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OSCE Review (A) > MDSO - ADULT - RESP > Flashcards

MDSO - ADULT - RESP Flashcards

1
Q

Clinical Guidelines: Ventilation Strategies in Asthma : Target for Te, Vt, RR, PEEP, pH, Sedation, and focus of strategy.

A

Longer Te
Lower volumes (5-6 ml/kg)
Lower RR (8-12)
PEEP 5
pH > 7.25
Use adequate analgesia/sedation/paralysis. Ketamine is preferred.
Focus on minimizing gas-trapping

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2
Q

Guidelines : Asthma : How do you treat Auto PEEP assoc w Hypotension / Shock / PEA in an intubated/apneic asthmatic.

A

Compress Chest to allow for exhalation
The increased pressure may be the reason for hypotension etc…..
Also, don’t forget to assess for Pneumo

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3
Q

Bronchoconstriction: Meds and Doses, Patch status

A

Salbutamol - 8 puffs (8 x 100 mcg) x 3 q 5-15 PRN, Or ….5 mg NEB q 5-15 min x 3 - NP

Atrovent (Ipratropium): 5 puffs (5 x 20 mcg) x 3 q 5-15 min, or 500 mcg q 15 x 3 prn (do not use for peads using full face mask - issue for eyes) - NP

Epi - 0.01 mg/kg (1:1000) , max 0.5 mg IM - IP

Steroids (MythylPrednisolone - 125 mg IV/IO….or Dexamethasone 8mg IM/IV/IO - MP - - monitor for hypotension

MgSO4 - 2g(4 mL) / 100 mL > 15 min (400 mL/hr = 15 min for 100 mL) - MP

Epi Infusion - 0-0.5 mcg/kg/min

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4
Q

Bronchoconstriction - Flow Chart: What do you do with Asthmatic in Cardiac Arrest ?

A

Potentially due to high intrathoracic pressures.
DO:
-disconnect ventilator
-STOP ventilating
-Compress Chest
-Consider Bilateral needle decompression
-Restart ventilating at a very slow rate (6 per min)
-PATCH as soon as possible

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5
Q

TENSION PNEUMO: Indications:

A

Severe Resp Distress with Hemodynamic Compromise
AND/OR
Traumatic VSA
AND/OR
Severe hemodynamic compromise during PPV particularly in trauma, or asthma, or COPD
AND/OR
Chest trauma, Severe Asthma or COPD, hemodynamic compromise AND one or more of the following:
- - Decreased AE on affected sides; Cyanosis; JVD ; Tracheal Shift; Hyper resonance on affected side

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6
Q

Maintenance of Chest Tubes: What is the max negative pressure we can use ?

A

-20 cm H20, any more than that - you have to patch

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7
Q

Guidelines: Mechanical Ventilation: What is the mL/kg IBW Vt we should start at ?

A

6 mL/kg IBW

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8
Q

Guidelines : Mech Ventilation : Minimum Pressure Support ? Typical O2 Sat % target ?

A

min 8 or more for PS. O2 - 94-98

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9
Q

Guidelines: Mech Vent : in patients with severe hypoxia resp failure - may consider lower o2 targets, how low? What is the minimum even in “permissive hypoxemia”

A

Normal is 94-98, permissive hypoxemia is < 94/92……the lowest we can go is 88

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10
Q

Guidelines: Mech Vent : in ARDS and FiO2 > 0.6 - PEEP should be…..

A

Higher than 5 (the normal base value) - also see ARDSNet table

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11
Q

Guidelines: Mech Vent : Delta P (Pplat - PEEP) should be less than….

A

15

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12
Q

Guidelines: Mech Vent: Who should be considered for LRM ?

A

ADRS with high FiO2 (and corresponding PEEP) requirements and/or difficulty achieving oxygenation targets (discuss with TMP - what that target it, lowest is 88)

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13
Q

Guidelines: Mech Vent: What is the target Vt? PIP / Plat ? ETCO2 Normal Targets ?

A

6-8 mL/kg - can go to 4-6 if PIP/Plat too high; Want PIP/Pplat < 30 ; Normal ETCO2 35-45 mmHg

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14
Q

Guidelines: Mech Vent : ETCO2 targets for ICP no herniation, with herniation ?

A

33-38 mmHg ; 30-35 mmHg

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15
Q

Guidelines: Mech Vent: Extreme HCO3 should prompt adjusted ETCO2 targets to try to maintain pH. Must be discussed with TMP. At what high/low HCO3 should this be discussed ?

A

HCO3 > 35. (Want a higher ETCO2 target)

HCO3 < 15 (Want a Lower ETCO2 target)

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16
Q

Guidelines : Mech Vent: When do you need to consult TMP for permissive hypercapnea ? What is the min pH ?

A

Unable to hit Vt targets while keeping PIP < 30 - unable to keep pCO2 normal, they will be too high……need to accept “permissive hypercapnea” - still min pH is 7.25 - - TMP may allow ETCO2 to 60-80!

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17
Q

For all “difficult to ventilate” patients on Mech Vent - what should always be considered ?

A

Judicious use of sedation / paralytic - - - to improve compliance and decrease MvO2 demand.

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18
Q

Reversible Causes of higher driving pressures ?

A

Bronchoconstriction - ie if Asthma / COPD - use bronchodilators
Main Stem Bronchus Intubation
DOPE - displacement (ie Main Stem), obstruction (needs suction), Pneumo , Equipment ? Kinked ?
Pulmonary Edema - - consider Diuresis.

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19
Q

Causes of Ventilator Asynchrony ? How do you fix it ?

A

Ventilator Sensitivity Setting - adjust
Auto Cycling during turbulent transport - adjust
Patient Sedation - increase sedation / pain management - use vital signs to assess.

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20
Q

INITIATING OR MAINTAINING MECH VENT: INDICATIONS

A

Need for Mech Vent
Hypoxemic, Hypercapneic or mixed Resp failure
ETI management for transport

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21
Q

INITIATING OR MAINTAINING MECH VENT : Vt, Freq (RR), PEEP RANGE, Peak/PPlat , I:E ratio range; Sats, ETCO2…….do we need to patch to initiate ?

A

6-8 mL/kg
Freq - 10-20
PEEP 5-10
1:1.5 to 1:3.0
sats 94-98
etco2 35-45

Not required to patch if we can meet this target - that being said - you need to patch to tube

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22
Q

INITIATING or MAINTAINING Mech Vent : ETT Cuff Pressure ?

A

20-30 cm H20

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23
Q

According to the Medical Directive for initiating Mech Vent - who should get PSV ?

A

Only if awake and breathing spontaneously ……all others should be on PC or VC

24
Q

COPD/Asthma Vent Strategies - RR, IE, Vt, PEEP, Ti, PPlat, Sats , Target Vt if PIP > 30, Consider what meds ? What else ?

A

8 -12, 1:4 to 1:5, 4-6 mL/kg, Ti < 1.0 (0.7 -1.0), PPlat < 30 . PIP < 30 ; Consider Salbutamol and Atrovent vis MDI (or NEB - - -MDI easier in this case because they are on a vent) - then other meds from Bronchoconstriction Med Directive - ex MgSO4, consider paralysis, optimize analagosedation,

Consider dropping PEEP to match auto-peep ie dropping it to 2-3 from 5 to help with expiratory phase

25
Q

ARDS Ventilation Strategy from INITIATION of Mech Vent MDSO: RR, Vt, Initial FIO2 and PEEP and adjustments. ETCO2 strategy.

A

20-26 rate ; only drop FiO2 is sats > 98., initial FiO2 = 100 and initial PEEP 5

If sats < 90, increase PEEP to 10, and increase by 2 to max 20 - - - - as PEEP goes up, watch Vt….if it goes down, back off because you are at the top end of the compliance curve.

May have to consider permissive hypercapnea - 45-80, pH > 7.25

26
Q

ARDS NEt

A

FiO2 < 0.5 - PEEP 5
0.5 / 6
0.6 /8
0.7/10
0.8/12
0.9/14
1.0/16

27
Q

LRM - steps:

A

Mode: APRV
Set P high to 30 and T high to 30
P low = current PEEP, increase it by 2
On Apnea Screen - turn OFF apnea back up (need to turn it off each time)
Hit Confirm to start Maneuvre

As the T1 goes into APVR - pressure curve should show 30, if lower hit ‘manual breath’ to terminate current breath and start a new one. To terminate at any time hit the “manual breath” mode - which will kick it into the previous mode.

**As soon as LRM is working, open MODE again, and select previous mode (ex PC) - - - then when the LRM terminates it will automatically go into that mode, and keep the new PEEP (up by 2)

28
Q

LRM : reasons to terminate

A

Drop in BP (MAP drop 20%, or Sytolic below 80), drop in sats 10 below baseline and dysrhythmias

29
Q

NIPPV: Do the patients needs to be conscious and able to protect airway ?

A

YES

30
Q

NIPPV: Contraindications

A

-Active Vomiting / Unable to manage airway secretions
-Decreased LOA / Unable to protect Airway
-Repeated Hemoptysis
-Cardiac / Resp Arrest
-Immediate need for ETT
-Upper airway obstruction
-Facial Trauma
-Recent Esophagostomy

31
Q

NIPPV: Relative Contraintication

A

Hemodynamic Instability

32
Q

NIPPV: Initial Setting (PS/PEEP) (IPAP/PEEP) and MAX Settings

A

5/5 = 10/5

10/10 = 20/10

33
Q

NIPPV : what to do if persistent HYPERCAPNEA (high pCO2) or persistent HYPOXEMIA (low pO2)

A

HYPERCAPNEA: Increase IPAP by 2…..ie 5/5 = (10/5) ——-> 7/5 = (12/5)

HYPOXEMIA: Increase both IPAP and EPAP by 2…..ie 5/5 = (10/5) —-> 7/7 = (14/7)

34
Q

NIPPV : risks of higher pressures

A

Gastric Distension

35
Q

NIPPV : Patch ?

A

To start ? - IP
To continue from Hosp ? - IP

36
Q

NIPPV: Clinical Considerations:

A

NIPPV may benefit in hypercarbic patients in ventilator failure even with altered mental status - - - in these cases must patch first and discuss NIPPV vs ETT

In cases of agitated patients - TMP discuss need for sedations

37
Q

NIPPV: how do you use it in CPAP mode

A

IPAP = EPAP

T1 = 0/5 —-> (5/5)

38
Q

HFNC: Indications:

A

-Refractory (to NRB/ NC) hypoxemia (low sats) in patients with intact, acceptable resp drive
-COPD/CHF exacerbation requiring minimal amount of PEEP
-Palliative resp support where ETT of NIV not in care plan

39
Q

HFNC: Contraindications

A
  • definitive AW needed to protect airway
    -resp support in acute resp acidosis
    -complete nasal airway obstruction
    -use caution in Hx of facial trauma, acute sinusitis or otitis
40
Q

HFNC: Complication

A

Unmeasured PEEP - some risk of pneumo or lung inflation (particularly in COPD)

41
Q

HFNC: Tx / Patch ?/ Targets

A

30 LPM and titrate flow and FiO2 to target Sats > = 94%

Patch : IP

42
Q

HFNC: If set at 30 LPM at FiO2 0.5 - How many LPM of the O2 tank are you using ?

A

0.5 x 30 = 15 LPM
HFNC uses up L of O2 quickly - ensure you have enough

43
Q

NIPPV / O2 Delivery: Easy estimation : if K tank has 2000 psi, how many L do you have ?

A

Estimate: K tank 7000 L if full (2000 psi) and half (1000psi) roughly half , so 3500 L (this is from Geisel math)

44
Q

Calculate how many minutes of 02 you have left in the following cases:

1). 700 PSI, D Tank, running at 12 LPM
2). 1500 PSI, K (or H) Tank, running on a HFNC with FiO2 0.5 at 40 LMP

A

1. Time = (700-200) x 0.16 / 12 = 6.6 min

K / H - constant 3.14
M - constant 1.56
D - constant 0.16

Equation = Time in minutes = (PSI - Safe Residual) x constant)) / Flow Rate in LPM

Next:
(1500 - 200) x 3.14 / 20 = 204.1 min

45
Q

FLOLAN: Indications

A

Severe ARDS with refractory hypoxemia
Pulmonary HTN
Right Heart Failure

46
Q

FLOLAN : Contraindications

A

Severe LV systolic dysfunction
Pulm Hemorrhage

47
Q

FLOLAN: Relative Contraintication

A

-Thrombocytopenia ( PLT < 50)
-Active Hemorrhage
-Pulm Edema
-Hypotension

48
Q

Why is low platelets an issue with Flolan ?

A

Flolan is a potent platelet aggregate inhibitor, so if bleeding issues (such as low platelets) - often contraindicated due to risks of bleeding

49
Q

FLOLAN - how is it supplied ? How is it mixed in textbook, and in real life

A

Supplied as powder - either 0.5 mg or 1.5 mg - MDSO mixes it into 100 cc

But what we see is 1.5 mg in 50 cc. (The powder is reconstituted in 5 mL of water supplied)

So we end up with 0.03 mg/ mL = 30 000 ng/mL as a typical concentration

50
Q

What weight to you use to calculate dosing of Flolan ?

A

IBW

51
Q

FLOLAN: Tx MDSO - dose, and what you typically see, and patch status

A

MDSO Dosing : 0- 50 nano grams/ kg/ min - nebulized

Typically it’s 50 ng/kg/min

It’s a MANDATORY PATCH

52
Q

FLOLAN: You have a 75 kg male, 170 cm needing Flolan …. You have patched and gotten approval to give the max dose of flolan. You are given 1.5 mg of Flolan Powder. You’ve been told to mix it up in a 50 cc syringe? What is your final concentration ? What is the max dosing for this patient ? How many mL/hr is this ?

A

Must use IBW - so from app - IBW at 170 cm = 63.8 kg

Mix 1.5 mg into 50 mL (after reconstituting it in 5 mL) - 0.03 mg/mL —> 30 000 ng/mL is the final concentration

Dosing Max is 50 ng/kg(IBW)/min. = 50 x 63.8 = 3190 ng/min
ML / hr ——> 3190 x 60 = 191 400 ng/ hr - - - - > WANT / HAVE —> 191 400 / 30 000 —-> 6.38 mL/hr

53
Q

Transport in Prone MDSO: Indications

A

Severe ARDS (P/F < 150), FiO2 > 0.6, and PEEP > 5 with failed supine ventilation

54
Q

Prone Transport MDSO Considerations:

A

Maintain sedation / analgesia RASS -4 and Paralysis
MANDATORY PATCH
If Cardiac Arrest —> have PADS AP prior to transport ; CPR in prone position

55
Q

PRONE TRANSPORTATION: MDSO Meds

A

Analagosedation - should be continued , but not specifically in this MDSO

PARALYTIC in this MDSO (only meds in this MDSO)
Both are NO PATCH REQUIRED, BUT you have to patch to get approved to transport prone. - so it will be discussed

MEDS:
1) ROC Push 0.6 mg/kg to initiate, then 0.3 mg/kg q 20 min…AND/OR 10-15 mcg/kg/min infusion

2) Cistracurium (aka NIMBEX) 0.1 -0.2 mg/kg to initiate then 0.03 mg/ kg q 30 min…AND/OR 1-10 mcg/kg/min

56
Q

Chest Needle : Landmark Options ?

A

2nd ICS Mid Clavicular OR 4th or 5th ICS Mid Axilliary / Anterior Mid Axillary (Straight line from Nipple)

57
Q

Steps of Chest Needle / Turkel - think about it….then watch video for answer.

A

YOU TUBE: “Emergency Needle Chest Decompression….” Ken Strong

https://www.google.ca/search?q=turkel+chest+needle&source=lmns&tbm=vid&bih=803&biw=1261&client=safari&hl=en-US&sa=X&ved=2ahUKEwi5m8mHrPL9AhUQFVkFHUGKDNcQ_AUoA3oECAEQAw#fpstate=ive&vld=cid:7de73eb0,vid:-6y7vI_O7js

OSCE Review (A) (16 decks)

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