CRT

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CRT
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2012-11-26 00:08:55
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  1. Signs
    • Objective information, those things that you can see or measure
    • Color
    • pulse
    • Edema
    • Blood pressure
  2. Symptoms
    • sujective information, those things that the patient must tell you
    • Dyspnea
    • Pain
    • Nausea
    • Muscle weakness
  3. Decreased CVP can indicate
    Hypovolemia
  4. Increased CVP can indicate
    Hypervolemia
  5. Lethargic, somnolent, sleepy
    Consider COPD O2 overdose or sleep apnea
  6. Stuporous, confused
    • Responds inappropriately
    • drug overdose
    • Intoxication
  7. Semicomatose
    Responds only to painful stimuli
  8. Obtunded
    • Drowsy state
    • May have a decreased cough or gag reflex
  9. Orthopnea
    • difficulty breathing except in the upright position
    • Heart problem, CHF
  10. Clubbing of fingers
    • Caused by chronic hypoxemia
    • Pulmonary disease
  11. Kyphosis
    Convex curvature of the spine (lean foward)
  12. Scoliosis
    Lateral curvature of the spine (lean side to side)
  13. Kassmaul's Breathing
    • Causes of Metabolic acidosis
    • Renal failure
    • Diabetic Ketoacisosis
  14. Tachycardia indicates
    • Hypoxemia
    • Anxiety
    • Stress
  15. Bradycardia Indicates
    • Heart failure
    • Shock
    • Code/ emergency
  16. Bronchial breath sounds
    • normal sound over the trachea or bronchi
    • These breath sounds over the lung periphery would indicate lung consolidation
  17. Unilateral wheeze indicative
    of a foreign body obstruction
  18. Position of endotracheal Tube
    Should be below the vocal cords and no closer than 2 cm or 1 in above the carnia
  19. Infiltrate
    Atelectasis
  20. Consolidation
    • Solid white area
    • Pneumonia or pleural effusion
  21. Hyperlucency
    • Extra pulomany air
    • COPD
    • Asthma attack
    • Pneumothorax
  22. Vascular markings are increased with
    CHF
  23. Vascular markings are absent with
    Pneumothorax
  24. Fluffy infiltrates
    Pulmonary edema
  25. Butterfly/Batwing pattern
    Pulmonary edema
  26. Patchy infiltrates
    Atelectasis
  27. Peripheral wedge shaped infiltrates
    Pulmonary embolus
  28. Normal value for ICP
    • 5-10
    • Patient should be hyperventilated until PaCO2 is 25-30
  29. Mucoid
    • white/gray
    • Chronic bronchitis
  30. If a patient has very thick, tenacious secretions...
    The patient is dehydrating
  31. Yellow sputum
    • Presence of WBC
    • Bacterial infection
  32. Green sputum
    • Stagnant sputum
    • Gram negative bacteria
  33. Pink frothy sputum
    Pulmonary edema
  34. Sinus tachycardia
    Give oxygen
  35. Sinus bradycardia
    oxygen and atropine
  36. Premature ventricular contractions
    oxygen and Lidocaine
  37. Ventricular tachycardia
    • Defibrillate if no pulse
    • Lidocaine if pulse is present
  38. Ventricular fibrillation
    Defibrillate
  39. Transillumination
    • Recommend when a pneumothorax is present
    • Normally a lighted halo is seen around the point of contact
    • A pneumothorax will cause the entire hemithorax to light up
  40. Capnography monitoring of PetCO2
    • Normally the PetCO2 will read lower than the PaCO2
    • PaCO2= 40
    • PetCO2= 30
    • Sensor should be placed proximal to the patients airway connection (at the ETT)
  41. Transcutaneous PO2 and PCO2
    • Tempature has to be heated to 43- 45 C
    • Best placement is over flat areas with good perfusion
    • Normally on the chest just beneath the center of the right or left clavicle
    • Site should be changed every four hours
  42. artery
    going away from heart
  43. vein
    towards the heart
  44. Curved/Macintosh blade
    fits into vallecula, indirectly raises epiglottis
  45. Straight/miller blade
    Fits directly under the epiglottis
  46. The laryngeal mask airway (LMA) is indicated for...
    Short term ventilation and when intubation is not possible by the oral or nasal route (facial or nasal injuries)
  47. Severe respiratory stridor and/or marked inspiratory
    Reintubate the patient
  48. Moderate distress/stridor
    Oxygen, cool mist aerosol and racemic epinephrine to reduce swelling
  49. Mild distress/stridor
    Provide humidity, oxygen and/or racemic epinephrine as necessary
  50. Consider bronchial hygiene therapy for patients with:
    • Bronchiectasis
    • Cystic fibrosis
    • COPD
    • Acute atelectasis
    • Lung abscess
    • Pneumonia
    • Post operative
    • Prolonged bedrest
  51. Prone position
    Patient lying face down
  52. Supine position
    Patient laying on spine (Best for post craniotomy patients)
  53. Fowlers, semi fowlers, or reverse trendelenburg position
    • Best position for hypoxic patients
    • obese patients with dyspnea
    • Post op abdominal patients
    • Patients with pulmonary edema
  54. Trendelenburg
    patients with very low blood pressure
  55. Lateral fowlers
    Very obease patients with air hunger
  56. Lateral flat
    Best position to prevent aspiration
  57. Huff coughing
    • Coughing with an open glottis
    • More effective in patients with COPD or head trauma to prevent increased intracranial pressure
  58. PEP therapy
    • Improve secretion expectoration
    • Reduce residual volume(decrease hyperinflation)
    • Improve airway maintenance
  59. Hazards of suctioning
    • Trauma to mucosa
    • Contamination
    • Hypoxemia
    • Bradycardia
  60. Goals of aerosol therapy
    • To relieve bronchospasm and mucosal edema
    • To thin secretion that are thick and tenacious
    • To humidify the respiratory tract
    • To administer drugs
  61. Hazards of aerosol therapy
    • Bronchospasm
    • Secretion swelling
    • Fluid overload
    • Cross contamination
  62. Heated wick humidifiers
    • Can deliver 100% body humidity
    • Low risk of cross contamination because no particles are bein produced
  63. SPAG
    Deliver Ribavirn for treating RSV
  64. Mask CPAP
    • Short term, temporarly use for improving oxygenation in patients with CO poisoning,
    • pneumonia, post op atelectasis
  65. Clark electrode
    • PO2
    • Partial pressure of oxygen in sample
  66. Severinghaus Electrode
    • PCO2
    • Partial pressure of carbon dioxide in sample
  67. PaCO2 value above 45
    • Patient is not ventilating
    • Initiate ventilation or
    • Remove/Decrease deadspace
    • Increase current ventilation
  68. PaCO2 below 35
    • Ptient is ventilating but to much
    • Dont put on mechanical ventilation
    • Add deadspace (If PaO2 is acceptable) or
    • Decrease ventilation (If PaO2 is high)
  69. If patient is hypoxemia on FiO2 greater than 60% than its due to?
    Shunting and you need to add PEEP
  70. Decrease the FiO2 first if at or above 60%. Once the FiO2 is below 60% then...
    Reduce PEEP/CPAP
  71. Treatment for CO poison!
    100% oxygen and hyperbaric oxygen therapy
  72. Pulmonary Embolus
    • All of the sudden
    • Increased deadspace
    • VD/VT is increased
  73. Supect pulmonary embolus in
    • Post op patients
    • Bedridden patients
    • Obesity
    • Trauma
  74. Treatment for pulmonary embolus!
    • Prevention
    • Support ventilation
    • Prevent further emboli with anticoagulant therapy
  75. O2 Hb dissociation curve shift to the left
    Increased oxygen affinity
  76. O2 Hb dissociation curve shift to the right
    Decreased oxygen affinity
  77. Volume calibration and leaks test are done by...
    • Using a large volume syrine (Super syringe)
    • Standard syringe volume is 3.0 Liters
  78. Galvanic fuel cell
    • Measure partial pressure of O2, displays FiO2 as %
    • If unable to calibrate change fuel cell
  79. MIP Device
    • used to monitor and asses the rediness to wean ventilator patients
    • Assesses the degree of respiratory muscle impairment in guillain barre and myasthenia gravis
  80. Decreased volumes indicates
    Restrictive disease
  81. Decreased vital capacity is the best indicator of
    restrictive lung disease
  82. Forced vital Capacity
    (FVC)
    will provide important flow rates used to identify obstructive disease
  83. The following flows can be measured from a Forced Vital capacity
    • FEV1
    • FEV200-1200
    • FEF25-75
    • PEFR
  84. A decreased FEV1 is a go indicator of...
    obstructive disease
  85. Decreased FEV1/FVC is the best indicator of...
    Obstructive disease
  86. If the FEV1 is decreased but the FEV1/FVC is normal...
    Then the patient has restrictive disease only
  87. The FEV1/FVC should be at least...
    70%
  88. MVV
    • Measures the muscular mechanics of breathing
    • Decreased with obstructive disease, increased airway resistance, decreased compliance
  89. Pre and post bronchodilator testing
    Minimun increase of 12% and 200 ml in the FEV1
  90. Recommend flexible bronchoscopy for intubating in patients with...
    Suspected neck fracture
  91. disinfection and steralization of the Bronchoscopy is best done with...
    Alkaline gluteraldehyde (CIdex)
  92. Ventilator circuits should not be changed on a regular basis unless:
    • Circuit is grossly contaminated
    • Malfunctioning
  93. Indication for Mechanical ventilation
    • Apnea
    • Acute ventilatory failure-not breathing enough
    • Impending ventilatory failure-rising PaCO2, decreasing Vt,VC,MIP
  94. Increased airway resistance (Raw)
    • PIP increases
    • Plateau pressure remains the same
    • Raw= PIP-Ppl
    • Common causes:
    • Secretions in airway
    • Bronchospasms
    • Treatment:
    • Suction
    • Bronchodilator
  95. Decreased lung compliance
    • PIP increases
    • Ppl Increases
    • Common causes:
    • Atelectasis
    • Pulmonary edema
    • ARDS
    • Pneumonia
    • Treatment:
    • Increase PEEP
  96. Controls that directs affect mean airway pressure (Paw)
    • PIP
    • Rate
    • I time
    • PEEP
    • Peak flow
    • Tidal volume
    • Inflation hold
  97. Pressure control ventilation is recommended when
    • Patients requring high FiO2 and PEEP
    • High PEEP
    • High PIP
    • Low PaO2 and Decreased compliance
  98. Ventilator protocol for patients with asthma!
    • Reduce tidal volume to 4-6 ml/Kg
    • Set respiratory rate between 10-12
    • Consider permissive hypercapnia
  99. Decelerating wave
    The normal flow pattern for a pressure or pressure support breath
  100. Sine wave
    the normal flow pattern for a spontaneous breath
  101. Square wave
    The normal flow pattern for a volume controlled breath
  102. Pharmacological agents used for mechanically ventilated patients!
    • Analgesics- Reduced sensation of pain (morphine)
    • Sedatives-Decrease anxiety and promote relaxation (Versed, Ativan)
    • Anesthetics- Reduces patients ability to perceive sensation (Propofol)
  103. The lowest settings on the ventilator prior to extubation are as follows:
    • SIMV/IMV- 4 breaths per minute
    • FiO2- 0.40
    • PEEP- 5 cm H2O
  104. Summary of adverse condition
    • Increase in heart rate by >20 beats per minute
    • Change in blood pressure by 10-20 mm Hg
    • Increased PaCO2 by >10 torr
    • Respiratory rate increases by >10 or is >30b/min
  105. Complications of ventilation
    • Gastric distention- most common
    • Pneumothorax
    • Gastric rupture
    • Cross contamination
    • Aspiration
  106. Complications of external cardiac compliocations
    • Rib fractures
    • Fractured sternum/Clavicle
    • Contusions to the heart and or lung
    • Lacerated liver and or spleen
    • Pulmonary/fat embolism
    • Pneumothorax/hemothorax
  107. Evaluation of effectiveness of Cardiopulmonary resuscitation!
    • Carotid pulse should be present during
    • Colors returns to normal
    • Do not remove cervica collar on during resuscitation- check femoral pulse
    • ECG shows sinus rhythm with no pulse- continue CPR
  108. Cardioversion
    • Electrical shock delivered on the R wave of ECG
    • Non leathal dysrhythmias suck as:
    • Atrial fibrillation
    • Atrial flutter
    • Ventricular tachycardia with a pulse
  109. Defibrillation
    • Emergency lethal cardiac dysrhythmias
    • Pulseless ventricular tachycardia
    • Ventricular Fibrillation
  110. Emergency Resuscitation Bag
    • If bag fills rapidly and collapses easily on minimal pressure- check inlet valve
    • If bag becomes difficult to compress and patient compliance is normal, patient valve may be stuck open or closed
    • Excessively high flow may cause valves to jam. use 15 L/min or low range of flush
    • When there is a problem do not attempt to fix the bag, use another form of ventilation
  111. Pulmonary Edema/CHF
    Description
    • Left ventricular failure and lung reaction
    • Excessive fluid accumulates in the lungs and affects ventilation and espically oxygenation
  112. Pulmonary Edema/CHF
    Assessment
    • Orthopnea, pitting edema, Distended neck veins and increased respiratory distress
    • Pink, frosty, watery secretions
    • Fine crepitant audible rales or crackles
    • Chest X ray: Fluffy infiltrates, butterfly or batwing pattern
  113. Pulmonary Edema/CHF
    Treatment
    • Improve gas exchange- give 100% O2 via non rebreather, IPPB with 100% O2 and PEEP or CPAP if necessary
    • Increase strength of heart contraction (Inotropy)- Give digitalis
    • Decrease venous return- give lasix (diuretic)
    • Body position (Fowlers)
  114. Pulmonary Embolism
    Description
    Deadspace disease (ventilation without perfusion)
  115. Pulmonary Embolism
    Patients at risk
    • Post op
    • Bedridden
    • History of DVT
    • long periods at rest
  116. Pulmonary Embolism
    Assessment
    • Sudden onset of dyspnea, tachycardia
    • Patient appears to be hyperventilating (tachypnea) but is not (ABG shows normal PaCO2)
    • Anxious, chest pain
    • Chest X ray: Peripheral wedge shaped infiltrates
    • V/Q scan or spiral CT scan
  117. Pulmonary Embolism
    Treatment
    • Oxygen therapy 100%
    • Anticoagulation therapy (heparin and Coumadin)
    • Thrombolytic drugs, screens, surgery
  118. Pneumothorax
    Assessment
    • Decreased vocal fremitus, percussion note is hyperresonant or tympanic
    • X ray shows hyperlucency without vascular markings and a flattened diaphragm
  119. Pneumothorax
    Treatment
    • Give 100% oxygen O2 via non rebreathing mask
    • Immediate chest tube/ thoracentasis or releive pressure with needle and tubing inserted into plueral space (needle aspiration)
  120. Status asthmaticus
    Description
    • Sustained asthma attack unresponsive to bronchodilator therapy
    • Will have marked affect on ventilation and oxygenation
  121. Status asthmaticus
    Assessment
    • Diagnosis made by history
    • Retractions and pulsus paradoxus
    • ABG indicating respiratory acidosis or respiratory failure (PaCO2 >45)
  122. Status asthmaticus
    Treatment
    • 100% O2 therapy via a non rebreathing mask
    • Continuous bronchodilator therapy (Albuterol and ipratropium)
    • Corticosteriods IV and Oral
  123. Examples of Trauma
    • Head trauma
    • Chest trauma
    • Neck trauma
    • Burn victims
    • Near drowning
  124. Trauma
    Treatment
    • Always atart with airway, breathing and circulation
    • Administer 100% oxygen
  125. CO poisoning
    Treatment
    • 100% O2 via non rebreathing mask
    • Hyperbaric Oxygen
  126. The most common pleural disorder that requries a thoracentasis...
    Pleural effusion
  127. The most common position for thoracentasis is...
    To have the patient sitting up and leaning foward
  128. Central apnea
    Apnea due to a loss of ventilation effort
  129. Obstructive apnea
    Due to blockage of the upper airway
  130. If nasal flow decreasesand respiratoryeffort decreases then desaturation is a result of...
    Central apnea
  131. Chest tube placement for air
    It is placed in the anterior chest up high
  132. Chest tube placement for fluid
    It is placed in the fourth or fifth intercostal space in the midaxillary line
  133. Bronchoalveolar lavage
    • This procedure is for the diagnosis and treatment of alveolar filling disorder
    • Alveolar proteinosis
    • Interstitial Pneumonitis
    • Cystic fibrosis
    • Pneumocystic pneumonia
  134. Qualifications for a low flow system
    • Tidal volume: 300-700
    • Respiratory rate: less than 25
    • Regular ventilator pattern
  135. Nasal cannula
    • Delivered FiO2: 24% - 45%
    • Flow:1-6 L/min
    • Most appropriate intial oxygen device for COPD patients with stable respiratory rates and tidal volumes
    • For every 1 L/min, increase FiO2 by 4%
  136. Simple mask
    • Delivered FiO2: 40%-55%
    • Flow: 6-10 L/min
    • Flow must be at least 6 L/min to flush out exhaled CO2
  137. Partial rebreather mask
    • Delivered FiO2: 60%-65%
    • Flow: 6-10 L/min
    • Has no one way flap valve
  138. Air entrainment mask/ Venturi mask
    • Delivers precise FiO2 concentrations (ideal for patients wtih COPD)
    • Ideal for patients with irregular tidal volumes rates and breathing patterns
    • The FiO2 remains the same with increases or decreases in the flow threw the oxygen inlet
    • The FiO2 will increase as the internal diameter of the gas injector increases or with increases resistance or obstruction downstream
    • The FiO2 decreases as the size of the air entrainment ports are increased
    • Total flow increases as the size of the air entrainment ports are increased
  139. Oxygen hood
    • Used with infants
    • Flow range 7-14 L/min
  140. Mist tent, oxygen tent, croupette
    • Used for children
    • Set flow at 12-15 L/min
  141. Helium/oxygen therapy
    • Decreases the patients work of breathing by delivering low density gas that can easily maneuver around obstruction
    • Used for patients with
    • increased airway obstruction
    • Edema
    • foreign
    • foreign object obstruction
    • partial vocal cord paralysis
  142. Disinfection
    Kill the bad guys
  143. steralization
    Kill everybody
  144. Ethylene oxide sterilization
    ETO
    • IPPB machine
    • Flowmeter
    • non disposible resuscitation ag from a HIV room
  145. Alkaline gluteraldehyde (Cidex)
    • Disinfection or sterilization
    • Appropiate method for resuable plastics
    • (mouthpieces, tubing, nebulizers, humidifiers)
  146. Routes of transmission of infection
    • Contact
    • Respiratory droplets
    • Airborne droplet nuclei
  147. Wright respirometers and other equipment used with multiple patients should have...
    One way valves or personal sampling chambers to prevent cross infection
  148. Prevention of ventilator associated pneumonia
    • Use of close suction system
    • Regular oral hygiene
    • Keep patient's head elevated 30- 45 degrees
    • Not routinely changing ventilator tubing condensate appropriately
    • Use of heated wire circuits or HME to prevent tubing condensate
    • Use of MDI instead of SVN
  149. Pursed lip breathing
    • Increased tidal volume
    • Decrease respirate rate
    • Decrease alveolar collaspe
    • Prolong slow exhalation
    • Most benificial for patients with emphysema
  150. Huff coughing
    • Coughing with an open glottis
    • More effective in patients with COPD and in head trauma patients to prevent increased intercranial pressures
  151. Liquid bulk oxygen system
    For patients that are mobile
  152. Oxygen concentrators
    For patients that are home bound
  153. COPD
    Assessment
    • Expiratory wheeze, barrell chest, clubing, and cyanosis
    • Percussion note- resonant or hyperresonant
    • Hyperlucency, hyperinflation, increased A-P diameter
    • Compensated respiratory acidosis with hypoxemia and hypercapnia
  154. COPD
    Treatment
    • Low flow O2 and aerosol therapy
    • Rehab therapy (pursed lip breathing), proper nutrition and monitor fluids
    • If a patient comes into ER in a full arrest- resuscitate with 100% O2
  155. Pneumonia
    Assessment
    • Chills, fever, cought, purulent sputum, dyspnea,cyanosis, rales and rhonchi
    • Scattered patchy opacity/ consildation on x ray
  156. Pneumonia
    Treatment
    • Oxygen therapy if needed
    • Bronchial therapy
    • Antibiotics- Penicillin for gram negative infections, streptomycin, gentamycin and tobramycin for gram negative infections
    • Mechanical ventilation if PaCO2 is above 45 and PaO2 is below 60
  157. Pleural effusion
    Assessment
    • Dyspnea, chest pain, decreased breath sounds and dry no productive cough
    • Mediastinal shift to the unaffected area
    • Obiliteration of the costophrenic angle, unilateral basilar infiltrate with meniscus formation
  158. Pleural effusion
    Treatment
    • Thoracentasis or chest tube drainage
    • Antibiotics
  159. ARDS
    Assessment
    • Respiratory distress with tachypnea and cyanosis
    • Refractory hypoxemia, Increased A-a DO2 gradient and work of breathing
    • X ray shows diffuse alveolar infiltrates in honeycomb/ ground glass pattern
  160. Myasthenia Gravis
    • Slow, fatigue improves with rest
    • Monitor VC/MIP
    • Neostigmine, pyridostigmine
    • Intubation/ mechanical vent- short term
  161. Guillain Barre syndrome
    • Acute, sudden weakness
    • Monitor VC and MIP
    • Steriods Prophylactic antibiotics
    • Mech vent/ Trach- long term
  162. Emergency room treatment for acute Asthma attack should include:
    • Oxygen therapy
    • Aerosol therapy with SABA and Atrovent
    • Oral steriods
    • Close monitoring
    • Intubation and mechanical Ventilation if respiratory arrest occurs

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