Lecture Week 2 Flashcards
How does an intraaortic ballon pump work
cath goes from the femoral artery into the aortic arch. During ventricular diastole (when the aortic valve closes) the ballon inflates pushing blood back toward the left ventricle where it can enter the coronary artery orifaces
what should you do to decrease cardiac workload
- give o2
2. decrease SVR
what are the two types of respiratory failure
- hypoxic (such as in pneumonia)
2. hypercapnic (such as in COPD)
what are the early signs of hypoxic respiratory failure
- restless
2. premature ventricular contractions
what are the early signs of hypercapnic respiratory failure
1.lethargic
what do you do to treat hypercapnic respiratory failure
give BiPaP to reduce CO2 levels, but the patient needs to be awake because unlike cPAP it does not push the air in and the patient actually has to breath.
normal CO2 levels for COPD patients
60-70 you really dont wanna drop them lower then that because their instinct to breath is dependent on CO2 rather then O2 like us
what kind of people end up getting elective intubations
surgery and CVA patients
what are the ET sizes in men vs women
women: 7-7.5
men: 7.5-8
where is a normal ET placement? what happens if the ET tube gets pushed down? what happens if it gets pulled up?
about 1 inch above the carina. If it gets pushed down it will go down the right lung and cause the left lung to collapse. If it goes up neither lung will receive proper oxygenation.
what drugs do you give patients before intubation
- benzo(versed)
2. paralytic agent (succenylcholine, proprofol, vecuronium)
which patients are hardest to put an ET in? what are they at risk for? how do you care for these patients
1.short necks
2.obese
at risk for hypoxia (due to multiple attempts) watch for bradycardia and hypoxia(observe monitor) during insertion
how do you confirm ET placement and which landmark is the carina at?
CXR, 4th intercostal space at the nipple line.
what will happen if you have no fully inflated an ET cuff
you will hear gurgling
What are the different modes on a vent and what do they do
- AC (assisted control)-machine does all the work
- SIMV(synchronized intermittent mandatory ventilation) -it will help the patient reach some goal. such as if the patient inhales 200 it will push the extra 300 in.
- CPAP (continous positive airway pressure)-patient does all the work the machine just helps keep the alveoli open
- PEEP (positive end expiratory pressure) - increases oxygenation by keeping the alveoli open. It is contraindicated in hypotension because it increases intrathoracic pressure which decreases preload. You need an order to add PEEP to patients post CABG. Normal PEEP (5-10)
What is the VT setting on vent
Tidal volume, it is dependent on weight normal tidal volume is 6-8 ml/kg
what is the normal RR on a vent
14 plus minus 2
what vent setting would you adjust first if a patient is hypoxic
set FiO2 to 100%
what is hyperventilation
has nothing to do with oxygen and everything to do with RATE of respirations and flushing of CO2
what vent setting would you adjust to lower CO2
increase the RR
what is the difference between O2 sat and PO2
- O2 sat is the % of hemoglobin that has oxygen attached to it
- PO2 is the amount of oxygen dissolved in blood. (80-100)
what is the difference between hypoxemia and hypoxia
hypoxemia means the PO2 levels are dropping (60-80)
hypoxia means that the PO2 levels have dropped below 60 and due to the oxyhemoglobin dissociation curve the tissues are now not getting enough oxygen.
describe the oxyhemoglobin dissociation curve
O2 sat lateral and PO2 level horizontal. It looks like the graph of pH buffers the magic numbers being PO2 of 60 and O2 sat of 90%
what is the general purpose of the pulmonary function test (PFT)
tell us how good the lungs are
what can you do with a bronchoscopy other then visualize the throat
- deep suctioning
2. bronchial wash(biopsy)
distinguish between a pneumothorax
hemothorax, pleural effusion and pulmonary edema
- pneumothorax is air trapped within the pleural space
- hemothorax is blood trapped in the pleural space
- pleural effusion-transudate/exudate in the lungs
- pulmonary edema-fluid in the lungs
what is the difference between an open pneumothorax vs a closed(tension) pneumothorax
- open requires penertration of the chest wall (e.g: stabbing) air goes in and doesnt come out
- closed is worse because its not obvious you have a one way leak
what is a major risk for clients on vents and why
tension pneumothorax because of the high pressure
does CPR help in pneumothorax?why
no, the pressure increase pushes down on organs and vessels. The heart will not be able to accept venous return.
how would you poisiton a patient for CXR for fluid in the lungs
sitting upright so that the fluid collects at the bottom
describe what you see on xrays and what they mean for example what does black mean
black means air
white are fluids
what diagnositic do you have to run before and after placement of a swan gauz
CXR
indiciation for chest tube insertion
if you do a CXR and there are fluids from ICS 8-12
how is patient positioned for chest tube insertion
lying on unaffected side
what do you do first if a chest tube gets disconnected from the machine?
put the end of the tube into sterile water to maintain negative pressure
how much chest tube drainage is to much per hour
over 70 mL you should call the doctor
are air bubbles normal in the water seal chamber?
kinda, up to the 2 cm mark is okay because the lung is damaged as it heals the bubbles will go away. Once they fully go away it indicates the lung is fully healed. Also it should not continously bubble
what is subcutaneous emphysema
a chest tube complication where air collects inside the skin causing it to swell. It will crackle on paplitation
should you milk a chest tube?
no you risk pulling it out instead hit the tube with a clamp to break up clots
what diagnostics should be done for PE
pulmonary angiogram(gold standard)
V/Q scan
D-Dimer (.44-2.33)
what drugs do you give for PE
TPA then lovenox 1mg/kg
what is ARF
severe lung injury that causes insufficent O2 transfer to blood and insufficent removal of CO2
what drugs do you give in ARF
sedation(benzos)
paralytics(proprofol, vecuronium)
These are to decrease the metabolicc requirements of the body
lasixs-to remove fluid from capillary leaks
s/s of tension pneumothorax
- mediastinal shift(severe)
- dyspnea
- assymeterical chest rise
how much water should be added to the water seal chamber? suction control chamber?
- 2cm
2. 20 cm
procedure for Chest tube removal
one quick movement while patient does Valsalva maneuver. Apply sterile cause. Monitor respiratory status. Get chest xray
s/s of PE
- chest pain
- dyspnea
- hemoptysis
- tachycardia
- low grade fever
- pleural effusion
- anxiety
- impending doom - petechiae
- cough
- diaphoresis
- hypotension
s/s of PE again
- vitals
- tachycardia, hypotension, low grade fever, chest pain, hypoxia, tachypnea(decrease CO2) - Respiratory
- dyspnea, cough, crackles, pleural effusion, hemoptysis - Integumentary
- Petechiae,diaphoresis
causes of hypercapnic RF
1.CNS problems
-drug overdose, brainstem infarction, spinal cord injury
2.chest wall problems
-flail chest, kyphosis,obesity
fracture
3.Neuro
-Muscular dystrophy, MS, guillain barre syndrome
what is the main problem in ARDS
capillary membrane is dilated due to injury to the alveolar-capillary membrane. therefore it leaks into the pulmonary interstitum(pulmonary edema)
what are the two possible outcomes of injury to the alveolar capillary membrane
- damage to the type 2 alveloar cells
2. release of inflammatory mediators
what occurs when type 2 alveolar cells are damaged
- decreased surfactant production
- >decreased alveolar compliance and recoil
- >atelectasis
- >(1)hyaline membrane formation ->impaired gas exchange
(2) decreased lung compliance->impaired gas exchange
what happens when inflammatory mediators are released
- Bronchoconstriction
(1) ->impaired gas exchange
(2) pulmonary HTN
- >impaired gas exchange - Increased alveolar capillary membrane permeability
- >capillary leak of blood cells and fluids
- >pulmonary edema
- >impaired gas exchange
what kind of breathing will patients with ARDS present with
1.rapid shallow with dyspnea
what signs will ARDS present with
- severe morning headaches
- early signs
- tachycardia,tachypnea, mild hypertension
interventions ARDS
- maintain PaO2 above 55
- Positive pressure ventilation
- BiPaP, CPAP,vent - mobilize secretions
- hydration,chest physiotherapy, suction - for airway inflammation use steroids
- for pulmonary congestion use diuretics and nitrates if HF is present
what are the features of moderate sedation
- can respond to verbal stimuli
- has gag reflex
- independently maintains patent airway
