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CARDIO > W10 > Flashcards

W10 Flashcards

1
Q

What are the 2 criteria for ICU admission

A
  1. Medically unstable
  2. Potential for instability of an essential body system
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2
Q

Name 10 reasons for ICU admission

A
  1. Need for one-on-one nursing, specific monitoring or equipment
  2. Failure of one or more organs (respiratory failure most common)
    * Post operative respiratory failure
    * Medical respiratory failure e.g. pneumonia
    * Severe exacerbations of asthma, COPD, bronchiectasis, pneumonia, other respiratory conditions
  3. Post major surgery for monitoring/management
    * Cardiac e.g. AAA surgery (abdominal aortic aneurysm)
    * Abdominal (e.g. Ivor Lewis esophagectomy), Whipple’s (pancreatic cancer)
  4. Weakness of respiratory muscles
  5. Major burns
  6. Major trauma/haemorrhage/chest trauma/spinal injuries
  7. Head injuries
  8. Overwhelming sepsis
    * When there is an infection and systemic inflammatory response
  9. Medical conditions
  10. Shock
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3
Q

Define SHOCK

A

Shock refers to an acute state of failure of circulation and poor tissue perfusion.

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4
Q

What are symptoms of someone in shock

A

Pale, sweatiness, rapid breathing, weak pulse, low BP, reduced urinary output (oliguria), or absent (anuria)

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5
Q

What is initial management of shock

A

The initial management is usually with fluid replacement (as appropriate i.e. not in the case of a cardiac patient who fluid overloaded).
If this is insufficient to raise the blood pressure, inotropic (increased cardiac contractility) and vasopressor (increased vascular tone) support will be commenced:

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6
Q

What is the action of noradrenaline

A

Noradrenaline acts on the α and β receptors of the sympathetic nervous system. The main effect is vasoconstriction of the peripheral blood vessels, but there is also increased cardiac contractility and rate.

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7
Q

What is the action of adrenaline

A

o Adrenaline acts on the β receptors of the sympathetic nervous system, resulting in increased cardiac output, increased heart rate and increased stroke volume.

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8
Q

Ddopamine actions

A

o Dopamine (when administered at enough doses) indirectly stimulates β1 receptors of the sympathetic nervous system by causing a release of noradrenaline and thereby increasing contractility of the heart and systemic blood pressure.

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9
Q

What is the physio’s role in the ICU

A
  • Demonstrate a thorough understanding of body systems and their interactions
  • Understand pathophysiological processes
  • Undertake a systematic, accurate assessment and implement appropriate clinical decision making
  • Optimise rehabilitation of cardiorespiratory, neurological and musculoskeletal function
  • Apply evidence based clinical practice to maximise outcome and minimise harm
  • Help facilitate a timely discharge from ICU
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10
Q

Key information gathered from bedside chart

A
  • Vital signs
  • Fluid balance
  • Medications
  • Nutritional information
  • Daily plan
  • Investigation requests and results
  • Equipment details: ventilator settings, O2 therapy, ICC drainage, CVVHD, AIBP etc.
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11
Q

Neurological activity - what are 5 outcome measures

A
  1. Glasgow coma scale (level of consciousness)
  2. Pupils – PEARL (pupils equal and reacting to light)
  3. Intracranial pressure (ICP)
  4. Jugular venous saturation
  5. RASS score
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12
Q

What is the RASS and an ideal score for a patient to get

A

Measures level of sedation and alertness (e.g. Richmond Agitation and Sedation Scale (RASS))
 Ideal score between -1 & +1

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13
Q

Factors impacting a patient’s psychological state in the ICU

A

o Events leading to admission
o Effects of drugs/medications
o Results of surviving a near fatal illness/trauma, outcome and resultant disability; may have lost a close person during the incident
o Length of stay in intensive care- sleep deprivation, dependence, delirium, anxiety, fear, pain
o Sleep wake cycle

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14
Q

What to note on an ECG

A

 Ideally HR between 60 – 80
 130 at baseline indicative of sepsis
 Rhythm – note new rhythm changes

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15
Q

When looking at blood pressure of a patient, what should you take note of?

A

The support they’re receiving (e.g. inotropes). They don’t have good internal blood pressure control – might not autoregulate. If you are getting them up, their medication amount may need to change because they cannot change BP manually

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16
Q

What is the MAP aim?

A

> 70mmHg - 105mmHg

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17
Q

What are the main objective measures for the respiratory system?

A
  • SpO2 and FiO2 or oxygen support
  • Respiratory support (invasive ventilation vs spontaneously breathing)
  • EtCO2
  • ABGs
  • Cough and sputum/secretions: quantity, type, cultures
  • Radiology e.g. CXR
  • ICC/UWSD
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18
Q

What musculoskeletal info can be gotten from medical charts?

A
  • Fractures
  • Orthopaedic injuries – and treatment for these
  • Spinal injuries
  • Contractures
    Contraindications/precautions
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19
Q

What are indicators of renal function?

A

o Urine output - chemistry, cultures
o Biochemistry
 Urea  should be <10
 Creatinine  should be <100
o Indwelling catheter (IDC)
o Haemofiltration dialysis via vascular catheter
o Glomerular filtration rate (GFR)  should be >100
o Fluid balances  if kidneys are not clearing excess fluid. Good thing or bad thing – if trying to get fluid into vascular space but it ends up elsewhere. Fluid overload can cause lung oedema  crackles, reduced compliance, increase respiratory support. Reduced fluid can cause ARF.

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20
Q

Considerations in assessing the metabolic system from the charts/monitors:

A
  • Temperature (often check with CVS obs)
  • ABGs  in particular, pH, HCO3- (often check with respiratory)
  • Hb  blood transfusions
  • Infections  MRSA/VRE/CPE – HIV, Hep A, B, C
  • Clotting times  international normalised ratio (INR). Normal = 1 – 1.4s. Low = fast clotting. Elevated = slow to clot, will lose more blood if bleeding occurs. Will be measured when patients are on anticoagulant medications
21
Q

Different medication types in the ICU

A
  • Sedation
  • Muscle Relaxants (Neuromuscular Blockers)
  • Inotropes and Vasopressors (Sympathomimetics)
  • Antihypertensives (anti-anginals)
  • Anti-arrhythmias
  • Diuretics
22
Q

Objective assessment in the ICU - what are its 3 components?

A

look, listen, feel

23
Q

ICU OE - look. what should you do?

A

Essential
 Temperature
 Ventilator, oxygen mask
 Pulse oximeter
 ECG (rate and rhythm) and position of ECG leads
 BP / Arterial line traces
 Arterial line
 Central lines
 Peripheral lines
 Feeding lines / Nasogastric tube
 Urine Catheter

If present
 Pulmonary Artery Catheter (Swan Ganz)
 IABP
 Epidural
 Drain tubes / bottles
 Dialysis shunts
 Intercostal catheters and UWSD
 Intracranial Pressure Monitoring
 Alertness
 Breathing pattern, rate, work
 Colour
 Body posture / position
 Pain - subjective, if possible, otherwise facial expression
 Ability to move
 Spasm
 Limb #’s POP, ORIF, External fixation.
 Cervical Collars
 Traction
 Oedema
 Integrity of skin
 Attachment of any lines etc.
 Wounds / dressings

24
Q

ICU OE - listen. What should you do?

A

LISTEN (auscultation, cough, etc)
 To the ALARMS AND RESPOND APPROPRIATELY
 Auscultation
 Cough if the patient is not intubated

25
Q

ICU OE - feel. what should you do?

A

 Tone /movement
 Chest movement
 Temperature
 Sweatiness

26
Q

ICUAW is most common in which ICU patients?

A

It is very common in mechanically ventilated (25 – 60% in those mechanically ventilated >7days), as well as those with multiple organ failure and sepsis

27
Q

What are strategies to prevent & manage ICUAW?

A

Inspiratory muscle training
Cycle ergometry
Exercise rehab
Electrical muscle stimulation
Mobilisation

28
Q

What are the 4 components of the PFIT?

A
  1. Shoulder flexion strength
  2. Knee extension strength
  3. Sit to stand assistance
  4. Marching cadence
29
Q

What are the 5 components of the De Jonghe Criteria? What does this assessment test?

A

assesses alertness.
Open/close your eyes
Look at me
Poke out your tongue
Nod your head
Raise your eyebrows

30
Q

What are treatment techniques to increase lung volume in the ICU?

A

Positioning - sitting up in bed, side to side
Ventilation - either manual or ventilator hyperinflation
Suctioning airway
Mobilisation

31
Q

Define hyperinflation (as a technique). What are its indications to use?

A
  • The act of increasing lung volumes without increasing ventilation.
  • Indications = mechanically ventilated patients with lung collapse/atelectasis and/or sputum retention.
  • Giving large breaths to the patient (up to 3x TV), but slowing down RR, therefore not increasing minute ventilation.
  • Focus on long, slow deep breaths in to get air to base of lungs and behind secretions. On exhalation, helps bring secretions with it, and move them out/make them easier to suction
32
Q

What is the technique of hyperinflation?

A

o Slow assisted inspiratory breath
o Breath hold
Fast expiratory flow rate (shearing effect moves secretions centrally, facilitates cough)

33
Q

Treatment techniques to remove sputum in the ICU - peripheral secretions

A

 Positioning /gravity assisted drainage.
 Hyperinflation.
 Percussion and vibrations.
 Use of nebulisers and humidification.

34
Q

Treatment techniques to remove sputum in the ICU - central secretions

A

 Suctioning via an artificial airway:
– Via ETT or tracheostomy (open or closed suction).
 Suctioning without an artificial airway:
– Via a Nasopharyngeal Airway (NPA) or Guedel Airway

35
Q

Treatment techniques to remove sputum in the ICU - adjunctive techniques

A

 NIV: BiPAP / CPAP / IPPV
 Manually assisted cough (can also be used in ventilated patients).
 Cough Assist - insufflation / exsufflation.
 Tracheal stimulation.
 Nasopharyngeal/Oropharyngeal airway.
 Minitracheostomy.

36
Q

What does someone need to have an effective cough?

A

 Large inspiratory volume.
 Closed glottis.
 Strong contraction of intercostal / abdominal muscles.
 Forceful expiratory flow.
Co-ordination of all of the above.

37
Q

What is manually assisted coughing, and when is it indicated in the ICU?

A

 Used when there is an inability to cough effectively due to poor abdominal muscle contraction:
– Denervation (eg Spinal Cord Injury).
– Weakness (eg Neuromuscular disease, ICU AW).
 Use of compression over upper abdomen and stabilisation of the chest to assist force of cough.
 Requires cooperation from patient and intact bulbar function

38
Q

Precautions for manually assisted cough

A

o Contraindicated in the presence of acute abdominal trauma / abdominal distension or burns.
o Caution with hand placement if fractured ribs or sternum.
o Modify force if not tolerated by patient for comfort reasons.
o Do not fatigue patient by using suboptimal technique and position.
 Easiest to first learn, and perform the assisted cough in supine

39
Q

Describe a cough assist machine’s use (insufflation/exsufflation)

A

 A large positive pressure breath followed by a rapid negative pressure exhalation.
 The insufflator /exsufflator can be used via:
– mouthpiece,
– face mask,
– tracheostomy.
 Can be used in bulbar dysfunction.

40
Q

Most important treatment for fractured ribs without intrapleural injury

A
  • Effective analgesia very important because you can’t immobilise the ribs (breathing)
  • Physio to increase lung volumes (TEs + mobilisation)
  • No manual techniques
  • Mobilising +++
  • Positioning/breathing exercises if focal problem
  • NIV, IPPB, or bubble PEP if required & not contraindicated (e.g. pneumothorax without ICC)
  • Monitor ABG/oxygenation and CXR closely
41
Q

Most important treatment for Fractured ribs with pneumothorax/haemothorax:

A
  • Intercostal drain required  commonly on suction
  • Pain control most important
  • Treatment options dependent on presence of absence of air leak
  • Physio to increase lung volumes (upright positioning, mobilising, TEs)
  • May include positive pressure – ensure air leak does not increase with PP.
42
Q

What do you expect to see when someone has Flail segment rib fractures + pneumothorax/haemothorax:

A
  • Overall ventilation expected to be decreased due to:
    o Poor expansion, decreased compliance lung areas
    o Pain
    o Loss of ribcage integrity – paradoxical breathing (flail segment moves in opposite direction)
    o Associated often with pulmonary contusion
43
Q

Primary vs secondary damage in a TBI:

A

Primary damage
Contusion (cortex without haematoma)
Haemorrhage and/or haematoma
o Intracranial
o Subdural
o Extradural
Lacerations/shearing of brain tissue
Diffuse axonal injury

Secondary damage
Consequence of primary damage.
Cerebral oedema
Ischaemia from:
o Decreased CBF
o Hypotension
o Hypoxia
o Hypovolaemia
o Hypothermia

44
Q

Management of head injury - considering ICP

A

o MAP gives an indication of brain perfusion
o Patients are often hyperventilated slightly to achieve PaCO2 between 35-40mmHg. Causes slight vasoconstriction, decreasing the size of blood vessels and thus room they are taking up in the brain.
o Inotropic support to augment MAP
o PEEP kept low <10cmH20 (as decreases in cerebral venous return increase ICP).
o Avoid permissive hypercapnia
o Avoid prolonged inspiratory phase manoeuvres

45
Q

What is the innervation of the diaphragm?

A

C3,4,5

46
Q

What is the innervation of the intercostals?

A

T1-11

47
Q

What is the innervation of the abdominals?

A

T2-L1

48
Q

What problems with breathing can occur with cervical spinal cord injuries?

A

o Intercostal muscle paralysis. Inspiration is reliant on diaphragm & accessory muscles. Muscle weakness leads to hypoventilation. In addition to anaesthetic/analgesia effects from sedation/surgery.
o Low lung volumes  atelectasis
o Abdominal muscle paralysis – weak cough = sputum retention. Compromised ventilation in sitting, lying flat is more optimal.

49
Q

Spinal cord injury treatment techniques in the ICU for respiratory system

A

o Promote lying in the immediate post-extubation phase for a few days
o NIV – positive pressure ventilation
o IPPV – increase lung expansion
o Remove secretions  manually assisted cough, cough assist machine, suctioning, Mini tracheostomy

CARDIO (12 decks)

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