Q

curare cleft

A

waveform sign of patient-ventilator dyssynchrony

260
Q

interventions for patient-ventilator dyssynchrony

A 
manage auto-peepadjust rate to pt demand, adjust sensitivity Y minute volumesuctionanalgesia & sedation
261
Q

what settings does teh algorithm have you look at if sudden acute respiratory deterioration while on a m. ventilator

A 
PIP (decreased/increased/no change)plateau pressure (no change or increqased)
262
Q

troubleshooting the ventilator| acute respiratory deterioration and the PIP is decreased

A

air leakhypoventilationhyperventilation

263
Q

troubleshooting the ventilator| acute respiratory deteroration w/o PIP changes

A

consider PE

264
Q

troubleshooting the ventilator| acute respiratory deterioration w/PIP increased

A

next consider if the pPlat is increased or if no change

265
Q

troubleshooting the ventilator| acute respiratory deterioation with increased pPLAT -6

A 
abd distensionatelectasispneumop. edemaatelectasispleural efflusion
266
Q

troubleshoot the ventilator| acute respiratory deterioration with no change in pPlat

A

airway obstruction, bronchospasm, ET tube cuff herniation

267
Q

RASS

A

Richmond Agitation-Sedation Scale+4 = combative0= alert and calm-4= deeply sedated

268
Q

tool used to monitor m. vented pt for over/undersedation

A 
RASS = Richmond Agitation-Sedation Scale+4 = combative0= alert and calm-4= deeply sedated
269
Q

decreased V/Q

A

ventilation is not keeping up with perfusion| *resp fail/pneumonia/ARDS, low PaO2, high PaCO2

270
Q

formula for V/Q

A

alveolar ventilation/CO| = ~.08

271
Q

low V/Qnormal V/Qhigh V/Q

A

normal V/Q = ~0.8. alveoli are ventilated and perfusedlow V/Q = shunted. alveoli are perfused but not ventilatedhigh V/Q= deadspace. alveoli are ventilated but not perfused

272
Q

example of low V/Q

A

shunt perfusion = alveoli are perfused by not vented| ET in mainstem bronchus

273
Q

example of high V/Q

A

deadspace| alveoli are ventilated but not perfused

274
Q

what is the problem of asthma

A

breathing out.| respiatory acidosis due to hypercarbic respiratory failure

275
Q

CXR in asthma

A

flattened disaphragm on CXR. chest cavity is overexpanded due to air trapping

276
Q

shark fin ETCO2

A

asthma

277
Q

asthma as reflected on ETCO2

A

shark fin

278
Q

interventions for asthma -ventilator

A

increase I:E ration to 1:4 (b/c this is an exhalation problem)zero PEEP or under 5

279
Q

I:E setting on ventilator if asthma attak

A

increase to 1:4 b/c exhalation problem

280
Q

PEEP if on a ventilator & asthma attack

A

zero to under 5 PEEP

281
Q

rx for asthma attack

A 
bronchoDsteroidepiimagnesiumketamine if sedated
282
Q

cutesy names for COPD

A

blue bloater - chronic bronchitis| pink puffer = emphysema

283
Q

CXR if COPD

A

flatted diaphragm. chest cavity is expanded from air trappign

284
Q

problem if COPD

A

problem is breathing out| respiratory acidosis b/c hypercalrbic respriatory failure

285
Q

benefit of increased I:E ratio

A

more expiratory time increases CO2 clearance but it does carry a risk of atelectasis(increased I only is uncommon but it may be used to increase oxygen at a cost of CO2 clearence)

286
Q

pleural efflusion

A

fluid in the pleural space| gravitates to the most dependent space

287
Q

CXR of pneumonia

A

patchy infiltrates| lobular consolidation

288
Q

what happens = hypoxemia & p. HTNin ARDS

A

diffuse alveolar injury* increased permeability of the alveolar-capillary barrier* influx of fluid into the alveoliar space

289
Q

CXR of ARDS

A

ground glass appearencepatchy infiltratesbilateral diffuse infiltrates

290
Q

ground glass appearence on CXR

A

ARDS

291
Q

Swan-Ganz findings in ARDS

A

high PAWP (18-20) b/c the right heart is pumping against incresed resistance in the lung vasculature

292
Q

ARDS treatment

A

focus on oxygenation-increase PEEP & FiO2-lower tidal volume (4)increase rate (F)

293
Q

calculate male predicted body wt

A

50 + 2.3(height in inches - 60)

294
Q

calculate female predicted body wt

A

45.5 + 2.3(heigh in inches -60)

295
Q

inclusion criteria for ARDS

A
  1. PaO2/FiO2 under 300 2. bilateral infiltrates consistent w/p. edema3. no clinical evidence of left atrial HTN
296
Q

oxygenation goal for ARDS

A

minimam PEEP of 5. incremental FiO2/PEEP combos to achieve goal fo PaO2 55-80 & SpO2 88-95%

297
Q

pPlat goal if ARDS

A

under 30check pPlat q4hrs or after each change in PEEP/VtpPlat over 30 = decrease Vt by 1ml/stepspPlat under 25 and Vt under 6ml/kg = increase Vt by 1ml/kg until pPlat is over 25 or Vt 6ml/kg*pPlat under 30 and breath stacking, incrae Vt in 1ml/kg increaments to 7 or 8

298
Q

3 Stages of Tylenol overdose

A
  1. flu-like (N/V, abd pain, swat, pale)2. liver injury (RUQ pain, LFT elevate)3. peak liver enzymes (hepatic fialure (glucose/lactate/phosphate abnormal), encephalopathy, hypoglyemia, coma, death
299
Q

late stage serious complications of tylenol overdose

A 
hepatic failureencephalopathyhypoglyvemiacomadeath
300
Q

abnormal labs in tylenol overdose

A

LFT elevatedlow glucosephosphate abnormal

301
Q

asprin overdose

A

N/V| tinnitis

302
Q

acid base in asprin overdose

A

r. alkalosis| can progress to m. acidosis

303
Q

cause of REye’s disease

A

pediatric asprin overdose

304
Q

complications of asprin overdose

A

liver & brain damagehigh ICP possible encephalopathyhepatic encephalopathy

305
Q

treatment of asprin overdose

A

sodium bicarb (b/c liver damage causes high ammonia) and dialysis

306
Q

labs in asprin overdose

A

r. alkalosis progressing to m. acidosis| high lactate b/c liver damage

307
Q

benzodiazepines

A 
diazepam = valiumlorazepam = ativanmidazolam = versed
308
Q

treatment of benzodiazepine overdose

A

activated charcoal if ingested| flumazenil

309
Q

Fluzemanil

A

benzo overdose

310
Q

pushing Flumazenil too fast

A

seizures

311
Q

antidoate for Beta Blocker overdose

A

glucagon

312
Q

s/s of BB overdose

A 
low bp/hrconduction delayslow glucosep. edemabronchospams
313
Q

glucose in BB overdose

A

low glucose

314
Q

overdose with low glucose

A

consider BB overdose

315
Q

treat BB overdose

A

glucagonpacing, atropinerIVF for low bp

316
Q

difference between BB and CaChB overdose s/s

A

both have low HR/BP/conduction delaysBB = low glucoseCaChab= high glucose

317
Q

s/s CaChB overdose

A

low BP/HR/conduction delaysm. acidosishigh glucose

318
Q

treatment of CaChB overdose

A

activated charcoalatropine/pacingIVF for low BP

319
Q

s/s of digoxinoversoe

A

flu-likeyellow green halosrisk of high Kslurred upstroke on ERS

320
Q

avoid if digoxin overdose

A

avoid electricity like pacing/cardioversion

321
Q

EKG of digoxin overdose

A

slurred upstroke on ERS

322
Q

use of phenytoin (DIlantin)q

A

seizures

323
Q

s/s of phenytoin (Dilantin) overdose

A

SVT, coma, confusion, tremores| DI-like s/s

324
Q

treat phenytoin (Dilantin) overdose

A

IVF/O2, supportative| maybe gastric lavage

325
Q

s/s of cocaine overdose

A

chest pain, HTN, seizures, rhabdo

326
Q

treat cocaine overdose

A

IVF, benzos

327
Q

treat PCP

A

sedatives. no ketamine b/c delirum can worsen

328
Q

risk of MDMA

A

overheadinglow Naserotonin syndrome

329
Q

treat alkalis

A

copious water

330
Q

treat anticholinergic

A

phyostigime

331
Q

treat ASA

A

bicarb

332
Q

treatment BB

A

glucagon

333
Q

treat CaChB

A

Calcium gluconate

334
Q

treat cocaine

A

benzos

335
Q

treat coumadin

A

vitamin K

336
Q

treat pit viper

A

CroFab, FabAV

337
Q

treat cyanide

A

sodium thiosulfate, sodium nitrite/amyl nitrate

338
Q

treat phenytoin

A

supportative

339
Q

treat ethylene gluycol

A

IV ethonol or Femepizole

340
Q

treat heparin

A

protamine sulfate

341
Q

treat hydrocarbons

A

intubate

342
Q

treat hydrofluoric aicd

A

calcium gluconate

343
Q

treat INH

A

pyridoxine (vitamin B6)

344
Q

treat iron

A

Desferal

345
Q

treat methanol

A

IV ethanol, Fomenizole

346
Q

treat organophosphates

A

atropine & 2-PAM

347
Q

atropine & 2-PAM

A

organophosphates

348
Q

treat alcohol overdose

A

IV ethanol or Fomepizole

349
Q

Fomepizole

A

alcohol overdose

350
Q

Desferal

A

iron overdose

351
Q

amyl nitrite/sodium nitrite/sodium thiosulfate

A

cyanide

352
Q

glucagon as an antidote

A

BB

353
Q

what does a tricyclic antidepressant overdose look like

A

anticholinergic-like

354
Q

EKG of tricyclic antidepressant overdose

A

widened QRS with prolonged QT

355
Q

treatment of tricyclic antidepressant overdose

A

bicarb, IVFtarget pH is 7.5-7.55vasopressors if refractory low bp

356
Q

how to give rx for iron overdose

A

Desferan creates rose colored urine and normal once yellow again

357
Q

Antizole

A

treat toxic alcohols

358
Q

ABG of toxic alcohols

A

lethal anion-gap acidosis over 16

359
Q

aka antiffreeze

A

ethylene glycol

360
Q

ethylene glycol

A

antifreeze

361
Q

windshield wiper fluid

A

methanol

362
Q

methanol

A

windshield wiper fluid

363
Q

treat alcohol overdose

A

IV ethanol, Antizol, hemodialysis

364
Q

complication of hydrocarbons

A

chemical pneumonitis. decreaed viscosity causes aspiration| DO NOT induce vomiting

365
Q

toxidrome of pesticides

A

organophosphate = cholinergic toxidrome

366
Q

s/s of cholinergic toxidrome

A

SLUDGE/DUMBELSoraganophosphatesneve gases like sarin & Vx

367
Q

SLUDE/DUMBELS

A

cholinergic toxidrome/organiophosphates| defecation (GI distress/emesiss)

368
Q

nerve gas s/s

A

cholinergic toxidrome| SLUDGE/DUMBELS

369
Q

Vx s/s

A

cholinergic toxidrome| SLUDGD/DUBELS

370
Q

DUMBBELS

A 
diarrheaurinationmiosisbronchorrheabronchospasmemesislacriminationlaxationsweating
371
Q

other s/s of nerve gas & organophosphates

A

SLUDGE/DUMBBELS| nicotinic stimulation = tachycardiat, HTN, fasciculations, paralysis of respiratoyr muscles

372
Q

death from nerve gas/organophosphates

A

paralysis of respirtory muscles

373
Q

treat organophosphate overdose

A

atropine to decrease aireay secreationspralidoxime2-PAM (crowbar organophophate off of ACh)benzos for seizures

374
Q

how does 2-PAM work

A

crowbar that takes the organophosphate off of ACh| *for organophosphate/nerve agent/cholinergic

375
Q

atropine overdose

A

anticholinergic

376
Q

benadryl overdose

A

anticholinergic

377
Q

tricyclic antidepressant overdose

A

anticholinergic

378
Q

`mad as a hatter….

A

anticholinergic overdose

379
Q

anticholinergic toxierome s/s

A 
mad as a hatter - AMSblind as a bat -mydrisasisred as a beethot as a haredry as a bone
380
Q

rx for anticholinergic overdose

A

benadryl/atropine, tricyclic antidpressants…atropine for secreationsphysostigimine pushed 1mg/min

381
Q

most important intervention for poisionings/overdose

A

revert back to ABC & antidote

382
Q

leveling a-line transducer

A

phelbostatic axis 4th ICS midaxillary

383
Q

dicrotic notch

A

notch in a-line that represents aortic valve closure

384
Q

a-line waveform feature that represents aortic valve closure

A

dicrotic notch

385
Q

how to determine proper pressure in a-line system

A

determine dampening*no more/less than 3 ossillations before returning to baseline

386
Q

too little dampening

A

many ossillations. too little dampening that the ossillations won’t die and continue to reverberate

387
Q

too much pressure in the a-line system

A

overdampening

388
Q

obstruction in a-line system

A

overdampened

389
Q

kinded a-line

A

overdampened

390
Q

air in a-line

A

overdampened

391
Q

pressure bag overfilled

A

overdampened

392
Q

Boyle’s law on a-line

A

overdampened

393
Q

what is overdampening

A

= obstruction in a-line systemtoo much pressure

394
Q

causes of overdampened a-line

A

obstruction in aline systemkinked alineair in systempressure bag overfilledBoyle’s law

395
Q

underdampening

A

a-line system is too dynamic & has too little pressure

396
Q

a-line if pressure bag isn’t full

A

underdampened -too little pressure

397
Q

a-line if noncompliant tubing

A

underdampened - too little pressure

398
Q

what does Swan Ganz measure

A

aka PUlmonary Artery Catheterright heart preload/afterloadleft heart preload

399
Q

insertion site of a Swan Ganz/Pulmonary Artery catheter

A

central line into subclavin vein

400
Q

what part of the PA catheter is used to measure pressure

A

distal tip

401
Q

distal tip of the PA catheter

A

measure pressure

402
Q

how much ml air to measure pressure via PA catheter

A

do not exceed 1.5ml

403
Q

how to take wedge pressures

A

PA catheterno more than 1.5ml into distal portdtake at the end of exhalationdon’t take for longer than 15 sec or 3 breaths

404
Q

how long to take a wedge pressure

A

no longer than 15 sec or 3 breaths

405
Q

when do you take a wedge pressure

A

at the end of exhalation

406
Q

PA catheter PA port

A

for monitoring/lab samples only

407
Q

PA catheter port for monitoring/lab samples of blood

A

PA port

408
Q

PA catheter port for infusions/fluids

A

proximal ports

409
Q

proximal port on PA catheter

A

influsions/fluids

410
Q

how to transport a pt with a PA catheter

A

deflate the balloon to prevent an inadgertent wedge pressure when it advances*balloon size increases at altitude b/c Boyle’s Law

411
Q

progression of Swan-Ganz

A

subclavianR atrium/ventricledestination = pulmonary arteryinflate in pulmonary artery to get wedge pressure

412
Q

site where you get the wedge pressure =

A

pulmonary arteryq

413
Q

dicrotic notch on the left side of PA catheter waveform

A

RV waveform = tricuspid valve closing

414
Q

dicrotic notch on the right side of the waveform

A

PA waveform = pulmonic valve closing

415
Q

measures right heart preload

A

Central venous pressure2-6 mm hg

416
Q

Central venous pressure

A

CVP = 2-6mm hgright heart preload

417
Q

2-6mm hg

A

Central Venous PRessure right heart preload

418
Q

Right ventriclar pressure

A

systolic = 15 - 25mm hgdiastolic = 0-5 mm hg

419
Q

Pulmonary arty pressure

A

systolic = 15 - 25 mm hgdiastolic = 8-15

420
Q

systolic pressure of right ventricle

A

15 - 25

421
Q

diastolic pressure of right ventricle

A

0 - 5

422
Q

systolic pressure of pulmonary artery

A

15 - 25 mm hg

423
Q

diastolic pressure of pulmonary artery

A

8-15 mm hg

424
Q

8-15 mm hg

A

diastolic pressure of pulmonary artery

425
Q

15 - 25 mm hg

A

systolic pressure of right ventricle & pulmonary artery

426
Q

PAWP

A

8-12 mm hg

427
Q

8-12 mm hg

A

PAWP

428
Q

what does PAWP measure

A

right heart afterloadleft heart preload

429
Q

how to measure left heart preload

A

PAWP

430
Q

how to measure right heart afterload

A

PAWP

431
Q

what is normal coronary perfusion pressure

A

50 - 60 mm hg

432
Q

calculate coronary perfusion prssure

A

DBP - PAWP= 50 - 60

433
Q

normal CO

A

4-8L/min

434
Q

normal cardiac index

A

2.5 - 5 L/min

435
Q

catheter whip

A

exaggerated waveforms w/elevated systolic pressure and additional peaks (generally only 2 are found) = result of excessive movemnet of the catheter within the artery

436
Q

how to deal w/catheter whip

A

inflate cuff w/1.5 ml aircoughlay on right side

437
Q

troubleshooting PA/Swan Ganz catheter

A

catheter whipinadvertent wedge

438
Q

2 cause of inadvertent wewdge

A

balloon migrationensure the balloon is deflated (Boyle’s law)

439
Q

treatment for inadvertent wedge

A

you’ll see a PAWP waveform* deflate the balloon* cough* position pt*withdraw until you see a PA waveform

440
Q

causes of ireased PA pressure

A

left ventricular failureliver failure/portal HTNcor pulmonary/increased pulmomnary vascular resistancemitral regurg/stenosis

441
Q

why is MAP decreased in hypovolemia

A

loss of volume

442
Q

central venous pressure in hypovolemia

A

decreased

443
Q

SVR in hypovolemia

A

increased

444
Q

CO in cardiogenic shock

A

decreased

445
Q

central venous pressure in cardiovenic shock

A

decreased

446
Q

PCWP

A

pulmonary capillary wedge pressure

447
Q

indirect estimate of left atrial pressure

A

PCWP = pulmonary capillary wedge pressure

448
Q

PCWP in hypovolemic shock

A

decreased

449
Q

PCWP in cardiogenic shock

A

increased

450
Q

normal SVR

A

800 - 1200

451
Q

800 - 1200

A

normal SVR

452
Q

normal PVR

A

50 - 250

453
Q

50 - 250

A

PVR

454
Q

SVR in neurogenic shock

A

decreased

455
Q

HR in neurogenic shock

A

decreased

456
Q

shock w/low HR

A

neurogenic

457
Q

skin temp in neurogenic shock

A

cool/moist abovewarm/dry below

458
Q

central venous pressure in late septic shock

A

decreased

459
Q

PCWP in late septic shock

A

decreased

460
Q

SVR in late septic shock

A

increased

461
Q

CO in anaphylaxis

A

increased

462
Q

CVP in anaphylasis

A

decreased

463
Q

PCWP in late anaphylaxis

A

decreased

464
Q

SVR in anaphylaxis

A

decreased

465
Q

indications for IABP

A

acute MI w/cardiogenic shockpost CABGcardiogenic due to HF-PAWP over 18-decreased urine output-SBP under 80

466
Q

PAWP where you may need an IABP

A

PAWP over 18

467
Q

contraindications to IABP -3

A

low plt b/c hemolysis of RBC smash during inflationaortic insufficiency/disease, severe peripheral vasuclar disease

468
Q

2 effects of IABP

A

increase coronary perfusiondecrease workload of the heart

469
Q

IABP balloon during systole

A

deflated

470
Q

IABP balloon during diastole

A

inflated

471
Q

insertion of IABP

A

inserted into femoral artery directed towards the heart

472
Q

where does the IABP sit

A

in descending aortadistal to left subclavian arteryabove renal artery

473
Q

how do you check IABP placement

A

left radial pusle (left subclavian blockage causes limb ischemia)adequate UOP b/c renal artery artery decreses UOPCXR

474
Q

intervention for IABP if power failure

A

manually pump every 3-5 minutes to prevent blood from clotting on the balloon

475
Q

IABP at altitude

A

dont need to purge air b/c self burge

476
Q

transporting IABP

A

bring exter helium tanks

477
Q

how to tell if IABP balloon has ruptured

A

rust/brown flankes in IABP tubing -flakes are clotted RBC’s inside the tubing

478
Q

rust brown flakes in IABP tubing

A

IABP balloon has ruptured

479
Q

what happens in IABP if you have normal timing

A

decreased workloadincreased coronary perfusion

480
Q

early IABP inflation

A

inflation before the aortic valve closesforces blood back into LV

481
Q

IABP timing error where blood is forced back into the left ventricle

A

early IABP inflation

482
Q

when does early iABP inflation occur

A

inflation before the aortic valve closesso blood is forced back into the LV

483
Q

effect of early inflation

A

HARMFULaortic regurgdecreased COincreased SVR

484
Q

what does early inflation look like

A

“U” shape

485
Q

when is late inflation of IABP

A

inflation after the aortic valve closes

486
Q

IABP error when inflation occurs after the aortic valve closes

A

late inflation

487
Q

appearence of IABP

A

W

488
Q

W shape of IABP waveform

A

late inflation

489
Q

U shape of IABP waveform

A

early inflation

490
Q

problem of late inflation

A

suboptimal augmentationdecreased coronary perfusion

491
Q

4 shapes of IABP timing errors

A

early inflation = Ulate inflation = Wlate inflation = cliff shapelate deflation = widened appearence

492
Q

cliff shape of IABP

A

late inflation

493
Q

shape of late inflation

A

cliffe

494
Q

shpe of late deflation

A

widened appearnce

495
Q

widened appearnence of IABP waveform

A

late deflation

496
Q

problem s of early deflation

A

decreaed negative pressuredeflation of balloon beore systoleincreased afterload

497
Q

when does the IABP balloon delfate in the timing error of early deflation

A

deflation of balloon before systole

498
Q

worst IABP timing error

A

late deflation

499
Q

what happens in late deflation of IABP

A

inflation of the balloon during systole

500
Q

problems of late inflation IABP

A

inflation of the balloon during systooleaincreased afterload & workloadharmful/worst tiing erro

ULTIMATE Critical Care (2 decks)

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