Multisystem part 2

Question 1

Targeted Temperature Management (TTM)

Answer 1

treatment that lowers the patient’s core temperature in order to prevent the neurological effects of an ischemic injury in the brain of survivors of cardiac death

INCLUSION criteria:
-cardiac arrest with ROSC
-unresponsive or not following commands after cardiac arrest
-witnessed arrest with downtime of less than 60 minutes

EXCLUSION criteria:
-core temp of <35*C
-age <18 or >85
-existing DNR status or terminal disease
-sustained refractory ventricular arrhythmias
-active bleeding
-shock
-hemodynamic instability
-drug intoxication

Question 2

3 phases of targeted temperature management

Answer 2

INDUCTION phase: lower the patient’s temperature to 32-36*C (ordered by provider); start this cooling ASAP; within 90 minutes of patient going into arrest and cooling may last for as long as 6 hours after the arrest

MAINTENANCE phase: keep the patient at the target temperature (32-36*C) for 24 hours

REWARMING phase:slowly increase the patient’s temperature to 36.5-37*C (ordered by provider)

Question 3

Systemic Effects of Hypothermia

Answer 3

insulin resistance -> HYPERGLYCEMIA

electrolyte and fluid shifts

shivering

skin breakdown

pupil and corneal reflexes may be absent d/t hypothermia

decreased CO (up to 25%)

alteration of coagulation (platelet dysfunction)

increased risk for infection (neutrophil and macrophage functions decrease at temperatures < 35*C)

Question 4

Meperidine (Demerol)

Answer 4

manage shivering in targeted temperature management with Meperidine (Demerol). Use a neuromuscular agent if shivering is not controlled with meperidine.

Question 5

Rewarming Phase (TTM)

Answer 5

program the cooling unit to increase the target temperature by 1*/hr

STOP all potassium administration 8 hours PRIOR to rewarming. Rewarming causes rebound hyperkalemia.

D/C paralytics after the patient is warmed to 36.5*C

Repeat labs when pt is rewarmed.

Neuro assessment. Pupil and Corneal reflexes may be absent for a time.

Question 6

Initial management of toxin/drug exposure

Answer 6

always assess ABCs (airway, breathing, circulation)

if the patient is comatose, be prepared to give 50% dextrose 50mL, thiamine 50-100mg, naloxone 2mg IV

to prevent absorption of the toxin/drug, give activated charcoal via gastric lavage (contraindicated with hydrocarbon or corrosive ingestions, not necessary for iron, lithium, or alcohols)

facilitate removal of the drug - urine alkalization, hemodialysis

give antidote (eg naloxone)

monitor for arrhythmias

monitor urine output

Question 7

acetaminophen (tylenol) overdose

Answer 7

early s/s: n/v, or none
treatment: acetylcysteine dosing effective up to 8 hours after ingestion

later s/s: RUQ pain, abnormal liver function test results, mental status changes
treatment: GI lavage with activated charcoal within 4 hours after ingestion

Question 8

Benzodiazepine overdose

Answer 8

s/s: drowsiness, confusion, slurred speech, respiratory depression, hypotension, aspiration
treatment: support airway, flumazenil/ aka romazicon (short half-life), gastric lavage with activated charcoal, fluids

Question 9

Beta-blocker overdose

Answer 9

s/s: bradycardia, hypotension, CV collapse
treatment: glucagon, epinephrine, insulin plus dextrose, sodium bicarbonate

Question 10

calcium channel blocker overdose

Answer 10

s/s: bradycardia, hypotension, CV collapse
treatment: calcium gluconate, epinephrine, insulin plus dextrose, sodium bicarbonate

Question 11

Cocaine overdose

Answer 11

s/s: seizure activity, agitation, hyperthermia, rhabdomyolysis
treatment: activated charcoal, fluid/glucose/thiamine, benzodiazepines for sedation/seizures, vasopressin is preferred over epinephrine in full arrest, vasodilators for hypertension, nitrates/calcium channel blockers for ischemia (NO beta blockers), cooling for hyperthermia

Question 12

ethylene glycol overdose

Answer 12

s/s: intoxication behavior, vomiting, metabolic acidosis/anion gap, renal failure
treatment: gastric lavage, sodium bicarbonate, antidotes (ethanol or fomepizole), dialysis

Question 13

ETOH overdose

Answer 13

s/s: stupor, respiratory depression, aspiration risk, intermittent agitation
treatment: protect the airway, fluids, multivitamins/thiamine 100mg, electrolyte replacement PRN, prevention of delirium tremens with benzos and CIWA protocol

Question 14

methamphetamine overdose

Answer 14

s/s: fever, tachycardia, hypertension, seizure, agitation, renal failure
treatment: fluids, cooling, benzos/haloperidol, restraints

Question 15

opioid overdose

Answer 15

s/s: drowsiness, hypoventilation, hypotension, hypothermia, deep sedation, pinpoint pupils
treatment: support the airway, naloxone, gastric lavage with activated charcoal

Question 16

salicylates overdose

Answer 16

s/s: vomiting, tinnitus, confusion, hyperthermia, respiratory alkalosis, metabolic acidosis, multiple organ failure
treatment: activated charcoal, urine alkalization, dialysis regardless of admission renal function to prevent AKI

Question 17

tricyclic antidepressant overdose

Answer 17

s/s: CV signs (arrhythmias, shock), neurological signs (drowsy, delirium, seizure, coma), anticholinergic signs (blurred vision, fever, twitching)
treatment: sodium bicarbonate, activated charcoal, fluids, cardiac monitoring

Question 18

PCP overdose

Answer 18

s/s: blank stare, rapid involuntary eye movement, hallucinations, severe moods, flushing, sweating, hypertension, tachycardia, seizure, coma
treatment: support the airway, calm environment (don’t leave alone), benzos, fluids/cooling/monitor renal function

Question 19

central line-associated bloodstream infection (CLABSI)

Answer 19

a laboratory-confirmed bloodstream infection that develops within 48 hours of a central line placement and is not related to an infection at any other sites.

perform hand hygiene prior to line manipulation/care, daily CHG baths, aseptic technique during dressing changes

Question 20

CAUTI (Catheter-Associated Urinary Tract Infection)

Answer 20

an infection of the urinary tract, where an indwelling urinary catheter was in place for more than 2 consecutive days

Prevention guidelines include:
-avoid inserting if possible
-develop standardized based policies for placement
-daily review of catheter need
-remove asap
-implement a nurse-driven protocol for removal
-utilize alternatives (external catheters, intermittent straight catheterization)

Insertion and maintenance practices
-use aseptic technique
-make insertion a 2-person activity
-hand hygiene
-routine catheter care
-maintain an unobstructed urine flow (tubing free of kinks or dependent loops, collection bag below the level of the bladder)
-do not disconnect/reconnect system components
-collect urine samples using aseptic technique

process measures
-competency training for those inserting catheters
-quality measures

Question 21

MDRO (Multi-Drug Resistant Organisms)

Answer 21

patients who are vulnerable to colonization and infection of MDRO’s include the critically ill especially those with compromised host defenses

most common organisms:
MRSA, VRE (vanco resistant enterococci), C. diff, CRE (carbapenem-resistant enterobacteriacaea

Strategies to prevent MDROs:
-hand hygiene
-chlorhexidine bathing and nasal decolonization
-rapid ID of MDRO
-develop a root cause analysis
-reliable cleaning of equipment
-education regarding soap and water vs alcohol hand foam

Question 22

Palliative Care

Answer 22

prevention and treatment of the symptoms and side effects of a serious illness. Physiological, emotional, social, and spiritual problems are considered.
-palliative care can be initiated anytime during a disease or life-threatening illness
-most beneficial when initiated early
-management of pain, anxiety, dyspnea, urticaria, n/v, constipation, diarrhea, etc

aggressive treatment may be continued
all critically ill patients deserve palliative care

Question 23

hospice care

Answer 23

the provision of symptom management for those with a TERMINAL illness

includes palliative, but disease-modifying treatments are discontinued unless they provide symptom management

grief and bereavement services are includes

Question 24

End-of-life care

Answer 24

End-of-life care supports the needs of patients and their families at the time of imminent death. It is always a part of hospice care, and it may or may not be a part of palliative care. It is provided to all patients who are at the end of their lives, regardless of whether or not palliative care or hospice care was initiated.

EOL care avoids prolongation of the dying process
EOL care provides support to the patient’s family