Chap 29, 30, 42, 43 Flashcards
1
Q
Guillian-Bare Syndrom (GBS)
A
AUTOIMMUNE DISEASE
- Causes an acute peripheral nervous system disorder results in a flaccid paralysis of the skeletal muscle and loss of muscle reflexes
- Paralysis of the diaphragm and ventricular failure can develop= needing to be on mechanical vent.
- “weak legs”
2
Q
Polyneuropathy
A
Flaccid paralysis of the skeletal muscle and loss of muscle reflexes
3
Q
Major Pathologic or structural changes of the lungs with GBS
A
- Mucous accumulation
- Airway obstruction
- Alveolar Consolidation
- Atelectasis
4
Q
Development of GBS is unknown, but they do know that it is from an
A
immune response of foreign antigens that attack nerve tissue and lymphocytes
-Macrophages attack and strip off the myelin sheath of the peripheral nerves and leave swelling and frags of neural axons
5
Q
Onset of GBS
A
1-4 weeks after a febrile episode caused by a mild resp. or gastrointestinal viral or bacterial infection
6
Q
Clinical History of GBS
A
- Symmetric muscle weakness in distal extremities or dysesthesias (unpleasant, abnormal sense of touch), accompanied by paresthesia (tingling, burning, shockline sensation)
- Pain (especially lower back, butt, legs)
- Numbness
7
Q
Dysesthesias
A
unpleasant, abnormal sense of touch
8
Q
Paresthesia
A
tingling, burning, shockline sensation
9
Q
Muscle paralysis in GBS
A
spreads upwards starting at the (g)round to (b)rain
-Ascending paralysis
10
Q
GBS paralysis spreads in what time period
A
In single day or several days
- peaks about 2 weeks
- 90% full recovery, as long as 3 years
11
Q
Diagnosis of GBS
A
Pts clinical hx
cerebrospinal fluid findings
EMG
Nerve conduction studies (NCS)= increase and protein
12
Q
EMG and Nerve Conduction Studies (NCS) show what with GBS
A
Acute polyneuropathy with demyelinating antibodies- associated with axonal subtypes of GBS
13
Q
Treat GBS with what
A
Corticosteroid
14
Q
GBS common in
A
Higher chance in whites 50 years old and older
-Similar male and female
15
Q
Acute Vent. Failure averages
A
Vital Capacity < 20ml/kg
NIF < -25cmH2O
pH < 7.32 or
PaCo2 > 45 mmHg
16
Q
We measure vital capacity with
A
NIF
17
Q
GBS potential medical emergency
A
30% -> acute vent. failure and require mechanical vent..
-Stabalize vitals and supportive care, frequent measurements FVC and MIP
18
Q
GBS primary treatment
A
- Plasma pheresis
2. Intravenous immune globulin
19
Q
Plasma pheresis
A
Removes antibodies from plasma that contributes to the immune system attack on peripheral nerves
20
Q
Intravenous immune globulin
A
Blood product that contains IgG from donors
-Lasts 2weeks - 3 months
21
Q
Added risk of thromboembolism increase=
A
patient receives anticoagulants , elastic stockings, and passive range of motion exercises (ev. 3-4 hours) turn patient frequently
22
Q
Myasthenia Gravis
A
Most common chronic disorder of the neuromascular junction, only affects myoneural (motor) junction, sensory function not lost.
-Interferes with acetylcholine (AcH) between the axon terminal and receptor sites of voluntary muscles
23
Q
Hallmark clinical features of Myasthenia Gravis
A
Fluctuating Skeletal muscle weakness usually improves following rest
-Fatigue and weakness usually improves as well with rest
24
Q
2 clinical types of Myasthenia Gravis
A
- Ocular
2. Generalized
25
Ocular
Type of Myasthenia Gravis
| -Muscle weakness limited to eyelids and extra ocular muscle
26
Generalized
Type of Myasthenia Gravis
- Involves a variable combination of
1. Muscles of mouth and throat respiratory for speech and swallowing (bulbar muscles)
2. Limbs
3. Respiratory Muscles
27
Dropped Head Syndrome
Neck extensor and flexor muscles affected
28
Myasthenia Crisis
When diaphragm goes-> mechanical vent. required
| -Mucous accumulation with airway obstruction, Alveolar Consolidation, and Atelectasis may develop
29
Cause of Myasthenia Gravis
Related to AcH receptor (AcHR) antibodies (IgG) that blocks the nerve impulse transmissions and neuromuscular junction
30
Seropositive/ Seronegative Myasthenia Gravis
with or without AChR and MUSK
| -90% Seropositive
31
Antibodies usually arise within
thymus or related tissue
32
Peak age of onset of Myasthenia Gravis
15-35 years old in females, and 40-70 years old in Males
33
Myasthenia Gravis provoked by
emotional upset, physical stress, exposure to increase temp changes, febrile illness, and pregnancy
34
Tests/ Diagnoses of Myasthenia
1. Clinical presentation and history
2. Bedside tests
3. Immunologic studies
4. Electrodiagnostic Studies
5. Elevation of conditions associated with myathenia gravis
35
Signs and Symptoms of Myasthenia Gravis
- Facial Muscle Weakness
- Ptosis
- Diplopia
- Ophthalmoplegia
- Difficulty breathing
- Speaking
- Chewing
- Swallowing
36
Ptosis
Dropping of one or both eyelids
37
Diplopida
double vision
38
Opthalmoplegia
Paralysis or weakness of one or muscles for eye movement
39
Bedside Diagnostic test of Myasthenia Gravis
- Ice pack test
| - Edrophonium (Tensilon)
40
Ice pack test on myasthenia gravis
3-5 minutes when ptosis(dropping of one or both eyelids) is present
41
Edrophonium (tensilon)
Pt with ptosis or ophthalmoparesis
- short acting drug, blocks cholinesterase from breaking down AcH (10 min)
- Has false neg/ positives
42
1st diagnostic of Myasthenia Gravis
Serologic tests
43
Two types of Drowning
```
DRY DROWING (10-15%)
-Laryngospasm keeps water out of lungs
-Normal lungs
WET DROWNING (85-90%)
-Glottis relaxes and patient inhales water
-Leads to pulmonary edema
```
44
Wet drowning that leads to pulmonary edema
-Alveolar/ Capillary Edema
-Loss of surfactant
=
-Atelectasis
-Frothy White secretions-> hard for alveoli to open, so add PEEP
45
Better the survival vs worse when drowning
```
BETTER
-Colder the water
-The younger
-The cleaner
-Shorter time in water
-No other serious the better
-Good CPR start ASAP
WORSE
-Suicides tend to have a lower survival rate
```
46
Drowning Sequence
1. Panic and violent struggle to return to the surface
2. Period of calmness and apnea
3. Swallowing of large amounts of fluid-> vomiting
4. Gasping inspirations and aspirations
5. convulsions
6. Coma
7. Death
47
Hypothermia while drowning=
shuts down body and cells arent eating up O2
| -Common in kids less than 4 and teenagers
48
Steps to treating drowning patients
1. Remove wet clothing- Hypothermia lowers med responses
2. Warm body up
- Warm IVs
- Warming blankets
- Heated aerosol for inhalation
- Lavage of warm solutions to gastric, bladder , rectum, etc
- Rarely ECMO
3. Oxygen
4. Ventilation
- May develop ards
49
Cough and sputum production of drowning patients
- Cough and sputum production= Frothy (blocking air), pink, stable bubbles
50
Chest assessment in drowning patients
-Crackles (Popping alveoli open) and rhonchi
51
Burn defined as
Denaturing and destruction of tissue proteins and bonecaused by thermal, electrical, or chem injury.
-20% suffer from inhalation injury as well
52
Degrees of burn
1st degree- Sunburn
2nd degree- deeper in the tissue= blistering
3rd degree- Basal cells= scarring and need surg intervention
53
Four Phases of Burn Care
- Initial Evaluation and Resuscitation
- Initial wound excision and biologic closure
- Rehab, Reconstriction, and reintegration
54
Initial Evaluation and resuscitation of burn
First 72 hours, achieve accurate fluis resuscitation and throrough evaluation.
-We make sure enough O2 and ABG
55
Initial wound excision and biologic closure of burn
Day 1-7
| -Identify and remove all full thickness wounds and optain biologic closure
56
Rehab, reconstruct and reintegration of burn
Entire hospital stay
| -Initially to maintain range of movement and reduce edema
57
Evaluate what on a burn
Extent, depth, and circumferential components
58
5 predicted events of burn
-Acute airway obstruction
-bronchospasm
-Infection
Leading cause of morbidity = Resp. Failure
59
1st goal treating burn
- Fluid resuscitation-IV
| - Remove Eschar (burn tissue) and closure of open wounds-> avoid infection/ sepsis and multiple organ failure-> ARDS
60
Inhalation definition
Damage to lungs by the inspiration of superheated gases (temp above 150*C), steam, or noxious of products of incomplete combustion
- Hot gas
- Steam
- Noxious Products
61
Diagnosing Inhalation injuries
- Morbidity increases with smoke inhalation
| - -History, Exam, CXR-Pulmonary Edema?, Bronchoscope, PaO2/ FiO2 ratio, Radioisotope scanning
62
PaO2/ FiO2 ratio with ARDS
If below 100
63
Interventions of Inhalation Injuries
Airway clearance
- Suction on vent.
- Heated wire circuit to provide humidity
64
Phases of inhalation injury
- Exudative
- Degenerative
- Proliferative
- Reparative
+Leads to ARDS
65
Management of Inhalation injuries
- Intubate anyone with suspected airway injury
- Edema comes on in first 4 hours and can be difficult to intubate if you wait
- Can be difficult to tape due to burned tissue, use twill tape
- Tracheostomy for severe cases
66
Complications of inhalation injuries
- Airway Obstruction
- Tissue Swelling
- Secretions
- Bronchospasm
- Tissue sloughing
- Pulmonary infections
- Resp Failure
67
Steam is far worse with
H2O
68
Carbon Monoxide Poisoning (CO) 1st intervention
Administer 100% O2 NRB- wide open
69
Contraindicated of CO poisoning
Pulse Oximeters
- Use co-oximeter to get actual HbCO
- Affinity for hgb is 210 times of oxygen
70
Carboxyhemoglobin results in
- An acute physiolgic anemia
- Anemic anemia= not enough O2 carried to cells-> Disruption to carrying
- -Hydrogen cyanide (HCN)- Poisoning is produced by the combusion of nutrogen containing compounds in a low O2 atmosphere
- HCN binds to cytochrome oxidase system and inhibits cellular
71
Hydrogen Cyanide (HCN)
poisoning is produced by the combustion of nitrogen containing compounds in a low O2 atmosphere
72
Patient is nice and pin but still hypoxic from CO poisoning why
Blood comes out very pink
73
Co-oximeter measures both
CO and SaO2
| -Subtract the CO from the SpO2 to find the real SaO2
74
So any amount of CO that reduces the SaO2 to less than
90% causes hypoxemi
75
normal people have what CO
0%
| -Heavy smokers can have up to 7% CO
76
SaO2=
SpO2-SaCO
77
20% or more SaO2=
CO poisoning
78
Treatment of CO poisoning
- 100% oxygen (NRB or intubate)
- Hyperbaric oxygenation
- Changes the atmospheric pressure
- So instead of 760mmHg for PAO2 , 2 atmospheres would be 1520mmHg
- Increasing the PaO2
79
The onset of the signs and symptoms of myasthenia gravis is / are
1. Slow and insidious
2. Sudden and rapid
3. Intermittent
4. Often Elusive
80
Myasthenis gravis
1. is more common in young men
2. Has a peak age of onset in females of 15 to 35 years
3. Is often provoked by emotional upset and physical stress
4. Is associated with receptor-binding antibiodies
2. Has a peak age of onset in females of 15 to 35 years
3. Is often provoked by emotional upset and physical stress
4. is associated with receptor binding antibodies
81
Which of the following is associated with myasthenia gravis
1. bronchospasm
2. mucous accumulation
3. Alveolar hyperinflation
4. atelectasis
Mucous accumulation, atelectasis
82
When monitoring the pt with myasthenia gravis, ALL of the following are indicators of acute ventilatory failure
pH 7.31
PaCO2 55 mmHg
MIP -15 cmH20
83
Which antibodies is believed to block the nerve impulse transmission at the neuromuscular junction in myasthenia gravis
IgG
84
In guillian barre syndrome, which of the following pathologic changes develop in the peripheral nerves
Inflammation, Demyelination, edema
85
Which of the following is associated with guillain barre syndrome
1. Alveolar consolidation
2. Mucous accumulation
3. Alveolar hypoinflation
4. Atelectasis
86
Guillain Barre syndrom is more common in
people older than 50 years of age, and white than in blacks
87
Full recovery from guillain barre syndrom is expected in approx what percentage of cases
90%
88
Which of the following are indicators for intubation and mech vent in pts with guillain barre syndrom
pH < 7.40
PaCO2 > 45
FVC < 20 mL/kg
MIP < -30cm H20
89
In the US, drowning is the
third leading cause of accidental death
90
according to the CDC and prevention, about how many people drown each year in the US
1500
91
Which of the following are the major anatomic alterations of the lungs associated with near drowning victims?
1. consolidation
2. bronchospasm
3. increased alveolar-capillary membrane thickness
4. atelectasis
5. excessive bronchial secretions
92
Which of the following clinical manifestations are associated with near drowning victims?
1. frothy, pink sputum
2. crackles
3. increased pH
4. increases SvO2
Frothy pink sputum
| Crackles
93
Which of the following pulmonary function testing values are associated with near drowning victims?
1. normal or decreased FEV1
2. decreased FVC
3. decreased RV
4. normal or increased FEV1/FVC ratio
d. 1, 2, 3, and 4
94
Near drowning refers to the situation in which a victim:
d. at least temporarily survives a liquid submersion
95
What anatomic alterations happen during a wet drowning?
1. the victim coughs out any water
2. the glottis relaxes
3. water enters the airways and alveoli
4. inhaled water causes bronchial constriction
c. 2, 3, and 4 only
96
The pulmonary effects of a near drowning victim inhaling water include:
1. capillary fluid moves into alveoli
2. surfactant production is increased
3. pulmonary shunting is increased
4. atelectasis develops
d. 1, 3, and 4 only
97
Given the following options, which would occur last in a near drowning sequence?
a. convulsions
b. panic and violent struggle to return to the surface
c. swallowing then vomiting large amounts of fluid
d. gasping inspirations and aspiration
A
98
An ambulance has just transported an apneic near drowning victim to the Emergency Department. The paramedic is performing bag-mask ventilations for the victim who has a pulse and blood pressure. As the respiratory therapist, what would you recommend be done?
1. initiate mechanical ventilation
2. continue bag-mask ventilations
3. intubate the victim
4. begin chest compressions
1 and 3
99
percentage hospitalized patients with thermal injury have an acute upper airway obstruction
20-30%
100
Except for the rare instance of steam inhalation, direct thermal injuries usually do not occur below the level of which of the following structures
Larynx
101
When chest wall burns are present, the pts pulmonary condition may be further aggravated by which of the following
1. Decreased lung and chest compliance
2. Increased airway resistance
3. Administration of narcotics
4. Immobility
102
Which of the following is/are the pulmonary related pathologic changes associated with smoke inhalation
1. Pneumomediastinum
2. Bronchospasm
3. Pulmonary edema
4. Pulmonary embolism
2, 3, 4
103
Which of the following produce carbon monoxide when burned?
1. Polyurethanes
2. wood, cotton, paper
3. Organic material
4. Polyvinylchloride
Organic material, Polyvinylchloride
104
Which of the following oxygenation indices is or are associated with smoke inhalation and burns during the early and intermediate stages
Increase VO2
Increase in C(a-v)O2
Decreased DO2
Decrease SvO2
105
f an adult's entire right arm, right leg, and anterior truck have been burned, approximately what percentage of the patient's body surface area is burned?
45%
106
healing time for a second degree
7-21days
107
Breathing 100% oxygen at 1 atmosphere reduces the COHb half life to less than
1 hour
