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Adult Critical Care > Final > Flashcards

Final Flashcards

1
Q

Dysrhythmias are caused by

A

Hypoxia, Ishemia, Sypathetic stimulation, drugs, Electrolyte imbalance, rate, stretch

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2
Q

1 reason adult cardiac arrest

A

underlyning heart problem. Kids- resp failure/ sepsis

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3
Q

Heart blood path

A

Superior Vena Cava, Inlet of the superior vena cava, right atrium, inlet of the inferior vena cava, Coronary sinus, Inferior vena cava, Coronary sinus, Inferior vena cava, Tricuspid valve, Right Ventricle, Interatrial septum, Interventricular Septum, Left atrium, Mitral valve, Left ventricle

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4
Q

Heart conduction

A
  1. SA Node
  2. AV node
  3. Bundle of His
  4. Bundle branches
  5. Purkinje fibers
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5
Q

AV node

A
  • Conduction is delayed at the AV node to allow the ventricles to fill with blood
  • Also limits the rate of ventricular stimulation during excessive atrial firings
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6
Q

Purkinje fibers

A

Finger like branches that penetrate the cardiac muscle

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7
Q

Properties of cardiac muscle

A
  1. Contractile muscle fibers

2. Auto-rhythmic cells

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8
Q

Contractile muscle fibers

A

Responsible for pumping activity of the heart, Make up bulk of musculature of myocardium

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9
Q

AutoRhythmic cells

A

Make up 1% of cardiac cells, most found in SA node, cause myocardial fibers to contract, stimulate and create action potential

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10
Q

Four properties of cardiac muscle

A
  1. Automaticity
  2. Excitability
  3. Conductivity
  4. Contractility
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11
Q

Excitability

A

Response to stimulation or irritation, Ischemia and hypoxia cause myocardial cells to become more excitable (irritated)

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12
Q

Conductivity

A

Unique ability of the heart cells to transmit electrical current from cell to cell throughout the entire conductive system

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13
Q

Contractility

A

Is the ability of cardiac muscle fibers to shorten and contract in response to an electrical stimulus

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14
Q

Electrolytes responsible for electricity

A
  1. Potassium (K+)
  2. Sodium (Na+)
  3. Calcium (Ca2+
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15
Q

Nervous system role

A

plays important role in the rate of impulse formation, conduction, and contraction strength

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16
Q

Sympathetic stimulation role

A
  • Cause increase in HR
  • Increase in AV conduction
  • Increase in heart contractility
  • increase in excitability
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17
Q

Parasympathetic stimulation role

A
  • Decrease in HR
  • Decrease in AV conduction
  • Decrease in contractility
  • Decrease in excitability
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18
Q

5 leads

A

White in the clouds over grass (green), with crap in the middle, then smoke (black) over fire (red)

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19
Q

Ectopic beat

A

any beat outside of SA node

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20
Q

foci/focus

A

where the ectopic beat originates

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21
Q

dysrhythmia

A

abnormal cardiac conduction, also termed arrhythmia

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22
Q

Escape Beat

A

a heart beat that originates outside the sinus node after a period of SA node inactivity

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23
Q

Myocardial Ischemia

A

partial or complete obstruction of blood flow, reducing oxygen supply to the heart

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24
Q

Angina

A

chest pain associated with reduced coronary blood flow

Stable-persistent, with excertion. Unstable-unexpected, at rest, more intense and longer

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25
Q

Myocardial infarction

A

death of muscle tissue

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26
Q

Atrial Kick

A

Responsible for cardiac output (10-30% ventricular filling)

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27
Q

Heart block

A

Conduction stopped or insignificantly delayed

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28
Q

Automaticity

A

ability of heart to beat on own

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29
Q

Normal rates: SA Node, AV junction, Bundle Branches, Purkinje Network

A

SA- 50-100
AV- 40-60
Bundle-30-40
Purkinji- 30-40

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30
Q

Steps to reading ECG

A
  1. HR
  2. Heart rhythm (reg/ irreg) R-R interval
  3. Presence of P wave
  4. Is there a QRS following each P wave
  5. PR interal (is it less than 0.20)
  6. QRS complex (Is it less than 0.12 seconds)
  7. ST segment (baseline)
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31
Q

PVC

A

Wide ectopic beat from ventricles

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32
Q

ECG run at same speed of

A

25mm/sec

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33
Q

Large ECG square

A

0.20, containing 5 small squares (0.04s)

1 minute= 5 large boxes

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34
Q

Ventricle rhythm, comparing the R-R ratio with the longest/ shortest… how many seconds to make irregular

A

> 0.12

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35
Q

Pwave

A

Represent atrial conduction originated in the SA node, Paces the heart.

  • Less than 2.5 mm in height
  • more than 0.10 seconds in length
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36
Q

PR Interval

A

Normal 0.12-0.20 seconds

-Longer= delay in conduction through the AV node (AV block)

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37
Q

Complete heart block=

A

third degree heart block

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38
Q

QRS Complex

A

-Normal is less than 0.12 seconds long,

Represents ventricular depolarization

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39
Q

Rules of QRS

A
  • If the first deflection is downward than it is a Q wave
  • The initial upward deflection is an R wave
  • The first neg. deflection following R is an S wave
  • QS is a negative deflection with no positive deflection at all
  • regardless of missing waves it is still called QRS complex and represents ventricular depolarization
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40
Q

Twave

A

reflects ventricular repolarization, inverted T waves suggest ischemia

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41
Q

ST segment

A

Normally baseline, A depressed ST segment suggests myocardial ischemia
-an elevated segment suggests myocardial infarction

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42
Q

Sinus Dysrhthmias

A

Sinus bradycardia- Regular rhythm, HR < 60bpm,

Sinus tachycardia- Regular rhythm, HR 100-160bpm

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43
Q

Supraventricular tachycardia

A

Ventricular rate: 150-250bpm

  • Regular rhythm
  • P waves may be hard to see
  • Narrow QRS
  • Connect SVT to adenosine as first line drug
  • Cardioversion
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44
Q

Complications of A. Flutter

A

-Diminishes atrial filling: results in minimal atrial assistance in filling the ventricles (10-30% CO)
-Development of thrombi in atrial walls: need for blood thinners
(blood in atrial for too long)

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45
Q

Tx of A. Fib

A

Reduce the heart rate with cardioversion,
Medication to maintain normal rhythm:amiodarone,
medication to control ventricular rate: calcium channel blockers, beta blockers,
Medication to reduce atrial thrombus: coumadin, Pradaxa, Xarelto, Eliquis,
Cardiac ablaton: burn places in heart

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46
Q

Associated causes of A. Flutter/ A. Fib

A

COPD, CHF, Valvular heart disease, Chronic hypertension, Ischemic heart disease, MI

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47
Q

First Degree AV block

A

Normal rate, regular rhythm, one p wave before each QRS,

  • PR prolonged and constant (longer than 0.20)
  • usually no tx needed
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48
Q

Second Degree AV block- Wenkebach type 1

A
  • Progressive prolongation of the PR interval until a Pwave is not conducted
  • Patterns repeats itself
  • it occurs when an abnormality in the AV junction delays or blocks conduction of some of the impulses through the AV node
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49
Q

Second Degree AV block- Mobitz type II

A

PR intervals: for conducted p waves, P-R intervals is consistent (normal or can have a 1st degree block), muliple p waves not followed by QRS wave

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50
Q

Mobitz type II result from

A

serious problem such as MI or ischemia, requires tx to improve cardiac output, pacemaker is indicated

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51
Q

3rd degree (complete) AV block

A

Normal everything, but no measurable PR intervals, heart must pace to maintain acceptable cardiac output

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52
Q

List one major complication/ risk of having Atrial fib.

A

Thrombi= must be on blood thinners, and emboli= stroke

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53
Q

H’s and T’s

A 
Hypovalemia 
Hypoxia
Hydrogen Ion (acidosis)
Hyper/Hypokalemia
Hypothermia
Tablets
Tamponade
Tension Pneumothorax
Thrombosis-coronary (MI)
Thrombosis-Pulmonary (PE)
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54
Q

Hydrogen Ion

A

Check if its acidosis/ or metabolic… fix with bicarb when acidosis

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55
Q

Hyper/Hypokalemia fix

A

Hyperkalemia-fixed with albuterol

Hypokalemia- fixed with potassium

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56
Q

Tamponade

A

Cardiac, Relieve pressure around heart (squeeze)

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57
Q

Thrombosis- coronary

A

MI- clut buster

PCI-Stent-relieve block, angioplasty-open up, see block

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58
Q

Thrombosis - pulmonary

A

PE- Clot buster

Remove clot

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59
Q

Run of 3

A

Run of v. tach: loses C.O.
Happens every 2? Bigemity
Every 3? Trigemity

60
Q

Ventricular Tachycardia

A

-Three Consecutive PVC’s is considered a “run” of ventricular tachycardia
-Ventricular Rate= 100-250 bpm
-Ventricular rhythm essentially regular
-QRS > 0.12 seconds
-Ventricular tach without a pulse is an emergent situation. BLS should be initiated as soon as possible and the pt defibrillated
DONT DELAY SHOCKING

61
Q

Ventricular tachycardia shocking?

A

Can have with or without pulse
With pulse-Can cardiovert
Without pulse- Defib/ CPR 2 min then check/ push meds= restore CO

62
Q

Polymorphic V. Tach

A

Twisting of points

63
Q

V. tach common causes

A
  • MI
  • Myocardial Ischemia
  • Pt may become severely hypotensive to the point of syncope
  • Cardiac output may deteriorate significantly causing the pt to become unresponsive
  • Serious arrhythmia, often leading to ventricle fibrillation
64
Q

Torsade De Pointes

A

THINK MAGNESIUM-important in muscle contraction
Polymorphic Ventricular Tachycardia (PVC)
“twisting of points”
Caused by multiple things
-Drugs including: antidepressants, antidysrhythmics, eating disorders, and electrolyte imbalances
-Treated with mg sulfate (in crash cart)

65
Q

V. fib tx

A

Follow pulseless ventricular tachycardia/ ventricular fibrillation ACLS algorithm
Compare asystole and PEA, SHOCK ASAP

66
Q

Asystole

A
  • Complete absense of electrical and mech activity
  • no cardiac output
  • Flatline: used to determine clinical death
  • must confirm in two leads

Tx: Follow asystole/ PEA ACLS algorithm
Remove monitors

Can only do CPR and EPI

67
Q

PEA

A

Pulseless Electrical Activity
Connected to Asystole
-Electrical Pattern that is seen on EKG or rhythm strip, bud does not produce a pulse

68
Q

CAB

A

Circulation- most important
Airway
Breathing
check PETCO

69
Q

External defibrillator

A

Can also perform cardioversion, external heart pacing-transcutaneously shocking or pacing(capture to see NRG is strong enough), synchronizing

70
Q

Defibrillation

A

Delivery of a uniform current of sufficient intensity to depolarize ventricular cells and terminate the abnormal heart rhythm

  • Momentary asystole provides opportunity for SA node to regain control
  • Also called unsynchronized counter shock
  • Monophasic 360 or biphasic 200
71
Q

Rhythms that we Defibrillate

A

Pulseless V. tach and V. fib

72
Q

Cardioversion Rhythms

A

SVT! Unstable tachycardia, Unstable A. flutter or A. Fib, High ventricular rate= 150bpm or more

  • No CPR , patient is awake and having symptoms
    goal: restore ventricular rate
73
Q

Routes of delivery

A

IV= Intravenous
IO= Intra-osseous
Endotracheal

74
Q

Approved ETT drugs

A 
NAVEL
N: Naloxone/ narcan- reverse opiates
A: Atropine- Symptomatic Brady
V: Vasopressing- Potent vasoconstrictor
E: Epinephrine- Given Q 2-3 min, PRN
L: Lidocaine- Antiarrythmia

(plus mycomyst, combivent, duo, ect)

75
Q

Drugs that have dose changes as increased

A

Amiodarone and Adenosine

76
Q

RES Q-POD

A

Improves cardiac output by improving venous return during chest recoil- creates a vacuum like effect in chest

  • also has a light that flashes to guide ventilation: keeps from hyperventilating
  • If pt is resuscitated successful, the Res Q POD must be removed (immediately after ROSC)
  • Aka impedence threshhold device
  • Can be used with ETT and BVM
77
Q

PETCO

A

End Tidal CO2

  • Reflects perfusion efforts during CPR- circulation not ventilation
  • If end tidal CO2 drops below 10mmhg, improve compressions or switch compressors
  • At 40mmhg; ROSC
  • Keep at 10-20 during CPR atleast
  • Measured during exhalation
78
Q

STEMI

A

ST elevated myocardial infarction

  • PROTOCOL; EKG within 10 minutes of ED admission
  • TX: Fibrolytics or percutaneous coronary intervention (PCI) (angioplasty, stenting): 90 minutes
  • MONA
79
Q

TX for suspected MI

A

MONA
M: Morphine- Helps pain, reduces stress
O: Oxygen- Treat hypoxemia, low dose 1-4lpm, maintain SpO2 (too much=coronary vasoconstriction)
N: Nitroglycerin- tx angina (chest pain), cause vaso coronary dilation be careful of low BP
A: Aspirin- doesnt bust clots, helps stop continue of formation

80
Q

Cardiovert at

A

50Joules- any tach

81
Q

Adenosin

A 
SVT
IV Access
6mg followed by rapid flush of saline 
12 mg rapid flush
No compressions
82
Q

Epinephrine

A

1mg every 3-5 minutes followed by CPR

PEA, Pulseless vtach,

83
Q

Amiodarone

A

300mg
150mg ETT
Pulseless Vtach
Continue CPR

84
Q

Norm Pleural fluid in a healthy adult is

A

approx 8ml hemi-thorax

85
Q

Mediastinum

A

Portion of the thoracic cavity lying in the middle of the thorax between the two cavities. It extends from the vertebral column to the sternum and contains the trachea, esophagus, heart, and great vessels of the circulatory system

86
Q

Apex of lung

A

Rises 2-3 cm above the medial third of clavicle into neck

87
Q

Lung Pleuras

A

serous membrane forming closed sacs
Two layers:
-Visceral pleura: adheres to lung; continuous with parietal pleura at root of lung
-Parietal pleural- lines the thoracic cavity

88
Q

Stomata

A

Normally pleural fluid is drained through small holes in the parietal pleura

  • Connected to intercostal lymphatic vessels and drain to mediastinal lymph system (creating and draining pleural fluid
  • Eventually emptying into left subclavian vein
89
Q

Pleural Effusions results when

A

the capacity of pleural lymphatic drainage is overcome with transudative or exudative occurance

90
Q

Pleural effusion: Transudative

A

Occurs when the integrity of the pleural space is undamaged

  • “train” fluid has to come from something else
  • CHF
91
Q

Pleural Effusion: exudative

A

Caused by inflammation in the lung or pleura

  • “Devil” comes from something nasty
  • Pleural lung cancer: Mesothelioma
  • Infection
92
Q

Airbronchograms

A

Airways stick out , tissue around it has increase densities

-CHF

93
Q

Causes of transudative

A

CHF, Cirrhosis of the liver, Atelectasis, CVP line in pleural space, Lymphatic obstruction, Renal Failure, Urinothorax

94
Q

Causes of exudative

A

Carcinoma, lymphoma, Mesothelioma, TB, Pneumonia, Drug induced (amiodarone), Yellow nail syndrome??

95
Q

Etiology of pneumothorax

A
  1. Air passes through the vessels pleura through the lungs and into the pleural space
  2. Perforation of chest wall and parietal pleura
  3. Gas forming microorganisms (empyema) in the pleural space
96
Q

Empyema

A

Pus

97
Q

Bleb

A

Small collection of air between the lung and outer surgace of lung (visceral pleural) usually found in the upper lobe of the lung

  • When bleb ruptures= pneumothorax
  • Small subpleural 1-2cm
98
Q

Bullae

A

no discernible wall more than 1cm

99
Q

Open Pneumothorax

A

opening in chest wall

  • Stab wound, surgery, gunshot, impalement
  • with or without lung puncture (usually always lung puncture)
  • Exposes pleural space to atmospheric pressure
  • sucking chest wound
100
Q

Closed Pneumothorax

A

Rupture inside

  • Chest wall intact
  • leak through lung and visceral pleura
101
Q

Pleural Pressures

A

-5 (exp/ resting lung)
-8 (inspired)
Vented-> if paralyzed= positive pressure on inspiration

102
Q

Pneumothorax types

A
  1. Spontaneous
  2. Traumatic
  3. Iatrogenic- due to med. procedure
103
Q

Spontaneous pneumothorax

A

Primary
-No underlying lung disease (blebs in 80%)
-Young patients 20’s: rapid growth spirts, not all required cx tube, tall thin males
Secondary
-Underlying lung disease, COPD/CF/Asthma

chest pain is seen in nearly every patient with a pneumo. Palpation of the chest wall does not worsen the pain

104
Q

Traumatic Pneumothorax

A 
Penetrating
- gunshot, knife puncture, auto or industrial accident
-Pleural space is in direct contact with atmosphere
Blunt 
-bat, airbag
-rib fracture, non piercing chest trauma
-Piercing into lung parenchyma
-alveolar rupture
105
Q

Tension Pneumothorax

A
  • Occurs when air pressure in pleural space is greater than atmospheric pressure
  • lung depressed toward mediastinum
106
Q

50% are diagnosed at bedside, clinical sings of tension pneumo are:

A
  1. Diminished BS on effected
  2. Hyper-resonance to percussion (tap)
  3. Tachycardia
  4. Hypotension
107
Q

Chest tube catheter size

A

Adult: 36-40 fr
Teens/ small adults: 28-32 fr
Children/ infants: 12-18 fr

For pneumothoraces size 16-20 may be used for adults

108
Q

Pleurodesis

A

Fuse visceral and periodal pleura- tx chronic pleural effusions

109
Q

Decortication

A

scrape out lung infection

110
Q

Chest tube placement

A 
Draining air (pneumothorax)
-2nd or 3rd intercostal space midclavicular or midaxilary line
Draining fluid 
-4th through 6th, away from diaphragm
hemo-towards front
-all chest tubes
111
Q

Pleural effusion vs. Pulmonary edema

A

Effusion-surrounding lung pushing up lung

Edema- In lung, from heart (L), in pulmonary sacs/ alveolar space

112
Q

Tx ARDS on mech vent

A

Use high peep and low FiO2 or Low PEEP and High FiO2

113
Q

Three bottle concept, chest tube

A

A. Suction control- attached to suction, filled 20cmH2O which draws in RA, and controls suction
B/C. Waterseal: set to -2cmH20, air cant return, see’s bubbles during pneumothorax
D. Collection Chamber: pneumo=dry, otherwise pulls in pleural fluid

114
Q

Desired suction applied to pleura space

A

-10 to -20cmH2O

115
Q

Intrapleural pressures

A

-8cmH2O

116
Q

Resting pressures

A

-4 cmH2O

117
Q

Ejection Fraction

A

Percent of the end diastolic vol that is rejected with each beat
Norm 50-70
?measure directly echo

118
Q

EDV

A

amount of blood in the ventricle at the end of filling
Measure indirectly with end diastolic pressure
Norm 120-180

119
Q

ESV

A

Norm 50-60ml

Amount of blood in ventricle at the end of emptying

120
Q

Ventricular Volume

A

End systolic volume and EDV

121
Q

Stroke Volume

A

Measure by echo or indirectly
Amount of blood ejected by left ventricle with each contraction
Norm 60-130
Composed of.. preload, contractility, afterloadMeasure by echo or indirectly
Amount of blood ejected by left ventricle with each contraction
Norm 60-130
Composed of.. preload, contractility, afterload

122
Q

Venous Return

A

All the blood coming back to heart
Venous system holds 64% of total blood vol for emergencies
10 in arteries
75 in pulmonary capillary bed

123
Q

Body surface area

A

Calc using pts weight and height
Found on monogram
Norm2.5-4.0
Universal

124
Q

Cardiac index

A

Varies with body size

CI= CO/ BsA

125
Q

Why do we worry about left side of heart

A

Provides blood flow/ pulse to body
Satisfies the bodies o2 demand
Removes waste
Transports hormones and nutrients

126
Q

Normal systemic BP, pulmonary, MAP

A 
Systemic= 120/80
Pulmonary= 25/8
MAP= sBP + (2xdBP) / 3, keep above 60
127
Q

Transition

A

Tricuspid valve closes (lub) when the ventricular pressure exceeds that of the attia

128
Q

Atrial Contraction

A

Sa mode causes atrial contraction filling the ventricles another 10-30% ( increases the volume of blood into the ventricles)

129
Q

Blood flow [right side of heart]: diastole

A

Blow flows into the atria and ventricle [85% of blood in the heart is received)

  • tricuspid valve remains open
  • ventricle is in a relaxed state (pressure below that of vena cava)
130
Q

Hemodynamic medications

A

Inotropes: Contraction
Chronotropes: Time, increase or decrease HR
-ex atropine: increase HR, Beta blockers Decrease HR
Dromotropic Effect: conduction
-Speed of conduction, Amiodorone

131
Q

Systolic heart failure

A

Heart muscle isnt strong enough to pump blood

132
Q

Diastolic heart failure

A

Heart cant relax

133
Q

Most common cause of an increase in PCWP is

A

left heart failure

134
Q

Placement of PA catheter

A

When it reaches the superior vena cava or the rt atrium the balloon is inflated

  • waveforms change as it advances into the pulmonary artery
  • Eventually a wedge pressure will be obtained
135
Q

Critical conditions where PA catheters are considered

A
  • Severe cardiogenic pulmonary edema, unstable angina, ventricular pathology
  • ARDS pts who are hemodynamically unstable
  • Major coronary bypass surgery with MI and poor ventricular function
  • Pts with cardiogenic (fix pump) or septic shock (fix underlying cause)
136
Q

Risks of Swan-Ganz catheter

A
  • Invasion of the catheter may cause dysrhythmias
  • Chance of pulmonary infarction with balloon occlusion
  • Air embolism
137
Q

Who gets swan ganz catheter

A
  • Benefits outweigh the risks
  • Recent studies (20years worth) suggest no significant change in improvement or mortality of pts
  • must be individualized
138
Q

Risk with balloon inflation

A

Pulmonary Infarction

139
Q

what can the swan ganz/ PA catheter do

A
  • Pace heart: temp internal pacing
  • Measure CO
  • Measure PCWP
  • Measure CVP
  • Measure PA

=While placing swan: Possible disrythmias

140
Q

Respiration and CVP

A
  • CVP decreases with inspiration (neg pressure)
  • CVP increases with positive pressure vent
  • CVP increases with PEEP
  • Respiratory factors skew CVP readings
  • CVP are used to trend
141
Q

Decrease in CVP

A
  1. Decreased venous return
  2. Decreased intra-thoracic pressure
  3. Increased ability of the heart to move blood forward
142
Q

Increase in CVP

A
  1. Increased venous return
  2. Increased Intra-thoracic pressure
  3. Decreased ability of the right heart to move blood
143
Q

CVP Measures, and reflects

A

right heart function and reflects:

  • Preload and end diastolic filling pressure
  • Ability of the right heart to pump blood into the pulmonary system into the left side of the heart
144
Q

PICC is less likely for

A

pneumothorax

145
Q

Types of Centrally located catheter lines: Central Venous lines

A

PICC (pick)-ICU pts
Porta Catheter-Chemo pts
Swan-Ganz- Cardiogenic shock pts
Tunneled catheter- Long term use

146
Q

Complications from arterial line

A

-Ischemia: Embolism, thrombus, arterial spasm
Prevented by irrigating with diluted heparin solution
-Hemorrhage: if arterial line becomes disconnected
-Infection: incidence increases over time

147
Q

Arterial line inserts

A 
only catheter going against stream
1. Radial (most common): easy access
2. Brachial
3. Femoral
RISK CAN BLEED OUT EVERY BEAT

Adult Critical Care (5 decks)

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