N176 test 1

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N176 test 1
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n176 test 1
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  1. VF ACLS algorithm
    • shock, shock, everybody, shock, AMEN!
    • shock, CPR, shock, CPR, epinephrine (1mg q 3-5min), shock, amiodarone (300mg, 150mg)
    • defibrillation: 120-200J
  2. VT ACLS algorithm
    • shock, shock, everybody, shock, AMEN!
    • shock, CPR, shock, CPR, epinephrine (1mg q 3-5min), shock, amiodarone (300mg, 150mg)
    • defibrillation: 120-200J
  3. asystole ACLS algorithm
    CPR, epinephrine (1mg q3-5min)
  4. PEA ACLS algorithm
    CPR, epinephrine (1mg q3-5min)
  5. H's and T's
    • Hypovolemia
    • Hypoxia
    • Hydrogen ion (acidosis)
    • Hypo-/hyperkalemia
    • Hypothermia
    • Tension pneumothorax
    • Tamponade, cardiac
    • Toxins/Tablets
    • Thrombosis, pulmonary
    • Thrombosis, coronary
  6. bradycardia algorithm
    • OMI: oxygen, monitor, IV access
    • if stable: continue OMI
    • If unstable: atropine (0.5mg q3-5 x2), transvenous pacing, dopamine or epinephrine infusion
  7. tachycardia algorithm
    • OMI: oxygen, monitor, IV access
    • stable: vagal maneuvers, adenosine (6mg slam with 20mL NS flush, then 12mg), SVT: beta-blocker or Ca-channel blocker (cardizin), VT c pulse: antiarrhythmic (procainamide)
    • unstable: cardioversion (50-100J)
  8. right coronary artery circulation
    • SA node
    • AV node
    • inferior wall of LV
  9. left coronary artery circulation
    • WIDOW MAKER
    • anterior wall of LV
  10. diastole
    ventricular relaxation/filling
  11. systole
    ventricular contraction
  12. depolarization
    polarized cell is reduced to a less negative value
  13. repolarization
    cell returns to resting polarized state
  14. SA node conduction
    • rate=60-100bpm
    • accounts for atrial kick
  15. AV node conduction
    rate=40-60bpm
  16. lead selection: lateral wall
    I, aVL, V5, V6
  17. lead selection: inferior wall
    II, III, aVF
  18. lead selection: anterior wall
    V1-V4
  19. lead selection: posterior wall
    V1-V4
  20. lead placement
    • right: clouds over grass
    • left: smoke over fire
    • center: chocolate near my heart
  21. P wave represents                        
    - notched/biphasic=
    - none definable=
    - sawtooth pattern=
    - inverted=
    • atrial depolarization
    • - notched/biphasic=atrial hypertrophy
    • - none definable=atrial fibrillation
    • - sawtooth pattern=atrial flutter
    • - inverted=retrograde conduction from the AV node
  22. PR interval is                             
    - time:
    -            boxes
    - prolonged=
    • time for the atrial impulse to reach the ventricles
    • - time: 0.12-0.20 sec
    • - 3-5 small boxes
    • - prolonged=delayed conduction through AV node=atrial hypertrophy, ischemia, etc.
  23. QRS complex represents                   
    - time:
    - # boxes
    • ventricular depolarization
    • - time: 0.04-0.12 sec
    • - 1-3 small boxes
  24. ST segment represents                      
    - elevated=
    - depressed=
    • ventricular repolarization
    • - elevated=myocardial injury
    • - depressed=myocardial ischemia
  25. T wave represents                       
    - inverted=
    - flattened or inverted=
    - tall or peaked=
    - notched=
    • ventricular repolarization
    • - inverted=myocardial ischemia
    • - flattened or inverted=hypokalemia
    • - tall or peaked=hyperkalemia
    • - notched=pericarditis
  26. QT interval represents                 
    - time:
    - # boxes
    • total duration of ventricular systole
    • - time: 0.35-0.40 sec
    • - 9-10 small boxes
  27. reading an EKG
    - horizontal axis=
        - 1 small square=
        - 1 large square=
        - 5 large squares=
    - vertical axis=
        - 1 small square=
        - 1 large square=
    • horizontal axis=time in seconds
    •     - 1 small square=0.04sec
    •     - 1 large square=0.20 sec
    •     - 5 large squares=1.0sec
    • vertical axis=voltage
    •     - 1 small square=1mm
    •     - 1 large square=5mm
  28. EKG rate calculation
    • 300, 150, 100, 75, 60, 50
    • boxes: 30, 10, 5, 3, 2
  29. tachydysrhythmias do what?
    - to diastole
    - to coronary perfusion time
    - to SV
    - to CO
    - to BP
    • increase myocardial oxygen demand
    • - diastole=shortens
    • - coronary perfusion time= shortens
    • - SV=decreases
    • - CO=decreases
    • - BP=decreases
  30. bradydysrhythmias do what?
    - to diastole
    - to coronary perfusion time
    • decrease myocardial oxygen demand
    • - diastole=prolonged
    • - coronary perfusion time=prolonged
  31. sinus tachycardia
    - rate=
    - presentation=
    - intervention=
    • rate=100-150
    • presentation: fatigue, weakness, SOB, hypotensive
    • intervention: treat the cause, ACLS algorithm
    • OMI: oxygen, monitor, IV access
    • stable: vagal maneuvers, adenosine (6mg slam with 20mL NS flush, then 12mg), SVT: beta-blocker or Ca-channel blocker (cardizin), VT c pulse: antiarrhythmic (procainamide)
    • unstable: cardioversion (50-100J)
  32. sinus bradycardia
    - rate=
    - presentation=
    - intervention=
    • rate=<60
    • presentation=dizzy, lightheaded, weak, confused, hypotensive
    • intervention=stop meds that slow HR, ACLS algorithm
    • OMI: oxygen, monitor, IV access
    • stable: continue OMI
    • unstable: atropine (0.5mg q3-5 x2), transvenous pacing, dopamine or epinephrine infusion
  33. premature atrial contractions
    - identifier=
    - presentation=
    - intervention=
    • identifier: premature P wave, may look different
    • presentation: asymptomatic, palpiations
    • intervention: OMI, avoid coffee, alcohol, smoking, possible use of procainamide or digoxin
  34. supraventricular tachycardia (SVT)
    - rate=
    - identifier=
    - presentation=
    - intervention=
    • rate: 150-250
    • identifier: P wave not seen
    • presentation: palpitations, weak, SOB, nervous
    • intervention: ID and treat cause, goal is to dec the ventricular response and convert to sinus rhythm, see ACLS algorithm
    • OMI: oxygen, monitor, IV access
    • stable: vagal maneuvers, adenosine (6mg slam with 20mL NS flush, then 12mg), beta-blocker or Ca-channel blocker (cardizin)
    • unstable: cardioversion (50-100J)
  35. atrial flutter
    - identifier=
    - presentation=
    - interventions=
    • identifier: sawtooth pattern
    • presentation: palpitations, weak, fatigue, SOB, anxious
    • intervention: assess perfusion, tachy algorithm
    • OMI: oxygen, monitor, IV access
    • stable: vagal maneuvers, adenosine (6mg slam with 20mL NS flush, then 12mg)
    • unstable: cardioversion (50-100J)
  36. atrial fibrillation
    - identifier=
    - presentation=
    - intervention=
    • identifier: irregularly irregular
    • presentation: loss of atrial kick - dec peripheral pulses, fatigue, SOB, distended neck veins - danger of clot formation
    • intervention: check pulses, tachy algorithm
    • OMI: oxygen, monitor, IV access
    • stable: vagal maneuvers, adenosine (6mg slam with 20mL NS flush, then 12mg)
    • unstable: cardioversion (50-100J)
  37. ventricular tachycardia
    - rate=
    - identifier=
    - intervention
    • rate: 100-250
    • identifier: wide QRS, no P waves
    • intervention: VT algorithm
    • shock, shock, everybody, shock, AMEN!
    • shock, CPR, shock, CPR, epinephrine (1mg q 3-5min), shock, amiodarone (300mg, 150mg)
    • defibrillation: 120-200J
  38. ventricular fibrillation
    - identifier=
    - presentation=
    - intervention=
    • identifier: squiggle
    • presentation: loss of consciousness, pulseless, apneic, death in 4-6min
    • intervention: VF algorithm
    • shock, shock, everybody, shock, AMEN!
    • shock, CPR, shock, CPR, epinephrine (1mg q 3-5min), shock, amiodarone (300mg, 150mg)
    • defibrillation: 120-200J
  39. post-arrest hypothermia
    - goal
    - when
    - temperature
    - how
    - how to rewarm?
    • goal: to minimize tissue ischemia in the heart and to decrease cerebral metabolic needs
    • when: 12-24hrs post arrest
    • temperature: 89.6-93.2deg F
    • how: ice packs, cold fluids, cold gastric lavage, cooling blankets
    • rewarm: 1deg q3hrs
  40. sxs hypokalemia
    weakness, lethargy, PVCs
  41. foods high in K+
    tomatoes, beans, prunes, avocados, bananas, strawberries, lettuce
  42. sxs hypomagnesemia
    weakness, ventricular irregularities
  43. foods high in Mg
    green leafy vegetables, nuts, dried peas, beans, whole grains
  44. respiratory failure=
    inability of cardiac and pulmonary systems to maintain adequate exchange of oxygen and carbon dioxide in the lungs
  45. oxygenation failure=                   
    - aka
    - identifier
    - causes
    • =inadequate O2 transfer between the alveoli and the pulmonary capillary bed
    • aka: hypoxemic respiratory failure
    • identifier: PaO2 <60 with O2 >60%
    • causes: low atmospheric O2, PNA, pulmonary edema, PE, ARDS, mechanical obstruction, shock
    • hypoventilation -> increase RR
  46. ventilator failure=                             
    - aka
    - identifier
    - causes
    • =mismatching in which perfusion is normal but ventilation is inadequate; insufficient O2 reaches the alveoli and CO2 is retained
    • aka: hypercapnic respiratory failure
    • identifier: PaCO2 >45 in pt with healthy lungs
    • causes: pneumothorax, abnormalities of alveoli or airways/CNS/chest wall, neuromuscular conditions
  47. minute ventilation
    • Ve=RRxVt
    • 5-10L/min
  48. mechanical ventilation
    - goal
    - indications
    • goal: to maintain alveolar ventilation appropriate to pt's metabolic needs (life support), to correct hypoxemia, and to maximize O2 transport
    • indications: apnea, acute respiratory failure, severe hypoxia, respiratory muscle fatigue, decreased LOC that threatens airway patency
  49. VAP bundle
    • hand washing
    • maintain vent circuits, suction set ups
    • oral care and tooth brushing
    • OG vs NG intubation and tube feeding
    • prophylactic antibiotics
    • aspiration prevention
    • frequent residual checks
    • sedation vacations
    • GI prophylaxis
    • DVT prophylaxis
  50. CPAP=
    - invasive vs noninvasive
    - how it works
    • =continuous positive airway pressure
    • - noninvasive
    • - constant pressure applied to keep the alveoli open
  51. BPAP=
    - invasive vs noninvasive
    - how it works
    • =Bi-level positive airway pressure
    • - noninvasive
    • - positive pressure on inspiration and positive pressure on expiration
    • - pt must be breathing spontaneously
  52. invasive ventilation:
    - volume cycled
    - pressure cycled
    - time cycled
    • air is pushed into the pt's lungs (inhalation), exhalation is passive
    • - volume cycled: inspiration ends when a preset volume is delivered
    • - pressure cycled: inspiration ends when a preset pressure is reached
    • - time cycled: inspiration ends when a preset time has elapsed
  53. controlled mandatory ventilation
    • pt with no spontaneous effort
    • pt receives a set Vt at a set rate
  54. assist-control ventilation (AC)
    - r/f
    • rate and volume are set
    • if the pt does not initiate a breath, they receive the set volume at the set rate
    • if the pt initiates a breath, it delivers preset volume
    • allows the pt to control rate
    • r/f hyperventilation
  55. synchronized intermittent mandatory ventilation (SIMV)
    • rate and volume are set
    • delivers set volume at set rate
    • allows spontaneous breats with no set rate or volume between mandatory breaths
  56. pressure regulated volume control (PRVC)
    • dual control = volume is controlled, pressure is regulated
    • breaths can be pt or ventilator initiated
    • set Vt is delivered while adjusting pressure from breath to breath
  57. pressure support ventilation
    augments spontaneous breathing with added pressure to overcome resistance of ET tube
  58. positive end expiratory pressure (PEEP)
    • adds positive pressure to mechanically assisted breaths
    • allows spontaneous breaths between mandatory breaths
    • prevents small airway collapse at the end of expiration
    • increases intrathoracic pressure - applies pressure to inferior and superior vena cava which collapse - decreases preload, SV, and BP
  59. tidal volume (Vt)
    • the amount of air delivered with each preset breath
    • usually 6-7ml/kg
  60. fraction of inspired oxygen (FiO2)
    percentage of oxygen delivered each breath
  61. sigh
    • breath that has greater Vt than the preset Vt
    • 1.5-2.0x the Vt
  62. low pressure alarm
    • indicates a loss of pressure
    • i.e. disconnect or leak in the system
  63. high pressure alarm
    • indicates increased pressure
    • i.e. blockage - sputum, condensation of fluid, coughing, pneumothorax, etc.
  64. some complications of mechanical ventilation
    barotrauma, R main stem intubation, accidental extubation, tracheal damage, acid/base imbalance, infection, DVT, PE
  65. emergency items to have at bedside with mechanical ventilation
    • suction equipment
    • Ambu bag
    • extra trach tube
    • 10cc syringe to check ET tube cuff
  66. VAP=
    • ventilator associated pneumonia
    • aka ventilator associated event (VAE)
    • defined at PNA in a pt intubated and ventilated at the time of or within 48hrs before the onset of the event
  67. weaning=
    -criteria
    - techniques
    - when to discontinue weaning
    • =gradual withdrawal of ventilator support
    • criteria: awake/alert, PEEP<5, no anesthesia, patent airway, stable CVS, relatively clear CXR and breath sounds, ABGs WNL
    • techniques: PSV, CPAP, IMV, SIMV
    • discontinue: SBP change >20, RR change >10 or RR>30, HR change >20 or HR>120, increased WOB, ABGs not WNL
  68. ABCDE bundle
    • Awakening and Breathing Trial Coordination - daily spontaneous breathing trial to promote earlier extubation
    • Delirium assessment and management
    • Early exercise and mobility
  69. ARDS
    - identifier
    - simple patho
    • acute onset of hypoxemia
    • identifier: refractory hypoxemia; hypoxemia despite O2
    • patho: capillary permeability increases, interstitial edema, heavy/wet/congested/stiff lungs unable to diffuse oxygen
  70. pulmonary embolism=
    - presentation
    - causes
    • =occlusion of the pulmonary artery or one of its branches
    • presentation: sudden onset of dyspnea, tachy
    • cause: Virchow's Triad
    • - prolonged stasis - bed rest, immobility
    • - altered coagulability - dehydration, clotting diseases, pregnancy, contraceptive use
    • - vessel wall damage - PICC lines, trauma, sepsis, atherosclerosis
  71. pulmonary embolism therapy
    • =anticoagulant therapy
    • heparin: doesn't dissolve clots, just prevents new ones. dose adjusted per PTT (2-2.5x norm (30) and INR 2-3). antidote=protamine sulfate
    • Coumadin: dose adjusted per PT (1.5-2.0x norm (12-14) and INR 2-3). antidote=vitamin K
    • aspirin: maintenance - prevents plt aggregation
  72. hemodynamics provide information about                         
    • vascular capacity
    • blood volume
    • pump effectiveness
    • tissue perfusion
  73. things to know about hemodynamic procedure
    • pressure monitoring system
    • slow drip heparinized saline solution
    • phlebostatic axis - 4th intercostal space, midaxillary line
  74. cardiac output=
    cardiac index=
    SVO2=
    • CO=4-8L/min
    • CI=2-4L/min
    • SVO2=60-80%
  75. why would hemodynamic values increase?
    • hypervolemia
    • pulmonary HTN
    • impedance to pulmonary blood flow
    • LV failure
    • pulmonary edema
    • tamponade
    • inc SVR, HTN
    • inc intrathoracic pressure
    • PEEP
    • tension pneumothorax
  76. MAP
    - how to calculate
    - what it depends on
    • mean arterial pressure
    • MAP= systolic + 2x diastolic /3
    • depends on: total blood volume, cardiac output, size of the vascular bed
  77. cellular changes in shock
    • decreased tissue perfusion
    • reduced O2 delivery
    • increased anaerobic metabolism
    • production of pyruvic acid
    • converts to lactic acid accumulation
    • decreases cellular pH
    • release digestive enzymes
    • destruction of cell membrane and cellular contents
  78. initial stage of shock
    - BP
    - HR
    - labs
    • 1st stage
    • BP: MAP dec 5-10 from baseline
    • HR: slight increase
    • labs: inc lactate
  79. compensatory stage of shock
    - BP
    - HR
    - skin
    - peripheral pulses
    - urine
    - LOC
    - respirations
    - GI
    - pupils
    - labs
    • 2nd stage
    • BP: dec MAP 10-15
    • HR: increased 100-150
    • skin: cool, pale, moist - from vasoconstriction
    • pulses: rapid, weak
    • urine: <30ml/hr
    • LOC: restless, agitated, confusion
    • resp: >20 - to blow off CO2 from acidosis
    • GI: hypoactive
    • pupils: dilated but reactive
    • labs: acidosis, hyperkalemia
  80. progressive stage of shock
    - BP
    - HR
    - skin
    - peripheral pulses
    - urine
    - LOC
    - respirations
    - GI
    - pupils
    - labs
    • 3rd stage
    • BP: MAP dec >20
    • HR: rapid >150
    • skin: edema, mottled, cold, cyanotic, jaundice
    • pulses: weak and rapid
    • urine: <20ml/hr
    • LOC: no longer responds to verbal stimuli
    • respirations: shallow, rapid, crackles - hypoventilation and resp. acidosis
    • GI: absent, GI bleeding
    • pupils: dilated with deteriorated response
    • labs: severe acidosis, hyperkalemia, hypoxemia, inc Cr, inc BUN, inc LDH, inc AST, inc ALT, inc lactic acid
  81. refractory stage of shock
    - BP
    - HR
    - skin
    - peripheral pulses
    - urine
    - LOC
    - respirations
    - GI
    - pupils
    - labs
    • 4th stage
    • BP: hypotension unresponsive to vasopressors and fluids
    • HR: varies, dysrhythmias
    • skin: cold, mottled, edema, pettechiae with DIC
    • pulses: absent
    • urine: anuria, renal failure
    • LOC: obtunded to coma
    • respirations: ventilator dependent
    • GI: absent BS
    • pupils: dilated and unresponsive
    • labs: acidosis, hyperkalemia, MODS DIC (inc PT, PTT, dec fibrinogen)
  82. sepsis=
    clinical signs of SIRS + definitive evidence of infection
  83. SIRS=
    - criteria
    • =systemic inflammatory response syndrome
    • if >2 criteria=SIRS
    • temp <96.8 or >100.4
    • HR>90
    • RR>20 or PaCO2<32
    • WBC<4,000 or >12,000 or 10% bands
  84. septic shock=
    severe sepsis with acute circulatory failure and persistent hypotension, despite adequate volume resuscitation
  85. severe sepsis 3 hour bundle
    • 1. measure lactate level
    • 2. obtain blood cultures prior to Abx
    • 3. administer broad-spectrum Abx
    • 4. administer 30ml/kg crystalloid for hypotension or a lactate >4mmol/L
  86. septic shock 6 hour bundle
    • 5. use vasopressors for goal MAP>65
    • 6. if persistent hypotension despite volume resuscitation or initial lacate >4mmol/L
    •     a. measure CVP
    •     b. measure SVO2
    • 7. remeasure lactate if initial lactate was elevated
    • 8. glycemic control
  87. ABG values:
    - pH
    - PCO2
    - HCO3
    • pH: 7.35-7.45
    • PCO2: 35-45
    • HCO3: 22-26
  88. normal ranges:
    - APTT
    - PT
    • APTT: 25-35
    • PT: 11-15
  89. anticoagulation therapeutic ranges
    - heparin
    - coumadin
    • heparin: APTT 60-75
    • Coumadin: PT 18-24

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