Intensive care cases and concepts Flashcards
if HCO3 changes first
either metabolic acidosis or alkalosis
if PCO2 changes first
either respiratory acidosis (elevated PCO2)
or respiratory alkalosis (reduced PCO2)
ventilator failure
high CO2
- acute: drug over dose, asthma, stroke
- chronic: emphysema, neuromuscular
oxygenations failure
Low O2
- acute: pneumonia, PE
- chronic: emphysema, fibrosis
- polycythemia
- clubbing
- pulmonary HTN
airway failure
cannot protect
-alerted mental status, NM weakness
NIPPV
CPAP
BiPAP
CPAP
continuous positive airway pressure
- pressure applied during inspiration and expiration at the same time
- sleep apnea patients
BiPAP
- bilevel positive airway pressure
- gives inspiratory pressure and expiratory
- inspiratory pressure augments patients own tidal volume this improving ventilation (blowing off CO2)
contraindications of NIPPV
- altered mental status: no gag reflex
- facial deformity or trauma
- stridor or burns or obstruction of airway
- cardiac or respiratory arrest
- unable to clear sputum
- recent thoracic surgery
- severe multilobar pneumonia
ARDS symptoms
tachypnea dyspnea retraction hypoxia tachycardia crackles
causes of ARDS
- massive trauma
- severe respiratory disorder
- prolonged mechanical ventilation (white lungs)
- hemorrhagic shock
- fat emboli
- septic condition
ABG’s of ARDS
- decreased PCO2
- increased dyspnea
- white lungs
SIRS criteria
temperature >38.3 or 20 or PCO2 32mmHg
WBC >12,000, 10% bands
sepsis criteria
SIRS + source of infection
severe sepsis criteria
sepsis + organ dysfunction/hypoperfusion
-moltted skin, delayed capillary refill, UOP 2 mmol/L, altered mentation, coagulopathy/DIC, ARDS
septic shock criteria
severe sepsis + persistent hypotension after adequate fluid challenge (40-60 ml/kg)
MODS criteria
Multiple organ dysfunction
-progressive mutliorgan dysfunction/failure in setting of septic shock
what antibiotics to give with S. pneumoniae, legionella, H. influenza, GNR’s, S. aureus, M. pneumonia, respiratory viruses (IVa)
beta-lactam plus macrolide
or
fluoroquinolone
IVa organisms, P. aerugenosa, what antboitics to give
antipseudamonal beta-lactam PLUS
aminoglycoside AND macrolide or fluoroquiolone or fluoroquinolone
what antibiotics for IVa organisms, P. aerugenosa and CA-MRSA
antipseudamonal beta-lactam PLUS
aminoglycoside AND macrolide or fluoroquiolone or fluoroquinolone
PLUS vancomycin
shock states
CHF septic neurogenic anaphylactic hypovolemic
CHF vitals
decreased CO
increased TPR
increased PCWP
-treat: diuresis, dobutamine
septic vitals
increased CO
decreased TPR
decreased PCWP
-treat fluids, NE
neurogenic
decreased CO, TPR, PCWP
-treat dopamine
anaphylactic vitals
increased CO
decreased TPR, PCWP
-Epinephrine
Hypovolemic vitals
decreased CO
increased TPR, PCWP
-treat: fluids, NE
oxygen content in blood
Oxygen on HgB+ Oxygen plasma
1.34 x [HgB] x SaO2)+ (.0031 x PaO2
oxygen delivery
CO X Oxygen content
-Q X CaO
clinical exam signs of malperfusion
-altered mental status
-urine output
capillary refill
skin mottling
heart rate
blood pressure
5 targets for goals of perfusion
-urine output .5 ml/kg/hr
-mean arterial pressure
lactate
central venous oxygen saturation
central venous pressure
if have a patient that is intubated, and hypotensive s/p fluid challenge
-maybe want to do an IJ
D-dimer
degradation product of cross linked fibrin
-very sensitive test
ELISA test for D-dime
sensitive
long turn around time
Latex agglutination test for D-dimer
more rapid
less sensitive
CXR in PE
- 40% have normal CXR
- elevation of ipsilateral hemidiaphragm
- platelike atelectasis
- westermark sign (no blood flow)
- enlarged proximal PA
- Cor pulmonale (dilatation of right heart)
- hamptoms hump (b/c of infarct)
- pleural effusion
ECG findings for PE
-sinus tachycardia
-P. pulmonae
RBBB
right axis deviation
S1Q3T3
PE presents with
respiratory alkalosis with hypoxemia
work-up for suspected PE with renal insufficency
D-dimer and clinical assessment
venous ultrasound
V/Q scan (if ultrasound negative)
if V/Q negative: serial ultrasound
treatment of PE
heparin
LMWH: with malignancy, warfarin better
fondaparinux: factor Xa inhibitor, subcut.
direct thrombin inhibitors (argatroban): allergic to herpain
warfarin
new oral factor Xa inhibitors
IVC filter: if unable to anticoagulate
