PA Tests Flashcards
The Palliative Ventilator Weaning Pathway is a multidisciplinary approach to discontinuing care on a patient. The pathway involves
a. Using sedative so that a patient with a drive to breath appears to be comfortable
b. Paralyzing the patient to decrease WOB
c. Hyper-oxygenating the patient
d. Using inhaled corticosteroids to improve WOB
a. Using sedative so that a patient with a drive to breath appears to be comfortable
During an assessment for Neurological Determination of Death, the physician tests the oculocephalic reflex. The head is vigorously turned to the left. What of the following would be considered a normal response
a. Eyes do not move
b. Eyes move to the right
c. Eyes move to the left
d. Both eyes blink
b. Eyes move to the right
Which of the following statements identifies a component of the Palliative Ventilator Weaning Pathway during End of Life Care
a. A verbal order from the nurse in charge of the patient is adequate to commence the procedure
b. Intubated patient with a spontaneous drive to breath are placed in the Airway Management Pathway before the ventilator weaning procedure is commenced
c. Additional sedation can be used if the patient Tobin Score remains >105 during titration of ventilator support
d. The ETT is usually left in situ during discontinuation of care
c. Additional sedation can be used if the patient Tobin Score remains >105 during titration of ventilator support
Uncuffed ETT Tube Size in Peds
Formula for uncuffed tube: 1 x ETT= (age/4) + 4
Cuffed ETT Tube Size in Peds
Formula for Cuffed tube: 1 x ETT= (age/4) + 3.5
Remember that you can used cuffed tubes in any child with the exception of neonates
NG/OG/Foley Size in Peds
2 x ETT
Depth of ETT Insertion in Peds
3 x ETT
Chest Tube Size in Peds
Chest Tube Size= 4 x ETT
*This is for the biggest chest tube size
In pediatric patient, which of the following signs of work of breathing involves the sternocleidomastoids
a. Head bobbing
b. Suprasternal retractions
c. Grunting
d. Nasal Flaring
a. Head bobbing
Which of the following is an ancillary test that is used in Neurological Determination of Death
a. Perfusion Scan
b. Caloric Test
c. Apnea Test
d. Pharyngeal Reflex
a. Perfusion Scan
A patient with a suspected anoxic brain injury due to prolonged CPR is taken for a CT head immediately after ROSC (Return of Spontaneous Circulation). Which of the following is the CT most likely to show
a. Abnormalities that confirm loss of brain stem function
b. Normal Scan
c. Midline shift
d. Intracranial Hemorrhage
b. Normal Scan
Whole brain death indicates
a. Higher brain death
b. The patient will not have spinal reflexes
c. Higher and lower brain death
d. The patient has a small chance of recovery
c. Higher and lower brain death
When comparing the airways of a paediatric patient to an adult patient, which of the following is TRUE
a. Apneas <20 seconds in pediatric patients are normal. Apnea is not normal in the adult population
b. The pediatric patient has increased resistance compared to an adult
c. The angle of Louis is located in the same anatomical position in both pediatric and adult patient
d. The pediatric has increased compliance compared to an adult
b . The pediatric patient has increased resistance compared to an adult
In preparation for the Apnea test the patient has a baseline ABG of pH 7.37, PaCO2 42, PsO2 90, HCO3 25, SaO2 97. The patient is prepared for Apnea Test according to the procedure 5 minutes after the Apnea Test commences another ABG is drawn. The results are pH 7.35, PaCO2 58, PsO2 55, HCO3 27, SaO2 88. The patient has not made any spontaneous efforts. What does this ABG indicate
a. Apnea test is negative
b. Apnea test should be discontinued
c. Apnea test is positive and the patient cannot be an organ donor
d. The patient was not preoxygenated adequately
b. Apnea test should be discontinued
. As an RRT on the Outreach Team, which of the following would you NOT do without a Physician’s order
a. Meet a patient’s increasing oxygen requirements by starting optiflow
b. Intubate a patient
c. Start chest compressions on pulseless patient
d. Puncture an obtunded patient for an ABG
b. Intubate a patient
An RRT working on the wards is called to assess a patient. Upon arrival the patient is only rousing with painful stimuli. The patient was speaking coherently with the bedside RN 30 minutes prior to your assessment. You called the switchboard and activate a Code 66. What would you expect?
a. The Outreach team to response within 15 min
b. The Outreach Physician to respond
c. The Outreach team to immediately response
d. The patient MRHP (most responsible health practitioner) to immediately response
a. The Outreach team to response within 15 min
Which of the following is a sign Respiratory Failure in a 4 year old patient
a. Hyperpnea
b. Cyanosis
c. Restlessness
d. Nasal Flaring
b. Cyanosis
You are paged to a ward. Upon arrival you are directed to a room. You enter and find two ward staff standing by a bed. As you enter the room your initial impression of the patient is that they are apneic and unresponsive. The patient has a HR of 50. As you are making these observations, the staff advise you that the patient has a Goal of Care R1. You ask the staff to:
a. Page for an additional respiratory therapist to help with your assessment of the patient
b. Activate a call for assistance (code blue)
c. Get an AED
d. Do nothing as an R1 is not category that includes CPR in the goals
b. Activate a call for assistance (code blue)
The Outreach Team is called to assess a patient. They categorize the call as level one. What does this mean?
a. A code blue should be activated
b. This category indicates the call is non-acute
c. The Intensivist must be notified
d. Only the MRHP (most responsible health practitioner) needs to be called
c. The Intensivist must be notified
The primary cause of most cardiac arrest in pediatrics is
a. Cardiovascular
b. Respiratory
c. Due to Trauma
d. Due to disturbances in neutral thermal environment
b. Respiratory
Which of the following parameters would prompt you to activate a Code 66
a. A desaturation resulting in SpO2 decreasing to 78% that recovers when placed on 4 lpm nasal cannula
b. The patient has suddenly gone into VTach with a pulse
c. The patient has to be shaken to be roused after given their sleeping pill
d. RR is 25
b. The patient has suddenly gone into VTach with a pulse
Which of the following characteristics would be most worrisome when assessing a three year old pediatric patient
a. Poor mentation
b. Crying loudly in response to pain
c. Intercostal retractions
d. A child displaying the characteristics of regressing in mental age
a. Poor mentation
Which of the following is NOT a reason to discontinue a bedside apnea test
a. Spontaneous respiratory effort is observed
b. The CO2 exceeds 60 mmHg and there has been a 20 mmHg change from baseline
c. The physician ask you to discontinue the test
d. The ventilator self cycles
d. The ventilator self cycles
. The family of the patient in bed 2 would like to discontinue care this afternoon. During you morning routine assessment of the patient, you notice copious amounts of oral secretions. Based on this information which of the following would you recommend to the physician
a. Salbutamol
b. Hypertonic Saline
c. Glycopyrrolate
d. Morphine
c. Glycopyrrolate
Member of the Outreach team should notify the Intensivist when
a. A patient requires BiPAP
b. An ABG is required
c. The outreach team has been called twice for the patient in one day
d. A chest X-ray needs to be ordered
a. A patient requires BiPAP
Which of the following may cause an increase in the AP diameter of the chest in a pediatric patient?
a. Cystic Fibrosis
b. Pneumonia
c. Pectus Excavatum
d. Kyphosis
a. Cystic Fibrosis
You are called to a stat call on the wards and perform an ABG on a patient due to decreased level of consciousness. He has a history of lung cancer and is currently recieveing treatment. You look in his chart and note he is a R2 level of care. This means
a. The patient has chosen comfort measure only
b. The patient would consider chest compression as an intervention
c. The patient does not want to go to ICU for care
d. The patient would consider intubation as an intervention
d. The patient would consider intubation as an intervention
What is the purpose of the Spontaneous Breathing Trial during the Airway Management Pathway
a. To demonatrate to family the accuracy of the Apnea Test
b. To predict how long it will take the patient to pass away after the disocntinuousation of care
c. To assess if the patient has an appropriate level of sedation for when they are taken off support
d. To assess the patient for excessive secretions
c. To assess if the patient has an appropriate level of sedation for when they are taken off support
Which type of Outreach team can be led by a RRT
a. Medical Emergency Team
b. Code Blue Team
c. Triage Team
d. Rapid Response Team
d. Rapid Response Team
In which Goals of Care designation would surgery never be considered
a. C1
b. M1
c. M2
d. C2
d. C2
In which period of fetal lung development is the diaphragm completely developed
a. Pseudoglandular
b. Canalicular
c. Embryonic
d. Saccular
c. Embryonic
In which phase of fetal lung development does the estimated age of viability occur
a. Pseudoglandular
b. Canalicular
c. Embryonic
d. Saccular
b. Canalicular
During fetal circulation
a. There are 2 umbilical veins and one artery
b. Oxygenated blood with an SaO2of 80% is carried away from placenta by umbilical vein
c. SVR is greater than PVR
d. The vast majority of oxygenated blood from the placenta passes through the ducts venous
b . Oxygenated blood with an SaO2of 80% is carried away from placenta by umbilical vein
Amniocentesis
a. Carries a risk of miscarriage
b. Commonly performed as a non-invasive test
c. Used primarily to determine gender
d. Relatively risk free
a. Carries a risk of miscarriage
What is the anticipated fetal outcome for a woman who is greater than 45 year old and about to deliver a baby?
a. Increased risk of genetic disorder
b. increased risk of fetal alcohol syndrome
c. Baby is more likely to be SGA
d. There is an increased likelihood of poor prenatal care
e. The baby is more likely to be post term
a. Increased risk of genetic disorder
You are assessing an infant and note the stethoscope you are about to use is cold. Before ausculatating tha baby you warm the diaphragm of the stethoscope in the isolate. You are trying to acoid heat loss due to
a. Convection
b. Evaporation
c. Radiation
d. Conduction
d. Conduction
What is the significance of an infant with RDS demonstrating a grunting during exhaalation
a. An attempt to overcome increased airway resistance
b. Resolution of the RDS
c. An effort to establish/maintain FRC
d. Impending death
c. An effort to establish/maintain FRC
What. Is the anticipated fetal outcome for a pregnant women who has diabetes mellitus
a. IUGR
b. Prematurity
c. Large for gestational age
d. Fetal Asphyxia
c. Large for gestational age
Assuming all other variable remain constant, as deadspace such as HME is added to neonatal circuit, you would expect
a. Decreased alveolar minute ventilation and decreased PaCO2
b. Increased alveolar minute ventilation and increased PaCO2
c. Decreased alveolar minute ventilation and increased PaCO2
d. Increased alveolar minute ventilation and decreased PaCO2
c. Decreased alveolar minute ventilation and increased PaCO2
Entonnox administered during labour
a. Should be used with caution as it causes respitroy depression
b. Mostly composed of oxygen
c. Common analgesic
d. Called nitric oxide
c. Common analgesic
A premature infant score 10 on the PIPP. This indicates
a. The infant should be wrapped for comfort
b. Fentanyl IV should be started
c. Tylenol should be administered
d. Infant has minimial pain
a. The infant should be wrapped for comfort
Which of these may be associated with cord prolapse during labor
a. An increased risk of infection
b. Dangerous bradycardia of the fetal heart rate monitor
c. Decreased RR
d. Alkaline scalp pH
b. Dangerous bradycardia of the fetal heart rate monitor
Which of these disorders may be treated with methylzanthines
a. Transient tachypnea of the newborn
b. Age of prematurity
c. infant respiratory distress syndrome
d. Congenital heart disease
b . Age of prematurity
A term neonate presents with central cyanosis, gasping respiration and a HR of 90. What is an appropriate action?
a. Observe for 30 seconds to assess if the baby is experiencing primary apnea
b. Provide CPAP with neopuff
c. Frimly shake the baby to stimulate
d. Commence positive pressure ventilation
d . Commence positive pressure ventilation
A symptomatic pneumothorax in a newborn would be treated with
a. Exposure to high FiO2
b. NCPAP and closely observe over the next 2 hours
c. Transillumination
d. Needle decompression
d . Needle decompression
You are assessing a term infant with a known congenital heart defect that is dependant on a patent ductus arteriosus. Which of the following options is appropriate for this circumstance?
a. Prostaglandin E1
b. Ligation
c. Oxytocin
d. Indomethacin
a. Prostaglandin E1
An expectant mom with pre-eclampsia is
a. At risk for placenta previa
b. At risk for hemolysis
c. At risk for sepsis
d. At risk for post term delivery
b . At risk for hemolysis
An expectant mom with pre-eclampsia is
a. At risk for placenta previa
b. At risk for hemolysis
c. At risk for sepsis
d. At risk for post term delivery
b . At risk for hemolysis
If an expectatnt mom’s membranes have ruptures for greater than 24 hours this is
a. Normal prior to delivery
b. Indication that the fetus is premature
c. Risk factor for possibility of baby developing sepsis
d. Normal in post mature infant
c. Risk factor for possibility of baby developing sepsis
If an expectatnt mom’s membranes have ruptures for greater than 24 hours this is
a. Normal prior to delivery
b. Indication that the fetus is premature
c. Risk factor for possibility of baby developing sepsis
d. Normal in post mature infant
c. Risk factor for possibility of baby developing sepsis
Which of the following is NOT considered an intrapartum risk factor
a. Epidural pain control
b. Meconium Stained amniotic lfuid
c. placenta abruption
d. premature labor
a. Epidural pain control
When comparing the anatomy of a neonate to an adult
a. A neonates tongue size is proportionally larger than an adults
b. Adults have twice the body surface are/body size ration
c. The diaphragm rests in a lower position in a neonate
d. A neonate trachea is less compliant than an adult
a .A neonates tongue size is proportionally larger than an adults
How is the percentage of functional hemoglobin that is saturated with oxygen determined via pulse oximetry?
The percentage of infrared light that reaches the photodector reflects SpO2
The sum of the amount of red and infrared absorbed by the tissue determines the SpO2
The ratio of the red and infrared light that reaches the photodiodes signified SpO2
The percentage of red light that lands on the photodiode represents oxygen saturation as determines by the pulse oximetry
The ratio of the red and infrared light that reaches the photodiodes signified SpO2
Early decelerations are likely ___________ and probably reflect ______________
Worrisome, cord compression
Benign, nucal cord
Benign, head compression
Worrisome, decreased placental perfusion
Benign, head compression
Which of the following is responsible for maintaining lung inflation during fetal development
Amniotic fluid
Fetal lung fluid
Surfactant
Type II Pneumocytes
Fetal lung fluid
Mom is actively laboring, post membrane rupture. You notice bradycardias and profound decelerations on the tocodynamometer. Which of the following is most likely the cause?
Nuchal cord
Cord compression
Intrauterine pneumonia
Multiple knots in the cord
Cord compression
Which of the following applies to GBS status
Routinely tested for during prenatal care
All GBS positive females need to be on antibiotics when attempting to conceive
It is associated with an increased risk of premature labour
It is associated with an increased risk of placenta previa
Routinely tested for during prenatal care
You are looking at an intubated neonate in the nursery. A mainstream etCO2 is situated inline and an ABG has been correlating well. The PaCO2 on a recent ABG is 48. What would most likely reading on the etCO2 at the time this ABG was drawn
44
48
52
A mainstream etCO2 would never be used on a neonate
44
You are attending a c-section delivery in the operating room. Mom is estimated to be 39 weeks gestation, and the c-section was emergent due to late decelerations. The neonates arrives and is placed on the warmer. After drying, stimulating and suctioning about 1 minutes has passed You quickly assess the following and find
Ruddy appearing face, hands/feet look dusky
Respiration are irregular and shallow
Baby is active and moving its limbs
Baby is crying
HR is palpated from umbilicus is 90
The APGAR is
7
Blood pressure is higher in the pulmonary artery than in the aorta
Only after the umbilical cord is clamped
Prior to birth
Until 3 days post delivery
Once the baby takes the initial breath
Prior to birth
When comparing normal fetal to normal newborn pulmonary vascular resistance
There is no immediate change in PVR post partum
PVR in a fetus is the same as a newborn until 3 days post partum
PVR is lower in the newborn than in the fetus
PVR increases in the newborn compared to in utero
PVR is lower in the newborn than in the fetus
What is the name of the structure that allows mixing of blood between the atria
Foramen ovale
External iliac artery
Ductus venosus
Ductus arteriosus
Foramen ovale
The rhesus status of mom and dad is important because
An Rh- woman who develops antibodies may react to an Rh- baby
If the fetus inherits the Rh factor from dad and Mom is Rh negative. Mom’s body develop antibodies to the fetus
An Rh-baby cannot be carried by an Rh + mom
A baby who is Rh is at an increased risk of spontaneously aborting
If the fetus inherits the Rh factor from dad and Mom is Rh negative. Mom’s body develop antibodies to the fetus
Which of the following events cause cessation of right to left shunting through the foramen ovale
Increased levels of PaCO2 in fetal blood
Decreased SVR
Increased SVR
Decreased levels of PaO2 in the fetal blood
Increased SVR
A fetal heart rate that drops from baseline between 150-140 bpm at the beginning of a contraction and returns to 143 bpm as the contraction ends would be consistent with
A variable deceleration
Tight nuchal cord
Decreased placental perfusion
Benign and normal fetal outcomes
Benign and normal fetal outcomes
Which of the following would give the best indication of oxygenation status
Transcutaneous monitor set to a temperature of 37 degrees Celsius
Capillary blood gas with the limb appropriately arterialized
etCO2 monitor
Pulse oximeter that tis correlating with HR and is located on a well perfused limb
Pulse oximeter that tis correlating with HR and is located on a well perfused limb
A transvaginal fetal scalp pH sample of 7.14
Would need to be repeated immediately to confirm accuracy
Should be repeated every 2 minutes
Is low normal
May necessitate a c-section
May necessitate a c-section
Dilation and effacement of the cervix occurs during
Durign stage 3 of labour
1stphase of the 2ndstage of labour
In the 1st20 minutes of labor
During the first stage of labor
During the first stage of labor
A healthy baby with normal amounts of fetal hemoglobin with have a PaO2 close to _______ when pulse oximeter is showing a saturation of 90%
60 mmHg
27mmHg
40 mmHg
70 mmHg
40 mmHg
Which of the following is associated with maternal fever and premature rupture of the membranes
Congenital anomalies
Maternal diabetes
Pneumonia
MEC
Pneumonia
Fetal Hemoglobin is _________ shift, demonstrating an __________ affinity for oxygen
Left, increased
Right, decreased
Left, decreased
Rght, increased
Left, increased
The goal temperature for therapeutic hypothermia in a neonate is _________oC
- 5
- 5
- 5
- 5
33.5
Placenta Previa
Always results in a c-section
Risk increased with young maternal age
Results in decreased vaginal bleeding because the uterus covers the birth canal
Occurs when the placenta covers the uterine opening
Occurs when the placenta covers the uterine opening
Which of these best describes the condition of “polyhydramnios”
A large for gestational age fetus
A large amount of amniotic fluid in the amniotic sac
Too much fetal fluid
More than one fetus
A large amount of amniotic fluid in the amniotic sac
A mom presents to labor and delivery with no prenatal care. You are present at the delivery and note the presence of lanugo. This indicates
The infant was born with the saccular phase of fetal lung development
The infant is large for gestational age
The neonate is not at a viable gestational age
The infant was born at 36 weeks gestation
The infant was born with the saccular phase of fetal lung development
Respiratory epithelium in the developing fetus emerges
As an off shoot of the heart
From the ectoderm
From the foregut bud
From the placenta
From the foregut bud
Which of these statement describes a “breech presentation”
When a baby presents with a should first through the birth canal
When the baby presents occiput first
When a baby presents with the face first through the birth canal
When a baby present with the feet or buttocks first
When a baby present with the feet or buttocks first
A pregnant woman goes in for a prenatal checkup. At the end of her assessment the Biophysical Profile is calculated to be 9. What does this number indicate
This is a normal BPP
This is a high score that indicates poor fetal outcomes
An emergency c-section is necessary
This is a low score that indicates poor fetal outcomes
This is a normal BPP
First Degree Heart Block
The PRI interval is long
No dropped beats
Wenckebach
Type I
Going, Going, Gone (PRI Interval)
AV node “getting tired” and delays are longer each time until a beat is not conducted
Results in a specific pattern in the PRI: longer, longer, (longer)…then a dropped beat
Second Degree Heart Block (Mobitz II)
When there is a PRI it will be constant but every so often a P wave will just not be there
AV node is unreliable results in dropped beats without warning; can be random or in a pattern (e.g. every third beat)
3rd Degree Heart Block
P Wave and QRS Complex have no relation
Atria depolarizing as normal but no signal gets through; either junction or ventricles takes over pacing of ventricles (at inherent rate and associated QRS width)
These two events (atrial and ventricular depolarization) occur simultaneously but independently, thus, the apparent PRI is random and unrelated to the QRS
Wandering Pacemaker
60-100 bpm (may be slower)
The p wave keeps changing
Atrial Tachycardia
Usually between 150-250 bpm
the p wave is flattened, peaked, and diaphasic and may be hidden
If the p wave is hidden it is a SVT
Premature Junctional Contraction
P Waves will be inverted
Underlying Rhythm
Junctional Escape Rhythm
P wave is inverted and rate is 40-60 with bpm
Accelerated Junctional
P wave is inverted and rate is 60-100 with bpm
Junctional Tachycardia
P wave is inverted and rate is 100-180 with bpm
PVC
Wil have an underlying rhythm and then there is a wide intrupting QRS
Normal PRI
0.12-0.20
Normal QRS
Less than 0.12
Pulseless Electrical Activity (PEA)
Will be no electrical activty on the ECG monitor
Is any pulseless rhythm except for V fib, V tach, or asystole
Idioventricular Rhythm
Will be regular
BPM is 20-40
No p wave
The QRS is greater the 0.12 (wide) and bizarre
Ventricular Fibrillation
Shockable heart rhythm
Completely irregular
Ventricular Tachycardia
150-250 bpm
Will look like a bunch of upsidedown U that are all the same shape and rate
Shockable heart rate
Premature Ventricular Contraction
Will have a normal underlying sinus rhythm and then a random wide QRS complex in the middle of the rhythm
Define underlying rhythm
Trigeminy PVC
Every third beat is a PVC
Quadrigeminy PVC
Every fourth beat is a PVC
Sinus Bradycardia
Rate is less than 60 bpm
P wave before very QRS
PRI is 0.12-0.20
QRS is less than 0.12
Sinus Tachycardia
Rate is over than 100 bpm
P wave before very QRS
PRI is 0.12-0.20
QRS is less than 0.12
Premature Atrial Contraction (PAC)
Will have an ectopic beat that intruppts the underlying regular rhythm
The P wave of the premature beat will look different than that of the underlying rhythm (this also may change the PRI interval as well)
Wandering Pacemaker
The QRS will be consisent but the p wave will change shape and where it is located (sometime might not be there)
Atrial Tachycardia
Bpm will usually be between 150-250
The shape of the p wave will be flattened, peaked, or diaphasic and can blend into the T wave
Unlike atrial flutter will still and an isoelctrical baseline (stright line where they originate from)
Atrial Fibrillation
No true P wave only a squiggly line
QRS will be between 0.12-0.20 and all the same shape
Atrial Flutter
Atrial rate between 250-350
Sawtooth patteren
QRS will be between 0.12-0.20 and all the same shape
Sinus Tachycardia
ECG Recording
All ECG will use the same paper which runs through the at the same speed (25 mm/sec)
Small Squares- 1 mm2
Junctional Rhythms
Originate in junction, and retrograde conduction in atria
Inverted or absent p-wave
Supraventricular Rhythm
Technically in order to classify the type/origin of the tachycardia you need to be able to see the p-wave
At rates greater than 150 bpm it is unlikely that you will be able to see p waves as they will be hidden in the t wave
SVT is a descriptive term applied to tachycardias that cannot be differentiated because the P waves are not able to be visualized
Paroxysmal SVT
PSVT = paroxysmal SVT, it occurs and ends without warning
Wolff-Parkinson White
A congential malformation resulting in a accessory atrioventricular pathway which allow the AV nose to activate ventricles prematurely
The risk is the potential rapid ventricular response
Atrial fibrillation will occur in 1/5 to 1/3 of WPW patients
More common in men
Wolff Parkinson White ECG
Patient is usually in as normal sinus rhythm but re-entry causes a tachycardia
PR is usually < 0.12s
QRS complex > 0.11
Has a characteristic “slur” (delta wave)
How do you find the QRS Complex
Look for the biggest QRS complex on a frontal plane lead and use the lead to determine.
Note: If the biggest deflection is negative then the axis is directly opposite of that l
MAP Equation
MAP =(Systolic x 2 diastolic) / 3
Systemic Vascular Resistance (SVR) Normal
1200-1600 dynes.sec.cm^ -5
CVP Normal
CVP 2-8 mmHg
Pulmonary Vascular Resistance (PVR) Normals
120-240 dynes.sec.cm^-5
Pulmonary Artery Pressure (PAP) Normal
(20-30)/(6-15) mmHg
Pulmonary wedge Pressure (PAWP) Normals
4-12
Stroke Volume (SV) Normals
60-130 ml/beats
Cardiac Index (CI) Equation
CI=CO/Body SA
neurogenic shock
All hemodynamic readings are low and there will be no increase in HR and SVR to compensate
hypovolemic shock,
In hypovolemic shock, we see decreased volumes, meaning decreased pressures and CO in the heart, however HR and SVR will increase to compensate (unlike in neurogenic shock)
septic shock,
In septic shock, patient’s are fluid resuscitated, meaning they will have lots of fluid on boarding, leading to an increased CO.
The SVR will be decreased in septic shock as the blood is pooling in the extremities and not returning to the heart, leading to decreased BP.
Therefore the HR will increase to compensate for the hypotension and lack of perfusion (even though there is lots of fluid)
HR and SVR are in a direct relationship and are compensatory measures (except for in septic and neurogenic shock). They will increase to compensate for decreased CO and decrease to compensate for increased CO.
SvO2
Measured in the PA port
Some have continuous monitoring via reflection spectrophotometry
Ca-vO2
Can assess for left to rt shunt by measuring from CVP (Proximal port) and PA distal
Mixed venous sampling
- Will get this sample from dital port of pulmonary artery catheter (only place you can get a true mixed venous smaple!
- Mixed venous is getting blood from all the body including blood from heart and lungs
- SvO2 and C(a-v)O2
Hypovoluemic shock
Everything is decreased so HR and SVR are trying to compensate
Cardiogenic Shock
Everythgin goes up but BP and CO
Septoc Shock
Everything goes down
CO can go up or down
HR and SVR go up to compensate
Neurogenic Shock
Everything absolutely go down
Obstructive Shock
CVP goes up
PAP and PAWP can go up or down
BP and CO go down
HR and SVR go up
Arterial O2 Content (CaO2)
Total amount of oxygen contained in arterial blood; going to the body
Oxygen is carried by
- Hemoglobin (Hb)-major carrier of O2
- Dissolved in Plasma
CaO2 = (Hb x 1.34 ml/g) * SaO2 + (PaO2 x 0.003 ml/100ml/mmHg)
Mixed Venous O2 Saturation (SvO2)
Saturation of the blood in the pulmonary artery
True mixed venous blood is in the pulmonary artery
The sample is drawn from the distal port of the PA catheter and analyzed on the blood gas machine
Some specialized PACs measure SvO2 continuously, in vivo
An early indicator of changes in O2 transport status
•Mixed Venous O2 Content (CvO2)
CvO2 = (Hb x 1.34 ml/g) * SvO2 + (PvO2 x 0.003 ml/100ml/mmHg)
Normal = 13 - 16 mL/dL (vol%)
•Oxygen Delivery (DO2)
Total oxygen delivered to body
- Requires:
- Arterial O2 content
- Cardiac Output (C.O.) or (QT)
DO2 = QT * (CaO2 * 10)
Shunt Fraction
<10%-Normal
10-19%-Seldom need vent support
20-29%Require PEEP or CPAP
30 or more- life threatening need mechanical vent with PEEP
Epinephrine
Class of Drug: Inotrope, vasoactive agent
Generic: Epinephrine
Trade: Adrenaline
Mechanism of Action: Will affect CO and SVR. Is an alpha and beta adrenergic agonist, vasopressor, chronotrope, and dromatatrope
Indications: Cardiac arrest (will be given as a bolus), pulseless arrythmia, Hypotension, Anaphylaxsis
Norepinephrine
Class of Drug: Inotrope, vasoactive agent
Generic: Norepinephrine
Trade: Levophed
Mechanism of Action: Will affect CO and SVR. Is an powerful alpha and beta1 which results in an increase in myocardial contractility
Indications: Hypotension, distributive shock
Dopamine
Class of Drug: Inotrope, vasoactive agent
Generic: Dopamine
Trade: Intropin
Mechanism of Action: Precurser to norepinphrine. Stimaultes alpha, beta, and dopmerginic recpetors. Only administered via IV
Indications:
Low Dose (1-5 mg/kg/min): Renal Dose (dilate renal arteries)
Medium Dose (5-10 mg/kg/min): Cardiac Dose (treat bradycardia by increase CO)
High Dose (1-5 mg/kg/min): Vasopressor Dose (treat hypothermia with alpha effects of decreaseing SVR and constrction)
Phenylephrine
Class of Drug: Inotrope, vasoactive agent
Generic: Phenylephrine
Trade: Neo-Synephrine
Mechanism of Action: Alpha agonists with minimal stimulation. Last 20 min (loner the epinephrine)
Indications: Hypotension and used in RSI for hypotension
Vasopressin
Class of Drug: Inotrope, vasoactive agent
Generic: Vasopressin
Trade: ADH
Mechanism of Action: Non adrenergic peripheral vasoconstrictor
Indications: PEA, Hypotension,
NO BETA STIMULATION
Dubutamine
Class of Drug: Inotrope, vasoactive agent
Generic: Dubutamine
Trade: Dobutrex
Mechanism of Action: Syntheteic catecholamine taht produces predominately beta effects (iontrope) and change BP
Indications: Patients with heart pumping problems and a systolic BP of >70mmHg
Isoproterenol
Class of Drug: Inotrope, vasoactive agent
Generic: Isoproterenol
Trade: Isuprel
Mechanism of Action: Nearly a pure beta agonists, patent iontrop and chronotrope, will decrease BP and increase SVR
Indications: Rarely used to treat bradycardia or b blocker overdose
Imamrione and Mitrinone
Class of Drug: Inotrope, vasoactive agent
Generic: Imamrione and Mitrinone
Trade: Inocar and Primacor
Mechanism of Action: Causes iontropic effects in the heart, peripheral vasodilation (does not affect sympathetic NS)
Indications: Severe CHF, Refractory cardiogenic shock
Atropine
Class of Drug: Chronotrope
Generic: Atropine
Trade: N/A
Mechanism of Action: Parasympathetic (enhance autonomacay of SA node which will increase rate through av conduction)
Indications: Symptomatic bradyarrhythmia but may not work in heart blocks
Lidocaine
Class of Drug: Class I Anti-Arrthymias (Na Channel Blockers)
Generic: Lidocaine
Trade: Xylocaine
Mechanism of Action: Suppress ventricle arrthymias and decrease myocardial conduction and increase VF threshold
Indications: Refractory Shock, VF (pulseless), and VT management. Manage PVC irritability
Class II Anti-Arrhythmias (B-Blockers)
Names: Mteoprolol, propranolol, labetalol, atenalol, esmalol
Mechanism of Action: Beta Blocker Adrenergic Receptor
Decrease the effect of catecholamines, decrease HR and BP, decrease myocardial contraction and O2 consumption
Avoid in diseases with bronchospasms
Indications: Acute Coronary syndrome, hypertension, actute tachycardia (SVT)
Amiadarone
Category: Class III Anti-Arrhythmias (K Channel Blockers)
Generic Name: Amiarone
Trade Name: Cardarone
Mechanism of Action: Second line in ACLS
Indications: Refractory shock, pulsleless VF, VT, tachycardia,
Can cause amidarone lung or smurf lung
Adenosine
Category: Class IV Anti-Arrhythmias (Ca Channel Blockers)
Generic Name: Adenosine
Trade Name: Adenocard
Mechanism of Action: Endogenous compound that depresses both the SA and AV node
Indications: Treat SVT, warn patients of sensations of heat, chest pain, and flushing
Do not give to asthmatic patients
Digoxin
Category: Class IV Anti-Arrhythmias (Ca Channel Blockers)
Generic Name: Digoxin
Trade Name: Lanoxin
Mechanism of Action: Cardiac glycoside, derivities of digitalis, anti-arrhythmia and inotropic
Indications: Decreased ventricular repsonpe in atrial fibirllation or atrial flutter
Narrow Therapeutic Range
May cause arrhythmias and precitate cardiac arrest
Nitroglycerin
Nitroprusside
Category: Nitric Vasodilator
Generic Name: Nitroglycerin, Nitroprusside
Mechanism of Action: Breaks down nitric oxide to produce vasodilation
Indications: Angina, AMI, CHF, hypertensive crisis
Can result in hypotension
ACE Inhibitors
Category: ACE Inhibitors
Generic Name: Captropril
Mechanism of Action: Prevent sysnthesis of angotensin which will result in vasodilation
Indications: Hypertension, Myocardial infarction
What are drugs with Positive Chronotropic Effects
Anything that stimulates B1 thus: epi, norepi, dopamine (moderate/cardiac dose), Dobutamine
Also, Atropine
What is a drug that is a powerful alpha agent
Levophed, Phenylephrine and dopamine (high/pressor dose).
What are the effects of beta 2 stimulation
Bronchodilation (for receptors in the lungs) and vasodilation (due to the receptors in the periphery)
Cautions with beta 1 stimulation
The increased HR and contractility cause an increase in myocardial demand/oxygen consumption and myocardial irritability. Also decreased time in diastole…may impact filling time at high rates.
Effects of Dopamine
Low Dose (1-5 mcg/kg/min) results in renal and splanchnic vasodilation (due to dopaminergic receptor stimulation)
Moderate Dose (5-10 mcg/kg/min) results in increased HR, contractility and rate of conduction due to B1 stimulation
High Dose (10-20 mcg/kg/min) results in increased SVR and increased BP due to a1 stimulation
When is a bolus of Epinephrine given
In pulsesless states! VT, VFib, PEA and asystole
Vasopressin is also an alternative that can be given and it will have the advantage that there is no B1 stimulation thus doesn’t further stress the heart (beyond the increased afterload it results) with the increased HR and increased irritability
How do “Iondilators” work and Why are they helpful in patients with CHF
Inhibit phosphodiesterase III (an enzyme that breaks down cAMP. Increased levels of cAMP in the heart results in increased inotropism and increased cAMP in peripheral smooth muscles causes vasodilation
Heparin
Coumadin
Category: Anti-Thrombolytic/Coagulation
Generic Name: Heparin, Coumadin
Mechanism of Action: Heparin inhibits clotting pathway, Caumadin will use used post heparin
Indications: Treat thromboemobulism, PE, atrial fib, intravascular coagulation
CAUTION: Bleeding, bruising, hemorrhage
ASA
Abciximab
Clopidagrel
Category: Anti-Thrombolytic/Platlet
Generic Name: ASA, Abciximab, Clopidagrel
Trade Name: Aspirin, Repro, Plavix
Mechanism of Action: prevent thromboxone fomation
Indications: Thrombolus embolism, myocardial infarction
Cation Increased risk of bleeding, relative contraindications when thrombolytics are used
Alteplase
Retephase
Streptokinase
Tenecteplase
Category: Anti-Thrombolytic
Generic Name: Alteplase, Retephase, Streptokinase, Tenecteplase
Trade Name: tPA, Retavase, Streptose, TNK
Mechanism of Action: Lyse formed thrombi be degrading fibrin
Indications: Acute myocardial infarction, PE,
