quiz 1 - vitals Flashcards
vital signs are vital
-Vital signs = “vita” (life) signs
-Be critical of vitals
-Failure to note or address abnormal vitals -> malpractice claims
-Be wary of vitals at discharge
-AVSS = All vital signs stable -> NO
-A dead pt has very stable vitals
-“Vital signs normal” is a better version
temperature
-Fever = 100.4F (38C) or greater (kids and adults!)
-Oral: mouth breathing, cool liquids can falsely lower
-Axillary and tympanic: often miss fevers
-!!Rectal temp are more accurate
-Most accurate -> esophageal or bladder (only in critically ill)
-Elevated temperatures can be caused by TIME:
-Toxic (anticholinergics, NMS)
-Infections
-Metabolic (hyperthyroidism)
-Environment (heat stroke) -> dont give tylenol -> cool them
-neutropenic patients CANT GET RECTAL TEMPS -> infection risk
-EX. CHEMO
antipyretics
-Acetaminophen
-15mg/kg orally for children q4-6 hrs PRN
-Do not exceed 5 doses in 24 hours or 75mg/kg/day
-650-1000 mg orally for adults q4-6 hrs PRN
-Do not exceed 4g a day
-Ibuprofen (NSAIDs)
-10mg/kg orally for children q6-8 hrs PRN
-Do NOT use in children < 6 months old
-Maximum daily dose: 40 mg/kg/day or 2,400 mg/day, whichever is less
-200-400mg orally for adults q4-6 hrs PRN
-Maximum 1.2g a day
-Both work well to bring down a fever
blood pressure
-guidelines are updated regularly
-If elevated -> repeat after a period of observation
-If being discharged with elevated BP, note “elevated blood pressure”, NOT “hypertension”, and refer to PMD for recheck
-Remember the sources of error in BP measurement -> legs crossed, wrong size, anxiety, heart level
-!!Do not treat elevated BP unless urgent medical need to do so!!
-headache, chest pain, vision change -> tx if emergent
-if you treat it emergently for no reason -> stroke or heart attack -> due to lack of perfusion
shock
-imbalance between oxygen delivery and demand causing tissue hypoxia
-Often, but not always, assoc with hypotension ± tachycardia
-BP/HR can remain normal despite a 30% acute blood loss
-Measurement of anaerobic metabolism via blood LACTATE levels (often on VBG) can detect shock when vital signs are not diagnostic
-Shock index = HR / systolic BP
-Should be <0.9 (normal range is 0.5-0.7)
-Can predict uncompensated shock
heart rate
-Take pulse yourself
-Check rate, regularity, strength
-Adults 60-100 (red flags past 90)
-If irregularities are found, consider a monitor
respiratory assessment
-Normal rate for adults is 12-16
-Even if “normal” rate, must consider:
-Tidal volume (shallow, deep)
-Respiratory effort (easy breathing vs. labored breathing)
-Measure of metabolism
pulse oximetry
-Sea level normal is 98%
-!!!Pulse oximetry <90% highly worrisome -> Translates to PaO2 of 60mmgh
-Assume low numbers are real -> monitor
-even if underlying COPD, obesity hypoventilation syndrome etc. that may cause baseline low pulse oximetry
-88-92 for COPD
-94-95 obesity hypoventilation syndrome
ABCDE review
-airway
-breathing
-circulation
-disability
-exposure
-watch the video
what are signs of unprotected airway
-GCS < 9 (obtunded)!!!!!
-Cardiac arrest
-Abnormal breathing sounds
-Stridor
-Snoring
-Expiratory wheezing
-Gurgling
-Paradoxical movements
-Cyanosis
-Expanding hematomas
what causes airway compromise
-Traumatic injury
-Tongue
-Foreign body
-Vomit, blood, secretions -> suction
-Angioedema, anaphylaxis -> Epi
-Can we do anything to reverse these causes of airway compromise? If not, what do we do?
Indications for ADVANCED airway management
-if you cant do an easy fix…
-Unprotected airway
-BVM / BiPAP not appropriate choice for oxygenation or ventilation
-Expected future airway difficulty (trauma, burns, angioedema)
->endotrachial tube
pt cant breathe = breathe for them
-unconscious and not breathing
-tubing takes too long -> while you get things ready…
-Bag valve mask (BVM)
-Brand: Ambu
-Can give: Oxygen, ventilation, PEEP
-One person: C-E grip
-Two person: JAWS
-Jaw thrust
-Airway adjunct (oral/nasal)
-Work together
-Slow, small squeezes
-Use before and in-between any attempts at definitive airway
airway management options
-endotracheal
-cricothyroidotomy -> if obstruction, burns, swelling from anaphylaxis, epiglottitis
-OPA- oral pharyngeal tube -> unconsious
-NPA
rapid sequence intubation- 4Ps
-Pre-oxygenation
-Non-rebreather or high-flow nasal cannula
-Nasal cannula 15L/min for apneic oxygen
-Physiologic optimization
-Fluids, pressors as appropriate
-dont want pt hypotensive
-Positioning
-“Sniffing”
-Ramped if obese/pregnant/trauma
-Room and team Preparation
-Equipment set up, checked, backup equipment
-Roles assigned
mallampati score
RSI
-Rapid sequence intubation at time 0
-INDUCTION AGENT:
Etomidate 0.3 mg/kg IV
Ketamine 1-2 mg/kg IV
Propofol 1-2 mg/kg IV
-PARALYSIS with NEUROMUSCLAR BLOCKING AGENT:
Succinylcholine 1-2mg/kg IV
Rocuronium 0.6-1.5mg/kg IV
-dont need to know med names
placement (laryngoscopy) once paralyzed and apneic
-Open mouth with scissor or fish-hook technique
-Insert laryngoscope
-Identify landmarks - epiglottis, vocal cords
-Insert endotracheal tube
post intubation mangement
-Respiratory therapy for ventilator
-Chest XR for ET tube confirmation
-EtCO2 monitoring
-Post intubation analgesia- Fentanyl, morphine, hydromorphone
-Post intubation sedation- Propofol
-capnography
-breath sounds
-chest x ray
-call RT to get the machine for you so you dont have to keep bagging
breathing: signs of respiratory distress
-Inspection
-Cyanosis
-JVD- PE, cardiac tamponade, tension pneumo
-Accessory muscle use- subcostal, intercostal, belly breathing (kids)
-Abdominal breathing
-Percussion
-Hyperresonance in pneumothorax
-Dullness in hemothorax or pneumonia
-Palpation
-Subcutaneous emphysema (crepitus, pneumothorax), tracheal shift, flail segments
-Auscultation
-Wheezing?
-Unequal breath sounds?
-↓ Oxygen saturation
-↓ end tidal CO2
oxygen delivery devices
indication for non-invasive positive pressure ventilation (NIPPV) such as BiPAP
-Examples of when to use NIPPV:
-COPD
-Pulmonary edema (CHF)
-when not tolerating the other choices
-Acute hypoxic respiratory failure
-Infection or pna
-Asthma exacerbation
-PE
-Atelectasis
-Post trauma (not face!)
-Acute hypercapnic respiratory failure ± resp failure
-Asthma or COPD exacerbation
-HF or pulm edema
-Hypoventilation from sedation
-Progressive obesity hypoventilation syndrome
-Progressive neuromuscular disease
CONSIDER NIPPV IN PTS WITH vs WHEN NOT TO USE NIPPV:
CONSIDER NIPPV IN PTS WITH:
-Awake and alert- aspiration, air goes into stomach
-Moderate to severe dyspnea
-Accessory muscle use
-Paradoxical abdominal movements
-Getting fatigued
-RR > 25
-pH < 7.25
-pCO2 > 45
WHEN NOT TO USE NIPPV:
-Altered mental status
-Respiratory arrest
-Absent respiratory drive
-Unstable hemodynamics
-Aspiration risk including secretions, uncontrolled vomiting, increased coughing/swallowing
-Unable to tolerate mask
-Mask does not fit
-Upper airway trauma or recent ENT surgery
-unconscious: If not awake - air goes to stomach -> aspiration PNA -> ARDS -> die
BiPAP- non-invasive ventilation complications
-Barotrauma (rare)
-Pressure ulcers of nasal bridge- TIGHT
-Claustrophobia /anxiety- give meds
-Aspiration from vomiting
-Hypotension (esp in Right HF)
circulation
-Causes of poor circulation
-Shock
-Arterial injury
-Cardiac arrythmias
-Heart failure
-Pulmonary embolism
-Circulation assessment
-Blood pressure
-Distal pulses
-Skin temperature
-Capillary refill time
-Urine output
-Circulation management
-Direct pressure on hemorrhages
-2 large bore IV
-Transfusion protocol
disability and dextrose
-Disability assessment is to determine if there is presence of neurologic injury
-pupil exam
-motor and sensory
-GCS for LOC
GCS
disability and exposure
-Exposure assessment is to evaluate and manage negative environmental effects
-Undress the patient to perform a full physical exam!
the ABCs and their possible interventions
assessment in emergencies - primary and secondary
Primary survey:
-Aka initial assessment
-ABCDE
-goal -> detect and correct immediate threats to life
Secondary survey:
-comprehensive eval of pt
-head-to-toe physical exam
-Reassessing vital signs
-Obtaining a detailed history
-Asking pt and others about incident
-Ordering lab and imaging studies
oral boards
Chief complaint
Vitals
General appearance
Primary survey
History
Secondary survey
Orders / Interventions / Consults / Reassessment
Dispo
-vitals, general appearance, cardiac monitor (3 lead ekg, pulse ox, BP cuff) , IV access, +- oxygen and defib pads
