kettering patient assessment Flashcards
K: key principles for ethics
- autonomy
- veracity
- nonmaleficence
- beneficence
- confidentiality
- justice
- role duty
K: What does the priniciple of “justice” in health care ethics stand for?
the fair distribution of health care
K: What does the principle of “role duty” in health care ethics stand for?
that practitioners understand the limits of their role, their scope of practice, and practice within those limits
K: What is the respiratory quotient?
the ratio of CO2 production to oxygen consumption:
VCO2/VO2
K: What is the normal range of the respiratory quotient?
0.67-1.3
K: What controllable patient factor influences the respiratory quotient?
the type of food metabolized
K: What is the respiratory quotient of carbohydrates?
1
K: What is the respiratory quotient of fats?
0.71
K: What is the respiratory quotient of proteins?
0.82
What lab abnormalities could be manifested by adrenal insufficiency?
- hyponatremia
- hyperkalemia
- hypercalcemia (rare)
- azotemia
- anemia
- eosinophilia
(UTD, accessed 20200907)
K: What is azotemia?
an excess of urea or other nitrogenous wastes in the blood as a result of kidney insufficiency
K: Name some clinical manifestations of acute adrenal insufficiency.
- hypotension refractory to fluids or pressors (UpToDate: characterized predominantly by shock d/t collapse of peripheral venous tone)
- weakness
- nausea and vomiting
- abdominal pain (“acute abdomen” UTD)
- tachycardia
- orthostatic hypotension
- fever (unexplained)
what conditions can generate a diabetic emergency?
a relative or absolute lack of insulin plus increased production of-- * glucagon * catecholamines * cortisol * epinephrine
name the diabetic emergencies
DKA
hyperglycemic hyperosmolar state
what are the common clinical manifestations of hyperglycemic hyperosmolar state?
- -Symptom onset progressive over several days
- -Dehydration (decreased skin turgor, dry axillae and mucosal membranes, tachycardia, low JVP, hypotension)
- -Polyuria
- -Polydipsia
- -Weight loss
- -then neurological symptoms as serum osmolality rises above 320-330 mosm/L–lethargy, focal signs (hemiparesis, hemianopia, seizures), obtundation, coma (UTD, accessed 20201106)
what are common clinical manifestations of DKA?
- -Symptoms onset rapid over 24 hours
- -Dehydration (decreased skin turgor, dry axillae and mucosal membranes, tachycardia, low JVP, hypotension)
- -Abdominal pain (associated with acidosis), nausea, vomiting
- -Kussmaul’s breathing
- -Odor of acetone on the breath
- -Neurological symptoms possible–due to acidosis rather than to hyperosmolar state (UTD, accessed 20201106)
hyperglycemic hyperosmolar state can present with (K short version)—
altered mental status
arrhythmias
who gets hyperglycemia?
diabetics
critically ill patients–diabetic or not
when should insulin therapy be initiated for critically ill patients?
persistent hyperglycemia >180 mg/dL
what glucose level should be targeted in critically ill patients?
140-180 mg/dL
what can give you an inverted t-wave?
ischemia
digitalis toxicity
hypokalemia
what ekg changes might accompany ischemia?
depressed T wave
inverted T wave
what ekg change accompanies cardiac injury?
elevated S-T segment
what ekg change signifies infarction?
significant Q waves
what changes to the Q wave are significant for infarction?
Q waves 1/2 the height of the R wave or Q waves 1 small square wide (0.04 mm) are significant.
classic ekg sign of hyperkalemia
spiked T waves
the three I’s of heart problems, each with definition
ischemia–reduced blood flow to the tissue
injury–acute damage to tissue (often from ischemia)
infarction–necrosis of death of tissue–may be recent (acute) or old
what changes in the heart will skew the axis of electrical activity?
hypertrophy–drawing the axis toward its increased electrical activity
infarction–pushing axis away from its lack of electrical activity
what is the normal direction (axis) of cardiac electrical activity?
down and to the left
what does the “axis” of the ekg represent?
the direction of electrical activity
how do you treat 3d degree a/v heart block?
pacemaker
how do you treat 2d degree mobitz 2 a/v heart block?
atropine
transvenous pacing
how do you treat 2d degree mobitz 1 a/v heart block?
usually regarded as benign and not treated
how do you treat 1st degree a/v block?
atropine
how long a pr interval defines 1st degree heart block?
> 0.2 (from the beginning of the P wave to the beginning of the QRS)
which heart block is wenckebach?
2d degree mobitz 1
what factors shift the oxyhemoglobin dissociation curve to the left
decreased H+ (increased pH)
decreased PCO2
decreased temperature
decreased 2-3 DPG
what factors shift the oxyhemoglobin dissociation curve to the right?
increased H+ (decreased pH)
increased PCO2
increased temperature
increased 2-3 DPG
what does a right shift of the oxyhemoglobin dissociation curve signify?
a lower oxygen content for any given PO2
what does a left shift of the oxyhemoglobin dissociation curve signify?
a higher oxygen content for any given PO2
what is the axis of an ekg?
The net direction of all the electrical activity through the heart during contractility.
How is asystole confirmed on ekg?
If it is seen in at least two leads.
Name 3 conditions where abg will look good while the patient looks bad.
CO poisoning—because sat calculated from PaO2 will be blind to carboxyhemoglobin
Anemia—where good saturation belies reduced oxygen delivery
PE—no hyperventilation despite pt hyperpnea
Name nine conditions that raise flags for PE
Post-op patients Bedridden patients Venous stasis (sitting for long periods of time) Hx DVT Varicose veins A fib Women in advanced stages of pregnancy Obesity Trauma
Treatment for PE
Prevention—
Support ventilation
Prevent further emboli with anticoagulant therapy
How will the hypoxia of the anemic patient present?
- PVC, tachycardia, distress–
* But not necessarily cyanosis
Quantify the effect of declining PaCO2 on pH.
For every drop of 1 mmHg in PaCO2 expect a rise in pH of 0.01—so every drop of 10 expect a rise of 0.1.
Quantify the effect on pH of rising PaCO2.
For every rise of 1 mmHg, expect a drop of 0.006 in pH—for every rise of 10, expect drop of 0.06
Calculate expected pH in hypercarbia.
Expected pH = 7.4 — (PaCO2 - 40) 0.006
Calculate expected pH in hypocarbia.
Expected pH = 7.4 + (40 mmHg - PaCO2) 0.01
normal pressure in left ventricle
120/0 mmHg
normal pressure systemic arteries
120/80 mmHg
normal map systemic arteries
90 mmHg
normal map in entry to capillaries
30 mmHg
normal map in capillaries
20 mmHg
normal map systemic veins
10 mmHg
normal map right atrium
2-6 mmHg
normal pressure right ventricle
25/0 mmHg
normal pressure pulmonary artery
25/8 mmHg
mean pressure pulmonary artery
14 mmHg
normal mean pressure pulmonary capillaries
8-10 mmHg
normal cardiac output in adults
4-8 L/min.
normal cardiac index
2.5-4 L/min./m2 (CARC)
which pulmonary wave form features the dicrotic notch?
the pulmonary artery wave form
what does the dicrotic notch in the pulmonary wave form register?
the closure of the pulmonic valve
you are monitoring for PAP and are having trouble tracking distinct high and low values. what do you troubleshoot?
ensure the catheter balloon is deflated
you are trying to monitor PAP and you are not seeing a distinct dicrotic notch. What do you troubleshoot?
The catheter is somehow obstructed—
blood clot,
bubble in catheter or transducer dome,
kinking in the tubing.
what actions correct problems from a blood clot in Swan-Ganz catheter?
aspirate
flush catheter
rotate the catheter
Elevated CVP
Low PAP
suggests what conditions?
right heart failure in the form of cor pulmonale or tricuspid valve stenosis
elevated PAP
elevated CVP
suggests what conditions?
lung disease—
pulmonary hypertension
ARDS
pulmonary embolism
elevated pcwp
low map
low QT
suggest what conditions?
left heart failure—
CHF/pulmonary edema
mitral valve stenosis
all hemodynamic values elevated suggests what condition?
hypervolemia
all hemodynamic values low suggests what condition?
hypovolemia
define pulse pressure
systolic pressure - diastolic pressure
normal value for pulse pressure
40 mmHg
what’s a TTE?
transthoracic echocardiogram (echocardiogram)
which proves better information—TTE or TEE?
TEE
What factors degrade quality of echocardiogram?
Air-trapping in COPD patients
Obesity
vascular uses of ultrasound
—evaluate patency of arteries and veins
—evaluate arteries for arterial insufficiency
—identify occlusions
—identify thrombosis (e.g. DVT)
—evaluate veins for swollen painful leg, varicosities, or edematous extremities
how does a pneumothorax appear on ultrasound?
with a highly echogenic reflective line that lacks the “gliding sign” associated with respiratory movement
How is thoracic ultrasound used for pulmonary examination?
To detect, characterize, and sample lesions located in the pleural space, the peripheral parenchyma, and the mediastinum
how does ultrasound assist thoracentesis?
allows visualization of needle and target during procedure
patient suspected of phrenic nerve paralysis should receive what noninvasive assessment?
thoracic ultrasound
what are the types of ileus?
mechanical/non-mechanical
or
obstructive/paralytic
Causes of obstructive ileus
volvulus (bowel turned on itself) hernias fecal impaction abnormal tissue growth foreign bodies
What is paralytic ileus?
Disruption of the propulsive ability of the GI tract
Name five common pathologies revealed on abdominal radiography.
trauma intestinal obstruction (e.g. SBO) soft tissue masses ascites peritoneal effusion
What feature on abdominal radiograph suggests SBO?
An abnormal accumulation of gas.
Name two common findings on normal abdominal radiograph .
Normal G.I. gas pattern
No calculi
What feature on abdominal radiograph suggests a ruptured viscus?
Free air outside bowel
What feature on abdominal radiograph suggests ascites?
ground glass over entire abdomen
General—five ways ultrasound can be used
—determine whether a lump or abnormality is a fluid-filled cyst or a solid tumor
—guide needle-directed biopsy
—stage a tumor
—evaluate pregnancy and placentals status
—evaluate disorders of arteries (aneurysm) and veins (DVT)
name five areas effectively evaluated through mri
—CNS —neck and back —bones —joints —breasts
name an area unsuitable for evaluation through mri
Abdominal evaluation
common complaint from patients with mri
Claustrophobia
How can claustrophobia be addressed in mri?
—sedation
—open mri
What advantage does mri imagery offer?
Greater contrast between normal and pathological tissue
What radiological descriptions corresponds with pulmonary edema?
Fluffy infiltrates
Butterfly/batwing pattern
What radiological descriptions correspond with atelectasis?
Patchy infiltrates—scattered densities
Plate-like infiltrates—thin-layered densities
What radiographic descriptions correspond with ARDS?
Ground-glass appearance (reticulogranular)
Honeycomb appearance (reticulonodular)
Diffuse bilateral radiopacity
An air bronchogram would accompany what condition?
Pneumonia
What condition would be indicated by a “deep sulcus sign” on CXR?
Pneumothorax
What is the normal size of the cardiac silhouette on CXR?
1/2 chest diameter
Where should the tip of a central venous catheter rest on CXR?
In the vena cava or right atrium
Where should the tip of an NG tube rest on CXR?
In stomach 2-5 cm below the diaphragm.
Where should pulmonary artery catheter rest on CXR?
In lower right lung field
Where should tip of pacemaker rest on CXR?
In the right atrium.
Where should tip of endotracheal tube rest on CXR?
2 cm or 1 inch above carina
At level of aortic knob
At level of aortic arch
Too high: level of the clavicle
Five conditions that could lead to loss of airway patency
Foreign body obstruction Edema as seen with allergic reactions Tracheal spasm Internal or external compression Trauma leading to air leak
What should be the size of the trachea in a normal CXR?
The same size as the vertebral column.
What are two primary uses of bubble echocardiography?
—evaluate for septal defects ASD and VSD
—evaluate problems in pulmonary arteries
Bubble echocardiography is done. Bubbles quickly travel through the heart. What is the pathology?
ASV, VSD
Bubble echocardiography is performed with the finding that bubbles are delayed in progress through the heart. What pathology is suggested?
Pulmonary arterial hypertension
Pulmonary AVM?
what happens to a patient getting a pet scan?
Patient is injected with a radioactive substance that is given time to distribute throughout the body. Then patient lies on a table and goes through a ring-like scanner. Scanning takes 15-120 minutes.
how does angiography work?
Invasive catheter is placed through femoral or brachial artery and advanced into desired artery. Radiopaque contrast dye is rapidly injected while x-ray films are obtained.
What kind of angiography is commonly used for GI bleed/hemorrhage?
Mesenteric angiography.
What kind of angiography is used for abdominal aortic aneurysms?
Gastrointestinal angiography.
Can a patient with a nicotine patch go through mri safely?
No—the foil in the patch can burn the patient.
Why the heck would you ever take an end-expiratory chest film?
To detect a small pneumothorax.
How might hyperinflation of an ETT cuff or tracheotomy cuff appear on x-ray?
Cuff extends beyond the end of the tube.
How to assess the major bronchi on chest film.
No narrowing of lumen at the carina or the distal end. The presence of narrowing suggests bronchogenic carcinoma.
Name features of normal chest film.
Both hemidiaphragms are rounded, dome-shaped.
The right hemidiaphragm is slightly higher than the left.
The right hemidiaphragm is st the level of the sixth anterior rib.
Trachea is midline.
Bilateral radiolucency.
Sharp costophrenic angles.
Head of the clavicles are level.
What term denotes immature neutrophil?
Band
What term denotes a mature neutrophil?
Segmented neutrophil
What normal percentage of WBCs are bands?
0%-6% (CARC)
What percentage of WBCs is normally mature neutrophils?
40%-75% (CARC)
What percentage of WBCs are normally basophils?
0%-1% (CARC)
What percentage of WBCs are normally eosinophils?
0%-6% (CARC)
What percentage of WBCs are normally lymphocytes?
20%-45% (CARC)
What percentage of WBCs are normally monocytes?
2%-10% (CARC)
Elevated bands suggests what?
Bacterial infection
Decreased neutrophils suggests what?
Bacterial infection
Inflammation (CARC)
Increased monocytes suggests what?
Tuberculosis
Chronic infections
Malignancies (CARC)
Decreased WBCs suggests what?
Viral infection
Term for elevated WBCs
Leukocytosis
White blood cells normal value
5,000-10,000 /mm3
If reported lab values doe not match the patient’s clinical condition, what should you consider?
- Was the sample obtained correctly?
- Was the sample processed promptly and correctly?
- Were the results reported verbally?
What test is the best indicator of renal function?
creatinine
creatinine normal value
0.7-1.3 mg/dL (kettering and CARC)
Elevated levels of creatinine indicate what?
renal failure
elevated levels of BUN indicate what?
possible renal failure
BUN normal value
7-20 mg/dL (kettering and CARC)
hemoximitry =
co-oximetry
What values does hemoximetry provide on top of oxyhemoglobin?
carboxyhemoglobin (COHb)
methemoglobin (MetHB)
COHb normal value
1-3%
Smokers may have COHb as high as
15%
how long does it take to get a gram stain?
10 minutes
what fluids can be analyzed with gram stain and C&S?
sputum blood urine stool pleural fluid
How long does it take to get back a C&S?
48-72 hours
What is the d-dimer of the famous d-dimer test?
a fibrin degradation products measurable in the blood after a clot has formed and is in the process of breaking down
what levels would define thrombocytosis?
> 1,000,000/mm3
what conditions may provoke thrombocytosis?
acute inflammatory reactions
splenectomy (trauma)
what levels define thrombocytopenia
< 50,000/mm3
what signs may accompany thrombocytopenia?
- -petechiae
- -ecchymoses
- -nose bleeds
- -bleeding gums
what lab values accompany thrombocytopenia?
PT and APTT are normal
bleeding time and platelet count are abnormal
what is target INR for warfarin therapy?
2-3
what is an INR?
the ratio of prothrombin time of patient sample to that of a normal (control) sample
use what tests to monitor warfarin therapy?
INR, prothrombin time
prothrombin time normal value
12-15 seconds
partial thromboplastin time normal value
24-32 seconds
what does an activated partial thromboplastin time measure?
the length of time required for plasma to form a fibrin clot
what test is used to monitor heparin therapy?
aPTT
if coagulation defect is suspected, how should platelets be evaluated?
- -for number
- -for size
- -for shape
platelet normal value
150,000-400,000
decreased platelets may arise in association with what problem?
decreased bone marrow function
what are uses for coagulation studies?
- -evaluate perioperative patients for bleeding risk
- -evaluate bleeding signs/symptoms
- -diagnose disseminated intravascular coagulation
- -monitor anticoagulation therapy
- -identify risk of deep vein thrombosis
serum glucose normal values
70-105mg/dL (CARC)
what are lactate levels are taken as a marker of?
overall oxygen delivery to the tissues
lactate normal levels
0.5-2.2 mmol/L
Where does BNP come from?
It is secreted by cardiac muscle when heart failure develops or worsens.
BNP normal values
< 100pg/mL
what troponin level indicates risk of death from MI?
> 0.5 ng/mL
Most common clinical manifestations of hypocalcemia.
Hypotension Bradycardia Arrhythmias Heart failure Cardiac arrest Digitalis insensitivity
Calcium normal range
4.5–5.25 mEq/L
What typically results in hypocalcemia?
Impairment of–
Parathyroid
Vitamin D systems
Magnesium normal range
1.7-2.4 mEq/L
What does magnesium off the body?
Energy transfer and electrical stability
Bicarbonate normal range
22-26 mEq/L
How much oxygen does hemoglobin carry?
1.34 mL/gram Hb
Formula for PVR
(MPAP — PCWP) / cardiac output
PVR normal values
< 2.5 mmHg/L/min
or
110-250 dynes/sec/cm-5
What value is a measure of right ventricular afterload?
PVR
Formula for SVR
(MAP — CVP) / cardiac output
SVR normal values
< 20 mmHg/L/min
or
900-1400 dynes/sec/cm-5
What is the formula for cardiac index?
cardiac output (QT)
/
body surface area (m2)
cardiac index normal values
2.5 - 4 L/min./m2
cardiac output normal values
4 - 8 L/min.
What method is used to estimate cardiac output?
Thermal dilution
Write out the Fick equation
QT = VO2 / C(a-v)O2 (10)
Formula for pulse pressure
systolic pressure - diastolic pressure
Pulse pressure normal value
40 mmHg
formula for mean arterial pressure
(diastolic pressure x 2) + systolic pressure
/
3
In arterial line, if the transducer is placed above the catheter, how are readings affected?
They are falsely low.
In arterial line, if the transducer is placed below the catheter, how are readings affected?
They are falsely high.
Three families of medication for vasodilation.
Direct vasodilators (nitroprusside, hydralazine)
Calcium channel blockers (nifedipine)
ACE inhibitors (lisinopril et al)
Name vasoconstrictors that matter to Kettering
Epinephrine
Phenylephrine
Dopamine
Dobutamine
Name the three basic factors that maintain blood pressure.
The pump
The fluid
The vessels
Systemic blood pressure normal values
Systolic = 120 mmHg
Diastolic = 80 mmHg
Mean = 93 mmHg
Name the most commonly used chronotrope.
Atropine
Name drugs that deliberately decrease heart rate.
Beta-blockers
Beta-antagonists
Atenolol, propranolol, labetalol
Drugs that increase contractility
Digitalis
Digoxin
Levosimendan
What is a normal p/f ratio?
> = 380
What percentage of cardiac output is normally shunted
3-5%
Formula for arterial oxygen content
CaO2 = (Hb x 1.34 x SaO2) + (PaO2 x 0.003)
Arterial oxygen content normal value
17-20 vol%
Mixed venous oxygen content
CvO2 = (Hb x 1.34 x SvO2) + (PvO2 x 0.003)
CvO2 normal values
12-16 vol%
A decrease in CvO2 suggests what?
A decrease in cardiac output.
Formula for arterial-venous content difference.
C(a-v)O2 = CaO2 - CvO2
What does the arterial-venous oxygen content difference measure?
The oxygen consumption of the tissues.
Arterial-venous oxygen content difference normal values.
4-6 vol% (CARC)
Alveolar air equation
PAO2 = (Pa - PH2O) FIO2 - PaCO2 / 0.8
Give ranges with interpretation for A-a gradient on 100% oxygen.
25-65 mmHg = normal range
66-300 mmHg = V/Q mismatch
> 300 mmHg = shunting
Under what conditions is A-a gradient best read?
After 100% O2 for >= 20 min.
Formula for dead space.
VD/VT = PaCO2 - PECO2 / PaCO2 x 100
What physiological phenomenon creates heart sounds?
The closure of the heart’s valves.
Kettering’s list of causes of stridor.
Species of upper airway obstruction:
Supraglottic swelling.
Subglottic swelling (post extubation.
Foreign body aspiration (solids or fluids).
Treatment options for stridor.
Topical decongestant (racemic epinephrine) for swelling and edema.
Suctioning and/or bronchoscopy for secretions and foreign body aspiration.
Intubation for marked or severe stridor.
Dead space to tidal bone normal ratio values
20-40%
Expect up to 60% for mechanically ventilated patients
Alveolar minute ventilation calculation
VA = (VT - VD) x f
Kettering value for anatomic dead space.
1 mL per lb IBW
What is physiologic dead space?
The sum of anatomic and alveolar dead space.
What is mechanical dead space?
The volume of circuit tubing between the patient and wye adapter in the ventilator circuit.
Kettering’s placement of etCO2 sensor.
At the ETT.
How does PETCO2 read relative to PaCO2?
Lower by 4-6 mmHg for normal reading.
PETCO2 normal values by Kettering.
34-36 mmHg.
How is etCO2 measured—that is, by what principle does the device work?
Infrared absorption.
In heart sounds, how is the S3 significant?
—low-pitched, difficult to discriminate
—abnormal
—May suggest CHF
In heart sounds, how is an S4 significant?
—abnormal
—low-pitched and difficult to discern
—suggests cardiac abnormality such as myocardial infarction or cardiomegaly
What creates heart sound S1?
Closure of the mitral and tricuspid valves at the beginning of ventricular contraction.
What creates heart sound S2?
The closure of the pulmonic and aortic valves at the end of systole.
Kettering associates pleural friction rub with:
Pleurisy TB PNA Pulmonary infarction Cancer “Etc.”
What, specifically, causes cyanosis?
An increase of >= 5 g of reduced hemoglobin.
What do we call drooping eyelids?
Ptosis.
What do we call pinpoint pupils?
Miosis.
What do we call blurred or double vision?
Diplopia.
What organ failure can lead to ascites?
Liver.
What causes peripheral edema?
CHF
Pulmonary hypertension
Venous insufficiency
Renal failure
Body temperature orally measured normal values.
36.5-37.5 degrees C
Body temperature measured rectally normal values.
37.1-38.1 degrees C
Body temperature measured by ear normal values.
37.1-38.1 degrees C
List some causes of fever.
A warm environment
Dehydration (no sweat)
Reactions to chemical substances
Drugs (medical as well as street—ecstasy)
Infection
Malignancies (lymphoma, leukemia, renal cell carcinoma, hepatocellular carcinoma it other tumors metastatic to the liver)
Connective tissue disease—rheumatic disorders
What common form of fainting & dizziness is caused by loss of peripheral venous tone?
vaso-vagal syncope
What is vaso-vagal syncope?
a common form of dizziness and fainting caused by loss of peripheral venous tone.
name four types of syncope
- Vasovagal syncope
- Orthostatic hypotension
- Carotid sinus syncope
- Tussive syncope
What is carotid sinus syncope?
associated with hypersensitive carotid sinus–more common in elderly patients
what is syncope?
loss of consciousness and postural tone caused by diminished cerebral blood flow
pain assessment
Onset of event
Provocation/Palliation
Quality of the pain
Region/Radiation
Severity
Time ("how long / has this been goin' on?")What responses are measured to quantify Glasgow Coma Score?
eye-opening response
most appropriate verbal response
most integrated motor response
what are the levels of eye-opening response measured in GCS?
1 = no response 2 = to pain 3 = to verbal stimuli 4 = spontaneous opening
what are the levels of verbal response measured in GCS?
1 = no response 2 = incoherent response 3 = inappropriate words 4 = confused 5 = oriented
what are the levels of motor response measured in GCS?
1 = no response 2 = extension to pain 3 = flexion to pain 4 = withdraws from pain 5 = localizes pain 6 = obeys commands
What is the old school interpretation of CVP in regard to fluid balance.
CVP < 2 mmHg = hypovolemia
CVP > 6 mmHg = hypervolemia
Urine output normal rate
Urine output is 40mL/hr
Approximately 1L/day
Four vital life functions
Ventilation
Oxygenation
Circulation
Perfusion
What is azotemia?
An excess of nitrogenous waste in the blood.
Synonym for azotemia.
Uremia.
So why the heck give the head injury patient pentobarbital?
It decreases cerebral metabolism and blood flow.
Name therapies to minimize cerebral oxygen requirements.
- Minimize stimulation
- Avoid or control fever and agitation
- Use high-dose barbiturates to decrease cerebral metabolism and blood flow
Describe 2nd degree AV block Mobitz 1.
The P-R interval becomes longer and longer until it skips a beat (no QRS responds to P wave).
Describe 2nd degree AV block Mobitz 2
The rhythm skips a beat–with no lengthening of the P-R interval leading up to the skipped beat.
VD/VT normal levels for healthy persons
25-40% (CARC)
Ejection fraction normal values
65%-75% (CARC) 55%-75% (Rob)
aPTT stands for what?
activated partial thromboplastin time
PT stands for what?
prothrombin time
What is the formula for cardiac perfusion pressure?
CPP = Diastolic BP - PCWP
Cardiac perfusion pressure normal values
60-80 mmHg
berlin definition of ards
Timing: within 1 week of a known clinical insult or new or worsening respiratory symptoms
Chest imagining: bilateral opacities: not fully explained by effusions, lobar/lung collapse, or nodules
Origin of edema: respiratory failure not fully explained by cardiac failure or fluid overload–need objective assessment (e.g., echocardiography) to exclude hydrostatic edema if no risk factor present
ardnet inclusion criteria
PaO2/FiO2 <= 300
Bilateral (patchy, diffuse, or homogeneous) infiltrates consistent with pulmonary edema
No clinical evidence of left atrial hypertension
ardsnet pdw formulae
males: 50 + 2.3 [height (inches) - 60]
females: 45.5 + 2.3 [height (inches) - 60]
ardsnet pt 1 vent setup and adjustment steps 1-6
1) calculate pbw (corrected for altitude)
2) select any ventilator mode
3) set vent setting to achieve initial Vt = 8mL/kg pbw
4) reduce Vt by 1mL/kg at intervals <= 2 hours until Vt = 6mL/kg pbw
5) set initial rate to approximate baseline Ve (not > 35 bpm)
6) adjust Vt and RR to achieve pH and plateau pressure goals
name initial ardsnet goals following entry of primary settings
oxygenation goal: PaO2 55-80 mmHg or Spo2 88-95%
plateau pressure goal: <= 30 mmHg (effectively, 25-30)
pH goal: 7.3-.45
I:E ratio goal: recommend that duration of inspiration be <= duration of expiration
how is plateau pressure measured under ardsnet protocol?
with a 0.5 second inspiratory pause
If patient falls below pH target of 7.3 (7.15-7.3), how does ardsnet protocol direct the adjustment of vent settings?
Increase RR until pH > 7.3
or
PaCO2 < 25 mmHg
(max set RR = 35)
If patient pH falls below 7.15, how does ardsnet protocol direct management?
Increase RR to 35
If pH remains < 7.15, may increase Vt 1 mL/kg steps until pH > 7.15, even if Pplat exceeds 30
May give bicarb
What are ARDSNET criteria for SBT?
1) FiO2 <= 0.4 and PEEP <= 8 OR FiO2 <= 0.5 and PEEP <= 5.
2) PEEP and FiO2 <= values of previous day
3) Patient has acceptable spontaneous breathing efforts. (May decrease vent rate by 50% for 5 minutes to detect effort.)
4) Systoic BP >= 90 mmHg without vasopressor support.
5) No neuromuscular blocking agents or blockage.
What is prothrombin time used to monitor?
- Warfarin therapy
- Liver damage
- Vitamin K status
Name and describe the three, yes, three types of posturing according to Wikipedia.
- Decorticate: arms flexed or bent inward on the chest, hands clenched into fists, legs extended and feet turned inward
- Decerebrate: extension of upper extremities in response to external stimuli; extended elbows; legs extended and rotated internally; rigidity; teeth clenched
- Opisthotonus: head and back arched backward (accessed 20201229)
Says Wikipedia, what pathology may decorticate posturing indicate?
- May indicate damage to cerebral hemispheres, internal capsule, thalamus
- May indicate damage to midbrain
- Usually indicates more severe damage to rubrospinal tract and hence the red nucleus is also involved–indicating a lesion lower in the brainstem (accessed 20201229)
Says Wikipedia, what pathology may decerebrate posturing indicate?
- -May indicate brain stem damage, specifically damage below the level of the red nucleus
- -May indicate pontine strokes (accessed 20201229)
Per Wikipedia, the progression from decorticate to decerebrate posturing often accompanies what pathology?
Uncal or tonsilar brain herniation. (accessed 20201229)
Normal Cstat per Cairo 6th edition
70-100 mL/cmH2O
Normal Raw range per Cairo 6th edition
0.6-2.4 cmH2O
