RPA orientation moodles Flashcards
for ventilation how many ml/kg??
This module is based on the ARDS network study published in the New England Journal of Medicine (NEJM 2000;342:1301-8). This was a trial of 861 patients with moderate to severe Acute Respiratory Distress Syndrome (ARDS) randomised to receive ventilation using tidal volumes based on Ideal Body Weight (IBW). The conventional ventilation group received tidal volumes of 12mL/kg IBW and the low tidal volume group using 6mL/kg of IBW. The study found that patients in the low tidal volume group had a significantly lower mortality (31% compared to 40% p=0.007) and a shorter time on the ventilator (10±11 days vs. 12±11 days, p=0.007). This mortality has been subsequently proven and improved in subsequent ARDS trials.
what is ards
The Berlin Definition of ARDS “is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance”.
Key components:
* acute, meaning onset 1 week or less
* bilateral opacities consistent with pulmonary oedema must be present and may be detected on CT or chest radiograph
* PF ratio <300mmHg with a minimum of 5 cmH20 PEEP (or CPAP)
* “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis.
risk factors for ards
RISK FACTORS FOR ARDS
There are Direct & Indirect insults that can precipitate ARDS.
Direct
* pneumonia (46%)
* aspiration of gastric contents (29%)
* lung contusion (34%)
* fat embolism
* near drowning
* inhalational injury
* reperfusion injury
Indirect
* non-pulmonary sepsis (25%)
* multiple trauma (41%)
* massive transfusion (34%)
* pancreatitis (25%)
* cardiopulmonary bypass
There are 5 classical pathophysiological phases described in the development of ARDS:
There are 5 classical pathophysiological phases described in the development of ARDS:
1) Injury
2) Exudative – alveolar capillary membrane disruption with inflammatory cell infiltrate and high protein exudate to form hyaline membranes
3) Proliferative – proliferation of abnormal Type II alveoli cells and inflammatory cells
4) Fibrotic – infiltration with fibroblasts which replace alveoli and alveolar ducts with fibrosis
5) Resolution – slow and incomplete repair and restoration of architecture
The main principles for delivering ARDS Net Ventilation at RPA are:
The main principles for delivering ARDS Net Ventilation at RPA are:
1) Paralysis with cisatracurium infusion
2) Controlled Mandatory Ventilation (CMV) mode
3) Tidal volume 6mL/kg*
4) Maximum respiratory rate of 35 breaths per minute
5) Plateau pressure <30cmH20
6) PEEP >5cmH2O, with specific level determined by PF ratio and FiO2 requirement
SpO2 = 88 to 95 % or PaO2 =
SpO2 = 88 to 95 % or PaO2 = 55 to 80 mmHg
Acidosis Management: pH < 7.10
- Increase the set ventilator rate to 35 bpm
- If pH remains < 7.10, tidal volume may be increased in 1mL/kg IBW steps until pH > 7.10 Inform the advanced trainee or intensivist of an increase in tidal volume above 8 mL/kg IBW
Acidosis Management: pH < 7.10
- Increase the set ventilator rate to 35 bpm
- If pH remains < 7.10, tidal volume may be increased in 1mL/kg IBW steps until pH > 7.10 Inform the advanced trainee or intensivist of an increase in tidal volume above 8 mL/kg IBW
hypertropic disease and SAM are both obstruction of outflow tract which increases afterload
they are both managed by
ensuring the ventricle remains full
in the cardiac moodles
when to suspect cardiac tamponade
when CVP = diastolic pulmonary artery pressure
what to do if?
high chest drain output
increasing norad
normal rotem
normal temp
normal ph
hb 100
call CTS urgently
what to do if?
high chest drain output
increasing norad
normal rotem
normal temp
normal ph
hb 100
what to do if
ST Evelvation in V2-4
call cts
urget echo/toe
dont need serial ecgs or troponins this will just delay things
acceptable drain outputs
300ml in the first hour
100ml per hour after that
what increases CVP and PA pressures?
cardiac tamponade
pneumothoraox
heamothorax
what increases CVP and PA pressures?
cardiac tamponade
pneumothoraox
heamothorax
when there is LV outflow obstruction, what to do>
keep them full
if decrease in acute contractility
ECG
Echo
troponin unclear significance given recent cts
a low cardiac index suggests an issues with
HR
Rythm
preload
afterload
controactility
To be eligible for ECR you need to have an
M1, proimxal M2, vertebral or basilar clot
TICI 0 to 3
all ecr cases are scored post procedure
0 complete occlusion
3 complete filling
when to call stroke code
sudden onset FAST positive signs or other stroke-like symptoms such as ataxia, dizziness, sensory or visual changes
note; do not call stroke code on neurosurgery inpatients–call them directly
all stroke called will get what imaging
non con CT, CT angio and CT perfusion scan
decision to thrombolyse can be made from
non-con CT
immediate exclusions to thrombolysis
DOACS within last 12 hours
inr greater than 1.7
previous ICH
plt less than 10
post thrombylsis
SBp less than 185
no invasive procedures
CT scan 24 hours post
criteria for ECR
less than 6 hours of less well
patient indepdnent
rankin scale less than 2
NIHSS greater than 10
and have favourable imaging criteria
In RpA guidelines a pf ratio ,150 is the indication for proning
pf ratio less than 150
condraindications of proning
an open abdomenalo or open chest
wounds or burns over anterior surface of patient
severe abdominal distention
insufficient staff is a relative contraindication
note intubation and CVC is difficult/impossible in proned patients
benefits of proning
improved vq matching
improved homogenous ventialtion
increasd frc
improved seretions
improvedmechanics of chest wall in obese patients, but note extreme obestity is a contraindicaiton
risks of proning
ett displacement
cvc dislodged
pressure areas
ng feed intolerance
facial edema
increase in intra-adominal pressure or intracrnail pressure
norad receptor effects
adrenoceptor agonist a1 >b1
a1 effects predominate at lower, b1 at higher doses
adrenaline receptor effect
adrenoceptor agonist b2 >b1
metaraminol type of drug
non-catecholaime synthetic sympathoomimetic
metaraminol receptor effect
a1 agonist predominately, minimal b effect
hot tip, will not work well in cardiogenic shock
milrinone effects
inotrope cardiac muscle
vascular smooth muscle causes vasodilation
