Critical Care: test 3: Hemodynamics, MV, Respiration, basic ACLS Flashcards
What is the most common symptom of MI in women?
Unusual Fatigue
What’s the fastest Anti-Hypertensive on the market and the DOC for Hypertensive crisis?
Nipride (Nitroprusside)
Normal PA systolic pressure? PA diastolic?
20-30; 8-15
How often do you “Zero” your PA transducer?
Do at beginning of shift minimum; can do it before every reading if you really want to.
What type of meds do you give in an Art-line?
You should never give meds via an arterial line because of potential harmful complications!
The physical movement of air = ______
Ventilation
For someone with a bad TBI/drug-induced coma, we would want their SVO2 to be _____
Up. We don’t want them in a hypermetabolic state.
What is the action of Cardene (Nicardipine HCl)?
Vasodilation & Smooth Muscle Relaxation
Which 2 wave forms of the PA cath monitor look similar? How are they different?
The Pulm. Art. Wedge (PAWP or PCWP) looks similar to the Right atrial, but is usually higher. [
Most common cause of Resp. Acidosis?
Hypoventilation
What is the max amount of gas that can be inspired at the end of a normal breath, and what is the normal value?
IRV (Inspiratory Reserve Volume); 3000; This is what is measured with an Incentive Spirometer
When is Pressure Ventilation used?
It’s not as common as Volume Ventilation; it is used when a patient has stiff lungs (ie with ARDS)
Diagnostic Tests for CAD: (4):
12-lead EKG
CXR
Echocardiogram & Multigated Blood Pool Study (MUGA): focus on ejection fraction (<45% is not good)
TEE (transesophageal echocardiogram)
Reasons for Apnea Alarm to go off on Vent? Treatment?
Alarms when a breath is not taken in a certain amount of time= Patient is Apneic (due to medical issue, disconnect, over-sedation)
Life-saver in CPAP mode
Wake them up, Relieve sedation
Call RT and have them put back to their previous settings, if available.
What is the pressure bag connected to a PA catheter always blown up to?
300 mmHg
What drug is often given after a stent placement?
Plavix (anti-platelet).
What side of the heart is most affected with physiological issues?
Left side most commonly involved except for trauma
What is the difference between the alveolar and arterial partial pressure called? What value should it be less than?
A-a Gradient; 20 (greater than 20=hypoxia)
What are the two most dangerous timing errors of an IABP?
Too early Inflation = will block flow => increases pressure to push against = inc. workload/O2 demand; won’t allow emptying
Too late Deflation= Most dangerous; can cause fatality; won’t allow Ventricle to contract which can cause rupture of vent.
4 complications of an Art-line:
Thrombosis
Air emboli
Exsanguination
Infection
pH=7.31
PaCO2=30
HCO3=20
Partially compensated Metabolic Acidosis
When inadequate VENTILATION occurs, the lower airways have nothing to perfuse = ______
Shunt unit
What do you need to watch for after the femoral artery is punctured to do a PTCA (heart cath)?
Have to put pressure on artery (usually femoral) for up to 20-30 mins
Watch for aneurysm formation (will feel like disc under skin; try to smooth it out)
Watch for hematoma and pseudo-hematoma: will sound like a bruit; bad
Do distal circ checks
In Critical care, you want to ______ nursing care, unlike Med-surg.
spread out
Nipride (nitroprusside) is a potent ______
vasodilator
Who is more likely to survive an MI (what ages)?
Actually, the older you get, the more likely to survive because as you age you create more collateral circulation. So you’re more likely to survive an MI at 80 than at 50!
Positive Inotropics increase ____ which increases ___,___, & ____. What are 4 examples?
Intracellular Ca++; Inc. Myocardial contraction; Increases CO; Inc. Renal perfusion; Mid-level Dopamine (2-10), Dobutrex, Levophed (Norep), Digoxin
Type of Ventilator mode where vent automatically raises and lowers pressures to maintain a certain Tidal Volume =
PRVC (Pressure Regulated Volume Control)
The amount of blood the heart pumps out of a ventricle with each beat =
Stroke Volume (SV)
An IABP has helium inflate the balloon during ____ and deflates it during ______
Diastole (when heart is resting it’s inflated so blood doesn’t back-track); Systole (contracting so you want blood to be able to pass)
Right-sided heart issues usually involve volume _____ (with what exception)?
deficits. Except left-sided HF where volume overload occurs (most common cause of right-sided HF).
What do you do with Right Mainstem intubation (ET moves into right stem bronchus)? How do you determine this?
Common; won’t hear breath sounds on left side; Will have to pull back on ET until you hear them on both sides.
Treatments for ARF & COPD:
O2 Bronchodilators Corticosteroids Antibiotics Preventative Issues (flu/pneumonia vaccine)
You can think of an IABP (Intra-Aortic Balloon Pump) as a ________
Left Ventricular Assist Device (but you don’t go home with these)
If the Oxyhemoglobin Dissociation Curve shifts to the Left, it means there’s a(n) ___ affinity of O2 and Hgb. What are 3 things that could cause this?
Increased; coLd, aLkaLosis, Low CO2
What does the Distal lumen measure when the balloon is inflated?
PCWP (Pulmonary Capillary Wedge Pressure), aka “Wedge Pressure”; Measures indirect pressures in the left ventricle.
What can cause Air Trapping with a vent? How would you fix this?
Can happen if patient is fighting the vent; if RR set too high (COPD/emphysema at risk)
RT needs to make sure patient has adequate time for exhalation
Can sedate patients who are fighting the vent.
Which type of ventilation mode delivers a set # of breaths of a set Vt, and between these mandatory breaths, the patient may initiate spontaneous breaths?
SIMV
Normal RV systolic pressure? RV diastolic?
20-30; 0-5
S/s of ARDS Development:
- High pressure alarms going off on ventilator and you can’t find a mechanical reason why
- Increased HR
- Increased RR
- “Stiff Lungs”–
- Inc. pressure alarms going off
- Tachycardia and tachypnea that don’t follow the full picture; “Something seems wrong”
- Dyspnea
- Rapid, shallow breaths with accessory muscle use
- Abnormal breath sounds
- Mottling or cyanosis of the skin
- Dry cough
- Change in LOC
- Restlessness
- Retro-sternal discomfort
- Fever
Treatment of Left-sided heart problems =
Med therapy
Invasive therapy (IABP or assistive device)
May or may not require pacing.
Pulsus paradoxus can occur with which patients? What does this mean?
Cardiac tamponade: constriction of heart
Constrictive pericarditis
Pulm. HTN
Hypovolemia
Tension Pneumothorax
*Can mean that they are decompensating and/or there’s constriction on the heart
Risk Factors for Respiratory Failure: (7)
Aged Obesity Surgical Patients Smoking Imminent Surgery Trauma Patients Drug Abusers
What is the treatment for a right-sided MI?
Fluid replacement
Pressure left in the alveoli upon the end of expiration =? Allows ease in opening the alveoli upon the next inspiration; improves ability for gas exchange; decreases workload of lungs
PEEP (Positive End Expiratory Pressure)
Chemoreceptors respond to ___ changes like what? (4). Baroreceptors respond to ____ like ______
chemical; Inc. CO2, Dec. pH, Inc. H+, Dec. O2 (carotid and aortic bodies); Stretch of BV’s; If BP increases, leads to decreased HR; If BP decreases, leads to Increased HR
What is a normal P/F Ratio?
400-500 mmHg
Things that Increase Afterload (PVR and/or SVR): (6):
Hypervolemia Vasoconstriction Systemic HTN Pulmonary HTN (PPH) Dissecting Aortic Aneurysm Increased Blood Viscosity
An abnormal fall of SBP greater than 10 mmHg during INSPIRATION=? What do you do if you suspect this?
Pulsus Paradoxus;
1) Observe fluctuations on art-line
2) Manually obtain pressure
a) inflate BP cuff 20 mmHg above SBP
b) Slowly deflate, listening for Korotkoff sounds to appear during expiration
c) Continue to slowly deflate until sounds heard on both inspiration and expiration
d) Normal findings = less than 10 point difference
What are some shorter-acting sedation meds that can be used/may be preferred in ARDS treatment?
Precedex
Propofol
Possibly Versed (but lasts longer than the above two)
ARDS Treatment:
- Mechanical Ventilation
- Expect PEEP of about 15-20
- Expect Pressure Support as opposed to volume support ventilation
- Meds:
- Anti-inflammatory: ie steroids
- Vasodilator meds
- Surfactant therapy (not as common; controversial)
- Beta-agonist meds for bronchodilation
- Other “Investigational” therapies:
- Nitric oxide
- Liquid Ventilation
- ECMO: heart/lung bypass
- Surfactant therapy
Reasons for the Low Exhaled Volume Alarm to go off? Treatments?
Patient is disconnected from the vent (re-attach them) Loose tubing (tighten the tubing) Machine Malfunction (silence the alarm, remove from vent, bag the patient with O2 turned as high as possible, and call RT STAT)
Lung Compliance measures _____; ___ compliance means they stretch but they don’t want to recoil (ie with ____); _____ compliance means they are very stiff and have a decreased ability to stretch (ie with __,__,&___).
How stiff the lungs are; Increased; COPD; Decreased; ARDS, Pulm Fibrosis, Interstitial Fibrosis
What do you do with the syringe after you get a Wedge Pressure (PCWP)?
After you do the wedge, pull the syringe off, depress it, then reattach it. DO NOT LEAVE THE SYRINGE WITH THE PLUNGER PULLED BACK!
Preload aka ___ & ___; it predicts ____
CVP; RAP; CO
pH=7.47
PaCO2=48
HCO3=30
Partially compensated Metabolic Alkalosis. It’s only partially compensated because the pH didn’t return to normal (which would have made it fully), and it’s compensated because the CO2 was high like the HCO3
Mid-level Dopamine (2-10) mostly stimulates ___ which does what?
Beta 1; stimulation results in increased HR, Contractility, Conduction (Pos. Inotropic & Chronotropic)
Alarm that goes off when something is not allowing the volume to flow into the lungs as usual; resistance being met =
High pressure alarm.
A person in a hypermetabolic state (ie Trauma, burn, shock) would have an SVO2 that would be ___ than normal.
lower because the body is trying to heal itself. For example, in a normal person, a reading of 70% means that the body is using 30% of O2. Therefore, a person in the example, may have a low SVO2 (like say 30%) because the body is using 70% O2 to try to heal itself. If they didn’t have a low SVO2 then we may be worried that the body has given up. Mixed venous oxygen saturation (SvO2) is the percentage of oxygen bound to hemoglobin in blood returning to the right side of the heart. This refects the amount of oxygen “left over” after the tissues remove what they need
_____ is how saturated the Hgb is with O2 at the end of the circulation pathway.
SVO2 (systemic venous O2); can see how much O2 the patient has used (compare it to an ABG from earlier).
How is an IABP inserted?
A 30-40 mL balloon introduced through the femoral artery into thoracic aorta; connected to bedside console; it should stay below the L.subclavian and above the renal arteries
The distal port of the PA catheter is found where and measures what?
is in the pulmonary art; measures PAP and PAOP; this is where the readings take place; gives waveform and #
Too Early Deflation of an IABP will cause what?
It won’t allow it to “suck”/assist = It’s like the device doesn’t exist
Normal CVP/RAP?
2-6 mmHg
What is the wave form you want to see on the PA cath monitor every time you walk into the room?
The pulmonary artery one that has the dichrotic notch. Normal PA systolic is 20-30 mmHg and PA diastolic is 8-15 mmHg
pH=7.33
PaCO2=50
HCO3=30
Partially compensated Respiratory Acidosis.
Normal SV =
60-100 mL/beat
pH=7.31
PaCO2=50
HCO3=22
Resp. Acid.
How, why, and where is a PA catheter inserted?
Inserted under sterile conditions, usually in the diagnostic lab (ie cath lab), however, can be inserted at bedside usually with fluoroscopy (can go blindly, though), or in surgery. It is inserted in the internal jugular, subclavian vein, or can be brachial or femoral if needed. You have to confirm placement with an x-ray. The purposes are to measure pressures of the heart (via the PA-Pulm. Art)–Continuous CO (CCO), continuous Right ventricular end diastolic volume (RVEDV), Right Ventricular Ejection Fraction (RVEF), and continuous mixed venous oxygen saturation SvO2….etc… They can also measure core body temp, give large amounts of fluids thru them, and specialized ones can also pace.
pH=7.52
pCO2=18
HCO3=24
Uncompensated Resp. Alk
Common causes of Resp. Acidosis?
(Retention of CO2)
Hypoventilation CNS depression (drugs, drug overdose, anesthesia) Resp. Neuromuscular Disorders Trauma: spine, brain, chest wall Restrictive Lung Diseases COPD Acute Airway Obstruction (late phases)
Type of Respiratory Failure with decreased ventilation = _____; Some causes?
Hypoxemic Hypercapneic Failure (Type 2); Musculoskeletal and/or Neurologic system failure, MD, ALS, Guillain-Barre, Skeletal deformities like scoliosis, kyphosis
What is a typical tidal volume/pressure for the vent?
10-15 mL/kg (ARDSnet recommends 4-8 as lung protective strategy).
What test do you have to do before insertion of an art-line in the radial artery? How do you do it?
Allen Test–assesses the patency of the ulnar artery; To do it–
1) Patient forms tight fist with wrist in neutral position
2) Occlude both radial and ulnar arteries for approx. 10 seconds
3) Patient opens hand to reveal blanched hand
4) Release pressure on ulnar artery (pinky side) while maintaing pressure on radial side
5) Ulnar circulation is adequate if blanching resolves within 5 secs; inadequate if >10 seconds
Things that decrease Cardiac Output (CO): (9):
Hypovolemia Hemorrhage HF AMI Right-sided HF/AMI Third-spacing/pooling Arterial blood clot/DVT Tachycardia/Bradycardia Cardiac Tamponade
Name 4 drugs to increase afterload:
Epi, High dose dopamine, Norep (Levophed), Neosynephrine —vasoconstrict
What is the half-life of Corlopam?
5 min
Vascular resistance to the forward flow of blood leaving the right & left ventricles =
Afterload (SVR): aka the amt of pressure the left side has to work against. aka The resistance to the flow of blood from the heart.
The ____ usually dictates Cardiac Output.
Preload
Name 3 drugs to reduce preload & afterload:
Nipride, Nitroglycerin, & Diuretics
Which heart valves are anchored by chordae tendineae?
AV valves
Causes of Respiratory Alkalosis:
(Hyperventilation)
Hypoxemia
Anxiety, fear
Pain
Fever
Stimulants
CNS Irritation (e.g. Central Hyperventilation)
Excessive Ventilatory Support (bag-valve mask, mech. ventilation)
What is a typical Rate for the ventilator?
8-12 is typical for adults (slower for COPD and higher for non-compliant lungs)
What happens if the balloon breaks while you are trying to obtain a PCWP (“Wedge Pressure”)?
Don’t have to remove catheter, but won’t be able to obtain PCWP’s anymore. Will have to replace if needed, or have to tape off and put up sign not to use. Risk of air emboli.
What are some adequate ABG measurements before Respiratory Failure occurs?
pH=greater than 7.25
PCO2= less than 50
PaO2= greater than 50
*loose definition of what they should be. Depends on patient.
Things that decrease Afterload (PVR and/or SVR): (4):
Hypovolemia
Vasodilation
Sepsis
Hypotension
How much blood is coming off the left ventricle in a minute =
CO (Cardiac Output)
What treatment is used for Stridor upon extubation?
Racemic Epi (aerosolized) for Mild Stridor; Reintubate for Moderate Stridor
Which type of ventilation avoids Intubation/Tracheotomy and closely mimics normal breathing?
Negative Pressure Ventilators
Most common cause of Met. Alkalosis?
Vomiting.
What is the amount of air remaining in the lungs after maximum expiration (amount that keeps the lungs open), and what is the normal value?
Residual Volume (RV); 1300
What do you do with Barotrauma?
Keep pressure at minimum, if possible. This will mean less perfusion which may cause bad ABG’s (hypercapnia, etc) which you may just have to deal with. Barotrauma can cause a tension Pneumo.
___ or ___ is used to measure Preload.
RAP (Right Atrial Pressure) or CVP (Central Venous Pressure)
Which side of heart problems may recover spontaneously and which side often reuqires assistance?
Right may recover spontaneously; Left often needs assistance.
What is a typical Pressure Support setting for the ventilator?
Complete support: around 15-20
As boost with SIMV or CPAP: 5-15
*anywhere from 5-20
How do you prevent Oxygen Toxicity from the vent (damage to the lung due to high O2 levels)?
Use lowest O2 available, if patient desats–dont forget to wean O2 when they recover.
The extent of damage of an AMI depends on what? (6)
Amount of damage Area of damage Pre-existing illnesses Time to initiation of healthcare Time to tx upon this initiation Presence of collateral circulation
What do you want to watch for with an IABP to make sure it hasn’t moved and why?
It’s supposed to be below the L. Subclavian and above the renal arteries. Therefore, WATCH Urinary Output (if blocking perfusion to renal arteries, then UO can change), and watch Circulation to left arm (to make sure it hasn’t moved up to block arm; watch left leg circ too).
What does a low SVR mean?
The left side of the heart isn’t working against a lot of pressure; they probably also have a low BP
What do you do if you are even in doubt of the functioning of a ventilator?
Take them off and bag them! And call respiratory therapy.
What’s a V/Q Mismatch?
A ventilation or perfusion problem.
