Chapter 4 - Critical Care Concepts and Complex Health Issues

Question 1

What is right atrial (RA) pressure?

Answer 1

• preload
• the pressure in the RA reflects the amount of blood returning to the heart and the ability of the heart to pump blood into the arterial system
• normal range: 2-6 mmHg

Question 2

What is the central venous pressure (CVP)?

Answer 2

• preload
• reflects the amount of blood returning to the heart; a good approximation of RA pressure
• normal range: 2-6 mmHg

Question 3

What is right ventricle (RV) pressure?

Answer 3

• indicates right ventricular function and general fluid status
• increased RVP may indicate pulmonary HTN, RV failure, CHF
• normal range: 15-30 mmHg (systolic); 2-6 mmHg (diastolic)

Question 4

What is pulmonary artery (PA) pressure?

Answer 4

• reflects the BP in the pulmonary artery
• increased PA pressure can indicate a left-to-right shunt, PA HTN, COPD, PE, pulmonary edema
• normal range: 20-30 mmHg (systolic); 5-10 mmHg (diastolic); mean 10-20 mmHg

Question 5

What is pulmonary capillary wedge pressure (PCWP/PAW)?

Answer 5

• preload
• measures the LV pressure when mitral valve is open
• high wedge pressure can indicate LV failure, mitral valve pathology, cardiac insufficiency
• normal range: 8-12 mmHg

Question 6

What is systemic vascular resistance (SVR)?

Answer 6

• afterload
• measures resistance of the systemic vascular bed to blood flow
• increased SVR can be caused by vasopressors, hypovolemia, or late septic shock
• decreased SVR can be caused by early septic shock, vasodilators, morphine, nitrates
• normal range: 900-1400

Question 7

What is cardiac output (CO)?

Answer 7

• contractility
• the volume of blood pumped by the heart in 1 minute
• increased CO indicates high circulating volume
• decreased CO means a decrease in circulating volume or a decreased in the strength of ventricular contraction
• normal range: 4.8-6.4 L/min

Question 8

What is cardiac index (CI)?

Answer 8

• contractility
• the amount of blood pumped per minute per meter square of body surface area
• normal range: 2.5-4.2 L/min

Question 9

What is saturation of mixed venous oxygen (SvO2)?

Answer 9

• the estimate of the amount of oxygen returning to the cardiopulmonary circulation
• reflective of the patient’s ability to balance O2 supply and demand at the tissue level
• normal range: 70-75% (60-80%)

Question 10

Hypovolemic shock - pathophysiology

Answer 10

• nothing to fill up the vessels
• most common form of shock in trauma
• multiple organ failure d/t inadequate circulating volume leading to inadequate tissue perfusion

Question 11

Hypovolemic shock - common causes

Answer 11

• acute hemorrhage
• severe dehydration
• severe burns

Question 12

Hypovolemic shock - cardiac pressures

Answer 12

• SBP: < 90 mmHg
• CVP: ↓ (not a lot of fluid returning to heart)
• PAOP: ↓ (nothing to fill up vessels & ventricles)
• CO/CI: ↓ (no fluid to circulate = no fluid to put out)
• SVR: ↑ (vasoconstriction as compensatory mechanism)
• SvO2: ↓ (not enough fluid to circulate and oxygenate)

Question 13

Hypovolemic shock - treatment

Answer 13

• treat underlying cause
• volume replacement
• transfuse PRN

Question 14

Cardiogenic shock - pathophysiology

Answer 14

• have enough fluid, just the pump isn’t working

- inadequate tissue perfusion secondary to a loss of contractile function; “pump failure”

Question 15

Cardiogenic shock – common causes

Answer 15

• Acute MI
• Acute heart failure
• Dysrhythmia

Question 16

Cardiogenic shock – cardiac pressures

Answer 16

• SBP: < 90 mmHg
• CVP: ↑ (fluid backs up)
• PAOP: ↑ (fluid backs up)
• CO/CI: ↓ (pump not working effectively)
• SVR: ↑ (not d/t vasoconstriction! Due to fluid backing up and putting pressure on vessels)
• SvO2: ↓ (not enough blood returning because you can’t pump it out and circulate it)

Question 17

Cardiogenic shock – treatment

Answer 17

• Treat underlying cause
• Support cardiac output with inotropic agents
• Support oxygenation

Question 18

Distributive shock – pathophysiology

Answer 18

• Vasodilation!
• Systemic event causes the loss of the normal responses of vascular smooth muscle to physiologic vasoconstrictive agents coupled with direct vasodilating effect

Question 19

Distributive shock – common causes

Answer 19

• Septic shock
• Anaphylactic shock
• Neurogenic shock

Question 20

Distributive shock – cardiac pressures

Answer 20

• SBP: < 90 mmHg
• CVP: ↓ (plenty of fluid but vessels are wide open so they seem empty)
• PAOP: ↓ (vessels don’t fill up)
• CO/CI: ↓ (fluid not returning back to heart because vessels are too wide)
• SVR: ↓ (vessels are wide open)
• SvO2: ↓ or ↑

Question 21

Distributive shock – treatment of septic

Answer 21

• See later slides for full treatment

Question 22

Distributive shock – treatment of anaphylactic

Answer 22

• Volume replacement
• Epinephrine (terminates anaphylaxis)
• Glucocorticoids (IV or PO) (extends life of Epi and suppresses inflammatory response)
• Antihistamines (suppresses inflammatory response)

Question 23

Distributive shock – treatment of neurogenic

Answer 23

• Volume replacement followed by alpha antagonists

Question 24

Septic Shock – pathophysiology

Answer 24

• A dysregulated response to infection resulting in severe vasodilation and a critical reduction in tissue perfusion leading to organ dysfunction

Question 25

Septic Shock Hemodynamic Parameters – Hyperdynamic Shock/”Warm Shock”

Answer 25

* CVP: INCREASED or decreased * PAOP: normal * CO/CI: increased * SVR: decreased * SvO2: increased * As compensatory mechanisms begin to fail, move from warm to cold shock

Question 26

Septic Shock Hemodynamic Parameters – Hypodynamic Shock/”Cold Shock”

Answer 26

* CVP: increased or DECREASED * PAOP: decreased * CO/CI: decreased * SVR: decreased * SvO2: increased or decreased

Question 27

Surviving Sepsis Management of Septic Shock – within 3 hours…

Answer 27

* Measure lactate level * Obtain blood cultures prior to administration of antibiotics * Administer broad-spectrum antibiotics (narrow coverage later based on cultures) * Administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L

Question 28

Surviving Sepsis Management of Septic Shock – within 6 hours….

Answer 28

* Apply vasopressors (Levophed) (for hypotension that doesn’t respond to initial fluid resuscitation) to maintain a MAP ≥ 65 mmHg * In the event of persistent hypotension after initial fluid bolus (MAP < 65) or if initial lactate was > 4, reassess volume status and tissue perfusion and document findings * Re-measure lactate if initially elevated

Question 29

Evaluation and Follow-Up of Septic Shock

Answer 29

Option #1 o Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings Option #2 – more of an ICU follow-up o Measure CVP, ScvO2, bedside cardiovascular ultrasound, and dynamic assessment of fluid responsiveness with passive leg raise or fluid challenges

Question 30

Overall Goals of Septic Treatment

Answer 30

* CVP 8-12 mmHg * MAP ≥ 65 mmHg * Urine output ≥ 0.5 ml/kg/hr * ScvO2 > 70%

Question 31

ABG Interpretation with normal levels

Answer 31

pH: 7.35-7.45 o ↑ = alkalosis state; ↓ acidosis state PaCO2: 35-45 mmHg o ↑ = respiratory acidosis; ↓ respiratory alkalosis HCO3: 22-26 mEq/L o ↑ = metabolic alkalosis; ↓ metabolic acidosis * Full compensation means normal pH * Partial compensation means abnormal pH + PaCO2 and HCO3 will also be abnormal

Question 32

ABG Example: pH 7.3, PaCO2 68, HCO3 28, PaO2 60

Answer 32

• Respiratory acidosis, partially compensated

Question 33

ABG Example: pH 7.0, PaO2 90, PaCO2 23, HCO3 12

Answer 33

• Metabolic acidosis, partially compensated

Question 34

ABG Example: pH 7.6, PaO2 120, PaCO2 31, HCO3 25

Answer 34

• Respiratory alkalosis, uncompensated

Question 35

ABG Examples: pH 7.5, PaO2 85, PaCO2 40, HCO3 34

Answer 35

• Metabolic alkalosis, uncompensated

Question 36

Burn Sources/Types of Burns

Answer 36

* Thermal – caused by heat source such as a hot item, steam, smoke, etc. * Electrical – caused by a form of electrical current such as AC or DC current * Chemical – caused by a chemical agent such as acid or alkali chemical substance * Radiation – caused by a form of radiation such as sun exposure or cancer treatments

Question 37

Common Complications of Burns

Answer 37

* Pulmonary injury * Capillary leak syndrome (third-spacing) * Mechanical obstruction (esp. with circumferential burns) * Loss of skin integrity * Loss of temperature control * Other forms of trauma/injury

Question 38

Treatment of Burns

Answer 38

* Safety of patient and provider * Stop the burning process – wipe chemical away, deactivate chemical, remove hot items (ex: jewelry) * Pain control – typically with opioids, but dictated by extent, degree of burn, and other comorbidities * Fluid replacement – Parkland formula (if > 15-20% TBSA) * Maintain urinary output of 0.5 mg/kg/hr

Question 39

Parkland Formula

Answer 39

* 24-hour fluid replacement = 4 ml/kg/%TBSA | * ½ volume in 8 hours from time of burn and remaining ½ in the remaining 16 hours

Question 40

How to figure out protein status?

Answer 40

* Serum albumin – reflects nutritional status for previous 1-2 months * Serum transferrin – reflects nutritional status for previous weeks * Serum pre-albumin – reflects nutritional status for previous week * Nitrogen balance – an estimate of nitrogen in vs. nitrogen out; reflects immediate nutritional status

Question 41

Nitrogen Balance – what does it mean?

Answer 41

* Neutral balance – burning off all protein that goes in * Negative balance – burning off more than going in, in a malnourished state * Positive balance – burning off less than going in, have protein reserve

Question 42

Basic way to calculate caloric needs in acute illness

Answer 42

* All patients: 25-30 kcal/kg/day * Moderate illness, injury, or malnutrition: 30-35 kcal/kg/day * Critical illness or injury: 35-40 kcal/kg/day

Question 43

Nutritional support – can use the gut

Answer 43

If > 6 weeks – use endostomal tube If < 6 weeks – need to assess risk for aspiration o If risk for aspiration – duodenal tube o If no risk for aspiration – nasogastric tube

Question 44

Nutritional support – cannot use the gut

Answer 44

* If > 2 weeks – use central venous access and TPN | * If < 2 weeks – use peripheral vein (PPN)

Question 45

Normal BMP levels – Na, K, Ca, Mg

Answer 45

* Na: 135-145 * K: 3.5-5 * Ca: 8.5-10.5 * Mg: 1.7-2.2

Question 46

Pathophysiology of Hyponatremia

Answer 46

• Most common electrolyte disturbance in acute care. There are 3 main types of hyponatremia and each have their own pathophysiologic basis

Question 47

Initial diagnostic workup of hyponatremia

Answer 47

* Step 1: obtain a serum sodium value | * Step 2: obtain a serum osmolality value (normal is 270-290 mOsm/L)

Question 48

Pathophysiology of isotonic hyponatremia

Answer 48

* “Normal serum”; serum osmo is 270-290 mOsm/L * Typically r/t a chronic process, where sodium is chronically displaced. An increase in one of the indissolvable solutes displaces the sodium and plasma water. The most common cause is HLD

Question 49

Additional workup for isotonic hyponatremia

Answer 49

• None typically needed

Question 50

Potential consequences of isotonic hyponatremia

Answer 50

• No risk of fluid shift and no risk of neurologic complications

Question 51

Treatment for isotonic hyponatremia

Answer 51

* Sodium replacement is not necessary in this solution | * Correct the indissolvable solute

Question 52

Pathophysiology of hypertonic hyponatremia

Answer 52

* “Thick serum”; serum osmo > 290 mOsm/L * Typically r/t to acute increase in another dissolvable solute, which causes the kidney to acutely dump sodium – there is too much of another solute (like another electrolyte) so the kidneys make room for it. Since Na is most abundant, Na usually is the one that gets kicked out

Question 53

Additional workup for hypertonic hyponatremia

Answer 53

• None typically needed

Question 54

Potential consequences of hypertonic hyponatremia

Answer 54

* Risk of fluid shift from intracellular space to intravascular space, resulting in cellular shrinkage * Fluid will move from inside the cell to outside to try and dilute the serum – risk of neurologic complications

Question 55

Treatment for hypertonic hyponatremia

Answer 55

* Sodium replacement is typically not acutely necessary | * Correct the underlying cause (remove the excess dissolvable solute)

Question 56

Pathophysiology of hypotonic hyponatremia

Answer 56

* “Thin serum”; serum osmo < 270 mOsm/L | * Typically r/t volume overload or volume depletion, resulting in a change in ADH secretion from an acute process

Question 57

Additional workup for hypotonic hyponatremia

Answer 57

* Step 1 – assess patient’s volume status | * Step 2 – obtain a urine sodium level (if volume depleted) (normal urine Na is 10-20)

Question 58

Diagnostic findings of hypervolemic hypotonic hyponatremia

Answer 58

* Serum sodium < 135 * Serum osmo < 270 (“thin serum”) * SIGNS OF FLUID OVERLOAD

Question 59

Cause of hypervolemic hypotonic hypernatremia

Answer 59

* The patient is retaining free H2O | * Most commonly caused by cardiac, hepatic, or renal failure

Question 60

Consequences of hypervolemic hypotonic hyponatremia

Answer 60

* Risk of fluid shift from intravascular to intracellular space, resulting in cellular swelling * Risk of neuro complications if homeostasis is not restored

Question 61

Treatment of hypervolemic hypotonic hyponatremia

Answer 61

* Treat underlying disease process | * Free H2O restriction, consider diuresis

Question 62

Diagnostic findings of hypovolemic hypotonic hyponatremia

Answer 62

* Serum sodium < 135 * Serum osmo < 270 (“thin serum”) * SIGNS OF FLUID DEPLETION * Urine Na < 20 = renal losses * Urine Na < 10 = extrarenal losses

Question 63

Causes of hypovolemic hypotonic hyponatremia

Answer 63

* Patient is losing H2O and sodium at equal rate * Most common renal cause is excessive diuresis * Most common extrarenal causes are third spacing, GI losses, and/or excessive diaphoresis

Question 64

Consequences of hypovolemic hypotonic hyponatremia

Answer 64

* Risk of fluid shift from the intravascular to intracellular space, resulting in cellular swelling * Risk of neuro complications if homeostasis is not restored

Question 65

Treatment of hypovolemic hypotonic hyponatremia

Answer 65

* Volume replacement with NS at a slow rate * Once volume status is restored the stimulus for ADH is removed * Correcting Na is necessary while treating the underlying cause

Question 66

Additional workup for euvolemic hypotonic hyponatremia

Answer 66

* A urine osmo is required for accurate diagnosis * Urine osmo > 100 – consider SIADH, hypothyroidism (most common), or glucocorticoid deficiency * Urine osmo < 100 – consider 1st degree polydipsia or low solute

Question 67

General Principles for Na Replacement

Answer 67

* For asymptomatic or chronically symptomatic patients, correct Na at a rate of ≤ 0.5 mEq/L * For acutely symptomatic patients, correction should be more rapid (2 mEq/L for first 2-3 hours) until symptoms resolve * In general, Na increase should not exceed 6 mEq/L/day (in chronic patients) or 8 mEq/L/day (in acute patients) to avoid central pontine myelinolysis or osmotic demyelination syndrome * Check serum Na every 2 hours during acute replacement * If overcorrection occurs, institute D5W and DDAVP

Question 68

Hypernatremia physiology

Answer 68

• Typically r/t a loss of hypotonic fluid (H2O) and/or a decreased access to free H2O. This leads to a hypertonic state

Question 69

Hypernatremia further assessment

Answer 69

* Urine osmo is needed for accurate assessment and diagnosis * Normal urine Na osmo is 300-900 mOsm/kg * Urine osmo < 700-800 = renal losses * Urine osmo 300-600 mOsm/kg = partial DI, osmotic diuresis, or loop diuretics * Urine osmo < 300 mOsm/kg = complete DI * Other causes (urine osmo > 700-800; normal) and needs a urine sodium assessment * Urine Na < 25 = GI H2O, insensible losses, or increased cellular osmoles from seizure or extreme exercise * Urine Na > 100 = Na overload

Question 70

Hypernatremia treatment

Answer 70

* Determine and treat underlying cause * Calculate free water deficit and replace the free water deficit with D5W, 0.45%NS, ¼ NS, or free water via gastric tube * Be cautious – do not decrease Na more than 0.5 mEq/L/hr to avoid cerebral edema * When calculating infusion rates, the goal is 8-10 mEq/L/day * Check Na levels every 2 hours * Treat DI with DDAVP or Na restriction * Treat Na overload with D5W and diuresis

Question 71

Hypokalemia pathophysiology

Answer 71

* K < 3.5 | * Typically results from K+ losses from the GI tract, renal system, or from transcellular shifts

Question 72

Hypokalemia assessment

Answer 72

* Most common symptoms are CARDIAC RHYTHM DISTURBANCES (increased QT interval, v-tach, v-fib, and ventricular ectopy) * Can also experience nausea, vomiting, ileus, muscle cramps, or rhabdomyolysis

Question 73

Hypokalemia additional diagnostics

Answer 73

* A urine K+ can assist in identifying the cause (normal urine K+ is 25-125 mEq/day) * Urine K+ < 25 = GI losses or transcellular shifts * Urine K+ > 100 = renal losses (hypotension, HTN, or mineral corticoid excess)

Question 74

Hypokalemia treatment

Answer 74

* Treatment is more aggressive if cardiac rhythm disturbances are present * Replace potassium (KCl); 10 mEq of KCl will raise serum K+ by ~ 0.1 mEq/L) * Non-urgent treatment: 40 mEq PO q4-6h * Urgent treatment: 10 mEq/h IV * Check Mg level – if serum Mg is < 1.2, replace with IV MgSulfate 1-2g q2h. Do NOT use PO Mg as it is poorly tolerated (need a normal Mg to be able to ‘hold on’ to the K replacement)

Question 75

Hyperkalemia pathophysiology

Answer 75

* K > 5.0 * Typically results from K+ retention from renal failure and transcellular shifts (acidosis, insulin deficiency, drug induced, and cellular necrosis)

Question 76

Hyperkalemia assessment

Answer 76

* The most common symptoms are CARDIAC RHYTHM DISTURBANCES (peaked T-waves, increased PR interval, increased QRS width, PEA, asystole, v-fib) * Can also experience weakness, paralysis, paresthesia, and palpitations

Question 77

Hyperkalemia treatment

Answer 77

* Treatment is more aggressive if cardiac rhythm disturbances are present * Calcium gluconate 1-2 amps IV (onset < 3 minutes); useful in dialysis patients * 10 units regular insulin IV + 1-2 amps D50W IV (15-30 minute onset) * Sodium polystyrene (Kayexalate) 30-90g PO/PR (1-2 hour onset) * Albuterol 10-20 mg inhalation or 0.5 mg IV (30-90 minute onset) * Lasix ≥ 40 mg IV (30 minute onset) * Dialysis – decreases total body K+ concentration

Question 78

Hypocalcemia pathophysiology

Answer 78

* Ca < 8.5 * Typically results from a secondary process including hypoparathyroidism, chronic renal failure, vitamin D deficiency, and calcium confiscation

Question 79

Hypocalcemia assessment

Answer 79

* Most common symptoms are NEUROMUSCULAR IRRITABILITY and increased DTRs * Chvostek’s sign: tap face/cheek causes facial twitch * Trousseau’s sign: place BP cuff on arm and inflate 20 mmHg above SBP for 3-5 minutes, causes carpal spasm * Can also experience seizures, laryngospasms, cramping, irritability, and psychosis * Ca is protein-bound so you may need to calculate corrected Ca (based on albumin) or do a ionized Ca

Question 80

Hypocalcemia treatment – symptomatic patients

Answer 80

• Ca gluconate IV 1-2g over 20 minutes + calcitriol

Question 81

Hypocalcemia treatment – asymptomatic/chronic patients

Answer 81

• Oral Ca 1-3 g/day (calcium citrate better absorbed than calcium carbonate) + Vitamin D PO weekly for 8-10 weeks

Question 82

Hypocalcemia treatment – chronic renal failure

Answer 82

• Phosphate binders + oral calcium

Question 83

Hypercalcemia pathophysiology

Answer 83

* Ca > 10.5 * Typically results from a secondary process including hyperparathyroidism, MALIGNANCY (90%), and vitamin D excess * More likely to be hyperparathyroidism if patient is asymptomatic or condition is chronic

Question 84

Hypercalcemia assessment

Answer 84

* Most common symptoms are vague and non-specific such as changes in mental status, abdominal pain, nausea, vomiting, fatigue, weakness, and depression * Ca > 13-15 is considered a medical emergency (hypercalcemic crisis) (especially if patient has neuro symptoms as well)

Question 85

Hypercalcemia treatment

Answer 85

* NS 4-6 L/day, consider adding Lasix if patient is volume overloaded (onset < 1 hour) – increases renal excretion * Bisphosphonates (onset 1-2 days); useful in malignancy involving bone, inhibits osteoclasts * Dialysis can be considered in emergency situations

Question 86

WHO Chronic Pain Management Standards – Step 1 (Mild Pain)

Answer 86

* Non-opioids: aspirin, acetaminophen, NSAIDs, ± Adjuvants (take weeks to receive max effects) * Acute pain score of 1-3 * If pain persists or increases, move to step 2

Question 87

WHO Chronic Pain Management Standards – Step 2 (Moderate Pain)

Answer 87

* Weak opioids: codeine, hydrocodone, oxycodone, tramadol, ± NSAIDs, ± Adjuvants * Acute pain score of 4-6 * If pain persists or increases, move to step 3

Question 88

WHO Chronic Pain Management Standards – Step 3 (Severe Pain)

Answer 88

* Strong opioids: morphine, hydromorphone, methadone, fentanyl, ± NSAIDs, ± Adjuvants * Acute pain score of 7-10

Question 89

Stepwise approach to ventilator management – quick and dirty steps

Answer 89

* Step 1 – choose ventilator mode * Step 2 – choose a volume or pressure target * Step 3 – determine other settings

Question 90

Ventilator Modes: Assist Control (AC)

Answer 90

* Also known as continuous mandatory ventilation (CMV) * Vent delivers a specific number of pre-set supported breaths * Additional patient breaths trigger a fully-assisted breath * May be pressure or volume targeted * Do not use in tachypnea (can lead to hyperinflation and respiratory alkalosis)

Question 91

Ventilator Modes: Synchronized Intermittent Mandatory Ventilation (SIMV)

Answer 91

* Vent delivers a minimum number of breaths that are synchronized with the patient’s efforts * Additional patient breaths are possible with a tidal volume determined by patient effort * May be pressure or volume targeted * Can lead to decreased CO in patients with LVD

Question 92

Ventilator Modes: Pressure Support Ventilation (PSV)

Answer 92

* No minimum set rate | * All breaths are triggered by the patient with vent support through a set inspiratory pressure and PEEP

Question 93

Choosing a Volume or Pressure Target – Volume Targeted

Answer 93

* Ventilator delivers a set Vt * Pressures adjust (vary) to meet Vt requirement based on lung compliance * Benefits – increased control of ventilation, good use in ALI/ARDS, good initial setting * Cons – uncomfortable for patients

Question 94

Choosing a Volume or Pressure Target – Pressure Targeted

Answer 94

* Ventilator delivers set pressures * Vt adjusts (vary) based on lung compliance * Benefits – more comfortable and less sedation, better pressure control to prevent injury

Question 95

CPAP vs. BiPAP

Answer 95

* CPAP: constant pressure is maintained throughout respiratory cycle with no additional inspiratory support * BiPAP: a set expiratory positive airway pressure and the inspiratory airway pressure are determined, respirations triggered by patient

Question 96

Liver transplant rejection

Answer 96

* Common; 60% experience a single episode of rejection within first 3 months * Slight elevation in transaminases * Signs and symptoms of liver failure – fever, malaise, anorexia, abdominal pain, ascites * Diagnosis typically made with biopsy

Question 97

Heart transplant rejection

Answer 97

* 50-80% of rejection – common in first 6 months * Most patients are asymptomatic * Signs of LV dysfunction – dyspnea, paroxysmal nocturnal dyspnea, orthopnea, syncope * Tachydysrhythmias – atrial more common than ventricular * Diagnosis established by routine surveillance

Question 98

Pancreas transplant rejection

Answer 98

* 20-30% rejection within first 6 months * Typically asymptomatic * Slight elevation in amylase/lipase levels * Fall in urinary amylase * Hyperglycemia – late sign * Diagnosis made by allograft biopsy

Question 99

Kidney transplant rejection

Answer 99

* 10% rejection rate * Decreased urine output * Edema * Worsening HTN * Evaluate for other causes – infection, surgical complications, obstruction * Diagnosis made by renal biopsy

Question 100

Lung transplant rejection

Answer 100

* Most common type of transplant rejection; most patients have 1 episode of rejection * Vague, non-specific signs and symptoms – fever, dyspnea, non-productive cough * CXR is non-diagnostic – pleural effusions, peripheral infiltrates * ≥ 10% reduction in FEV1 is clinically significant , but not specific * Diagnosis made by fiberoptic bronchoscopy with lavage and biopsy * Infection must be ruled out

Question 101

General Transplant Rejection Treatment Concepts

Answer 101

* Steroids * IV fluid resuscitation * Treat for shock state * Consult/transfer to transplant surgery service – anti-rejection medication levels * Loading doses of anti-rejection medications

Question 102

Opioid Overdose – manifestations

Answer 102

* Respiratory depression * Change in mental status * Pupil changes (miosis)

Question 103

Opioid Overdose – diagnostic workup

Answer 103

* Typically a subjective and manifestation-based diagnosis * UDS – little utility * CXR only with a concern for aspiration

Question 104

Opioid overdose – ED-focused treatment

Answer 104

* Airway management * Naloxone hydrochloride (Narcan) for respiratory depression * 0.04-2mg IV bolus * Consider IV infusion when multiple doses are administered * May need up to 10 mg IV for methadone overdose * Can be administered SubQ, IV, or sublingual

Question 105

Acetaminophen overdose – manifestations

Answer 105

* Typically asymptomatic | * Nausea, vomiting, abdominal pain

Question 106

Acetaminophen overdose – diagnostic workup

Answer 106

* Diagnosis is made based on history of overdose (need timeframe) * APAP/acetaminophen serum levels (4 hours after ingestion or later) * Liver enzyme testing (transaminase elevation) * INR (suggestive of acute liver failure) * Coagulation studies

Question 107

Acetaminophen overdose – ED-focused treatment

Answer 107

• N-acetylcysteine (NAC) • Indicated by patients with a toxic overdose (150 mg/kg is toxic limit) • Administer within 8 hours of overdose • Oral dosing: loading dose of 140 mg/kg, then 70 mg/kg every 4 hours (total of 17 doses) • IV dosing: 2 options o Option 1: 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours o Option 2: 150 mg/kg over 1 hour, then 14 mg/kg for 20 hours

Question 108

Primary Trauma Survey

Answer 108

* Intervene if any abnormalities are found as you are evaluating these areas * The only time this stepwise approach changes is if the patient is acutely bleeding – stop the bleed first and then proceed with ABCDE * A – airway * B – breathing * C – circulation * D – disability * E – exposure and environment

Question 109

Primary Trauma Survey – A

Answer 109

* A – airway, alertness, and cervical spine stabilization * Airway patency * Maintain spine immobilization * Interventions – suction, airway adjuncts, definitive airways

Question 110

Primary Trauma Survey – B

Answer 110

* B – breathing, ventilation, and oxygenation * Breathing effectiveness – spontaneous breathing, chest inspection, general breathing assessment * Skin color * Injuries * Auscultation * Palpation * Interventions – open airway/consider adjunct, assist ventilation, high-flow oxygen, EtCO2 measurement, maintain SpO2 ≥ 94%

Question 111

Primary Trauma Survey – C

Answer 111

* C – circulation (hemorrhage control and volume replacement) * Uncontrolled external bleeding * Skin color * Heart sounds * Central pulse assessment and heart rate * Interventions – control external hemorrhage, establish 2 large-bore IVs, warm crystalloid solution boluses, consider need for blood transfusion

Question 112

Primary Trauma Survey – D

Answer 112

* D – disability * Evaluate GCS * Assess pupils * Interventions – consider head CT, consider intubation if GCS < 8

Question 113

Primary Trauma Survey – E

Answer 113

* E – exposure and environment control * Expose the patient to identify any additional injuries * Ensure warming methods are applied * Consider preserving evidence if this is crime-related * Intervene on any life-threatening injuries discovered

Question 114

Secondary Trauma Survey

Answer 114

* F – full set of vitals and family presence * G – get resuscitation adjuncts * H – history * H – head-to-toe assessment * I – inspection

Question 115

Secondary Trauma Survey – F

Answer 115

* Obtain a full set of vital signs | * Facilitate a family presence

Question 116

Secondary Trauma Survey – G

Answer 116

* G – get resuscitation adjuncts | * Lab evaluation (baseline labs, ABGs, type and screen, lactic acid)

Question 117

Secondary Trauma Survey – H

Answer 117

* H – history * Obtain info on MOI, info found in the field, and treatment administered prior to arrival * Obtain medical history * Last oral intake * Events regarding the injury

Question 118

Secondary Trauma Survey – H

Answer 118

* H – head-to-toe assessment * Perform a complete head-to-toe assessment * Identify additional injuries sustained and the need for intervention/evaluation * Re-evaluate previous interventions

Question 119

Secondary Trauma Survey – I

Answer 119

* I – inspection * Inspect the posterior surface (log-roll the patient) * Determine the need for removal of backboard * Check rectal tone

Question 120

Which type of shock places the patient at highest risk for disseminated intravascular coagulation? a. Septic b. Hypovolemic c. Obstructive d. Neurogenic

Answer 120

a. Septic

Question 121

The AGACNP recognizes that patients in which shock state will initially exhibit an increased CO followed by a decreased CO? a. Cardiogenic b. Hypovolemic c. Septic d. Neurogenic

Answer 121

c. Septic

Question 122

The AGACNP is caring for a 24-year-old male patient who was involved in a MVC approximately 15 minutes ago. The patient presented with severe bradycardia and hypotension. A shock state is suspected. Which of the following types of shock is most likely in this patient? a. Cardiogenic b. Hypovolemic c. Obstructive d. Neurogenic

Answer 122

d. Neurogenic D is correct because: complete vasomotor failure which cases hypotension AND bradycardia

Question 123

A 47-year-old female patient was admitted to the medicine service earlier today for a complicated UTI. Blood cultures and urine cultures are currently pending. The patient was started on ciprofloxacin (Cipro) 400 mg IV. You are called by the nruse because the patient now has an AMS, a respiratory rate of 20 breaths/min, and a BP of 75/40 mmHg. Which of the following would be the initial management for this patient? (select all that apply) a. Order broad-spectrum antibiotics b. Measure lactate levels c. Consult nephrology d. Start isotonic crystalloids at 30 ml/kg e. Continue current treatment and re-evaluate in 1 hour to see if the patient improves

Answer 123

a. Order broad-spectrum antibiotics b. Measure lactate levels d. Start isotonic crystalloids at 30 ml/kg

Question 124

Which on call you are asked to evaluate a deteriorating patient. A 55-year-old female patient was admitted for pneumonia and exacerbation of CHF. The SBP is < 90 mmHg and urine output is < 10 ml/hr. ECG reveals no acute processes but reveals previously noted changes consisted with bilateral atrial and ventricular enlargement and a marked left axis deviation. You insert a line to measure pressures and anticipate which of the following pressures? a. Cardiac index of 1.9 L/min, PAWP of 12 mmHg; CVP of 6 mmHg b. Cardiac index of 2.4 L/min, PAWP of 18 mmHg; CVA of 8 mmHg c. Cardiac index of 1.4 L/min, PAWP of 7 mmHg; CVP of 4 mmHg d. Cardiac index of 1.3 L/min, PAWP of 27 mmHg; CVP of 18 mmHg

Answer 124

d. Cardiac index of 1.3 L/min, PAWP of 27 mmHg; CVP of 18 mmHg D is correct because: This is a cardiogenic shock picture – cardiac index is low because the “pump” isn’t working and PAWP is high because the fluid is backing up A is incorrect because: would expect a high PAWP (normal 8-12) B is incorrect because: would expect a low cardiac index (normal CI 2.5-4.2) C is incorrect because: would expect a high PAWP (normal 8-12)

Question 125

A 22-year-old male admitted to the medical floor was eating his lunch, when he realized the dessert on his lunch tray contained peanut butter. The patient develops severe SOB and urticarial lesions over the trunk, head, and extremities. His partner informs you that he is allergic to peanuts. The patient VS are as follows: HR 115, RR 22, BP 80/52, and Pox of 93% on RA. Which of the following is the priority intervention? a. Famotidine (Pepcid) IV b. Diphenhydramine (Benadryl) IV c. Methylprednisolone (Solu-Medrol) IV d. Epinephrine 1:1000 IM

Answer 125

d. Epinephrine 1:1000 IM D is correct because: epinephrine stops the anaphylaxis

Question 126

A 57-year-old female with an exacerbation of COPD is intubated and initially placed n the following ventilator settings: TV 750 ml, SIMV rate 18, FiO2 60%, PEEP 5. The following morning her ABG results are as follows: pH 7.45, PaCO2 38, PaO2 88, HCO3 35. Which of the following actions by the AGACNP would be most appropriate? a. Increase the FiO2 b. Increase the PEEP c. Decrease the rate of ventilation d. Add a nebulized bronchodilator

Answer 126

c. Decrease the rate of ventilation C is correct because: COPD'ers need a higher CO2; this patient is blowing off too much CO2 for them

Question 127

A 45-year-old male patient is admitted to the ICU and progresses to respiratory failure requiring intubation and mechanical ventilation. The NP chooses assist control with volume targets. The patient’s ideal body weight (IBW) is 220 lbs. (100 kg). What would be the best initial ventilator settings? a. TV of 800 ml and PEEP of 5 b. TV of 400 ml and PEEP of 10 c. TV of 600 ml and PEEP of 10 d. TV of 1000 ml and PEEP of 5

Answer 127

a. TV of 800 ml and PEEP of 5 A is correct because: TV = 6-8 ml/kg = 600-800 ml, PEEP is appropriate to start B is incorrect because: TV is too low C is incorrect because: starting at a PEEP of 5 is more appropriate D is incorrect because: TV is too high

Question 128

You are managing a 24-year-old female patient who sustained severe thermal burns over 25% of her body after a gas container exploded in her garage. She has already received 6L of LR over the past 24 hours. While reviewing the intake and output recordings, the AGACNP notes a urine output of 20 ml/hr. What is the most appropriate initial intervention for this patient? a. Insert a CVP catheter b. Order additional IV fluids c. Order a loop diuretic d. Observe for 4-6 hours for any changes in urine output

Answer 128

b. Order additional IV fluids B is correct because: you want to maintain a urinary output of 0.5 ml/kg/hour

Question 129

The AGACNP is called to the ED to evaluate a burn patient. an 18-year-old male was brought in from the sidewalk just outside the ED. The roof is being tarred and hot tar fell on his passerby. He is in acute pain (rating 10/10) and has tar on the entire anterior surface of his left arm. What is the next step in the immediate treatment of this patient? a. Calculate the IV fluid replacement needs using the Parkland formula b. Calculate the total body surface area burned using the rule of nines c. Cool the affected area d. Remove tar with petroleum jelly

Answer 129

c. Cool the affected area

Question 130

You are the AGACNP working in the hospital’s burn unit. You are called to the ED to evaluate a burn patient who has just arrived. The patient is a 45-year-old female who sustained thermal burns to the entire trunk one hour ago. The patient weighs 176 lbs. (80 kg). Which of the following is the most appropriate intervention a. 2.8 L of LR to be infused over 24 hours b. 4.3 L of LR to be infused over 8 hours c. 5.8 L of LR to be infused over 7 hours d. 11.5 L of LR to be infused over 16 hours

Answer 130

c. 5.8 L of LR to be infused over 7 hours C is correct because: The entire trunk = 36% TBSA burned; Using the Parkland Formula: 4 ml x 80 kg x 36 = 11,520 ml in 24 hours (5,760 in the first 8 hours)

Question 131

An 81-year-old male patient with a permanent tracheostomy secondary to a previous history of throat cancer is admitted from an LTC for treatment of pneumonia. His baseline mental status is confused, and with the infectious process he has become increasingly obtunded. He will need nutritional support as his PO intake has decreased significantly since he has become ill. What is the most appropriate choice for nutritional support? a. A nasoduodenal tube b. A PEG tube c. Peripheral parenteral nutrition d. A nasogastric tube

Answer 131

a. A nasoduodenal tube A is correct because: feeding support likely < 6 weeks and he has an increased risk of aspiration B is incorrect because: he will need feeding support for < 6 weeks C is incorrect because: you can use the gut

Question 132

A 79-year-old female patient recently started receiving enteral nutrition via a PEG tube secondary to a stroke. The patient develops diarrhea within 24 hours of starting the tube feedings. What is the most appropriate intervention for this patient? a. Decrease the feeding rate and reintroduce gradually b. Order a stool culture for C. diff. c. Order a daily antidiarrheal medication to be administered via the PEG tube d. Supplement fluid losses with an IV isotonic solution

Answer 132

a. Decrease the feeding rate and reintroduce gradually A is correct because: this allows the gut time to adjust to the hyperosmolar solution B is incorrect because: she is not at risk for C. diff. C is incorrect because: diarrhea is likely d/t the tube feed solution D is incorrect because: nothing in this scenario makes us think she is currently dehydrated

Question 133

A 45-year-old male patient was admitted for an asthma exacerbation. While reviewing baseline lab studies you note a serum sodium of 129. While gathering more of your patient’s history he tells you that he was been using an OTC “water pill” for weight loss. What type of hyponatremia would be most likely in this patient? a. Hypotonic, hypovolemic b. Hypertonic c. Hypotonic, hypervolemic d. Isotonic

Answer 133

a. Hypotonic, hypovolemic B is incorrect because: this is caused by too much of another indissolvable solute (think diabetes) C is incorrect because: patient is not fluid overloaded as he is taking a "water pill" and likely dry D is incorrect because: typically r/t to a chronic process, common with HLD and HD patients

Question 134

A 45-year-old male with small cell lung cancer is admitted for a complicated UTI. While reviewing AM lab studies, the AGACNP notes a serum Ca of 14. The patient is awake, alert, and oriented and only complains of nausea. The patient appears to be euvolemic. What is the most appropriate intervention? a. 10 units of regular insulin b. Consult nephrology for emergent HD c. NSS (0.9%) infusion at 200 ml/hr d. 1 amp IV of calcium carbonate

Answer 134

c. NSS (0.9%) infusion at 200 ml/hr C is correct because: while it may be considered an emergency based only on the lab value, the patient is stable A is incorrect because: this is for hyperkalemia and not hypercalcemia B is incorrect because: the patient is not unstable D is incorrect because: with electrolyte questions they will test if you know normal lab values and will always give you something that is the opposite of what you should be doing

Question 135

An 89-year-old female patient was admitted for a COPD exacerbation. The patient is form a LTC facility with a medical history of dementia and malnutrition. While reviewing baseline lab values, the AGACNP noticed a Ca of 7.9. what is the most appropriate intervention for this patient? a. Order IV calcium gluconate b. Order nebulized albuterol c. Order an albumin level d. Order a Mg level

Answer 135

c. Order an albumin level C is correct because: you need to make sure the Ca is truly low since she has a hx of malnourishment; need to obtain a correct Ca

Question 136

A 35-year-old male patient presents to the ER with a chief complaint of a “racing heart”. The patient’s HR varies between 110 and 120 bpm. A cardiac monitor shows frequent PVCs with runes of V-tach. Lab studies are significant for a serum K 2.8 and a serum Mg 2. Which of the following interventions would be most appropriate? a. KCl 40 mEq PO b. KCl 10 mEq/hr IV c. Mg sulfate 1g PO d. Mg sulfate 2g PO

Answer 136

b. KCl 10 mEq/hr IV B is correct because: need IV since the patient is unstable and oral isn't fast enough A is incorrect because: oral route isn't fast enough for this unstable patient C and D are incorrect because: the Mg is normal

Question 137

A 23-year-old female patient with a history of active opioid abuse is experiencing chronic low back pain resulting from an automobile accident that occurred 6 months ago. The patient is currently taking tramadol (Ultram) as needed for pain control at home. The patient states she is experiencing pain in-between doses of the PRN regimen and is currently rating her pain at 9/10. Which of the following medications would be most appropriate for immediate pain control? a. Lorazepam (Ativan) b. Ketorolac (Toradol) c. Naloxone (Narcan) d. Amitriptyline (Elavil)

Answer 137

b. Ketorolac (Toradol) C is not correct because: this would be useless here D is not correct because: Amitriptyline (Elavil) isn't used for immediate pain control

Question 138

A 78-year-old male patient with metastatic hepatocellular carcinoma is taking oral morphine controlled-release (MS-Contin) 30 mg q12h and oral oxycodone immediate-release PRN q4h for pain control. The patient’s pain has worsened over time and he now requires oxycodone IR every 2 hours. What is the most appropriate intervention? a. Add fentanyl patch daily b. Increase the oral oxycodone IR dose c. Increase the oral morphine CR (MS-Contin) dose d. Add alprazolam (Xanax) to the current regimen

Answer 138

c. Increase the oral morphine CR (MS-Contin) dose C is correct because: the goal of long-acting agents is 24-hour control A is incorrect because: don't use fentanyl patches daily, we haven’t maxed out the controlled-release doses yet B is incorrect because: doesn't solve the issue that they aren’t getting good 24-hour control D is incorrect because: that do anything for pain

Question 139

A 40-year-old female patient is post-op day #7 following a hepatic transplant and exhibiting signs and symptoms of rejection that have been confirmed by histologic exam. You know that the first-line management of mild rejection consists of: a. Cyclosporine (Gengraf) b. Azathioprine (Azasan) c. Methylprednisolone (Solu-Medrol) d. Sirolimus (Rapamune)

Answer 139

c. Methylprednisolone (Solu-Medrol) C is correct because: When thinking rejection, think of steroids

Question 140

In the patient having bone marrow transplantation, which of the following is given to reduce the incidence of graft-versus-host reaction? a. Immune globulin b. Cyclosporine c. Prophylactic antibiotics d. Systemic glucocorticoids

Answer 140

b. Cyclosporine

Question 141

A 20-year-old male patient presents for emergency care. He overdosed on acetaminophen 4 hours ago, taking an estimated 6g. What is the most appropriate intervention for this patient? a. Acetylcysteine b. Gastric lavage c. Activated charcoal d. Ipecac syrup

Answer 141

a. Acetylcysteine A is correct because: this acts as a synthetic buffer to the toxic byproduct of Tylenol breakdown B and C are incorrect because: these have no benefit with Tylenol overdoses

Question 142

23. A patient recently had a cast placed on their lower extremity for a non-displaced tibia/fibula fracture. The patient returns with complaints of worsening pain, not relieved by analgesia. While considering the diagnosis of compartment syndrome, which of the following signs and symptoms would the AGACNP be expecting to find? Select all that apply a. Pain b. Paresthesia c. Fever d. Paresis e. Pallor f. Poikilothermia g. Leukocytosis h. Pulselessness i. Hypotension

Answer 142

a. Pain b. Paresthesia d. Paresis e. Pallor f. Poikilothermia h. Pulselessness

Question 143

You are the AGACNP on the trauma service. A patient arrives in the trauma bay following an MVC. The patient was entrapped in the vehicle and required extrication. The patient has a partially amputated left lower extremity and you note profuse bleeding from this site. Which of the following assessments/interventions would your first priority? a. Assess for a patient airway b. Control the bleeding c. Obtain a set of vital signs d. Order warmed, isotonic IV fluids to be infused rapidly

Answer 143

b. Control the bleeding B is correct because: control bleeding first and then proceed with ABCs for trauma patients