S4E4 Flashcards
Pt with ARDS needs to…
Be moved to ICU stat
Monitored closely
Can lead to organ failure
Adventitious lung sounds
**Crackles : liquid in aveoli (impaired gas exchange ⬆️CO2⬇️O2)
Ronchi: mucus in bronchioles (sputum) rumble,
ARDS
Refractory to O2 therapy****
Sudden/progressive onset resp. Failure
Immune response to damage in lungs
Alveolar cap damage
⬆️fluid in lungs bc ⬆️ WBC
Impairs gas exchange
Hear crackles
⬇️O2
⬆️CO2
First ARDS assessment / SBAR
S
Check for cyanosis & confusion
B
Pneumonia?
COPD?
Smoke inhalation?
A
Check VS
Sit pt up
Get o2 started or increased
Re-eval (⬇️ in o2sat)
Lung assessment
R
Call a rapid & physician
Get an ABG
Chest XR
Pressors
Continuous monitoring (ICU)
ARDS ABG
PaCO2 >50
O2 <60
PH <7.35
When to Re-eval during ARDS
Immediately
ARDS s/s
Asymptomatic
Confused, Agitated, restless
Dyspnea
Tavhypnea
Cough
Scattered crackles
Refractory hypoxemia
Alveolar edema
Interstitial edema
“Refractory hypoxemia” means
Increase O2 but doesn’t help
ABGs
CO2 35-45
O2 80-100
Bicarb 22-26
PH 7.35-7.45
ARDS can stick around for ….
Weeks
ARDS tx
Ventilation
Possible pressure o2
IV Diuretics (drops BP, do pressors too)
IV Antibiotics for route cause
IV Steroids for stiff lungs
IV Bicarb
Expected outcome for mechanical ventilation?
Forcing oxygenation
Increase PH
ARDS cause
Sepsis (most common)
Pneumonia
Smoke inhalation
Drug overdose
DIC
Massive transfusions
Cardio pulmonary bypass
Lung infection
Aspiration
Metabolic disorders(uremia, pancreatitis)
Shock
Trauma
Fat/air embolism
Etc
With ARDS we are trying to prevent…
Stiff lung
How can ARDs affect the lungs
⬇️ heart flow/perfusion
Hypertension
Corpormenal
⬇️body perfusion
ARDS dx
Refractory hypoxemia
Chest CT
Chest XR
⬆️Pulmonary artery wedge
Cultures for sepsis/inflammation
ARDS phase 1
Injury
Damage in aveoli
Edema
Refractory hypoxemia
ARDS phase 2
Reparative
1-2 wks post injury
Strong inflammatory response
Fibrous tissue begins
ARDS phase 3
Fibrotic phase
2-3 wks after initial injury
Lung remodeled by fibrous tissue
⬇️lung capacity
⬇️surface area for gas exchange
Pulmonary hypertension
Vascular destruction
ABG concern during ARDS
Are they compensating?
Are they unable to make bicarb bc kidneys are damaged? Excuse
ARDS recovery phase
Hypoxemia gradually resolves per ABG
CXR improves
Lungs become more compliant
ARDS meds
Salumedrol (inflammation)
Abx (infection)
Purple pressors (pulm hypertension)
Diuretics (decrease fluid volume)
PPIs for stress ulcers (Zantac, protonix, carafate)
Dobutamine (strengthens heart muscle)
ARDS complications
Hosp acquired pna
Barotrauma
-Alveoli rupture from too much
pressure
-can result in pneumothorax,
interstitial emphysema
Valupressure Trauma
Prevent damage to alveoli by using
smaller tidal volumes
Stress ulcers
Renal failure due to nephrotoxic drugs(abx) or hypotension/hypoxemia/hypercapnia
In extreme ARDS cases tx can be…
Lobectomy
Lung transplant
Nurse interventions
Monitor creatinine/BUN/UOP
ARDS collab care with…
RT: oxygen,mechanical vent,positioning
Maintaining cardiac OP/tissue perfusion
Maintain fluid balance & nutrition
Pharmacy
ARDS positioning
Prone:
Alleviate dependent edema
Alleviate pressure on lungs from heart
Redistribution of blood flow to less
damaged places in anterior chest
Slow lateral rotation:
Enhance secretion drainage
Pt can deoxygenate🚨
ARDS nursing for cardiac output and tissue perfussion
⬇️ Venus return R/T peep intrathoracic pressure
⬇️Cardiac output R/T impaired contractility
⬇️preload
Monitor CO/BP/ABGs with art catheter
Crystalloid/colloids/inotropic drugs
Hgb >9
O2 >90
May need PRBC transfusion
ARDS nursing for fluid balance and nutrition
Parenteral/Antero feedings
Including omega-3 fatty acids
Mild fluid restriction/diuretics
Keeps pulm artery wedge pressure⬇️
Limits pulm edema
ARDS goals for recovery
PaO2 within norm range
(FIO2 of 21%)
SaO2 >90%
Patent airway
Clear lungs on auscultation
PaO2 of at least 60
Adequate lung vent to maintain normal
PH
Indications to get a mechanical ventilation for your patient
Continuous⬇️ in PaO2
⬆️ In PaCO2
Persistent acidosis ⬇️pH
Respiratory failure
What is a mechanical vent?
Breathing device that maintains ventilation and oxygen delivery for prolonged periods
ABGs, pulse ox, bedside pulm function test determine O2 concentration & vent settings
What is considered aggressive supportive care in ARDS?
Intubation
Mechanical Ventilation
Supplemental oxygen therapy
Goals for mechanical ventilation
ABGs satisfactory
Prevent CV compromise
What is PEEP for mechanical vent?
Positive End Expiratory Pressure
⬆️ functional residual capacity
Opens collapsed alveoli
Reverses/prevents microatelectasis
Improves O2 with lower fraction of
inspired O2
Nurse care for mechanical vent
Anxious, inability to communicate
Check for unnatural breathing patterns
Ensure machine is working properly
Check for blocks/ kinks
Call RT for beeping
Assist with ADLs
Prevent pressure ulcers
Analgesia for comfort
Communicate with pt & fam
Paralytic agent used during mechanical vent
Vecuronium
If sedatives are inadequate
Loses motor function but retains
sedation/hearing
Must be used with adrquate sedation and analgesia
Sedation used during mechanical vent
Ativan
Versed
Propofol
⬇️ pt anxiety
⬇️ O2 consumption
Allows vent to provide full support
Nurse MUST _____while on Vecuronium
Closely monitor connections to vent
Monitor and respond to alarms
Provide eye care, positioning, monitor for DVTs, muscle atrophy, skin breakdown
Trouble shooting mechanical vent
⬆️ peak airway pressure
Tubing kinked
Plugged airway
Atelectasis/bronchospasm
Pt bucking vent
⬇️ lung capacity
Check tubing
Reposition pt
Insert oral airway if necessary
⬇️ in pressure/loss of volume
Leak in vent tubing
Check entire vent circuit for latency
Correct any leaks
Loosened cuff on tube/humidifier
Patient problems on mechanical vent
Infection: wash hands, clean
instruments, wear gloves
Barotrauma/pneumothorax: notify Dr
CV compromised: keep monitoring
How to monitor is someone is well nourished or not?
Serum Albumin 3.5-5
Metabolic syndrome
A group of risk factors that occur together and ⬆️ risk for CAD, stroke & T2DM
Most important Risk factors for metabolic syndrome
Extra wt around middle and upper body
(Central obesity/Apple shape)
Insulin resistance
(Uses insulin less effectively)
Other risk factors for metabolic syndrome
Aging
Genes
Hormonal changes
Lack of exercise
Pro-thrombotic state
Pro-inflammatory state
Define physical trauma
Force applied to body resulting in wound or injury
Types of physical trauma
Blunt
Penetrating
What is the #1 physical trauma from ages 1-44?
Unintentional injury
Most commonCauses of physical trauma
- MVA
- Falls
- Violent acts
- Accidents
- Natural Disasters
Trauma center levels
Lvl 1-5
Lvl 1 trauma center
Any trauma incident/age
Prevention->rehab
***24hr immediate coverage of gen surgeons/specialties
-Ortho
-Neuro
-Plastics
-OMS
-Anesthesia
-Emergency/Internal medicine
-Radiology
-Pediatrics
-Critical Care
Local lvl 1
Adults: st Anthony, DH, University, Swedish
Peds: children’s main in Aurora
Lvl 2 centers
Initiate definitive care for all injuries
🚫rehab
🚫public education
🚫academic ties
24hr immediate gen surgeon/specialty coverage
🚫OMS
🚫plastics
🚫internal medicine
Local lvl 2
Adults
Sky Ridge
Parker
Littleton
Good Samaritan
TMCA
Peds
DH
Lvl 3 trauma center
Prompt assessment, resusc., sx, intensive care, & stabilization
24hr immediate emergency med physician, prompt Gen Surgeon/anesthesia
Has to have Transfer agreements with higher lvl trauma centers for pts require more care
Lvl 4 trauma center
Personal capable to provide ATLS prior to transfer to higher lvl trauma center
What is “ the golden hr”
Get them to definitive care as soon as possible
Concept of time between injury & definitive care
What is the “platinum 10 minutes”?
EMS Total minutes from arriving to scene to leaving scene
Role of EMS in Trauma care
1st responders
Identify
Stabilize
Transport
BLS & ALS care
EMTs
Advanced EMTs
Paramedics
What do EMTs do?
Basic life support
Airway
Suction
Manual techniques
OPA/NPA
Supraglottic airways
Breathing
O2 administration
Bag-Valve-Mask
Circulation
CPR/AED
Tourniquets
Bandaging/splinting
IV fluids
Warming measures
And more…
C-Spine
C-spine position
Neutral (not hyper extended or hyper flexed) & inline (no tilted left or right)
What do ADVANCED EMTs do?
Limited ALS + EMT
Airway
Supraglottic (all states)
Breathing
Inhaled nitric oxide(some states)
Circulation
3 lead ECG rhythm interpretation
Intraosseous(IO) fluids &meds
Epi for cardiac arrest
What can Paramedics do?
Complete ALS + EMT + Advance EMT
Airway
Endotrachial intubation
Needle or surgical cricothyrotomy
Breathing
Ventolilators
ETCO2 monitoring
Needle decompression
Circulation
12-lead ECG interpretation
Manual defib/cardioversion
ACLS including vasopressors
And more….
EMS goals
Identify
Rapids assessment
Immediate tx
Control ABCs
Stabilize
Prepare for transport
C spine
Bandage/splint
Transport
Destination consideration
Hospital lvl for pt need
Get there asap & safe as possible
What is shock?
Circulatory compromise
⬇️oxygen supply
⬇️tissue hypoxia
⬇️ multi organ damage
☠️
Types of shock
Obstructive (blood flow is prevented)
Cardiogenic (heart is failing)
Distributive (wide spread vasoconstriction)
Neurogenic (spinal)
Anaphylactic (allergy)
Septic (infection)
Hypovolemic
Hemorrhagic
Non-hemorrhagic
All shock can be attributed to…
Failure of 1 aspect of circulation
What 3 parts must be present and functioning?
Heart (pumps)
Blood vessels (pipes)
Blood (fluid)
If the heart fails what type of shocks will you see?
Cardiogenic
Obstructive
If the blood vessels fail what type of shock will you see?
Distributive
If fluid fails what shock will you see
Hypovolemic
What is Obstructive shock
Puts pressure on the heart so the heart isn’t able to expand and contract
Causes for obstructive shock
Pericardial tamponade
Open&tension pneumothorax
Hemothorax
Hemopneumothorax
What is pericardial tamponade
Collection of blood fluid in the pericardium
How does pericardial tamponade present?
Beck triad
JVD
Muffled heart Tones
Narrow pulse pressure
How to treat pericardial tamponade
Pericardiocentesis
US or XR guided
What is a Hemo pneumothorax?
Puncture or tear of lung tissue or blood vessel, causing leak of air or blood into the thoracic cavity and preventing lung expansion
Can Progress to tension pneumothorax.
Hemopneumothorax presents as…
Respiratory distress
Hypoxia
Unilateral decrease/absent breath sounds
Chest
JVD
Tracheal deviation (late sign)
How to treat a Hemo pneumothorax
Needle decompression
Thoracostomy
Chest tube placement
Common site for hemothorax and pneumothorax
Hemo: lower bc fluid pools
Pneumo: upper bc air rises
What is cardiogenic shock?
Failure of the heart to adequately pump
How does cardiogenic shock present?
Diaphoresis
Depends of cause
Myocardial infarction
Cardiomyopathy(failure of heart muscle)
Congestive heart failure(crackles, OSA, etc)
Cardiogenic shock tx
Depends on cause
What is distributive shock
Inappropriate raise of dilation or redistribution of vascular volume
How does distribution shock present
Diaphoretic
Pale
⬇️CO
Depends on cause
Spinal cord injury
Paralysis
Anaphylactic shock
Uticeria
Sepsis
Hypotension
Bacterial infection
Fever
⬆️WBC
Distribution Shock tx
Depends on cause
Spinal cord injury
Fluids
Vasopressor prn
Steroids prn
Anaphylactic
Epi
Sepsis
Fluids
Abx
Vasopressor prn
What is hypovolemic shock?
Loss of circulating, blood or fluids
Hemorrhagic versus non-hemorrhagic
How does hypovolemic shock present?
Tachycardic
Hypotension
AMS
Depends on cause
Hypovolemia shock tx
Stop the bleeding!
Replace blood/fluids
Hemorrhagic shock class 1
Up to 15% lost of total blood volume
Normal HR/slightly elevated
Hemorrhagic shock class 2
15-30% Lost of total blood volume
Tachycardic & tachypnic
Trying to get O2 to body
Hemorrhagic shock class 3
30-40% lost of total blood volume
significant drop in BP
Changes in mental status
significantly ⬆️HR & RR
⬇️UOP
Delayed cap refill
Hemorrhagic shock class 4
> 40% lost of total blood volume
Hypotension with narrow pulse pressure
Profound mental status changes
Profound tachycardia
Minimal or Absent UOP
Significantly delayed cap refill
What is pro-thrombotic state?
Excess blood clotting
⬆️fibrinogen levels (norm 200-400)
>700=danger of forming clot
What is pro-inflammatory state?
⬆️inflammatory blood markers
C-reactive >0.3
Signs/DX for metabolic syndrome*****
> 3 signs:
BP > 130/85
Insulin resistance: fasting BS > 100
Large waist circumference
Men _>_40 in
Women _>_35 in
Low HDL
Men <40
Women <50
Triglycerides > 150
Tx goal for metabolic syndrome
Reduce risk of heart disease/diabetes
Lifestyle changes/medicine to reduce BP, LDL cholesterol, blood sugar
Lose weight 7 to 10%
30 min of mod intensity exercise 5-7 days/wk
Quit smoking
Possibly low-dose aspirin daily
Metabolic syndrome prognosis
⬆️ long-term rest for developing heart, disease, type 2? diabetes, stroke, kidney disease, and poor blood supply to the legs
What is the lethal ♦️ of trauma
Hypothermia
Coagulopathy
Hypocalcemia
Acidosis
Hypothermia
< 35 C or 95 F
Cold extremities
ECG changes
Widened____
Bradycardic
Why is hypothermia significant in trauma
⬇️platelet & clotting factor activity/efficacy
(Worsen coagulopathy)
Causes cellular influx of calcium ions (worsen acidosis &hypocalcemia)
Decreases liver metablism (worsen acidosis &hypocalcemia)
How to tx hypothermia
Passive/active warming techniques
Bear blankets
⬆️room temp
Blankets
Warm fluids/blood
What is coagulopathy
Abnormal function of hemostasis
Excessive bleeding vs clotting
How did coagulopathy present
Excessive bleeding or clotting
Why is coagulopathy significant in Trauma?
⬇️ clotting=⬆️bleeding=⬇️Ca
⬆️ tissue ischemia
Worsen acidosis
Worsen Hypocalcemia
How to tx coagulopathy
Transfuse platelets and FFP
TXA
DDVAP (synthetic vasopressor)
Amicar
Factor
Nurses can:
H&H
Type&screen
PT/PTT/Fibrinogen
TEG(how the pt is clotting over time)
1:1:1 ratio before labs
Less colloid/crystalloid use
How to ensure proper blood product transfusion based on target goals before lab value
1:1:1 ratio
1 unit PRBC:1 unit FFP:1 unit Platelets
What is acidosis
pH < 7.35
How does acidosis present
Tachypnea
⬆️lactate
Why is acidosis significant to trauma
Anaerobic metabolism
⬇️ cardiac contractility bc ⬆️K extracellular space= ⬇️CO
⬇️efficacy of fibrogen, thrombin, factor Xa & platelets
Worsens coagulopathy
How to tx acidosis
⬆️tissue oxygenation &perfusion
Permissive hypotension
Nurses:
Give LOTS of o2
MAP >60
Draw labs soon & often
Lactate & pH
Ensure adequate o2
Encourage less use of colloids/crystalloids
Worsens acidosis/coagulopathy
What is Hypocalcemia
< 9
Why is Hypocalcemia significant in trauma?
⬆️circulating citrate=⬇️Ca=⬇️pH
(Worsen acidosis)
Clotting favors less effective
(Worsen coagulopathy)
How does Hypocalcemia present
Hyper reflexia
⬇️ muscle contractility(heart/hypotn)
⬇️CO & signal (arrhythmia)
How is Hypocalcemia tx
Calcium chloride
Higher volume but less bioavailability
Calcium gluconate
Higher bioavailability, affects shifting
What can nurses do for hypocalcemia
Hyper reflexia
⬇️ muscle contractility(heart/hypotn)
⬇️CO & signal (arrhythmia)
Who has an increased risk for shock & why?
Geriatric
Meds:
Ca channel blocker
Beta blockers
Anticoagulants
Antiplatelets
Thinner skin
Less efficient organ ability
EMS pre-hospital Communication
Lights/Siren
Report:
Mechanism of injury
Identified injuries
Patient status
Treatments
ETA
EMS bedside communication
Hands off report:
Describe the scene
Describe impacting patterns
Safety equipment
Trending vitals
Pt status
Documentation
Effect documentation is essential
Accurate/legible
Follows pt wherever they go
Tells the whole story
A basis for eval/quality improvement
Small trauma team consists of…
1 physician
2 nurses (1 does actions/1 scribes)
Big trauma teams consists of…
3 physicians
4 nurses
2 techs
1 RT
1 Rad tech
Small team positions to pt
Head of bed: ER doc
Pt in the middle
Big team position to pt
Head of bed : ER doc
Pt in the center
Trauma assessment purpose
Recognize life threatening conditions
determine priority of care
Phase 1: ABCDE
Phase 2: FGHI
Circular process for continual reassessment
Before assessing…
PPE!!
Primary survey/assessment
A
Airway/Alertness
Also,C-spine
B
Breathing / ventilation
C
Circulation
Control hemorrhage
D
Disability (neuro status)
E
Exposure
Environmental control
Secondary survey/assesment
F
Fell set of vitals
Family pressence
G
Get adjunct ( Co2 wave forms)
H
Hx
Head to toe assessment
I
Inspect posterior surface
What is a 6 foot assessment
Quick overview of what you see while the patient is approaching
Whole body?
Bleeding?
Awake/responding?
Etc
Airway & alertness
Look : listen : feel
AVPU: Alert, Verbal, Pain, Unresponsive
Suction
Securement: airway/c-spine
Breathing & ventilation
Look : listen : feel
RRQ: Rate, Rhythm, Quality
Circulation & controlling hemorrhage
Look : listen : feel
RRQ: Rate, Rhythm, Quality
Skin signs: Color, Temp, Condition
Disability
Look: Listen: Feel
Glasgow Coma Scale
Pupils
Motor function
Sensory function
Get adjuncts
Labs
Monitor ECG/ETCo2
NG/OG/Foley considerations
Pain management
OPQRST
Onset
Paliation
Quality
Radiation
Severity
Time
History/head to toe
SAMPLE
Signs/symptoms
Allergies
Medication
Past mhx
Last oral intact
Events leading up to
What does triage mean?
To sort pt on acuity
How many types of triage is there?
A bunch
ESI triage
START triage
ESI
emergency severity index
Used in emergency departments
START Triage
Used during mass casualties
Any incident that overwhelms available resources
Simple
Triage
And
Rapid
Resources
Color designations
Black: expectant/deceased
Red: immediate/emergent
Survivable with immediate intervention
Yellow: Delayed/Urgent
Can be delayed up to 3 hrs w/o threat to life
Green: Minor, Not urgent
Delayed several hrs
Eventually needs treatment
Often ambulatory
What is acute coronary syndrome?
Reduce myocardial, blood flow, causing ischemia or infarct
Types of acute coronary syndrome
Angina (stable vs unstable)
STEMI
NSTEMI
How does AcS present?
Pallor
Sweaty/diaphoretic
Chest pain
Shortness of breath
Dizziness
Fatigue
N/V
How to diagnose ACS
12 lead
Troponin
Echocardiogram
How to treat ACS
Aspirin
Anti-platelet
Anticoagulant
Angioplasty
Thrombectomy
CABG (blockage in 3 or more blood vessels)
Thrombolytics
Mechanical circulatory support
IABP
Impella
What to expect after ACS
Myocardial Tissue death
Treat symptoms & improve heart function
Prevention
DAPT:dual Anti platelet therapy
Cardiac Rehab
General ACS protocols
12 lead ECG within 5 min
(EMS,ED, inpatient)
STEMI=call cardiac alert
324mg chewable aspirin
(Other meds as ordered)
Maintain SPo2 94-99%
2 large bore FA IV access >20 & labs
(Troponin, BMP, CBC)
Prep for cath lab : gown only, shave prn
