Exam 3 Flashcards
normal intrapleural pressure is
negative compared to atmosphere
pleural disorders result from:
Change in amount of pleural fluid Infections trauma congenital malformations These disorders restrict lung expansion secondary to inflammation, fibrosis or other fluid in the pleural space
Pleurisy (what is it and causes)
Pleural inflammation
Definition- acute inflammation of parietal pleura
Causes: pneumonia, pulmonary infarction, rib injury, viral respiratory illness
Pleurisy symptoms
Sharp stabbing pain with any movement of the chest wall(especially inspiration), dyspnea, fever, abrupt onset of pain, unilateral, Crackles, pleural friction rub, Decreased breath sounds, area tender (pt can pin point location of pain)
Pleurisy Diagnosis and treatment
Medical treatment-relief of pain and treat underlying cause
Pleural Effusion (what is it)
Accumulation of fluid in the pleural space
normally, fluid seeps in from parietal pleura capillaries and is reabsorbed by visceral pleura capillaries and lymphatics- any condition that changes either of these can lead to pleural effusion
(increased hydrostatic, hyperalbumin, trauma, infection)
Pleural Effusion clinical manifestations
Depends on the size of the effusion
-less than 250ml may only be seen on CXR
-large effusion-lung expansion will be restricted and pt. may have dyspnea especially on exertion
dry non productive cough-due to bronchial irritation and mediastinal shift
-decreased tactile fremitus and breath sounds
Empyema
PUS IN THE PLEURAL CAVITY
must be drained and infection treated
may need surgical intervention if it becomes solidified and compresses the lung
Thoracentesis (what is it used for)
Used to remove fluid or air from the pleural space
used to decrease symptoms and diagnose source of fluid
note color and consistency of drainage
send specimen to the lab for: specific gravity, Glucose, Protein, pH, C&S, cytology
Pre-procedure thoracentesis
Informed consent, explain procedure
sit upright while leaning over a table
insertion of needle painful- medicate for pain
important to remain still during procedure- sudden movements can damage lung
takes ten to fifteen minutes to drain
Care during thoracentesis
Assist the doctor provide emotional support to the patient monitor the vital signs observe for dyspnea, nausea, pain encourage the patient to be still
Post-care thoracentesis
Turn to unaffected side for one hour for lung expansion
VS per institution policy, assess breath sounds
monitor for hemoptysis
record amount of fluid removed
CXR to assess lung reexpansion and presence of pneumo
assess for crepitus- mark the amount
Rib Fractures
One of the most common chest injuries
simple fracture-nondisplacing, little or no damage to the underlying tissues
treat with analgesics
symptom- pain at site of injury
CXR to confirm
Pt. Must cough and deep breathe
Monitor for 24-48 hours for lung contusion (ARDs)
Flail Chest (what is it)
Fracture of 2 or more ribs on the same side and possibly the sternum. Each rib is fractured in two or more places.
Can develop hemothorax if fractured rib tears pleura
chest wall is unstable
paradoxical chest movement with respiration-in with inspiration out with expiration
Flail Chest (signs and symptoms)
Pt can develop pulmonary edema, pneumonia, and atelectasis because fluids tend to increase and collect at injured site
altered chest movement
decreases patients ability to attain normal tidal volumes and cough effectively
hypoxemia and hypercapnia result
fear and fatigue due to pain with breathing
Flail Chest Diagnosis and treatment
- Ineffective airway clearance, alteration in comfort, impaired gas exchange, ineffective breathing pattern
- medical treatment depends on the severity of the case. Surgical stabilization and mechanical ventilation may be necessary
Pneumothorax (what is it, open/ closed)
Air in the pleural space- prohibits complete lung expansion
Closed pneumothorax- due to puncture or tear in internal respiratory structure (bronchiole, alveoli). Fractured rib can lead to this
Open pneumothorax- air enters pleural space directly through a hole in chest wall secondary to trauma
Pneumothorax symptoms (early)
Acute chest pain especially with chest movement, breathing, or coughing
apprehension (anxiety, restlessness)
Dyspnea, tachypnea, tachycardia, asymmetrical chest expansion
decreased or absent breath sounds on the affected side
Chest tube placement for pneumothorax
2nd intercoastal midclavicular line
Chest tube placement for hemothorax
5th/6th intercoastal mid-axillary line
Pneumothorax symptoms (late)
Distended neck veins, crepitus, decreased tactile fremitus, progressive cyanosis
tracheal deviation toward the unaffected side
pneumothorax is confirmed by CXR-chest tube must be placed
Open Pneumothorax
- Opening in chest wall is big enough for air to move freely in and out of the chest cavity with ventilation
- audible sucking noise
- must emergently cover the wound
- dressing of choice is sterile petrolatum gauze 4x4 and tape (not all 4 sides)
tension pneumothorax
Air enters the pleural space with each inspiration and becomes trapped (not expelled with expiration)
frequently associated with flail chest injuries, blunt traumatic injuries
if untreated collapses lung on unaffected side due to mediastinal shift
immediate intervention is required
Hemothorax
Blood in the pleural space
if small amount it may be reabsorbed (<300 cc)
if severe, 1400-2500cc, life threatening due to hypovolemia. Would also cause pressure on the unaffected lung.
Manifestations- tachycardia, hypotension, shock
treat with IV fluids(blood) and chest tube to suction
Chylothorax
Lipid-like fluid that accumulates in the pleural space
After cardiothoracic surgery
Treatment: Chest tube to drain
Decrease amount of fats and lipids pt receives
Thoracic Surgery
Wedge resection- pie like piece
segmental resection- larger section
lobectomy- lobe of lung (r-3, l-2)
pneumonectomy-only one that won’t need chest tube, postion on effected side (whole lung)
can be necessary because of lung cancer or possibly trauma
Pre-opertive Care pneumonectomy
Pulmonary function test will be performed
Alleviate anxiety
assess tidal volume, minute volume, vital capacity
Teach about post op expectations: presence of chest tubes, intubation and mechanical ventilation, oxygen therapy, available pain relief measures
Teach post op exercises, respiratory exercises, arm and shoulder exercises to maintain normal range of motion (shoulder is main problem), splinting
Post-op care pneumonectomy
Monitor airway- observe for respiratory failure
observe for signs of tension pneumothorax, crepitus especially if close to trachea
position for maximal expansion of lung tissue and gas exchange
Range of motion exercises to prevent shoulder
Increasing size of crepitus area
Monitor fluid status
pneumonectomy pts are more likely to get fluid overload due to IVFs and no CTs
Chest tubes (what for)
Required if:
sufficient air or fluid in the pleural space and ventilation is compromised
conditions that cause loss of negative intra-pleural pressure
PURPOSE:
remove air and fluid and restore normal negative pressure
Purpose of Drainage Systems
Provide for collection of drainage
provide one way system to prevent air or fluid from returning to the chest (water seal is the one way valve)
provide for control of suction to assist with removal of air and fluid
Reasons for a chest tube
Pneumothorax, Hemothorax, Tension Pneumothorax, Flail Chest, Pleural effusion, empyema, to prevent cardiac tamponade post open heart
Closed Pneumothorax
blunt trauma
Pneumothorax and hemothorax children
account for half of childhood intrathoracic injuries
clinical indications for chest tube
Physical Exam -Decreased breath sounds or change in pitch -Tachypnea -Increased Respiratory Effort -Sudden decrease in O2 saturations Tension Pneumo -agitation, hypotension from obstruction of venous return, severe hypoxemia, unilateral chest wall movement, tracheal deviation Subcutaneous air (crepitus) -Feels like Rice Krispies when palpated
key points for set up of drainage system
For set up:
- Must use sterile water; CANNOT use sterile saline
- Only fill Water Seal Chamber to the O or where the dotted 2cm line is (if over pt may have trouble breathing)
- Only fill suction control chamber to order pressure (usually -20 cm H2O)
- Adjust suction, after securing chest tube, so that gentle bubbling, NOT vigorous bubbling occurs in the suction chamber
Key points for monitoring a drainage system
Each shift, check the water levels in each chamber. Be sure to briefly stop suction to check suction chamber. Add water when levels are low. Only add water with suction stopped, then restart suction
If the water levels are overfilled, you can remove the water.
-Scrub the corresponding port on the back of the system
-Use a 20 gauge needle or smaller to access the port
Assess for air leak by looking for right to left bubbling in the water seal chamber
Ensure all connections are tight
Assess dressing site to ensure it is occlusive
Milking
Involves manipulations such as squeezing, twisting, or kneading to create bursts of suction within the tubing and chest tube lumen, increases thoracic pressure
Stripping
Done by compressing the chest tube with the thumb and forefinger against the chest wall to prevent dislodgement
Using the other hand, employ a pulling motion down the tubing away from the chest wall
Increases thoracic pressure
Patient safety with drainage system
Always secure Atrium Box to floor with tape or use hooks to secure to bed
Ensure tubing is NEVER kinked off; Monitor patient to avoid laying or positioning on tubing
Even if transporting on water seal, always have suction available
Have hemostats and gauze and/or vaseline gauze available in case of dislodgement
Always replace a system that has been tipped over
key points for chest tubes
Tape all connections
Maintain water at correct level
Keep drainage system below the level of the chest(2-3 ft.)
NO dependent loops
Do not clamp. Clamping can cause a tension pneumo.
Milking or stripping CTs is not recommended- increased negative pressure can be damaging to the lungs
Tidaling
Tidaling-water seal chamber fluctuates with respirations(fluid rises with inspiration and falls with expiration). DO NOT see tidaling when: lung has fully reexpanded when pts position kinks CT when using suction.
Bubbling in the waterseal chamber:
-can be air moving out of the pleural space
Investigate continuous waterseal bubbling- can indicate a leak in the system- check chest insertion site, check tubing
-notify physician of sudden increase in bubbling of waterseal chamber
Waterseal chamber must have an airvent to provide escape route for air coming out of the pleural space
Chest tubes to suction
Continuous gentle bubbling in suction control chamber- lack of bubbling means not enough wall suction, if vigorous bubbling, water will evaporate
Usually 10-20cm of suction is used
The more fluid in the chamber, the more suction
Newer systems have float and dial
chest tube removal
Indications for readiness for CT removal:
-cessation of tidaling(when no suction)
-chest auscultation-adequate aeration on affected side
-CXR-no evidence of pneumo or fluid in pleural space
Usually a lung is re-expanded 2-3 days postop
Usually leave CTs in place 24 hours after all air and significant fluid drainage have stopped
sometimes temporairly clamped to see if pt can tolerate CT removal
Removal of CTs is very painful.
Pt must take a deep breath, hold his breath and bear down (to increase intrathoracic pressure) while CTs are being removed
After removal of chest tube
After removal, apply petrolatum gauze to insertion site followed by a 4x4 and tape
After removal the nurse must:
-observe dressing
-monitor for signs and symptoms of pneumothorax
-auscultate breath sounds per institution policy
Air leak?
check water seal chamber for bubbles
Drawing cultures from a chest tube
20g syringe, 30s CHG scrub, withdraw from tubing
Opioids
Morphine
Hydromorphone
Fentanyl
Reversal Agents: Narcan
benzodiazepines
Lorazepam (Ativan)
Midazolam (Versed)
Propofol
stops RR
Paralytics
Do not give without KO
vecuronium
rocuronium
Cholinergic blocking agents
Atropine
Ipatropium, (Atrovent)
Tiotropium (Spiriva)
increase HR
Adrenergic agents
Albuterol (Proventil)
Pirbuterol (Maxair)
Salmeterol (Serevent)
Levalbuterol (Xopenex)
Inhaled corticosteriods
Beclomethasone (Beclovent) Budesonide (Pulmocort) Fluticasone (Flonase, Flovent) Triamcinolone (Azmacort) Flunisolide (AeroBid)
Oral and parental corticosteriods
Hydrocortisone (Solu-cortef) (IV)
Dexamethasone (IV)
Methyprednisolone (Solu-medrol) (IV)
Prednisone (oral)
ETT
Endotracheal tube
WOB
work of breathing
VAP
ventilator associated pneumonia
Tidal volume
amount of air in normal breath
6-10 mL/Kg ideal body weight
I:E ratio
inspiratory to expiratory
normal is 1: 2( adult); 1: 1 (infant) -volume, flowrate, and rate control alter I:E ratio
PEEP
Peak End-Expiratory Pressure
used to improve oxygenation
keeps airway open
Fraction of inspirated O2
FiO2= 0.4= 40% o2
CPAP
is continuous positive airway pressure. It helps keep the alveoli open.
Can be used with mask or intubation or nasal prongs
Indicated for sleep apnea, COPD, pulmonary edema, heart failure, chronic or acute respiratory failure
BiPAP
is bilevel positive airway pressure and is the same concept but different amount of pressure can be applied during inspiration and expiration
Why intubate
Upper airway obstruction Apnea High Risk of Aspiration Ineffective Airway Clearance Respiratory Distress
Intubation: Equipment
Ambu Bag, Mask, Oxygen, Suction setup, Oral Suction (Yankhauer), Suction Catheters, Endotracheal Tube (the right size) Adult: usually 7.0 – 9.0, Tape or Twill ties for securement, CO2 detector, Laryngoscope and Blade
Drugs
Will need to sedate and/or paralyze pt unless FULL ARREST
Oral ETT
Cuffed or Uncuffed, Use larger size Advantages: -Decrease WOB because less airway resistance -Easier to remove secretions -Easier to do Bronchoscope
Nasal ETT
Cuffed or Uncuffed, Use smaller size than oral, Used when head/neck manipulation is risky
DO NOT USE when: Facial fractures, Fracture at base of skull, Post-op cranial surgeries
Issues:
-Increased WOB due to smaller tube size
Some studies:
-Increased sinus infection risk
-Increased VAP risk
Intubation Procedure
Provider places ETT
Confirm tube position:By auscultation of the chest, Bilateral chest rise, Tube location at teeth, CO2 detector – (esophageal detection device), CXR also used to confirm location of ET
Intubation risks
Difficult to place (especially nasally)
Teeth may be chipped or broken
Increased salivation and increased difficulty swallowing
Obstruction because of biting
Decrease good oral care because of difficulty to use toothbrush
If nasal, then may kink easy
Monitor for ETT placement
Monitor for placement every 2-4 hours
Confirm exit mark on tube remains constant while at rest AND while repositioning pt
Pt Assessment: Symmetrical chest rise and movement, Auscultate bilateral breath sounds
If dislodged, pt at risk for: Minimal or NO oxygen, No tidal volume (TV) delivered to pt OR one lung gets entire TV, Risk for pneumothorax
Maintain proper cuff inflation ETT
Normal cuff pressure is 20-25 mmHg
Measure and record immediately after intubation and tube placement confirmation AND every 8 hours
Improperly inflated cuff leads to: Too much air leak, Too much pressure on trachea
Indications for suctioning ETT
Visible secretions Sudden onset of resp distress Suspected aspiration Increased peak airway pressures Auscultation of adventitious breath sounds Increased resp rate and/or coughing Sudden or gradual decrease in PaO2
complications of intubation
Unplanned Extubation *Signs of unplanned extubation: -patient speaking -low pressure alarm on ventilator -decreased or absent breath sounds -respiratory distress -gastric distention Aspiration
Goals of Vent
Decrease work of breathing
Increase alveolar ventilation
Maintain ABG values within normal range
Improve distribution of inspired oxygen
PCO
35-45
SaO2
95-100
PO2
80-100
Volume modes
Volume is constant and pressure will vary with patient’s lung compliance. TV= mL per breath varies w/ pressure
Examples:
Assist-Control Mode (AC) (also known as Assisted Mandatory Ventilation (AMV)
Intermittent Mandatory Ventilation (IMV)
Synchronized Intermittent Mandatory Ventilation (SIMV)
Pressure Modes
Pressure is constant and volume will vary with patient’s lung compliance.
Examples:
Pressure Support Ventilation (PSV)
Volume mode- control mode
Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.
The patient CANNOT generate spontaneous breaths, volumes, or flow rates in this mode.
Volume mode- assist control
Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.
The patient CANNOT generate spontaneous volumes, or flow rates in this mode.
Patient can initiate a breath but will be given the set volume of air
Each patient generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.
Volume mode- Synchronized Intermittent Mandatory Ventilation (SIMV)
Delivers a pre-set number of breaths at a
set volume and flow rate.
Allows the patient to generate
spontaneous breaths, volumes, and flow
rates between the set breaths.
Detects a patient’s spontaneous breath
attempt and doesn’t initiate a ventilatory
breath
alarm for low minute volume
Pressure support
Extra support is provided with each inspiration
Pt must be spontaneously breathing
Preset- Inspiratory pressure, PEEP, Sensitivity
Patient determines: Own tidal volume, Own rate, Inspiratory time
POSITIVE END EXPIRATORY PRESSURE (PEEP):
This is NOT a specific mode, but is rather an adjunct to any of the vent modes.
PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase.
Utilized to keep otherwise collapsing lung units open while hopefully also improving oxygenation.
CPAP Mode
This IS a mode and simply means that a pre-set pressure is present in the circuit and lungs throughout both the inspiratory and expiratory phases of the breath.
CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less WOB.
The CPAP mode is very commonly used as a mode to evaluate the patients readiness for extubation.
Cardiac issues vent
Decreased venous return to the heart Decreased left ventricular end-diastolic volume-Preload Decreased Cardiac Output Hypotension can vegal
Pulmonary issues vent
Barotrauma- increased pressure Trauma from Overinflation Alveolar Hypoventilation Alveolar Hyperventilation Ventilator-Associated Pneumonia
Electrolyte issues vent
Fluid Retention- Especially with increased PEEP
Decreased urinary output
Increased Sodium Retention
Perhaps all from decreased cardiac output = decreased renal perfusion
Also, with stress response = release of ADH and cortisol which leads to sodium and water retention
Neuro issues vent
Venous drainage from the head- JVD
With head injury…impaired cerebral blood flow
-Increased intracranial pressure because of impaired venous return and increased cerebral volume
GI issues vent
Stress ulcers, GI bleeding, Ischemia of gastric and intestinal mucosa, Gastric and bowel dilation- From increased air swallowing, Decreased Peristalsis- From immobility, sedation, pain meds, stress and decreased cardiac output
Musculoskeletal issues vent
Loss of muscle strength- Related to: sedatives, paralytics, lack of nutrition
Foot drop
Pressure Ulcers
Immobility
Psychosocial issues vent
Physical and Emotional stress
Eat, speak, move or breath = NOT normal if ventilated
Feeling of being UNSAFE; If needs are met, patient will feel safe
4 needs:
Need to KNOW, Need to have CONTROL, Need to HOPE, Need to TRUST
High Pressure Alarms
Secretions, coughing, gagging, patient fighting ventilator, water in tubing
Decreased compliance issues: Pulmonary edema, Pneumothorax
Increased resistance: bronchospasm, kinked tubing
Low Pressure Limit
Ventilator disconnected!
Patient extubates self-partially or totally
Patient trying to speak
Cuff Leak
Apnea
Oversedation, change in patient condition, total or partial extubation
High Volume
Pain, anxiety, change in patient condition
Low Volume
Cuff leaking, pt becomes disconnected from circuit (or loose connections), change in patient’s effort
phases of weaning
- Preweaning
* Consider respiratory and nonrespiratory factors
* SBT (Spontaneous Breathing Trial) - Weaning
* Reduce settings gradually and assess how patient tolerates - Extubation (Outcome)
Criteria for extubation
TV of at least 5 ml/kg
MIP (maximum inspiratory pressure) of at least -20 cm H20. The more negative the number the more strength the pt has to pull in a breath.
Vital capacity (VC) of 10-15 ml/kg
Minute volume (MV) of at least 5 liters (TV X RR)
RR within normal limits WNL), not labored, not shallow, no use of accessory muscles
LOC WNL
O2 sat >95%
Heart rhythm WNL
They should be calm and able to follow verbal commands.
They should have the strength to lift and hold their arms up as well as lift their head off the pillow
Patients who have a threat to__________ should be treated first
life, vision, or limb
Uses 4 factors to determine Triage level
Stability of Vital Functions (ABCs)
Life threat or Organ Threat
How soon the pt should be seen
Expected resource intensity
five level emergency index
1-threat to life 2-High Risk Situation, Confused, severe pain & dangerous VS 3- Stable VS and need many resourse 4-one resource needed 5-no resources needed
primary survey-
Trauma care begins with the primary survey- rapid assessment of the patient’s ABCs with the addition of disability (what can kill the patient now)
Followed by secondary survey
complete head-to-toe assessment to identify other serious injuries that could kill or disable the patient later
Airway
Cervical Spine Stabilization &/or Immobilization (Cervical Collar, Cervical immobilization device (CID) – head blocks)
Breathing
medical problems cause alterations in breathing—-fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks
signs & symptoms of alterations in breathing
-Dyspnea, Paradoxical or Asymmetric chest wall movement, Decreased or absent breath sounds, Visible wound to chest wall, Cyanosis, Tachycardia and/or Hypotension
Circulation
Two large-bore (14-16 gauge) IV catheters should be inserted & fluid resuscitation initiated using lactated Ringer’s solution or normal saline
Direct pressure with a sterile dressing should be applied to bleeding sites
Disability
A brief neurologic exam completes the primary survey
The degree of disability is measured by the pt’s level of consciousness
Determining the pt’s response to verbal &/or painful stimuli is one approach to assessing level of consciousness
Pupils are assessed for size, shape, equality, and response to light
AVPU
AVPU
A = Awake V = Responsive to Voice P = Responsive to Pain U= Unresponsive
Exposure/enviromental control
Secondary
All trauma patients should have their clothes removed
Once the patient is exposed, it is important to limit heat loss and prevent hypothermia by using warming blankets, overhead warmers, and warmed IV fluids
History
Use AMPLE: Allergies Medication history Past Health History Last Meal Events/Environment provides clues to the cause of the crisis and suggests specific assessment and intervention needs
Raccoon eyes
closed head injury, happens 2-3 days later, basal skull fracture
Battle sign
bruising behind the ear
Drainage
Do not block or clear drainage from ear or nose
Check ear for blood or cerebrospinal fluid
Blunt Injury
Mechanisms of blunt injury include motor vehicle crashes (MVCs), falls, assaults, contact sports
Multiple injuries are common with blunt trauma & extent of injury is less obvious than penetrating injuries and the diagnosis can be more difficult.
Penetrating injury
Refers to an injury produced by foreign objects penetrating the tissue
-stabbings, firearms
impalement- injuries that penetrate the skin and result in damage to internal structures
Damage is created along the path of penetration
Can be misleading because the condition of the outside of the wound does not determine the extent of internal injury
Cullen’s Sign
Purplish discoloration of the flanks or umbilicus- indicative of blood in the abdominal wall
turners sign
ecchymosis on flank- may indicate retroperitoneal bleeding or pancreatic injury
Priapism
errection that doesnt go away
FAST
Focused abdominal sonography for trauma- used to see if fluid is present
Cannot rule out Retroperitoneal bleed
Internal hemmorage
If a patient shows no signs of external bleeding but exhibits tachycardia, fall in B/P, apprehension, cool and moist skin, or delayed capillary refill, internal hemorrhage is suspected
PRBCs are administered
Patient is prepared for more definitive treatment (surgery)
Maintained in supine position until hemodynamic parameters improve
Heat exhaustion
Assessment Findings: Fatigue, Light-headedness, N/V, diarrhea, Feelings of impending doom, Tachypnea, Hypotension, Tachycardia, Elevated body temperature, Mild confusion, Ashen color, Diaphoresis
Treatment: place patient in cool area, oral fluid and electrolyte replacement or normal saline solution IV
Heat stroke
Increased sweating, vasodilation, and increased respiratory rate deplete fluids and electrolytes.
Eventually, sweat glands stop functioning, so core temperature increases rapidly.
Assessment Findings: core temperature above 104° F, altered mentation, absence of perspiration, circulatory collapse, skin is hot, dry, and ashen.
Treatment:
Reducing the core temp rapidly (until 102)
Administration of 100% oxygen
Fluid & electrolyte imbalances are corrected
Frostbite treatment
Controlled yet rapid rewarming is instituted- painful.
Part is elevated to help control swelling.
Dehydration, hyperkalemia, and hypovolemia are corrected.
After rewarming, hourly active motion of the affected digits is encouraged to promote maximal function
Rewarming- the extremity is placed in a 37 to 40 degree (98.6-104) circulating bath for 30 to 40 minute spans
Avoid tobacco, alcohol, and caffeine because of their vasoconstrictive effects
degrees of Hypothermia
mild hypothermia 90°- 95°F
moderate hypothermia 87°- 90°F
profound hypothermia less than 87°F
Hypothermia
Assessment Findings
-Shivering (diminished or absent at temperatures less than 92°F), Hypoventilation, Hypotension, Altered mental status, Areflexia, Pale, cyanotic skin, Blue, white, or frozen extremities, Arrhythmias, Fixed, dilated pupils
Treatment:
-Rewarm patient, Continuous ECG monitoring because cold-induced myocardial irritability lead to ventricular fibrillation
Carbonmonoxide poisoning
will need blood gas to assess.
Biological agents of terrorism
Anthrax, Plaque, Tularemia -Can be treated with antibiotics Smallpox -Prevented with vaccination Botulism -Treated with antitoxins Hemorrhagic fever -No current treatment
Chemical agents of terrorism
Sarin nerve gas – paralyzes respiratory muscles
-Atropine, Pralidoximine chloride
Phosgene gas – causes respiratory distress and pulmonary edema
Mustard gas – causes skin burns and blisters
Radiologic or nuclear agents of terrorism
RDD – radiologic dispersal devices (RDD) (dirty bombs)
-Mix of explosive and radiologic material
-Most damage from explosion, but should take measures such as covering nose and mouth and showering to limit exposure
Ionizing Radiation
-Damage to nuclear reactors or nuclear bomb
-Initiate decontamination procedure.
-Can develop acute radiation syndrome (ARS)
Acute Respiratory Distress Syndrome (ARDS)
Sudden progressive form of acute respiratory failure
Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid.
Alveoli fill with fluid.
Worse ALI
ARDS results in
Severe dyspnea
Hypoxia- pO2 remains low despite increasing FIO2 (fraction of inspired oxygen)
Decreased lung compliance
Diffuse pulmonary infiltrates
50% mortality rate
Etiology of ARDS
Develops from a variety of lung injuries
Most common cause is sepsis.
Direct lung injury: aspiration of gastric contents, pneumonia
Indirect lung injury: massive trauma, sepsis
Exact cause for damage to alveolar-capillary membrane not known
Pathophysiologic changes of ARDS thought to be due to stimulation of inflammatory and immune systems
Neutrophils in ARDS
Neutrophils are attracted and release mediators, producing changes in lungs.
- ↑ pulmonary capillary membrane permeability
- Destruction of elastin and collagen
- Formation of pulmonary micro emboli
- Pulmonary artery vasoconstriction
3 phases of ARDS
Injury or Exudative Phase
Restorative or Proliferative Phase
Fibrotic or Chronic Late Phase
Injury or Exudative Phase
1 to 7 days after direct lung injury
-Damage to vascular endothelium, ↑ capillary permeability
-Engorgement of peribronchial and perivascular interstitial space- interstitial edema
-alveoli fill with fluid, and blood passing through cannot be oxygenated.
-Surfactant dysfunction → Atelectasis
-decreased gas exchange and decreased lung compliance
-V/Q mismatch- refractory hypoxemia.
Hypoxemia unresponsive to increasing O2 concentrations
Restorative or Proliferative Phase
1 to 2 weeks after initial lung injury
Influx or neutrophils, monocytes, and lymphocytes
Fibroblast proliferation
Lung becomes dense and fibrous
Lung compliance continues to ↓ due to interstitial fibrosis
Hypoxemia worsens.
Thickened alveolar membrane
Diffusion limitation and shunting
If reparative phase persists, widespread fibrosis results.
If phase is halted, lesions resolve
Injury or Exudate Phase assessment
↑ work of breathing
↑ respiratory rate
↓ tidal volume (stiff lungs)
Produces respiratory alkalosis from increase in CO2 removal (due to the increased RR)
Eventually have ↓ CO and ↓ tissue perfusion
Fibrotic/Chronic or late phase
2 to 3 weeks after initial lung injury
Lung is completely remodeled by collagenous and fibrous tissues.
Results in
↓ lung compliance
↓ area for gas exchange with resultant hypoxemia
Pulmonary hypertension
Results from pulmonary vascular destruction and fibrosis
ARDS early clinical manifestations
Dyspnea, tachypnea, cough, restlessness
Chest auscultation may be normal or may reveal fine, scattered crackles.
ABGs- Mild hypoxemia and respiratory alkalosis caused by hyperventilation
Chest x-ray may be normal or may show minimal scattered interstitial infiltrates.
-Edema may not show on CXR until 30% increase in lung fluid content
ARDS late clinical manifestations
Symptoms worsen with progression of fluid accumulation and decreased lung compliance.
Pulmonary function tests:
-decreased compliance and lung volume.
Evident discomfort and increased work of breathing
-Tachypnea, suprasternal and intercostal retractions
Tachycardia, diaphoresis, changes in sensorium with decreased mentation, cyanosis, and pallor
Hypoxemia and a PaO2/FIO2 ratio <200 despite increased FIO2
chest xray with ARDS
whiteout or white lung because of consolidation and widespread infiltrates throughout lungs
Assessment of ARDS
Shallow breathing with increased respiratory rate Tachycardia Abnormal breath sounds Somnolence, confusion, delirium Changes in pH, PaCO2, PaO2, SaO2 Decreased tidal volume, FVC Abnormal x-ray Normal pulmonary artery wedge pressure (noncardiogenic pulmonary edema)
Oxygen therapy with ARDS
Give lowest concentration that results in PaO2 60 mm Hg or greater to prevent O2 toxicity
Risk for O2 toxicity increases when FIO2 exceeds 60% for longer than 48 hours.
Patients will commonly need intubation with mechanical ventilation because PaO2 cannot be maintained at acceptable levels.
Mechanical vent with ARDS
PEEP at 5 cm H2O
-Opens collapsed alveoli
Higher levels of PEEP are often needed to maintain PaO2 at 60 mm Hg or greater.
High levels of PEEP can compromise venous return.
-↓ preload, CO, and BP
High levels of PEEP can cause barotrauma
HYPOXIA is the issue and PEEP helps this
Positioning with ARDS
Turn from supine to prone position.
Fluid pools in dependent regions of lung.
Proning typically reserved for refractory hypoxemia not responding to other therapies
Plan for immediate repositioning for cardiopulmonary resuscitation.
Continuous lateral rotation therapy (side to side turning via a rotation bed)
Conplications of ARDS
Infection
Related to Mechanical Ventilation
-Ventilator-associated pneumonia
-Barotrauma (rupture of alveoli due to increased pressure)
-Prevent barotrauma with higher rates and lower TV
-High risk for stress ulcers
-Renal failure (decreased perfusion due to decreased CO)
Ventilator Bundle Protocol
Elevation of the HOB 30-45 degrees Daily “sedation holidays” and assessment of readiness for extubation PUD prophylaxis DVT prophylaxis Oral care chlorhexidine solution
Cor Pulmonale
Hypertrophy of the RIGHT Ventricle
-Secondary to diseases of lung, thorax, pulmonary circulation
May be present with or without cardiac failure
Results from pulmonary hypertension
50% of US cases are from COPD (Late manifestation)
-INCREASED pulmonary vascular resistance
Cor pulmonale signs and symptoms
MOST COMMON: Dyspnea on exertion Tachypnea, cough Lethargy, fatigue Lung sounds:Normal or crackles in bases Right-Sided Heart Failure S&S: JVD, Hepatomegaly, Right upper quadrant tenderness, Peripheral edema, Weight gain, Full, bounding pulse
Diagnostics for Cor polmonale
H and P, ABGs, SpO2, Electrolytes, BNP, CXR, ECG, CT, MRI, Cardiac catheterization
