Nates Final Exam Flashcards
What resp disease causes inflammation of the mucosa with edema
Asthma
Which resp disease causes constriction of the smooth muscle (bronchoconstrcition)
Asthma
Which resp disease results in cardiac output and stroke volume lowered due to vasoconstriction
Congestive heart failure
Which resp disease is destruction of the alveolar walls which leads to permanently inflated alveolar air spaces (damaged alveoli)
Emphysema
How does a pt. With emphysema present?
PINK PUFFER
- CO2 retainers
- Skinny
- Warm flushed skin
- Severe dyspnea
- Older and Thin
What happens to the air when there is a partial obstruction of the bronchioles
Air trapping
What happens when there is a total obstruction of the bronchioles
When mucus plugs completely block flow of already narrowed passages
Patho of bronchoconstriciton
Airway becomes inflamed
Bronchioles are constricted
Vasoconstriction takes place as well!
Patho of hypoglycemia
Rapid onset that can be caused by…
- not taking meds
- not eating enough
- length and excretion of physical activity
- drinking alcohol
Severely low BGL is an emergency which can cause seizures, brain damage and syncope.
What is a drug blocker
Antagonist, it blocks an action of a neurotransmitter
Homeostasis
Maintaining a state of equilibrium in the body
What is a MIMETIC
Agonist- it initiates or mimics the action of a neurotransmitter
Examples of cardiovascular drugs
Beta blockers
Calcium channel blockers
Diuretics
Antiplatatlets
Anticoagulants
ACE inhibitors
Antihyperlipidemic agents
Nitrates
Antianginals
What are beta blockers and what is their function
They reduce O2 demand of the heart muscle, affects b1 (cardiac stimulation) and b2 (Bronchiole relaxation) cells.
They dilate blood vessels reducing BP
End in “lol”
Examples…
Metaprolol
Atenolol
Propranolol
What are calcium channel blockers
Relaxes smooth muscle, decreasing peripheral resistance.
Used to treat HTN
Typically ends in “INE”
What is the normal value for PaCO2
35mmHg-45mmHg
ETCO2 waveform
Capnogram begins before exhalation and ends with inspiration
What could a “Shark fin” wave form indicate?
Bronchospasm
Why the slope with bronchospasm?
Because the movement of air at the alveoli is delayed in a person with bronchospasm, the rise of the plateau is more gradual and the plateau itself becomes slopped
Devices to measure ETCO2
Sidestream- an indirect method of measuring exhaled CO2 in non-intubated patients, used for pt’s with resp complaints
In-line or mainstream- direct method of measuring exhaled CO2 with intubated pt’s or pt’s being ventilated with BVM (spragolttic airways or OPA’s)
Hyperventilation - Low CO2 levels
When a person hyperventilates, their CO2 goes down, essentially they are blowing off large amounts due to the increased rate of breathing
Causes of hyperventilation
- anxiety
- bronchospasm
- pulmonary embolus
- cardiac arrest
- hypotension
- decreased cardiac output
- cold
Hypoventilation- high CO2 levels
When a person hypoventilates, their CO2 goes up, essentially they are retaining CO2 due to the slow rate of breathing
Causes of hypoventilation
- overdose
- sedation
- intoxication
- postictal status
- head trauma
- stroke
- tiring CHF
- fever
- sepsis
- SOB
Relation between ETCO2 and cardiac output
When cardiac output is normal, ETCO2 measures ventilations but when cardiac output is decreased, ETCO2 measures cardiac output
ETCO2 in cardiac arrest
- Caponography provides feedback on the quality of CPR
- ETCO2 of <10 indicates compressions are not deep or fast enough
- Once circulation is restored spike in ETCO2 occurs
- ETCO2 values <10 indicate rosc is not likely
Why does ETCO2 suddenly spike in a ROSC
- Large amounts of acidic blood are suddenly returned to the lungs and high amounts of CO2 diffuse into the the alveoli
- This flood of CO2 causes a remarkable sharp rise in the ETCO2 levels to much higher then normal
Fluid bolus for >2 to <12
20mls/kg
Reasses every 100ml
Max of 2000ml
Fluid bolus for >12
20ml/kg
Reasses every 250ml
Max of 2000ml
Contraindications for IV canulation
Suspected # proximal to the access site
Contraindications for fluid bolus
Fluid overload
Conditions for fluid bolus
> 2 yrs old
Hypotensive
Conditions for IV canulation
> 2 yrs old
Indications for IV fluid therapy
Actual of potential need for intravenous medication or fluid therapy
S+S of air embolism
Hypotension
Cyanosis
Weak and rapid pulse
LOC
Management of air embolism
Close tubing
Turn patient on left side w head down
Check tubing for leaks
Administer high flow O2
Notify medical direction
S+S of phlebitis
Pain
Swelling
Redness
Tenderness
S+S of infiltration
Coolness of skin around the site
Swelling at IV site with or without pain
Sluggish or absent flow rate
No backflow of blood in the IV tubing when clamp fully opened and solution container lowered below IV site
What are IV sites based on…
Visibility of veins
Stability of vein
What IV’s would require an escort for PCP
- blood products
- medication being infused
- IV pumps
- Central lines
- jugular veins
Hypotonic
Lower solute in the solution then the cells, causes water to go into the cell
Ex. NS, LR
Hypertonic
Higher volume in the solution causes water to leave the cell (mannitol)
Isotonic
Equal inside and outside of the cell
Do paramedics consider pre-arrival interventions in cardiac arrest patient into their treatment?
As a general rule… NO
Can delivered prior can be documented
What is the most important intervention in cardiac arrest?
Good quality CPR with minimal time off the chest (ideally no more then 10 seconds for Rhythm analysis)
When and where should pulse checks be done in cardiac arrest?
Routinely done every 2 minutes, started on the last 15 seconds of the 2 min CPR cycle
Carotid and femoral
Joule setting for >24hrs to <8yrs
Initial dose 2j/kg
Subsequent dose 4j/kg
Interval of 2 mins
Joule settings for >8yrs
Zoll: 120, 150, 200
Lifepack: 200, 300, 360
Shockable rhythms
V-fib and v-tach
Yes Gavin we can shock v tach.
Non shockable rhythms
Asystole
PEA
ETCO2 at 20 mins in cardiac arrest
<10 associated with futility
>25 associated with survival
Signs of a ROSC
Sudden increase in ETCO2
Spontaneous respirations
Palpable pulses
Changes in colour
Spontaneous movement
What to do when you get a ROSC (ABCD)
A- advanced airway if needed
B- provide optimal ventilation and use waveform capnography: target ETCO2 of 35-40 and optional oxygenation with target sat of 94% to 98%
C- provide optimal perfusion with a target systolic BP of grater then 90, treat hypotension with IV crystalliods as needed… do 12 lead and look for ST elevation, findings should be communicated to receiving facility
D- consider raising head of the bed by 30 degrees
DNR
Establish presence of DNR asap
If one is present confirm it is valid
If valid can be honoured without patch
If incomplete/not present phone BHP to discuss
What interventions can not be done to a pt with a DNR
Chest compressions
Defib
Artificial ventilation
Insertion of oropharyngeal, nasalpharyngeal or supregolttic airway
Endotracheal intubation
Transcutaneous pacing
Advanced resuscitation drugs such as but not limited too… vasopressors, antiarrhythmic and opioid antagonists
What treatments can be given to a pt with DNR
Therapeutic, preventative, palliative, diagnostic, cosmetic or other health related purposes and includes a course of treatment or plan or treatment
What needs to be on the DNR to make it valid
Pt name
Check box that identifies plan of tax exists or physician current opinion is CPR will almost certainly not benefit pt
Check box to indentify the professional designation of MD, RPN, RN, NP
Printed name of MD, RPN, RN,
Signature of appropriate MD, RPN, RN
Date the form was signed which must be the same as or precede the date of request for ambulance services
Medical TOR
> 16
Altered LOA
Arrest not witnessed by EMS
No rosc in 20 mins of resus
No defib delivered
What drugs end with “dipine”
Calcium channel blockers
What drugs end with “pril”
ACE inhibitors
What drugs end with “Pam” or “Lam”
Benzodiazepines
What drugs end with “asone” or “solone”
Corticosteroids
What drugs end with “olol”
Beta blockers
Indications under the STEMI bypass protocol
> 18
Chest pain or equivalent consistent with cardiac ischemia / MI
Time from onset of current episode of pain <12hrs
12-lead ECG indicates an acute AMI/STEMI…
A- at least 2mm elevation in leads v1-v3 in at least 2 contiguous leads AND/OR
B- at least 1mm elevation in at least 2 other anatomically contiguous leads OR
C- 12 lead ecg computer interpretation of STEMI and paramedic agrees
Contraindications of STEMI bypass
- CTAS 1 and the paramedic is unable to secure the pt airway or ventilate
- 12 lead is consistent with LBBB, ventricular paced or other STEMI imitator
- Transport to PCI Center is >60 mins from patient contact
- Pt is experiencing complication requiring PCP diversion…
A- mod to severe resp distress and use of CPAP
B- hemodynamically unstable or symptomatic SBP <90 at any point
C- VSA without rosc - Pt. Is experiencing complication requiring ACP diversion…
A- ventilation inadequate despite assistance
B- hemodynamically unstable unresponsive/not amenable to ACP treatment/management
C- VSA without ROSC
Macro drip sets
10, 15, 20 gtt/ml
TKVO and large bolus
Micro drip sets
60gtt/ml
Used to deliver medication over a long period of time
Better to control the amount of fluid in peds and fluid overload
Intracellular fluid
45% of total body weight
Includes all fluids in the cells
Extracellular fluid
15% of total body
Water found outside the cell… consists of
Intravascular- in the blood vessel
Interstitial- outside the vasculature but not in the tissue
Arteries
Thick muscular walls
Consist of inner, middle and outer layer
Veins
Same 3 layers but have larger volume capacity
Valve to prevent back flow
Capillaries
Have thin walls, area of gas exchange
Catheter selection
Adult- 14g/16g/18g/20g
Elderly- 18g/ 20g/ 22g
Paediatric- 22g/ 24g
Selection is based on age, health, size of pt and need for medication, fluid or just tkvo
Stable angina
- typically follows same pattern for the pt… predictable pain and location
- insufficient O2 supply… anaerobic metabolism and accumulation of lactic acid and CO2
- typically lasts 1-5 mins and is relieved by rest
- at rest supply is OK despite narrowed arteries but as soon as the person exercises or experiences any type of stress blood flow is not enough to meet hearts needs
Unstable Angina
- Same ethology as stable, however the pain is more severe, different feeling and is not as easily relieved by rest or meds
- Lasts >15 mins and often indicative of pre-MI
- Greater degree of obstruction of the coronary arteries
Benefits from early and aggressive treatment to prevent infarction
AMI (acute myocardial infarction)
- Part of the coronary muscle is deprived of blood flow until the part subsequently dies (infarcts)
- Most common cause is plaque rupture and thrombus formation… can also occur from spasm of coronary artery with angina arteries already narrowed
- classified as either STEMI or NSTEMI… clinical presentation is the same only an ECG differentiates them and blood work- troponin is typically the distinguishing factor
Ventilation problems
Airway obstruction
Chest wall impairment
Neurological control impairment
Ventilation problems with examples
Upper airway obstruction- foreign body, epiglottis
Lower airway obstruction- asthma, airway edema
Chest wall impairment- trauma, MS
Neurogenic dysfunction- CNS depressant drugs, stroke
Diffusion
Process of gas exchange between capillaries and alveoli…
Diffusion requires…
- alveolar and capillary walls that are permeable to respiratory gasses
- interstitial spaces not enlarged or filled with fluid
- surface area or sufficient size
- presence of gasses for diffusion
Diffusion problems
- inadequate oxygen concentrations
- alveolar pathologies
- interstitial space pathologies
- capillary bed pathologies
Perfusion
Circulation of blood through pulmonary capillary bed
Perfusion requires…
- adequate blood volume
- adequate hemoglobin
- functioning pulmonary capillaries
- functioning left ventricle
Perfusion problems
Inadequate blood volume or hemoglobin- shock, anemia
Impaired circulatory blood flow- PE
Capillary wall pathology- Trauma
V/Q mismatch
V- ventilation Q- perfusion
- when lungs are functioning properly, 4 litres of air enter the resp track per minute and 5 litres of blood go through capillaries per minute. This leads to a V/Q of 0.8. Once the air is humidified by the respiratory tract, it ends up in the vicinity of 1.0.
- ideally, V/Q is equal meaning there is just enough o2 to fully saturate blood
Shunt and dead space
An area with perfusion but no ventilation (V/Q of 0) is termed Shunt.
An area with ventilation but no perfusion is termed dead space.
