PreLabs Flashcards
What basic examinations and physical examinations are done as part of a neurological assessment
Assessment of Level of Consciousness (LOC) Glasgow Coma Scale (GCS) Motor examination Posturing (decorticate or decerebrate) Reflex testing (including brain stem reflexes in stuporous or comatose patients) Pupils/ pupillary reflex C-Spine precautions Sedation Assessment Delirium (CAM-ICU)
How is a critically ill patient’s level of consciousness best evaluated
The Glasgow Coma Scale (GCS) is a standardized method of evaluating a patient’s LOC. This method ranks patient response in three categories to create a score than ranges from 3 (lowest LOC) to 15 (fully awake). These categories are eyes open, best verbal response, and best motor response.
How is the Glasgow Coma Scale level modified when the patient is intubated
If the patient is intubated, a “T” is placed after the score
Your patient has a cervical spine fracture at C4 with spinal cord involvement. How will this impact their respiratory system
A patient with a C-Spine injury may be unable to protect their airway. Due to limited mobility, this type of injury may result in difficulty stabilizing and securing the airway for spontaneous breathing. Further, if there is damage to the central or peripheral nervous systems, the patient’s drive and/or ability to breathe spontaneously may be affected and interventions may be needed in order to ensure proper ventilation occurs.
How can motor strength be assessed in an unconscious patient
An unconscious patient is assessed by applying a noxious stimuli and assessing the response.
What brainstem reflexes do RTs typically assess? Which cranial nerves are responsible for these
RTs are focused on the reflexes that affect gagging and coughing during suctioning because these reflexes protect the airway. The glossopharyngeal cranial nerve (9th) and the Vagus cranial nerve (10th) are responsible for these reflexes, respectively.
Your patient does not respond to your voice but withdraws to physical stimulation. What level of sedation is this according to the Richmond Agitation Sedation Scale (RASS)
According to RASS, a patient not responding to voice but withdraws to physical stimulation is under a deep sedation rated as a -4 on the Scale.
. Your patient is moving about spontaneously with non-purposeful movements. The ventilator is frequently alarming because of patient-ventilator dysynchony. What level of sedation is this according to the Richmond Agitation Sedation Scale (RASS)
According to RASS, a patient that is moving with non-purposeful movements and fighting with the ventilator is considered agitated and rated as a +2 on the Scale.
Define delirium
Delirium is defined as a sign of acute brain dysfunction resulting in a disturbance of consciousness with reduced ability to sustain or shift attention. Delirium develops over a short period of time and tends to fluctuate over the course of the day
What does delirium in the ICU patient indicate
If delirium is present in an ICU patient, it is a sign that there is an underlying medical problem that needs addressing immediately. Delirium can be monitored in the ICU by using the Confusion Assessment Method for the ICU (CAM-ICU) assessment or the Intensive Care Delirium Screening Checklist (ICDSC) assessment
List the non-pharmacologic interventions that can be used to manage delirium.
The nonpharmacological that can be used to manage delirium includes frequent reorientation of the patient, cognitively stimulating activities, sleep protocols, early mobility and ROM exercises, timely removal of catheters, use of aids (eyeglasses, hearing aids, etc), early correction of dehydration, and the minimization of unnecessary noise.
Summarize the ABCDE protocol
The ABDCE protocol is designed to standardize care processes and improve collaboration among members of the healthcare team. By using this protocol we can break the cycle of oversedation and prolonged ventilation. ABC is in regards to awakening and breathing coordination. D is in regards for delirium management and interventions. E is in regards to early exercise and mobility.
Describe why spontaneous awakening trials are coordinated with respiratory care
To make sure that is there is any problems in breathing when doing a spontaneous awakening trial it can be managed and taken care of with the respiratory care team.
Your patient’s intracranial pressure (ICP) is 20 mmHg and the mean arterial pressure (MAP) is 95 mmHg. Calculate the cerebral perfusion pressure and describe the impact on cerebral perfusion
CPP= MAP-ICP CPP= 95-20 CPP= 75 The capillary bed is compressed and microcirculation will be compromised.
Describe the purpose of jugular venous oxygen saturation monitoring.
Jugular venous oxygen saturation monitoring (SjvO2) assesses global cerebral oxygenation in patients with traumatic brain injuries by inserting a catheter into the internal jugular vein and directing it upwards to where the tip of catheter rests in the jugular venous bulb located at the base of the brain.
After insertion, blood samples can be taken to measure the partial pressure of oxygen or saturation of the jugular veins.
Typically, a normal SjvO2 is from 50-75% and can be taken continuously.
Describe the purpose of Licox monitoring.
Compare this to SjvO2 monitoring
The purpose of Licox Monitoring is to assess the level of brain tissue oxygenation by connecting to a catheter inserted in the brain. Licox monitoring is typically done in patients with a traumatic or neurological brain injury.
On the other hand, SjvO2 monitoring is only done on TBI patients and measures cerebral oxygenation in areas around the brain
When is Train of Four monitoring used and why
Train of Four monitoring is a peripheral nerve stimulator that measures the effects neuromuscular blockade agents (NMBA) have on musculoskeletal activity. Usually, electrodes are placed over the ulnar artery at the wrist or the elbow and clinicians measure the number of twitches in response to a stimulus. The number of twitches is indicative of the percentage of blockade effect the NMBA has
Describe purpose of therapeutic hyperventilation. Is this a routine therapy
The purpose of therapeutic hyperventilation is to increase minute ventilation in hopes of decreasing PaCO2. Subsequently, cerebral arteries vasoconstrict and reduce cerebral perfusion. Ultimately, decreasing intracranial pressure. This is not a routine therapy because if we decrease cerebral perfusion too frequently, then oxygen delivery to the brain decreases and may cause an anoxic brain injury
our patient is being sedated with midazolam and morphine and is receiving tubocurarine. The TOF is at 1⁄4 twitches. What do you expect when assessing their gag and cough response? Explain why
Since the patient displays only 1⁄4 twitches in response to the stimuli, 90% blockage is occuring due to the effects of tubocurarine. Tubocurarine is a NMBA, which means it will relax the skeletal muscle. When assessing their gag and cough response, we would not expect it to occur that much because of the lack of response seen during TOF monitoring. Also, since tubocurarine paralyzes the skeletal muscle, the gagging and coughing response will not occur as frequently as well
Describe purpose of therapeutic hypothermia. Is this a routine therapy
The purpose of therapeutic hypothermia is to lower body temperature of patients who have recently experienced cardiac arrest, a stroke, or a traumatic brain/spine injury. Essentially, reducing body temperature will reduce blood flow and consequently, reduce the risk of ischemic injury. This is not a routine therapy as there are complications, like arrhythmias, coagulation issues, risks of infection and a risk of electrolyte imbalance. Also, rewarming should be done slowly and steadily as it may cause harmful spikes in intracranial pressure. Most deaths that occur from therapeutic hypothermia are due to the rewarming process done inadequately.
Sedation level in the ICU is a delicate balance. Discuss the negative impact of too little and too much sedation
Too Little: -Feel pain and have anxiety -Increased stress levels -Patient-ventilator synchrony -Adverse neurocognitive sequelae (PTSD or depression) Too Much: -Failure to initiate spontaneous breathing, thus longer duration of mechanical Ventilation -Longer duration of stay in ICU -Increases risk for delirium -Impede assessment of neuro function -Many agent-specific risks
Propofol
Trade Name: Diprivan
Effects/Uses: General Anesthesia
Cautions: No analgesic effects
Lorazepam
Trade Name: Ativan
Effects/Uses: Treat anxiety, sleep issues, alcohol withdrawal, active seizures, and nausea
Side Effects: Weakness, sleepiness low BP, decreased effort to breath
Diazepam
Trade Name: Valium
Effects/Uses: Calming, benzodiazepines withdrawal, alcohol withdrawal,
Side Effects: Sleepiness, coordination issues, suicide, decreased breathing
Midazolam
Trade Name: Versed
Effects/Uses: Induction agent
Cautions: Should not be used in emergencies due to its slow onset, stops memory formation
Demedetomidine
Trade Name: Precedex
Effects/Uses:Anxiety reducing, sedative, pain med.
Used as a sedative without respiratory depression
Phenobarbital
Trade Name: Barbituates Effects/Uses: Seizure controller
Pethidine
Trade Name: Demerol
Effects/Uses: Anaglesic for moderate to severe pain. Rapid onset
Cautions:Effect only last 1-2 hours
Reversal Agent: Naloxone
Fentanyl
Trade Name: Actiq, Duragesice, Fentora Effects/Uses: Pain Med, used in combination with anaesthia. Rapid onset but effect only last 1-2 hours Reversal Agent: Naloxone
Haloperidol
Trade Name: Haldol Effects/Uses:Anti-psychotic, delirium management (only after her medicine/therapies have been tried)
Succinycholine
Trade Name: Anectine
Effects/Uses:Depolarizing Paralytic
Reversal Agent: No reversal agent
Atracurium
Trade Name: Tracrium Effects/Uses: Non-depolarizing Paralytic Reversal Agent: Neostigmine
Pancuronium
Trade Name: Pavulon Effects/Uses: Non-depolarizing Paralytic Reversal Agent: Neostigmine
Rocuronium
Trade Name: Zemuron Effects/Uses: Non-depolarizing Paralytic Reversal Agent: Neostigmine
CO
Cardiac output is the volume of blood pumped by the heart per minute. Normal value: 4-8 L/min. Directly Measured
SV
Stroke volume is the volume of blood ejected from the left ventricle per every contraction. Calculated
Assuming CO remains the same, as SVR is increased, BP ____________ (increases, decreases or remains the same).
___increases___
- Assuming SVR remains the same, as CO is decreased, BP ______ (increases, decreases or remains the same).
decreases__
- Describe how systemic vasodilation affects BP.
Systemic vasodilation will relax the blood vessels and reduce systemic vascular resistance. The reduction in resistance will will also lead to a decrease in blood pressure.
Cerebral Oximetry
SaO2 of the underlying tissue
Can be both a continuous monitor as well as a spot check
Idioventricular Rhythm
3rd Degree HB
Severe Mitral Valve Stenosis
HR Increased
SVR Decreased
BP Decreased
CO Increased
CVP Decreased
PAP Decreased
PAWP Decreased
When is defibrillation indicated
Pulseless VT and Vfib
When is trancutaneous pacing indicated
unstable bradyarrhythmia
When is synchronized Shock indicated
Unstable Tachyarrhythmia
In Pressure Control Why Can you not determine airway resistance
because flow will vary in this mode
What happens to CVP in PPV and spontaneous breathing
CVP will increase with PPV and decreased with spontaneous breathing
PPV and V/Q Mismatching
Will increase (worsening)
PPV and Pulmonary Vascular Resistance
Will decrease due to improved ABG
Will increase due to compression of alveolar capillary via overdistension of alveoli
PPV and Venous Return and CO
decreased venous return
Decreased CO
PPV and Renal System
Decrease urine output
Increased ADH and ANP release
activation of renin antiotension
Differentiate between barotrauma and volutrauma.
Barotrauma causes rupture of the A/C membrane and results in air leaking into places it shouldn’t be (pneumothorax, pneumomediastinum, PIE)
Volutrauma causes stretch injury to the A/C membrane and results in leaky A/C membranes and release of inflammatory mediators.
Differentiate between atelectatrauma and shear stress.
Arelectatrauma is the injury resulting from repetitive derecruitment/recruitment of alveoli—typically occurs in the dependent areas. Shear stress the is the strain injury on the alveolar wall between the expanded unit and derecruited unit; causes capillary injury.
Describe what is meant by “open lung ventilation”.
Using appropriate PEEPS to maintain recruitment of lung units throughout exhalation (i.e. avoiding derecruitment).
Describe how V/Q matching are impacted with positive pressure ventilation.
Both increased deadspace (in gravity independent areas) and increased shunt (in gravity dependent areas).
A high PEEP would be most likely to cause hemodynamic compromise in which of the following patients? (Rank from most likely to cause compromise (1) to least likely to cause compromise (4).
COPD patient
ARDS patient
Normal lungs
Patient with significantly increased intraabdominal pressure
__2__ COPD patient
__4__ ARDS patient
__3__ Normal lungs
__1__ Patient with significantly increased intraabdominal pressure
Your patient is being ventilated in CMV-VC with RR 15 and VT 500. As deadspace increases, you would expect to happen to the following
VD/VT
PECO2
VA
PaCO2
VD/VT Increase
PECO2 Decrease
VA Decrease
PaCO2 Increase
Hemodynamic profile in regards to CO, Hr, and SVR
Heart rate will always be opposite of CO an
SVR and HR will always go in the same direction except in septic shock
Hemodynamic Profile of Obstructive Shock
CVP Increase
PAP Can be normal, increased, or decreased
PAWP Can be normal, increased, or decreased
BP Decrease
CO Decrease
HR Increase
SVR Increase
Hemodynamic Profile of Neurogenic Shock
CVP Decrease
PAP Decrease
PAWP Decrease
BP Decrease
CO Decrease
HR Decrease
SVR Decrease
Hemodynamic Profile of Septic Shock
CVP Decrease
PAP Decrease
PAWP Decrease
BP Decrease
CO Increase
HR Increase
SVR Decrease
Hemodynamic Profile of Cardiogenic Shock
CVP Increase
PAP Increase
PAWP Increase
BP Decrease
CO Decrease
HR Increase
SVR Increase
Hemodynamic Profile of Hypovolemia Shock
CVP Decrease
PAP Decrease
PAWP Decrease
BP Decrease
CO Decrease
HR Increase
SVR Increase
