Critical Care Environment Flashcards
first line drug for all emergency situations Giving a drug to treat a disorder brought on by hypoxemia without effectively correcting the cause of hypoxemia is ineffective - O2 sat >96%
Oxygen
Nitrate Dilates peripheral vessels decreasing preload and afterload, reduces blood pressure ; Also dilates coronary arteries- used for chest pain Continuous blood pressure and heart monitoring SE: Hypotension, headache
Nitroglycerin
narcotic analgesic to treat chest pain associated with MI and acute PE Relieves pain and reduces anxiety, dilates venous vessels and reduces cardiac workload SE: Respiratory depression, hypotension Narcotic antagonist naloxone (Narcan)
Morphine sulfate
anticholinergic to treat bradycardia, heart block and asystole Inhibits vagus nerve Cardiac and blood pressure monitoring needed SE: dysrhythmias, increased HR, ischemia, restlessness, anxiety, mydriasis, thirst, urinary retention
Atropine sulfate
Beta-adrenergic To increase heart rate - temporary measure while waiting for transcutaneous pacemaker Increases myocardial oxygen consumption, therefore, myocardial ischemia is a concern Tachycardia, ventricular fibrillation may occur
Isoproterenol (Isuprel)
antidysrhythmic to treat paroxysmal supraventricular tachycardia (PSVT) Slows conduction through AV node, interrupts dysrhythmia producing re-entry pathways and can restore NSR Cardiac monitoring and vital signs SE: hypotension, dysrhythmias, short period of asystole following injection
Adenosine (Adenocard)
- antidysrhythmic to treat supraventricular tachydysrhythmias (SVT) Calcium channel blocker - (negative chronotropic & inotropic) - also used to treat angina Monitor HR and BP SE: headache, bradycardia, hypotension
Verapamil (Calan, Isoptin)
antidysrhythmic to treat PSVT, A-fib/flutter (with increased rate) Calcium channel blocker - (negative chronotropic & inotropic) - also used to treat angina Monitor BP and HR SE: myocardial depression, bradycardia, can increase digoxin levels
Diltiazem (Cardizem, Dilacor XR)
antidysrhythmic to treat ventricular dysrhythmias A fast sodium channel blocker, class 1B Local anesthetic effect on heart; ↓myocardial irritability Monitor cardiac and assess for S/S toxicity (confusion, drowsiness, hearing impairment, conduction defects, myocardial depression, muscle twitching, seizures) Metabolized in liver
Lidocaine
antidysrhythmic to treat atrial, ventricular and supraventricular dysrhythmias A fast sodium channel blocker, class 1A SE – severe ↓BP, heart block, rhythm disturbance & cardiac arrest Excreted via kidneys
Procainamide (Procan; Pronestyl)
to correct body depletions and dysrhythmias Works with Na+-K+ ATPase pump Physiologic effects similar to Ca++ channel blockers with neuromuscular blocking effects If Mg++ ↓ - atrial & ventricular dysrhythmias Uses - ↓Mg levels; refractory VT & VF & life threatening dysrhythmias associated with digoxin toxicity and tricyclic antidepressants, torsades de pointe SE - ↓BP, mild ↓HR, flushing, sweating
Magnesium sulfate
sympathomimetic to treat profound ↓HR, asystole, pulseless ventricular tachycardia and ventricular fibrillation (VF & VT) Catecholamine with alpha & beta adrenergic effects Improves perfusion of heart and brain in cardiac arrest Requires cardiac & hemodynamic monitoring Do not give at same site as sodium bicarbonate
Epinephrine
to treat metabolic acidosis Monitor ABGs Do not administer epinephrine, norepinephrine, or dopamine in same site
Sodium bicarbonate
osmotic diuretic to treat edema of CNS and other conditions Highly irritating to veins, use filter needle Assess neurological status, labs, serum osmolality, I/O
Mannitol (Osmitrol)
- glucocorticoid to treat edema of CNS and other conditions Stabilizes Na+/K+ pump – thus no excess H20 crosses cellular membrane SE – transient ↑BP, ↑BS
Methylprednisolone (Solu-Medrol)
opiate antagonist Competitively binds to opiate receptor sites Shorter duration than many opiates, may need to repeat dosing Can precipitate withdrawal symptoms SE – Potential for pulmonary edema and cardiovascular collapse in some OD patients
Naloxone (Narcan)
Reversal agent for the respiratory depressant and sedative effects of benzodiazepine medications (Valium, Versed, Librium)
Flumazenil (Mazicon, Romazicon)
to treat poisoning absorbs ingested toxins in GI tract & prevents absorption body
Activated charcoal
drugs should not be used to correct the hypotension associated with this condition → administer fluids or blood products
hypovolemic shock
to treat hypotension; low dose ↑urine output Sympathomimetic SE - ↑HR, dysrhythmias, myocardial ischemia, N/V Assess IV site hourly for S/S of drug infiltration, extravasations causes tissue necrosis, treat extravasations with phenotolamine (Regitine) 5-10mg diluted in 10-15cc NS
Dopamine
to treat shock states with ↓CO (↑BP D/T ↑CO – no vasoconstriction) Sympathomimetic with beta-1 adrenergic activities; beta-1 effects (↑force of contraction, ↑HR) Requires cardiac & BP monitoring, assess for ischemia Adverse effects are dose related – myocardial ischemia, ↑HR, dysrhythmias, headache, nausea, tremors
Dobutamine
to treat hypotension Catecholamine with potent vasoconstrictor (alpha adrenergic) effects Requires cardiac and BP monitoring, assess for ischemia, nursing care is similar to dopamine Additional effects – myocardial ischemia, dysrhythmias, impaired organ function; extravasation causes tissue necrosis
Norepinephrine (Levophed)
to treat anaphylactic shock Bronchodilator and maintains blood pressure due to vasoconstrictive effect, also ↑cardiac performance SE - ↑HR, dysrhythmias, ↑BP, angina
Epinephrine
antihypertensive to treat hypertensive crisis Rapid acting vasodilator, acts on the smooth muscle of the vessels Protect from light- keep wrapped with aluminum foil, medication has a faint brown color, increases cyanide levels (measure cyanide and thiocyanate levels every 24 hours)
Sodium nitroprusside (Nipride)
loop diuretic Diuretic effect Depletes Na+ and K+ - assess electrolyte levels
Furosemide (Lasix)
Indications for Arterial line
- Monitor blood pressure ( 5-15 mm Hg higher than manual ) 2. Obtain blood specimen and arterial blood gases 3. Administration of vasoactive medications
A-line : insertion points
Radial, brachial
A-line : measurements - waveforms
- Systolic (top waveform) , diastolic( bottom ) and mean arterial pressure ( min 60 - to perfuse vital organs) * Dicrotic notch - closure of aortic valve
Small, wavy , dampened - obstruction or inducer imbalance
A-line : complications
- Bleeding 2. Infection 3. Thrombosis 4. Neurovascular impairment
Phlebostatic axis ( R atrium level ) - Level and calibrate transducer Q8hrs , when pt bed or position is changed
4th intercostal space on the R sternum - to the side of the pt chest midway between ant and post chest
PA catheter : indications
for patients with complicated fluid balance conditions
PA catheter : measurements
- CVP - right atrial pressure 2. PAP - pulmonary artery pressure 3. PCWP - pulmonary capillary wedge pressure 4. CO
CVP
1-8 mmHg
PAP
15/5- 25/15 mmHg
PAWP
indirect measurement of left atrial pressure + left ventricular and diastolic pressure 4-12 mmHg; High - left ventricular failure , hypervolemia
PA catheter insertion
jugular or subclavian veins
PA catheter complications
- Infection 2. Air embolism 3. Pulmonary infarction or rupture 4. Ventricular arrhythmias
Cardioversion
deliver a synchronized shock during QRS wave
Cardioversion: indications
for unstable atrial and ventricular dysrhythmias ( pulse is present - fast rhythm) - A-fib, A-flutter, V-tach
Cardioversion: sedate
IV Valium, Versed if awake ; consent
Cardioversion : pad placement
- Upper right chest, just under the clavicle, next to the sternum 2. Left lower chest, just lateral to the precordium
Cardioversion : monitor
- Maintain airway 2. Monitor VS & LOC
Defibrilation
asynchronous electric shock
Defibrilation : indications
Pulseless ventricular rhythms - Vtach & Vfib
Defibrilation : procedure
- Biphasic -start at 200 joules ( mono - 360) 2. Perform within 15-20 sec of the onset or arrhythmia 3. CPR - Shock 4. Two minutes of CPR between shocks
IABP - intra-aortic balloon pump - purpose
increased coronary perfusion - increases CO by as much as 40 % - decreases LV work and myocardial oxygen requirements
IABP - insertion
through the femoral artery , threaded into the descending aorta
IABP - diastole
Ventricles are filling - balloon inflates ( blocking the aorta ) - blood forced into coronary artery
IABP - systole
balloon deflates when ventricles contract - creates a vacuum affect ( reduces afterload) - improves LV ejection + CO
IABP - indications
- Failure to wean from cardiopulmonary bypass 2. Cardiogenic shock 3. HF 4. MI
IABP - complications
- Vascular injuries 2. Displacement of balloon 4. Peripheral nerve damage + thrombus formation 5. IABP destroys platelets - thrombocytopenia 6. Infection 7. Improper timing - can increase afterload ( decrease CO ) 8. Pt is relatively immobile - HOB less than 45 ; cant flex leg
VAD - ventricular assist device
TX of end stage heart failure - improve CO
VAD used …
short term - bridge while waiting for a heart transplant long term - when unresponsive to medication or surgery
VAD for L ventricular heart failure
more common - Tube pulls blood from left ventricle into a pump - sends blood to the aorta
CO
4-7 L/min
Amount of blood pumped from the LV each minute
CO
Preload = CVP = Right atrial pressure
how much the myocardial fibers are stretched at the end of diastole just before the next contraction
Amount of blood ejected with each contraction
SV
Pressure or resistance the heart must overcome to eject blood through the semilunar valves during systole
Afterload
Locus of control
degree of control : * inner ( decisions ) & external ( fate, luck ) or combination
Respiratory failure
PaO2 < 60 mm Hg & PaCO2 > 50 mmHg
Endotracheal tube - verify placement
- check end-tidal CO2 levels - use CO2 detector 2. listen for bilateral breath sounds 3. X-ray
Hemodynamic monitoring consists of
- Catheter 2. Infusion system 3. Transducer 4. Monitor 5. Pressure bag
Pressure bag - A-line & PA catheter
- NS or D5W 3-10 ml/hr - prevent back up of the blood and oclusion 2. 300 mmHg - maintains pressure
Allen’s test
prior to insertion of A-line - 1. patency of the ulnar & radial artery 2. adequacy of collateral circulation
Central venous pressure cather ( CVP line ) - measures and provide
- RA pressure - preload - monitor pt fluid status
- Venous access for fluids and blood sampling
CVP line inserted
subclavian, jugular, femoral veins ; catheter tip - superior vena cava
CVP readings - high & low
High - fluid overload - decrease IV rate, IV diuretics
Low - hypovolemia - increase IV rate
PA catheter : balloon
- wedged briefly 8-15 sec - get reading - remove - risk for pulmonary infarction
CVAD
- PICC lines ( long term IV TX - vesicant ; 1 year)
- Non-tunneled CVAD ( few weeks )
- Tunneled CVAD ( years )
- Subcutaneous ports ( non - coring needle ; years )
CVAD complications
- Infection
- Bleeding
- Pneumothorax and hemothorax
- PE
- Cardiac tamponade
AED
Automatic external defibrilator ; * “ All clear “
ICP catheters - Infection !!! - strict aseptic technique
- Epidural ( easy, low risk )
- Intraventricular ( most invasive, drainage + sampling of CSF )
- Subarachnoid ( easy )
Quinton catheter
double lumen dialysis catheter ; jugular or subclavian veins; for ARF or CRF ( while waiting for fistula to mature)
Sengstaken-Blakemore tube
TX bleeding esophageal varices ( last resort ); two ballons ( one -stomach; second - esophagus) ; pt is intubated on mechanical ventilator
Parenteral nutrition - PPN & TPN
- PPN ( peripheral parenteral nutrition) - peripheral IV - lower osmolarity
- TPN ( total parenteral nutrition ) - central IV - higher osmolarity
Paternalism
restriction of one’s freedom ( autonomy ) to protect the pt from harm (making decision for pt )
Beneficence
prevent harm
Nonmaleficence
do no harm
Fidelity
keep promises
Veracity
tell the truth
