Final Review Flashcards
What Temperature Should the Pt be Before the Apnea Test Begins
>34
Confirmation of the Apnea Test
ALL of the following must be present
- pH >/= 7.28
- PaCO2 >=60 mmHg and a 20 mmHg change from baseline
- No spontaneous efforts noted
The Apnea Test Should Be Discontinued If
Spontaneous respiration noted
SpO2 <90% OR PaO2 <60 mmHg
Significant hypotension refractory to vasopressors
MAP < 60 and Systolic <90 mmHg
What is the Purpose of the First ABG You Draw for the Apnea Test
To Make sure that the pt has a normal and stable ABG after you preoxygenate them
Neurological Determination of Death
Testing for brain function from a known irreversible cause
Ex, Apnea test
Code 66 Breathing Criteria
<8 or >35
SpO2 <90% on 5 L/min O2
Code 66 Criteria
Other
Urine Output <50
Worried about the pt
Code 66 Criteria
Circultaion
HR <40 or >140
Systolic <90 or >200
Acute change in systolic pressure
Categorization of Code 66 Calls
Will be categorized with 10 min of arrival and may change over the course of the call
Categorization of Calls
Level 1 Call
The Intensivist is needed to come and help
The team not the MRHP will make this call
Code 66 Calling Criteria
Airway
Threatened airway – e.g. Stridor, gasping for air
Code 66
Level 3 Calls
The MRHP will alway need to be informed that a code 66 was called and have them sign off on the call
The reason for this is in the case of “silent decompensation”, the patient is the MRHPs responsibility and they should be assessing their patient.
Criteria for Code 66
Neurological
GCS <8 or Decreased by 2
Sudden and Prolonged Seizures
The Outreach Team should consider notifying the Intensivist/delegate when:
A higher level of intervention and/or adminssion to ICU is needed
Unsure of what to do and pt not responding to therapies
Difficult to communicate with attending staff
Non-invasive ventilation (NIV) is required
Cardiac or respiratory crisis is imminent
A call has lasted more than 1 hour with no apparent resolution
3 or more calls for the same patient
MRHP Expectations According to Category of the Call
Level 1 – Provide immediate direction of care for the patient in collaboration with the Outreach Team and provide handover to the Intensivist/delegate if/when necessary.
Level 2 - Provide immediate direction of care for the patient in collaboration with the Outreach Team
Level 3 – May/may not involve direction of care, however, will be notified of the call.
What are the Initial Steps when the Call is Categorized as a Code 1
Immediately contact the Intensivist/delegate
If direct contact cannot be made within 5 minutes of this categorization, a Code Blue may be called
GCS-Motor Response
Score of 6-Obey Commands
Score of 5-Localized Pain: Will use other appendage to stop the painful stimulus and is higher level response as opposed to withdrawal
Score of 4-Withdrawal: Attempt to pull away from painful stimuli
Score of 3-Abnormal Flexion: Arms come up and curl and toes will curl over tends to be bilateral
Score of 2-Abnormal Extension: Arms extend and tends to be a bilateral extension
Score of 1-Flaccid: No response completely limp
GCS-Verbal Response
Score of 5-Oriented
Score of 4-Confused
Score of 3-Inappropriate Words
Score of 2-Inappropriate Sounds
Score of 1-No Response
Poorly suited for patients with impaired verbal response (e.g., aphasia, hearing loss, tracheal intubation)
If intubated put a “T” after the level (e.g. 5 T) because it will affect their score as they cant score higher than 1)
GCS-Eye Opening Response
Score of 4-Spontaneously
Score of 3-To Speech
Score of 2-To Pain
Score of 1-None
Head Bobbing
Chin up and neck extended on inspiration
Chin falling during expiration
=Respiratory Failure
Seesaw Respiration
Seesaw respiration indicted by chest retractions and abdomen expanding during inspiration
Oxygen Therapy and Cardiac Anomalities
These babies may be dependant on intracardiac shunts and increased saturation will promote the constriction of these shunts
Hyperoxia can increase aortic pressure and systemic vascular resistance decreasing the cardiac index and O2 transport in children with acyanotic congenital heart disease
Nebulizer Treatment
If more than one tx is needed it is common to give 3 onsective treatments
If a patient continues to be symptomatic continuous bronchodilators therapy may be delvered with a nebulizer attached to an infusion pump set to administer a bronchodilator continuously
What is the BORG Scale
Exertional scale for Dyspnea and Respiratory Distress
Transfer to Hospice
Patient feels/is unsafe at home
Steep rapid decline over 2 weeks
Gradual decline but increasing care needs with family exhaustion
Death expected within 3 months
Hospice Care
When remaining at home is no longer possible, and a hospital admission is no longer required
24 hr palliative care
Family are included as part of the team “ to whatever extent they are comfortable”
No daily accommodation fee
Oxygen is provided (some costs covered by AADL)
Pharmacy-Alberta Blue Cross Palliative Coverage Program (30% of the cost to a max of $25 per prescription. Lifetime maximum an individual will pay is $1000)
End of Life Care in COPD
Pt Profile
Very Severe Airflow obstruction (FEV1 <0.30 % Predicted) and hyperinflation
Poor functional status
Poor nutritional status
Older age
Recurrent AECOPD
Pulmonary Hypertension
MRC Dypnea Scale
Grade 0: Only get breathless with strenous activity
Grade 1: I get short of breath when hurrying on level grounf or walking up a slight hill
Grade 2: On level ground I walk slower becuase of breathlessness or have to stop for breath
Grade 3: I stop for breath after walking about 100 yeard or after a few minutes on level ground
Grade 4: I am too breathless to leave the house
Sudden Changes in COPD in EOL
SOB with any activity (eating, talking etc.)
Cachectic, very frail
Bilateral ankle edema
Sleeping much of the day
SpO2 becoming refractory to increasing oxygen
Sudden Changes in ALS/NM in EOL
Swallowing
Nausea/vomiting
Discomfort / transferring
Communication
Constipation
Anxiety
Breathing (dyspnea)
Infection
Restlessness
Medications for Dyspnea
Opioids e.g. morphine, fentanyl, other
Lorazepam (Ativan)
Midazolam (Versed)
Medications for a Cough
Opioids e.g. codeine, morphine
Medications for Retained Scretions
Anticholinergics e.g. glycopyrolate, scopolamine, atropine
Acetylcycsteine (mucomyst)
Dyspnea and O2 saturation in EOL
No correlation between dyspnea and hypoxemia in chronic diseases
Asses for dyspnea on using intervention other than O2 to mange SOB
O2 when already in use should be titrated carefully to manage dyspnea and not necessarily the O2 saturation.
Pallitaive Sedation
Medication to induce and maintain deep sleep
Purpose is to relieve symptoms when all other interventions are:
- inadequate of providing relief OR
- Associated with intolerable side effects OR
- Cannot provide relief in an acceptable time frame
AND
When the patient is expected to die imminently
Pallitaive Sedation Versus MAID
Goal
Goal
- PS: Decreased suffering
- MAID: Decrease suffering
Pallitaive Sedation Versus MAID
Timeline
Palliative Sedation: Unpredictable
MAID: Immediate
Pallitaive Sedation Versus MAID
Immediate Outcome
Palliative Sedation: Decreased level of consicouness
MAID: Death
Pallitaive Sedation Versus MAID
Process
Palliative Sedation: Administration of sedation drugs, titrated to effect
MAID: Administration of a lethal dose of drugs
Pallitaive Sedation Versus MAID
Intent
Palliative Sedation: To Sedate
MAID: To Euthanize
