CRITICAL CARE EXAM 1

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CRITICAL CARE EXAM 1
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2014-01-27 15:23:57
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Critical Care Nursing
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Critical Care Nursing
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  1. Morphine
    • Most common opiate
    • Onset - 5 mins
    • Duration - 4-5 hours
    • Dose - 2-4 mg IV Q4H
  2. Hydromorphine (Dilaudid)
    • Onset - 15 mins
    • Duration - 4-5 hours
    • Dose - 0.2-1 mg IV !2-3H
    • Reversal - Narcan - .1-.2mg IV @ 2-3 min intervals
  3. Fentanyl
    • Synthetic opiate analgesic 
    • Dose - 50mcg-100mcg (.05-.1mg)
    • Duration - .5-1 hour (IV)
  4. Acetominophen (Tylenol)
    • Nonopiods
    • Do not exceed 2g in 24H
  5. Titration
    Adjustment of a drug for an individual level to provide the greatest comfort to the patient with min side effects
  6. midazolam (Versed)
    • Benzodiazepine
    • Duration - 4H
    • Dose - Weight based (1-4mg)
  7. Versed Antidote
    • Romazicon (flumazenil)
    • .2mg every min
    • Max 4 doses
  8. Lorazepam (ativan)
    • Benzodiazepine
    • Duration - 12H
    • S/E - seizures
  9. Ativan antidote
    • Romazicon
    • .2mg -1mg max IV
  10. Propofol (diprivan)
    • Onset - 2 mins
    • Duration - 2-5 mins
    • Metabolized in liver ; excreted in kidney
    • NO reversal agent
  11. Propofol Syndrome
    • Cardiac failure
    • metabolic acidosis
    • rhabdomyolsis
    • renal failure
  12. Sedation Assessment
    • Patients response to vent
    • restlessness
    • LOC
    • VS
    • RASS
  13. RASS
    • Sedation scale
    • +4 - -5
    • Target Score - MD determined
    • Actual Score - RN assessed
  14. Neuromuscular Blockade
    • Drug-induced paralysis
    • Paralyzes skeletal muscle ONLY - not brain
    • S/E - Tachycardia, HTN
  15. Vecuronium
    • Neuromuscular block
    • onset - 3 mins
    • duration - 30-40 mins
  16. Pavulon
    • Neuromuscular block
    • onset - 2-3 mins
    • duration - 45-60 mins
  17. Leading traumatic injuries...
    • 1. Falls
    • 2. Stuck by person or object
    • 3. Transportation related injury
  18. Most important question in trauma?
    Mechanism of injury?
  19. Types of kinetic injury
    • 1. Blunt
    • 2. Penetrating
  20. Blunt trauma
    • NO skin interruption
    • covert injury
  21. Degree of blunt trauma is determined by...
    • 1. velocity of energy transmission
    • 2. surface area of injury
    • 3. elasticity of tissues impacted
  22. Shearing force blunt trauma
    • Sliding of body structures in the opposite direction upon impact from blunt force
    • **Coup-contrecoup chearing C7-T1
    • **Aortic Tearing
  23. Acceleration force in blunt trauma
    • Increase in the velocity of a moving body or structure 
    • increased tissue/organ damage with greater velocity
    • Example : hitting steering wheel in MVA
  24. Deceleration force in blunt trauma
    • Decreased in velocity of a moving object
    • force impedes forward movement of person
  25. Tensile stress in blunt trauma
    • Not a force
    • limited longitudinal stretch or stress upon a tissue or organ
    • Example: AC dislocation
  26. Compression force in blunt trauma
    • Organ or tissue is squeezed or pressed by force
    • Example: heart and lungs between the chest wall
    • Example: Bowel,liver, or spleen between spine and seatbelt
  27. Spleen (trauma)
    #1 organ injured in blunt force trauma
  28. Penetrating traumatic injury
    • Transmission of energy from a moving object into the body tissues
    • disrupts skin integrity 
    • DO NOT REMOVE OBJECT
  29. Blast effect
    damage to surrounding area
  30. Advanced Trauma Life Support (ATLS)
    • 1. Primary survery
    • 2. Resuscitation 
    • 3. Secondary survery

    Primary and resuscitation occur together!
  31. Primary survey 
    ATLS
    • Identify life-threatening injuries and intervene simultaneously 
    • ABCDE approach
  32. A - Airway
    ATLS
    Maxillofacial Fx - highest cause of airway obstruction
  33. Two types of airways
    • 1. Nasopharyngeal 
    • 2. Oropharyngeal
  34. Nasopharyngeal Airway
    • Conscious patient
    • used when c-spine cannot be hyperextended
    • Contraindications - Cribriform Fx or Basal skull Fx
  35. Oropharyngeal Airway
    • Endotracheal Tube
    • Unconscious patient
    • can cause aspiration in conscious patient
  36. Capnography
    • Measures end tidal CO2
    • Normal - 35-45 mmHg
  37. Shock
    (Trauma)
    Clinical state of inadequate circulation
  38. Hypovolemic Shock
    • Caused by acute blood loss from injury
    • Most common traumatic shock
    • shifting or loss of fluids from intravascular space
  39. Hypovolemic Shock
    Symptoms
    • 1. Mild to marked tachycardia
    • 2. Hypotension
    • 3. Tachypnea and anxiety
  40. Exsanguination
    • Extreme hemorrhage
    • ALWAYS = hypovolemic shock
  41. Trauma related death
    • First Peak - Dead at the scene
    • Second Peak - within 2 hours
    • Third Peak - Within days to weeks
  42. Resuscitation Phase
    ATLS
    • Done with primary
    • Exsanguination resuscitation - 14G-16G IV - 2L LR or plasmolyte
  43. Flail Chest
    • Lack of bony support due to 2+ rib Fx
    • complications - hypoxemia, PNA
  44. Tension Pneumo
    • Caused by blunt force trauma
    • Trapped air
    • Plusus Paradoxus
    • Neck vein distension
    • Absent breath sounds on affected side
  45. Tension Pneumo
    Treatment
    • Needle Asp
    • Chest Tube
  46. Pulsus Paradoxus
    • Drop in SBP by 10mmHg or more upon inspiration 
    • Seen in tension pneumo and cardiac tamponade
  47. Open Pneumo
    • Penetrating chest wall injury
    • appears same as tension pneumo
  48. Open Pneumo 
    Treatment
    • Sterile dressing taped on 3 sides
    • Chest Tube
    • Sx
  49. Massive Hemothorax
    • Accumulation of >1500cc of blood in chest cavity
    • autotransfusion used
    • CT placed 
    • Sx
  50. Cardiac Tamponade
    • Caused by blunt or penetrating trauma
    • pericardium fills with blood
    • impedes venous return
  51. Cardiac Tamponade
    Clinical Manifestations
    • Becks Triad - Increased RAP with neck vein distension
    •                 - Hypotension
    •                 - Muffled heart sounds
    • Pulsus Paradoxus
    • PEA
  52. Pericardiocentesis
    Procedure where fluid is aspirated from pericardium
  53. Best Indicators of end points of resuscitation
    • 1. Hemodynamic Monitoring 
    • 2. Decrease in lactic acid levels
    • 3. Raise base levels
  54. Damage Control Survery
    3 Phases
    • 1. Initial Operation - control source of bleeding
    • 2. Resuscitation - In ICU for trauma resuscitation
    • 3. Definitive Resuscitation - Back in OR within 72H
    • Complications: Intraabdominal compartment syndrome
  55. Metabolic response to stress injury
    Body response to traumatic injury
  56. Ebb Phase
    • Metabolic Response to Stress Injury
    • 24-36H
    • Decreased O2 consumption
    • Decreased body temp
  57. Flow Phase
    • Metabolic Response to Stress Injury
    • After 36H - Recovery State
    • Increase in body temp
    • Protein breakdown - catabolic state
    • think high energy, high use of O2
  58. Ventilation
    Ability to move air in and out of lungs
  59. Respiration
    Gas exchange at cellular level
  60. Acute Ventilatory Failure
    • Patient unable to move air in and out
    • acute resp acidosis 
    • Increased CO2 (>50) - because they cant exhale 
    • Decreased pH (< 7.30) - Acidosis
  61. Hypoxemia - Shunting
    • PO2 (<60)
    • O2 sat 88%
  62. Pulmonary Mechanics
    • Example: ALS d/t paralysis of muscles
    • Obstruction, decreased compliance, weak pulmonary muscles
  63. Post-intubation assessment
    • 1. Auscultate
    • 2. etCO2
    • 3. CXR
  64. Tracheostomy
    • Prolonged needs for airway
    • Prevents skin breakdown around mouth
  65. Negative Pressure Ventilation
    • "Iron Lung"
    • Diaphragm goes down...lungs go out
  66. Positive Pressure Ventilation
    Volume-Cycled
    • Delivers a preset volume of air to lungs
    • pushes certain amount of air
    • most common setting
  67. Positive Pressure Ventilation
    Pressure-Cycled
    • Delivers a preset gas pressure to lungs
    • keeps pushing air until pressure is achieved
  68. Tidal Volume
    • Amount of air delivered to lungs in one breath
    • 5-12mL/Kg (500-800mL)
  69. Barotrauma
    Damage to alveoli
  70. FiO2
    • % of O2 inspired gas
    • Room air - 21%
    • Usually starts at 30%
  71. PEEP
    Keeps alveoli inflated during expiration
  72. Peak airway pressure
    • Pressure required to deliver volume of air 
    • Normal - 20cm H20
    • Goal - < 40cm H20
    • Increased peak = decreased lung compliance
    • Decreased peak = improving status 
    • Highest amount of pressure it takes to push air into lungs determines how healthy lungs are
  73. Assist Control
    A/C
    • Patient guaranteed to get certain amount of breaths per min
    • Additional inspiratory breaths are assisted at set tidal volume
    • Patient can become alkalotic from breathing off to much CO2
  74. Synchronous Intermittent Mandatory Ventilation
    SIMV
    • Patient gets guaranteed amount of breaths 
    • machine does not assist with patient attempting to take their own breath
    • setting used to wean patient from vent
  75. Continuous Positive Airway Pressure
    CPAP
    • no RR or TV preset 
    • Patient generates their own Rate and Tidal volume
    • Just gives a source of O2, does not provide breaths
  76. Pressure Support Ventilation
    PSV
    • Overcomes increased airway resistance
    • little bit of pressure that stays in the vent circuit all the time
    • decreases work of breathing
  77. High Pressure Vent Alarm
    • Indicates resistance in the circuit
    • Usual Causes are : Secretions, coughing, biting on ET tube, high lung compliance
  78. Low Pressure Vent Alarm
    • Indicates a disconnection or leak in the system
    • check tubing and make sure everything is connected
  79. Major Complications of Mechanical Ventilation
    Cardiovascular
    • Decreased CO, preload, SV
    • Heart cant fully expand when lungs are over inflated
  80. Major Complications of Mechanical Ventilation
    Pulmonary
    • Changes in flow of gas
    • O2 toxicity
    • R/O VAP, barotrauma
  81. Major Complications of Mechanical Ventilation
    Renal
    • Decreased perfusion
    • Rare
  82. Major Complication of Mechanical Ventilation
    GI
    • Stress Ulcers!!
    • Very Common
    • Vented patients need to be on PPI or H2 blocker!
  83. Major Complications of Mechanical Ventilation
    Neuro
    • Decreased flow to head
    • Increased ICP
  84. Oxygen Toxicity
    • Risk with > 80% FiO2 for > 48H
    • Damages endothelium
    • Use min O2 to obtain acceptable PaO2%
    • Add PEEP - PEEP will increase O2 consumption and decrease % of O2 needed
  85. Alteration in Cardiac Output
    Mechanical Ventilation
    • Increased intrathoracic pressure over distends lungs and prevent cardiac filling
    • Lungs very expanded = increased pressure on heart = hard time filling and pumping = decreased CO
  86. Weaning Mechanical Ventilation
    • Assess readiness to wean (RTW)
    • All patient parameters must be optimized
    •   - < 50% FiO2
    •   - PEEP < 5
    •   - Optimal Nutrition
    •   - Afebrile
    •   - No GI Bleed
    •   - Stable hemodynamics
    •   - Mental Status
  87. Weaning Modes
    Manual
    Removed from vent and placed on T piece, Trach collar, serially increase time off vent
  88. Weaning Modes
    Vent
    • More common
    • usually CPAP setting
  89. Weaning Modes
    CPAP Wean
    • Remain attached to vent
    • provides oxygenated air
  90. Weaning Modes
    IMV Wean
    • Patient starts with high number of breaths
    • over time breaths are decreased
    • this setting often used with a difficult to wean patient
  91. Assessing a weaning trial
    • Increased TV and Decreased RR
    • Rapid shallow breathing index
    • Target - < 100
  92. Most common immediate complications of post extubation
    Stridor, laryngospasms
  93. Post Extubation Care
    • Assess breath sounds
    • humidified air
    • Pulm Hygiene
    • Swallowing eval
  94. Noninvasive Intermittent Positive Pressure Vent
    NIPPV
    Forces air into lungs as you breathe on your own
  95. Complications of NIPPV
    • Gastric distention
    • Aspiration - Keep NPO
    • Hypoventilation
    • Skin irritation
    • Nasal problems
    • Conjunctivitis 
    • Removal/ non-compliance
  96. 2 major functions of spinal column
    • 1. Protection
    • 2. Structure/support
  97. Unstable vertrebral column...
    • 1. Lack of vertebral support
    • 2. Lack of ligament support
    • 3. 2+ damaged vertebral columns
  98. Spinal Cord
    • 31 pairs of nerves
    • Begins at foramen magnum
    • *Ends at approx L1-L2
  99. Upper Motor Neurons
    • Originate at cerebral cortex
    • Carries motor signals from brain to the end of the spinal cord
    • convey impulses for voluntary movement
  100. Lower Motor Neurons
    • Originate in brain stem
    • connects upper motor neuron by synapses
    • branch out as spinal nerves
    • innervate with skeletal muscle
  101. Meningeal Layers
    • Protective layer around brain and spinal cord
    • 1. Dura Mater - Outermost 
    • 2. Arachnoid - Middle Layer
    • 3. Pia Mater - Innermost
    • CSF = Subarachnoid Space**
  102. Gray Matter Region
    • Inner region
    • Motor activity is transmitted from brain to body
    • sensory messages are related from the body to the brain
  103. White Matter Region
    • 3 Tracts
    • 1. Corticospinal - transmits motor activity
    • 2. Spinothalamic - transmits pain and temp
    • 2. Posterior (dorsal) - carries sensations of vibration, proprioception, touch, fine touch, pressure and texture
  104. Mechanisms of Injury frequency...
    Spinal injury
    • 1. MVC
    • 2. Falls
    • 3. Violence
    • 4. Sports
  105. Laminectomy
    Decompression that alleviates pain from neural impingement stenosis
  106. Discectomy
    Removal of all or part of the damaged disc
  107. Classifications of SCI based on...
    • 1. Location
    • 2. Incomplete or Complete
  108. Complete SC Transection
    Lack of sensory and motor function below the level of injury
  109. Incomplete SC Transection
    • Preservation of some sensory and/or motor function below the level of injury
    • altered sensory and/or motor function
    • range of degree preservation
  110. Tetraplegia
    • Formally known as Quad
    • Complete severing of SC between C1 and T1
    • Probably no bowel or bladder function
  111. Paraplegia
    • Complete severing of SC between T2 - L1
    • Possible bowel and bladder training
  112. Incomplete injury at T12 and ABOVE
    • Upper motor neuron injury
    • spasticity of muscles
    • exaggerated tendon reflexes
    • spastic neurogenic bladder
    • anal sphincter will respond
  113. Incomplete injury BELOW T12
    • Lower motor neuron injury
    • hypotonation
    • hyporeflexia
    • flaccidity
    • acontractile bladder and bowel
  114. C1-C3 Spinal Injuries
    • Can be fatal
    • Loss of phrenic nerve
    • vent dependent 
    • tetraplegia
  115. C4-C5 Spinal Injury
    • Common diving injuries
    • risk of vent support
  116. C7-T1 Spinal Injury
    Coup-contrecoup shearing injury
  117. T&L Spine Injury
    T-L junction most common site
  118. Primary SCI
    Occurs at the moment of impact
  119. Primary SCI Mechanisms of Injury
    • Hyperflexion
    • hyperextension
    • flexion-rotation
    • compression
  120. Secondary SCI
    Occurs within mins of primary injury
  121. Secondary SCI Manifestations
    • 1. Ischemia
    • 2. Elevated Intracellular Calcium 
    • 3. Inflammatory Processess
  122. Ischemia SCI
    • Decrease in circulation to injury site 
    • vasospasms
    • edema
    • hypoperfusion
    • neuronal death
  123. Elevated Intracellular Calcium SCI
    • Accumulation of calcium ions in injured cells
    • demyelination and destruction of cell membrane
    • damage to the cell membrane
    • neuronal death
  124. Inflammatory Process SCI
    • Infiltration of leukocytes at the site of injury
    • swelling of the injured SC
    • Swelling can take days to weeks
  125. Motor Assessment
    SCI
    • Assess strength and movement
    • ALWAYS begin at the end
    • Lower extremities assessed last
  126. Sensory Assessment 
    SCI
    • Checking for exact points of normal sensation
    • ALWAYS start distally and move proximally
  127. Reflex Activity Assessment - Deep Tendon Reflexes
    • Complete SCI - absence of deep tendon reflexes below the level of injury
    • Incomplete SCI - Presence of reflexes below level of injury
  128. Reflex Activity Assessment - Perineal eflexes
    • If present - Possible bowel and bladder training
    • upper motor neuron injury
  129. Spinal Shock Temp causes ....
    • 1. Absence of all reflex activity
    • 2. Flaccidity 
    • 3. Loss of all neurologic activity below the level of injury
  130. Spinal Shock
    Unable to classify SCI as complete or incomplete until shock resolves
  131. End of Spinal Shock...
    • 1. Return of deep tendon reflexes
    • 2. Spasticity and hyperreflexia
    • 3. Clonus - muscular spasm
    • 4. Increased muscle toen
    • 5. Return of perineal reflexes
  132. Neurogenic Shock
    • Occurs in SCI at or above T6; within 30 mins of SCI
    • Sudden loss of sympathetc stim to blood vessels = bradycardia
    • massive relaxation and vasodilation of vessels = severe hypotension
    • loss of vasoconstrictive effects = pooling of blood
    • unable to regulate temp = poikilothermia
    • **Severe arterial hypotension with bradycardia = classic neurogenic shock**
  133. Neurogenic Shock 
    Treatment
    • 1. Fluid resuscitation
    • 2. Vasopressor
    • 3. Atropine
  134. Arterial Hypotension with Tachycardia equals...
    Hypovolemic Shock!
  135. Steroid Therapy
    SCI
    • Methylprednisolone
    • Min inflammation
    • 24H infusion
    • D/C if symptoms resolve
    • can increase risk of PNA, sepsis, GI bleed, electrolyte imbalance, delayed healing
  136. Acute Care Phase
    Bradycardia
    • Atropine
    • SCI pts increased R/O bradycardia/asystole during ET tube manipulation, suction, NGT insertion
  137. Venous Thromboembolism
    SCI
    • **Leading cause of mortality and morbidity in SCI
    • Predisposing factors : Venostasis and transient hypercoagulable state
  138. Heterotopic Ossification
    • Ectopic overgrowth of bone below level of injury
    • Manifestations : loss of ROM and localized swelling, warmth and fever
    • Hip most common
    • Preventative measure - Indomethacin
  139. Autonomic Dysreflexia (AD)
    • Life-threatening medical EMERGENCY
    • SCI at or above T6
    • Overstimulated autonomic nervous system
  140. Autonomic Dysreflexia
    Episodic Triggers
    • BLADDER DISTENTION
    • bowel impaction
    • stim of anal reflex
    • pain
    • temp change
    • ingrown toenail
    • tight clothes
    • UTI
    • uterine contraction
  141. Autonomic Dysreflexia
    Clinical Manifestations
    • **HTN - Any SBP > 40 mmHg over baseline
    • profuse sweating
    • goose bumps
    • sudden HA
    • blurred vision
    • anxiety / doom
  142. Autonomic Dysreflexia 
    Treatment
    • LOWER BP
    • HOB 90
    • loosen clothing
    • relieve bladder
    • facilitate defecation
    • pain meds
    • anti HTN meds
  143. Blood flow through the heart
    Vena Cava --> RA --> Tricuspid valve --> RV --> PA --> LA --> Mitral valve --> LV --> Aorta --> out to body
  144. Atrial Systole
    Pressure in atria exceeds resistance in ventricles = opening of tricuspid and mitral valves
  145. Atrial ejection occurs equaling
    LV prefilling
  146. Atrial Kick is how much of C.O?
    20-30%
  147. Ventricular Systole
    Two ventricles exceed the resistance of outflow vessels = valves closing = S1 heart sounds
  148. Preload
    • "filling the tank"
    • the volume of blood filling the ventricles at the end of diastole
  149. Increased Right heart preload
    clinical manifestations
    • JVD
    • ascities
    • hepatic engorgement 
    • edema
    • * signs of fluid overload
  150. Decreased right heart preload
    Clinical Manifestations
    • Poor turgor
    • Dry membranes
    • orthostatic hypotension
    • Flat jugular veins
    • * signs of dehydration
  151. Increased left heart preload
    Clinical Manifestations
    • Dyspnea
    • Cough
    • 3rd and 4th heart sounds
  152. Starlings Law
    • Force of contraction of cardiac muscles is dependent on the stretch of cardiac muscle fibers
    • force of ventricular contraction is dependent on preload
    • Bigger stretch = bigger squeeze *
  153. Afterload
    • Measure of work or resistance
    • amount of resistance that push against aortic valve
    • Increased afterload = increased O2 need
    • Increased afterload = increased work of the heart
    • measured by SVR - directly related to arterial dilation and contraction
    • Dilation = Decreased SVR
    • Contraction = Increased SVR
    • Normal SVR - 800-1200**
  154. Contractility
    • Squeeze
    • ability of the cardiac muscle fibers to shorten in length
  155. Inotrophy
    • Agents that affect contractility
    • Positives - increase
    • negatives - decrease
  156. Invasive Hemodynamic Monitoring
    Measurement and interpretation of invasive hemodynamic parameters to determine cardiovascular functions and regulate therapy
  157. Pulmonary Artery Catheter
    Swan Ganz
    • Most invasive critical care monitoring catheters
    • Simultaneously assesses several hemodynamic parameters
    • Inserted in IJ, subclavian or femoral
  158. Normal CVP/RA pressure
    2-6
  159. Normal RV pressure
    20-30/2-8
  160. Normal PA pressure
    2-30/8-15
  161. Normal SVR
    800-1200
  162. CVP
    • Measures filling pressures in the Right heart
    • Normal 2-6
    • Low CVP = hypovolemia , dehydration
    • High CVP = fluid overload
  163. PA pressures
    • Reflects RV and lung
    • Normal 20-30/8-15
    • Low PA = hypovolemia
    • High PA = fluid overload, mitral stenosis, COPD, Pulm embolus, Idiopathic Pulm HTN
  164. PA wedge pressure
    • Reflects BP in LV at end-diastole
    • Measure of LV preload
    • Low wedge = hypovolemia
    • High wedge = fluid overload,MI, cardiogenic shock, CHF
    • Normal 4-12
  165. Cardiac Output
    • Amount of blood ejected by the heart per minute
    • Normal = 4-8L/min
    • CO= HR x Stroke Volume
    • CO is partially dependent on body size of individual
  166. Stroke Volume
    • Amount of blood ejected per beat
    • Normal 50-100cc
  167. Cardiac Index
    • CO divided by body surface area
    • Normal = 2.4-4L/min
    • CI < 2.0 = Shock
  168. Septic Shock
    • Endotoxins produce massive arterial vasodilation
    • Severe decrease in BP
    • Decreased SVR (<600)
    • Increased CO (>10)
  169. Cardiogenic Shock
    • Heart loses pumping ability
    • Severe decrease in BP
    • Increased SVR (>1600)
    • Decreased CO (<3)
  170. Pressure Bag
    • 3cc/hr - keeps line open and clear
    • filled to 300 of pressure
  171. Arterial Waveform
    Dichrotic notch signals closure of the aortic valve - beginning of diastole
  172. Care of A-lines
    • Ensure that all connections are tight
    • Kinked a-line will result in a dampened waveform
    • maintain the transducer level with tip of the catheter
    • NEVER INJECT MEDS INTO A LINE
  173. Absolute refractory period
    Cells will not respond to any further stimulation
  174. Relative refractory period
    • cells will respond to a stronger than normal stimulus
    • R on T phenomenon
  175. Normal QRS complex
    < .12
  176. Normal PR interval
    .12-.20
  177. Cardiac Conduction
    SA Node
    • Start of conductive system
    • typically determines HR
  178. Cardiac Conduction
    AV Node
    Receives from atria and transmits thru the ventricle thru purkinje finbers and breaks into bundle branches
  179. Sinus Brady
    • < 60 bpm 
    • may or may not be symptomatic 
    • Atropine - .5mg IV q3-5 mins ; max 3 mg
  180. Sinus Tach
    • > 100 bpm
    • always has a cause
    • Fix the cause, fix the rhythm
    • Beta blockers, calcium channel blockers
  181. A-fib
    • Irregularly irregular 
    • no meaningful P waves
    • No effective contraction = atria quivers
  182. A-flutter
    • > 250 bpm
    • Saw tooth P waves
  183. A-fib & A-flutter
    Treatment
    • Diltiazem and Amiodarone
    • Beta blockers and Digoxin
    • anticoagulate
  184. Superventricular Tachycardia 
    SVT
    • 150-250 bpm
    • always regular
    • Valsalva or adenosine
  185. Stable SVT treatment
    • O2
    • IV
    • cardiac monitoring
    • vagal maneuvers
    • adenosine
  186. Unstable SVT treatment
    • Adenosine
    • calcium channel and beta blockers
    • cardioversion
  187. Premature Atrial Contraction (PAC)
    • Early atrial depolarization before next scheduled sinus beat
    • usually asymptomatic
  188. Premature Ventricular Contraction (PVC)
    • QRS is wise and bizarre
    • T wave is opposite to QRS
  189. Ventricular Tachycardia (V-Tach)
    • Fatal
    • Significant cardiac disease
    • quick regular rhythm
  190. Stable V-tach Treatment
    • Amiodarone
    • lidocaine
    • Mag
    • Potassium
    • cardiovert
  191. Pulseless V-tach treatment
    • CPR
    • Defib
    • EPI
    • vasopressin
    • amiodarone
    • lidocaine
    • resuscitation
  192. Ventricular Fibrillation (V-Fib)
    • Always fatal unless terminated
    • no organized depolarization = no contraction = no perfusion
  193. 1st degree AV block
    • A-V node conduction delay
    • PR > .20
    • Least serious
  194. 2nd degree AV block Mobitz 1
    Wenkebach
    • PR lengthens until QRS is dropped, than starts again
    • less serious
    • treat symptoms
  195. 2nd degree AV block Mobitz II
    • PR constant
    • some beats are conducted and some arent
    • more serious
    • atropine, dopamine and Epi
    • pacer
  196. 3rd degree AV block
    complete heart block
    • No communication between atria and ventricles
    • no realtionship between P waves and QRS
    • P waves and QRS are on time but the do not work together

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