LAST CHANCE! Flashcards
normal base deficit/excess
-2 to 2
normal PaO2
80-100
what does pH represent?
pH is an inverse log of hydrogen ions
-% of hydrogen ions
what does CO2 indicate
acid
Co2 over 45
acidotic
apnea
hypotentilaton
Co2 under 35
hyperventilation
replacement formula for bicarbonate
0.1 x (-BE) x weight in kg = needd bicarb
base deficit pver-4
need blood transfusions
what happens in left shift?
LOW
HIGH affinity
relationship between O2 dissociation shifts and affinity for oxygen
opposite
left = low data= high affinity
right = high data = low affinity
relationships in O2 dissociation curve
left = high affinity, LOW values
H, temp, 2,3-DPG, PCO2
O2 shift if lot of CO2 is retained
CO2 is an acid so it makes the ABG more acidotic and moves left
O2 shift if lots of bicarbonate
bicarbonate is a base so more alkalotic and moves right
how to tell if it is compensated
the compensation mechanism is opposite of hte primary problem
r. acidosis is compensated by bicarb
partial compensation
pH outside of normal, values
both reps and metabolic are outside of normal values
fully compensated
pH normal|
both bicarb and cow are not normal
is it respiratory of acidotic?
if co2 folows pH = respiratory
if bicarbonate follows pH = metabolic
acid-base balance if Diamox
m. alkalosis
acid-base balance if steroids
m. alkalosis
criteria for lactic acidossi
lactate over 4
acid-base in seizures
m. acidosis
acid-base in rhabdomyolysism
acidosis
acid-base if breathing too fast
r. alkalosis.
intervedntion if on m. vent and breathing too fast
r. alkalosis
1. Vt
2. F
acid-base if hypermetabolic state
r. alkalosis
acid-base if pregnant
r. alkalosis
acid-base if high altitude
r. alkalosis
acid-base if pain
r. alkalosis
acid-base if anxiety attack
r. alkalosis
what happens in ASA poisniong
it is a respiratory center stimulant
can’t remove CO2
breathing slowly/hyperventilation is r. acksosis
acid-base in CNS depression
r. acisosis
acid-base irf lung or chest injury
r. acidosis
intervente r. acidosis
breathing too slow. so buildup CO2. so increase RR
acid-base in asthma
r. acidosis
acid-base in COPD
r. acidosis
every __ ETCO2
pH changes __
in ___ direction
every 10 mm ETCO2
pH changes 0.08
in opposite direction
10
0.08
__ direction
ETCO2
pH
oppsite
every __ pH
bicrab __
in __ direction
0.15 pH
10 bicarb
same direction
0.15
10
in __ direction
pH, bicarb, same
every __ pH
K shifts __
in __ direction
0.1
0.6
opposite
0.1
.6
__ direction
pH, K, opposite
every __ CO2
__ changes
__ direction
0.1 pH
K 0.5 shifts
same
0.1
0.5
__ direction
CO2, K, same
relationship between pH and K
as pH falls, K shifts outside the cell to make the K look false high
- when shifting imbalance by raising pH, K shifts intracellulary leaving life-threatening low K
shifts involving K
every 0.1 pH, shifts 0.5 in the same direction
every CO2 0.1m J sgufts 0.5 same
shifts involving pH
0.15 pH, bicarb 10 same direction
10 ETCO2, 0.08 opposite direction
ABG to intubate
only one off!
pH under 7.2
CO2 over 55
pAo2 under 60
LEMON
look
evaluate 3-3-2
mallampati
obstructions
neck mobnility
practice finger positions for the “E” of LEMON
mneumonic for the “E” of LEMON
3 fingers in mouth
3 fingers between jaw an dhyoid
2 fingers between hyoid and thyroid
predictor for diffiuclt airway
LEMON
HEAVEN - emergency difficult airway predictor
Mallampati II
tonsilar pillars are hidden by tongue
Mallampati III
only base of uvula can be seen
Mallampati IV
can’t see uvula
can’t see uvula
mallampati IV
only can see the base of the uvula
Mallampati III
can’t see the tonsilarpillars
Mallampati II
HEAVEN criteria
for difficult airway prediction in emergency
Hypoxemia under 93%
extremes of size (under 8,, obesity)
anatomic challenges
vomit/bood/fluid
exsanguination/anemia
neck mobility
blood concern that make an emergency intubation difficult
HEAVEN
= blood in oral cavity
- suspected anemia can potentially accelerate the rate of decompensation during RSI apneic period
ramping
ear to sternal notch
problems of supine transport/intubation
low runctional reserve capacity, Vt, preload
lifts epiglottis via vallecula
McIntosh blade
Macintosh blade
lifts the epiglottis via the vallecula
directly dispacement epiglottis
miller blade
miller blade
direct displacement of epiglottis
preferred intubation blade for pediatrics
miller
size bougie
adults 15 Fr
pediatic 10 Fr
inflate ETT cuff
20-30 mm hg
only use the amount you need to create a good seal
CXR confirms ETT
distal tip 4-5 cm above carina
level of T3-T4 (visualizing Murphy’s eye where the clavicle meets)
ETCO2 waveform
7 P’s for success
preparation
preoxygenate
pretreatment
paralysis with induction
protect and position
placement with proof
post intubation management
the D of LOAD
RSI pretreatment
- desfasiculating dose: 1/10 roc or vec
purpose of lidocaine as a RSI pretreatment
blunts the cough reflex preventing ICP
purpose of atripoine as RSI pretratmetn
prevents reflexive bradycardia in udner 1 yo
caution if use fentanyl for RSI
caution if low bp
chest wall rigidity
DO NOT use etomidate for RSI
adrenal suppression
shock
septic shock
COPD
asthma
DO NOT use as induction if shock
etomidate
side effect of the reversal agent for benzos
flumazenil 0.2 mg adversely affectsw bp
description of propofol
hypnotic with no analgesic properties
good induction agent for shocky patients
ketamine
contraindication for propofol
head injury b/c decreases CPP and MAP
not for hemodynamically unstable
not a good induction agent if head injury
propofol b/c decreases CPP and map
not a good induction agent if hemodynamically unstable
propofol
versed -bp
description of propofol
hypnotic without analgestic properties
electproblem of Succ
high K
burns where you shouldn’t use succ
over 24 hrs
contraindications to succinycholine - 7
crush
eye
narrow-angle glaucoma
malignant hyperthermia
burns over 24 hours
high K
nervous system disorder
problem of malignant hyperthermia
defect in the skeletal muscle sarcoplasmic reticulum
can’t remove Ca form teh cell
reverse Roc
sugammadex 16mg/kg
use sugammadex
reverse Roc
changes to make to RSI dosing if hemodynamically unstable
1/2 inducton dose (less needed b/c depleated catecholamine stores)
double paralytic ( low CO means slow onset of action)
SALAD tercnique
suction assisted laryngoscopy airway decontaminatin
-suction, once the airway is clear, place suction tube in esophagus while pass tube
post intubatin rx
fentanyl, ketamine, versed
Pediatic cric guidelines
surgical if over 8
needle if under 8
Fick’s Law of Diffusion
gases travel from high to low concentrations
gases travel from low to high concentration
Fick’s Law of Diffusion
apneuristic breathing
decerebrate posturing
deep gasiping inspiration with pause at full inspiration then breief insufficient release
deep gasping inspiration with a pause at full inspiration followed by a brief insufficient release
apneuristic
ataxic
complete irregular breathing with irregulart pauses and increasing periods of apnea
irregular breathing, pasues, and apnea
ataxic
BIots
shallow inspiration with apnea
shallow inspiration iwth apnea
Biots
brainstem heriniation breathign patern
cheyne-stokes
DKA breathing
Kussmaul
deep rapid and gasping breathign
Kussmaul
Kussmaul breathing
deep rapid and gasping breathing
Cheyne-Stokes breathign
progressively depeer and faster then decrease and apnea
treatment for hypoxic respiratory failure
FiO2 & PEEP
treatmetn for hypercarbic respiratory failure
increase pPlat then increase rate
double minute ventilation
Vt setting for weight
over 8ml/kg of IBW for Vt settings can cause VILI
normal Vt
4-8 ml/lg IBW
PIP
not over 35
- amount if resistence to overcome the ventilator circiut, appliances, the ETT, main airways
waveform on ventilator
pPLAT
under 30
-pressure applied to the small airways and alveoli
- represents teh static end inspirationry recoil pressure of hte respiratory system, lung, and chest wall
when do you measure pPLAT
durng inspiratory pause (i-hold)
Assist-control
trigger for deliver of bretht by either pt or elapsed time
-0 preferred mode for pt with respiratory distress
FULL Vt regardless of respiratory effort of drive
how much of a Vt do you get per breath on Assist control
trigger for breath is either pt or elapsed time
- gets full Vt regardless of respiratory effort or drive
prblem of auto-peep
- predispose to barotrauma & hemodynamic compromises
- increases teh effort to trigger the ventilator and WOB
- diminshes the efficiency of hte force generated by respiratory muscles
SIMV
if pt fails to breathe, the ventilator will provide the breathe
can breathe in between preset intervals
purpose of pressure support ventilation
Vt, rate
- must have consistent ventilation effort
0 decreases overall WOB
patient-ventilator dyssynchrony indication
inadequate pain and sedation. resp demands not being met
curare cleft per ETCO2 waveform
curare cleft
ETCO2 shows curare cleft
inadequate pain/sedation
fighting the vent
problem of patient-ventilator dyssynchrony
increased WOB, HR, BP, ICP, oxygen demand
treat patient-ventilator dyssynchrony
manage auto-peep
adjust rate to match pt demand
adjust sensitivity
suchtion
pain/sedation rx
adjust minute ventilation (F x Vt)
ventilator setting to check if acute respiratory deterioration is noted
DOPE
PIP first (decrease/increase/no change)
then plateau pressure
ventilator shows decreased PIP
air leak
hypERVENT
HYPOventilation
ventilator shows increased PIP
chec to see if there is a change or no change in pPLAT
ventilator shows no change in PIP
PE
extrathoracic process
acute respiratory deterioration
shows increased PIP
but no change in pPLAT
airway obstruction
acute respiratory deterioration
shows incrased PPLAT
and increased pPLAT
decreased compliance is the cause
calculate VQ
alveolar ventilation / CO
low V/Q
shunting (alveoli is perfused but not ventilated)
ET tube in mainstem bronchus
high VQ
deadspace: aveoli ventilation but not perfused (cardiac arrest)
normal V/Q
around 0.8
alveoli is perfused and ventilated
(low V/Q is shunting. alveoli perfused not ventilated)
high is deadapace: alveoli ventilated, not perfused
problem of lwo V/Q
ventilation is not keeping pace with perfusion
-r. failure, ARDS< pneummonia
-low PaO2
high PaCO2
problem of asthma
problem is breathing out
r. acidosis b/c hypercarbic r. failure
CXR of asthma
flattened diaphragm
chest cavity overexpanded b/c air traping
ventilation for asthma
increase I:E to 1:4
zero peep
consider bipap
rx for asthma
bronchoD
steroids
epi
magnesium
IVF
ketamine
CXR of COPD
flat diaphragm
chest cavity overexpanded b/c air trapping
COPD exacerbation intubatin
increase i:E to 1:4 to facilitate CO2 offloading
zero peep
thing to consider abotu I:E ratuis
uncomfortable & need deep sedation
longer E increases CO2 clearnence but can cause risk fo atelectasis
what happens in ARDS
diffuse alveolar injury
- incrased permeability of hte alveoliar-capillary barrier so influx of fluid in the alveolar space
= hypoxemia and p. HTN
CXR of ARDS
ground glass
patchy infiltrates
bilateral diffuse infiltrates
Swan-Ganz results of ARDS
PAWP is over 18 b/c the right heat is pumping against increased resistence inteh lung vasculature
treat ARDS
increase Peep and FIO2
Vt low at 4ml/kg
increase F to ensure adequate minute volume
intervention if IABP has condensation
place pump on standby,
disconnect at safety chamber/extension tubing,
pump for 30 seconds iwth tubing/chamber faced downward to expel droplets,
set pump back on standby,
reconnect/refill/resume
intervention if IABP has a consol malfunction
manually inflate/deflate balloon with 20-50ml luerlock syyronge q 5-15 minutes|-use at least 15ml lessfill gas or air (this is not counterpulsation- inflation can occur at systole
- replace IABP asap
