What is normal (RV/right ventricular pressure) pressure?
What is the normal pressure for PAP?
What is the A wave in CVP/RAP waveform?
Rise in atrial pressure as a result of atrial contraction
Normally seen during PR interval before the onset of the QRS on the ECG
What is the C wave in CVP/RAP waveform?
Nor alway’s visible
rise in the atrial pressure with closure of the AC valves (TM) bulge upward into the atrium following valve closure
What is the V wave in CVP/RAP waveforms?
Rise in atrial pressure as it refill during ventricular contraction
V-wave is generally seen immediately after the peak of the T wave on the ECG
What is the X wave in the CVP/RAP waveform?
Decline in right atrial pressure during atrial reaction
What is the Y wave in the CVP/RAP waveform?
Decline in right atrial pressure; atrial emptying
What does PAD stand for?
Pulmonary artery diastolic pressure
What is the normal PAD pressure?
What does PAWP stand for?
Pulmonary artery wedge pressure
What is the normal PAWP pressure?
What is the L of normal cardiac output?
How many L/min does cardiac index put out?
What does a PAWP between 13-14 indicate?
Acute respiratory distress
What does a PAWP between 15-18 indicate?
Optimal pressure for CHF
What does a PAWP of above 20, 25 and 30 indicate?
20 is pulmonary congestion
25 is moderat pulmonary congestion
30 is sever pulmonary congestion
What does CI stand for?
What is the normal range for cardiac index?
What is normal Systemic vascular resistance?
What does an SVR below 800CI indicate?
What does PVR stand for?
Pulmonary vascular resistance
What is normal PVR range?
What does PAS stand for?
Pulmonary Artery systolic pressure
What is PAS normal pressure?
What is normal ejection fraction?
What is normal CPP?
What does the Heart sound S1 and S2 indicate?
Normal sounds with no indication
What does S3 heart sound indicate?
CHF also called the Kentucky gallup
What does S4 heart sound indicate?
What is the Blue line on the Pulmonary artery catheter?
The proximal port
What is the yellow line on the Pulmonary Artery Catheter?
What is the Red line on the Pulmonary Artery Catheter?
Ballon inflation port
What is the max amount of air to inflate the balloon on the Pulmonary artery catheter?
No more then 1.5cc
What is the clear line on the pulmonary artery catheter?
What pressure are you reading when the Pulmonary Artery Catheter is at the depth of 20cm?
What pressure are you reading when the Pulmonary Artery Catheter is at the depth of 30-35cm
Means you are in the Right ventricle
What should you do when the you are in the right ventricle?
Pull back and change infusion to distal from proximal
What is the correct location for the PAC on an X-ray?
No more then 2cnm below the central helium
What does the Dicrotic notch on the arterial wave form?
Indicates the closure of the aortic valve
What does the Absence of the A line on the PAWP pressure indicate?
Hypovolemia or A-fib
What indicates a PA on the ECG?
inverted T-wave in V3 and isolated ST elevation in V3
What is a Thoracostomy?
Needle chest decompression
What does APSP/ASYSstand for?
Assisted systole associated with a balloon pump
What does PSP or SYS stand for?
Unassisted systole with a balloon pump
What is PAEDP?
Patient Aortic End diastolic pressure
What does DIA/BIP stand for?
What does ADIA stand for?
What does BAEDP stand for?
Balloon aortic end diastolic pressure
When does the Ballon pump know when to trigger?
ECG is the primary way,
By the R-wave
Balloon inflates during diastole
What does AUG or PDP stand for?
From Left to right state what each wave indicates for the balloon pump starting at the DN.
Dn is the closure of the Aortic valve
First depression - Unassisted Diastole
First peak - Unassisted Systole
Second valley - Assisted Diastole
Second Peak (Tallest peak) - AUG (Diastolic Augmentation)(peak diastolic pressure)
Third Valley, last before recycle. Assisted Diastole
Third peak, last before recycle. Assisted Systole
How to do you determine early inflation of the ballon pump?
Draw a line from the DN back to the first valley, if the middle valley is greater the 2mm above, it is early
How do you determine later inflation of the balloon pump?
Draw a line from the first valley to the final valley, if at or above it is late.
How many beats for how many seconds indicates a good acceleration for FHR?
<32 weeks gestation = 10x10 accelerations
> Weeks gestation = 15 x 15 accelerations
When should accelerations for FHR occur?
Durring the mothers contrition
What are Variable decelerations?
Decelerations in FHR that occur anywhere during contraction
What does Variable decelerations indicate?
What are early Decelerations?
Decelerations in FHR, they mirror contractions
What do early decelerations indicate?
What are late decelerations?
Decelerations in FHR that occur at the peak of contraction
What do late decelerations indicate?
What is a Sinusoidal pattern for FHR?
Smooth wave like line
What does Sinusoidal pattern indicate?
What is a Pseudosinusoidal Pattern for FHR?
What does Pseudosinusoidal indicate?
The administration of narcotics to mother, high baby
What is normal pH?
7.35 - 7.45
What is normal arterial oxygen partial pressure?
What is Henry’s law?
Gas Law, At a constant temperature, the amount of a given gas that dissolves in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liquid
What is Boyle’s Law?
The absolute pressure exerted by a given mass of an ideal gas is inversely proportional to the volume it occupies id the temperature and amount of gas remain unchanged within a closed system
What is Charles Law?
When the pressure on a sample of a dry gas is held constant, the kelvin temperature and the volume will be directly related
What is Gay-Lussac’s law?
The law of combining volumes
When gases react together to form other gases, and all volumes are measured at the same temperature and pressure; the Ratio between the volumes of the reactant gases and the products can be expressed in simple whole numbers
What is the normal HCO3 arterial?
What is the normal pCO2 ABG?
What is normal pO2 Arterial?
What is the normal Hemoglobin value for a male ?
What is the normal Hematocrit for a male?
What is the normal Creatinine levels?
What is the normal potassium level?
What is the normal Na+ level?
What is the normal lactic acid level?
What are normal HDL cholesterol levels?
What are normal LDL cholesterol levels?
What does a decreased CVP/RAP indicate?
Negative pressure ventilation
What does an elevated CVP/RAP indicate?
Right sided heart failure
Positive pressure ventilation
What does an elevated RVP elevated?
What does an elevated PAP (PAS/PAD) indicate?
Atrial or ventricular defect
What does a low PAWP indicate?
What does an elevated PAWP indicate?
What does an elevated PVR indicate?
What does a low SVR indicate?
What does an elevated SVR indicate?
What do you expect in for CVP, CI, Wedge and SVR for hypovolemic shock?
CVP - low
CI - Low
PAWP - Low
SVR - High
What do you expect in for CVP, CI, Wedge and SVR for Cardiogenic shock?
CVP - High
CI - Low
PAWP - High
SVR - High
What do you expect in for CVP, CI, Wedge and SVR for RVMI shock?
CVP - High
CI - Low
PAWP - Low
SVR - High
What do you expect in for CVP, CI, Wedge and SVR for Septic shock?
CI - High
SVR - Low
What do you expect in for CVP, CI, Wedge and SVR for Neurogenic shock?
CI - Low
What do you expect in for CVP, CI, Wedge and SVR for Anaphylactic shock?
CI - Low
SVR - Low
With an SVR of <800 what kind of shock is of highest suspicion?
Distributive or Vasodilatory shock
- Distributive shocks like Septic, Neurogenic or anaphylactic shock.
After discovering an SVR 800> what to look at next to distinguish between distributive shocks?
High for Septic,
Low for Neuogenic and Anaphylactic
After discovering that the SVR is 800> and the CI is low, how do you determine the difference between Anaphylactiv shock and Neurogenic shock?
In Neurogenic shock the the Heart rate will be normal or slow
for anaphylactic shock the HR will be fast
With an SVR >1200 what types of shock are of highest suspicion?
After finding an SVR >1200 how do you determine the difference betweenHypovolemia, Cardiogenci and RVMI shocks?
Look at CVP and PAWP
Hypo - CVP is low (no wedge needed)
Cario - CVP High/Wedge High
RVMI - CVP High/Wedge low
After finding an SVR >1200 and a Low CVP what type of shock is it?
After finding an SVR >1200 and a High CVP what type of shock(s) is it?
Cardiogenic or RVMI
Look at PAWP to distinguish
Cardio high PAWP
RVMI low PAWP
What is the Formula for CPP?
DBP - PAWP
What is the formula for MAP?
2 x DBP + SBR / 3
What is normal MAP?
What is the Allen’s test?
Blanch test to insure adequate perfusion to the radial and ulnar prior to Arterial line insertion
What does the PA actually Monitor?
Reflect right and left sided heart pressures
What does the PAWP actually monitor?
Pressure of the left side of the heart (Preload)
What is Cardiac index?
Body surface area and is more accurate, access blood blow
What are the types of Hypoxia?
Hypoxic hypoxia (altitude hypoxia)
Histotoxic hypoxia (Tissue poisoning)
What is Hypoxic Hypoxia?
Is a deficiency in the alveolar oxygen exchange, which can be caused by low barometric pressure
What is Hypemic hypoxia?
A reduction in the oxygen-carrying capacity of the blood
What is Stagnant Hypoxia?
When conditions exist that result in reduced total cardiac output, pooling of the blood within certain regions of the body, a decreased blood flow to the tissue, or restriction of blood flow
What is Histotoxic hypoxia?
Occurs when metabolic disorders or poisoning of the cytochromic oxidase enzyme results in a cells inability to use molecular oxygen
What are the inferior wall leads?
What are the Reciprocal inferior leads?
What are the Anterior-septal leads?
What are the reciprocal Anterior-septal leads?
What are the Lateral wall leads?
What are the reciprocal lateral leads?
What are the posterior wall leads?
What are the reciprocal posterior leads?
What is the normal Troponin I range?
What is the onset of Troponin?
4-6hrs, peaks in 12-24hrs
What is the normal Troponin T range?
What is the onset of Troponin T?
Peaks in 10-24hrs
What is Dressler’s syndrome?
A secondary form of pericarditis that occurs in the setting of injury to the heart or pericardium
Also known as post MI syndrome
What is a Pericardial effusion
The development of pericardial fluid as response to injury, acute pericarditits. Electrical alternanes can be present
What does Grave’s disease indicate?
What does Myxedema indicate?
What does Addisons disease indicate?
Acute renal insufficiency
What does Cushings disease indicate?
What is the Levine’s sign and what may it indicate?
Clutching of the chest
May indicate cardiac problem
What is the murphy’s sign and what may it indicate?
Right upper quadrant pain
May indicate gallbladder disease
What is Grey turner’s sign and what may it indicate?
May indicate pancreatitis or trauma
What is Cullens sign and what may it indicate?
May indicate pancreatitis or intra-abdominal bleeding
What is Halstead sign and what may it indicate?
Marbled appearance of the abdomen
May indicate necrosis of the pancreas
What is Kehr’s sign and what may it indicate?
May indicate spleen injury on the left side or ectopic pregnancy/rupture on either side
What is Hamman’s sign and what may it indicate?
Crunching sound heard with auscultation
May be synchronized with heart rate/pulse
May indicate a tracheobronchial injury
What is Orhopnea?
Increased SOB in supine/lying position and is relieved by sitting and or standing
What is Paroxysmal nocturnal dyspnea?
Also known as cardia asthma
A sudden, severe SOB at night that awakens a person from sleep often with coughing and wheezing.
Closely related to CHF (not immediate upon lying down)
What is Dilated Cardiomyopathy?
SXS of heart failure
What is Hypertropic cardiomyopathy?
Inappropirate LVH with preserved or enhances contractile function
Systolic murmur can be present
What is Restrictive Cardiomyopathy?
Least common of the Cardiamyopathies
Endocardial scarring of the ventricle with impaired diastolic filling
What is Cardiomegaly?
A medical condition wherein the heart is enlarged
What is Diabetic Ketoacidosis (DKA)?
Problem is lacking or low insulin
Usually can develop at any age and is most likely to occur in an insulin dependent patient
Acidosis is present
Usually BGL less the 1000mg/dL
What is Hyperglycemic hyperosmolar nonKetotic coma (HHNK)?
High sugar with high serum osmolarity
Most pts are older with other underlying disease and experience sudden sever neurologic changes
Usually no production of ketones or presence of acidosis
Usually BGL is >1000mg/dL
What is Hepatic encephalopathy?
Occurrence of confusion, ALC and coma due to liver failure
Caused by accumulation of toxic substances in the blood that are normal removed by the liver.
What is the normal Ammonia range?
15-45 ug adult
40-80 ug Peds
Test liver function
What is normal Albumin range?
Adult: 3.4-5.4 g/dL
Peds: 3.0-5.0 g/dL
Test liver function
Decreased during gestation
What is the normal Alkaline phosphatase range?
Male: 98-251 U/L
Female: 81-196 U/L
Test liver function but found in biliary tract, bone, intestine and placenta
What is normal Immunoglobins range?
IgG: 700-1500 mg/dL
IgM: 35-375 mg/Dl
What does an elevated IgA, IgD, IgG or IgM indicate
IgA - Chronic liver disease
IgD - Chronic infections and liver disease
IgG - Autoimmune hepatits, leannecs cirrhosis
IgM - Biliary cirrhosis, hepatitis and viral infections
What is normal Prothrombin time?
Female 9.5-11.3 sec
Peds 11-14 sec
What is Prothrombin?
A vitamin K dependent protein produced by the liver.
Can be used to assess liver function
What is normal Platelet range?
Adult: 150,000 - 450,000
Ped: 170,000- 380,00
Can be used to assess liver function
What is normal Alanine Aminotransferase range?
Male: 7-46 U/mL
Females: 5-35 U/mL
Peds: 3-37 U/L
What is Alanine Aminotransferase?
An enzyme produced by the liver that acts as a catalyst in amine acid production.
can be used to assess liver function
What is Aspertate Aminotransferase range?
Male: 8-26 U/L
Female: 8-20 U/L
What is Aspertate Aminotransferase?
An enzyme that catalyzes the reversible transfer of an amino between the amino acid.
Can be used to assess liver function
What is Gamma-glutamyl range?
Male: 10-39 IU/L
Female : 6-29 IU/L
Peds: 0-23 IU/L
What is Gammaglutamyl?
GGT or GGTP
Enzyme that participates in the transfer of amino acids and peptides across cellular membranes.
Can be uses to assess liver function
What is Bilirubin range?
Adult: Indirect Bili 0.3-1.1 mg/dL, Direct Bili 0.1-0.4 mg/dL
What is Bilirubin?
Degradation product of the pigmented heme portion of hemoglobin
Can be used to assess liver function
What is Diabetes insipidus?
Condition where the kidneys are able to conserve water
Hence the phrase “peeing like a racehorse
What is Syndrome of inappropriate antidiuretic hormone (SIADH)?
Occurs when excessive levels of ADH (arginine, vasopressine, AVP) are reduced which causes the body to retain water
What are the SxS of Diabetes insipidus?
Excessive thirst and excretion of large amounts of severely diluted urine
What are the SxS of SIADH?
irritability and seizures
What is the normal range of Hemoglobin?
What is the normal range of Hematacrit?
What is the significance of Hemoglobin?
Amenia, indicated hemorrhage, lead poison, sick cells and many other possible issues
What is the significance of Hematacrit?
High in COPD patients and low in dehydrated or hemorrhage
What is normal WBC range?
What is the significance of WBC levels?
Increases with infection and is known as leukocytosis
A decrease is called leucopnia
What is normal Na+ range?
What is normal potassium levels?
What is normal Ca+ levels?
What are normal Chloride ranges?
What is normal CO2 levels?
What is the normal BUN range?
What is the normal Creatinine range?
What is the significance of BUN levels?
May indicate blood in the gut, dehydration or renal failure
What is the significance of Creatinine levels?
>1.4 may indicate renal failure
What is the normal Serum OS range?
What is the normal range for Magnesium levels?
What does a pCO2 <35 cause?
High pH, Alkalosis
What does a pCO2 of >45 cause?
Acidosis, low pH
How to disguise between Acute and chronic respiratory acidosis
Acute respiratory acidosis- For q 10 increase of pCO2, there is a decrease of pH by 0.08 and/or an increase of HCO3 by 1
Chronic Respiratory Acidosis- For q 10 increase of pCO2, there is a decrease of pH by 0.03 and/or an increase of HCO3 by 3
How to distinguish between acute and chronic respiratory alkalosis.
Acute Respiratory Alkalosis - for q 10 increase of pCO2, there is an increase of pH by 0.08 and/or a decrease of HCO3 by 2
Chronic respiratory alkalosis - for q 10 increase of pCO2, there is an increase of pH by 0.3 and/or a decrease of HCO3 by 5
Range for HCO3 and causes of > and <.
What is the formula for the anion gap (AG)?
AG= NA - (Cl + HCO3)
What is the normal range of AG?
What are the rules to determine respiratory or metabolic acidosis and alkalosis?
Rule 1: Evaluate the pH
Rule 2: Evaluate the pCO2. Is it acute or chronic for respiratory disorder?
Rule 3: Evaluate HCO3 and calculate anion gap (AG) for primary metabolic disorder and/or delta gap is metabolic acidosis is present
Rule 4: Identify the primary acid-base disorder
Rule 5: Determine if compensation is present
What do you expect to fin in pH, pCO2 and HCO3 in Respiratory acidosis?
High HCO3 (compensatory response)
What do you expect to fin in pH, pCO2 and HCO3 in Respiratory alkalosis?
Low HCO3 (Compensatory response)
What do you expect to fin in pH, pCO2 and HCO3 in Metabolic acidosis?
Low pCO2 (compensatory response)
What do you expect to fin in pH, pCO2 and HCO3 in Metabolic Alkalosis?
High pCO2 (Compensatory response)
What is normal Tidal Volume?
Initial is 508mL/kg
Mechanical ventilator troubleshooting, High pressure. Cause, intervention.
Cause: Resistance to ventilation is high. This may occur secondary to deuced ling elasticity or airway obstruction or extrinsic compression
Intervention: Tube suctioning and adequate patient sedation are recommended after other causes of obstruction are ruled out.
Cause: Air leaks, these are the most frequently secondary to ventilatory tubing disconnection from the patient’s tracheal tube but can also occur in the event of balloon deflation or tracheal tube dislodgment.
Intervention: Tube placement, balloon inflation, amount go oxygen in tank and connection to the ventilator should be carefully verified.
Cause: Hypotension after intubation can be caused by diminished central venous blood return to the heart secondary to elevated intrathoracic pressures. Hypotension may also be secondary to vasovagal reaction to intubation, rapid sequence induction, sedation, and tension pneumonothoraz.
Intervention: This can be treated with fluid infusion and /or adjustment of ventilatory setting to lower intrathoracic pressure (reducing PEEP, tidal volume, and , if air trapping is suspected, respiratory rate)
What is a Noncompetitive depolarizing Neuromuscular blocking agent (NMBAs)?
What is the action of Succinylcholine (anectine)?
Binds with the motor-end plate and causes a continuous depolarization, which results in fasciculation
What is the result of Succinylcholine (anectine)?
Unresponsive to acetylcholine causing paralysis
What are the advantages of Succinylcholine (anectine)?
Short onset of action of less than 1 min and ultra short-acting duration of 4-6min
what are the disadvantages of Succinylcholine (anectine)?
Potential complications include hyperkalemia, bradycardia, especially in pediatric patients, bronchospasm
What are some examples of Competitive nondepolarizing Neuromuscular blocking agents?
What is the action at receptor sites of Rocuronium (Zemuron), Vecuronium (norcuron), Pancuronium (pavulon)?
Competitively binds with the motor-end plate and does not caused depolarization
What is the result of Rocuronium (Zemuron), Vecuronium (norcuron), Pancuronium (pavulon)?
Blocks acetylcholine causing paralysis
What are the advantages of Rocuronium (Zemuron), Vecuronium (norcuron), Pancuronium (pavulon)?
Used to extend the time of neuromuscular blockade after intubation
What are the disadvantages of Rocuronium (Zemuron), Vecuronium (norcuron), Pancuronium (pavulon)?
Longer onset of action and duration
What is the COPD Triad
What is Anterior cord syndrome?
Blood supply to the anterior portion of the spinal cord is interrupted, causing a complete motor paralysis below the level of the lesion due to interruption of the corticospinal tract. Loss of pain and temperature sensation at and below the level of the lesion due to interruption of the spinothalamic tract. Most commonly occurs after hyperflexion injury
What is the brown Sequard syndrome?
Any presentation of spinal injury that is an incomplete lesion can be called a partial Brown-Sequard or incomplete Brown-Sequard syndrome, so long as it is characterized by features of a motor loss and numbness to touch and vibration on the some side of the spinal injury and loss of pain and temperature sensation on the opposite side. Most often occurs from a penetrating injury that has damaged one side of the spinal cord
What is the central cord syndrome?
It is characterized by disproportionately greater motor impairment in upper compared to lower extremities and variable degree of sensory loss below the level of the injury. Most often occurs after hyperextension injury.
What is the Parkland Burn Formula?
[(4mL x kg) x % of TBSA]
What is the Modified Brooke Formula?
[(2mL x kg) x % TBSA]
What is the Consensus Formula?
Combined Parkland and Brooke
(2-4mL x kg)/ % TBSA
What are the common clinical findings of Hypovolemic shock?
Rapid, weak, thready pulse due to decreased blood flow combined with tachycardia; cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction; Increased thirst, altered mentation and hypotension
What are the common clinical findings of Cardiogenic shock?
Distended jugular veins due to increased jugular venous pressure; crackled; weak or absent distal pulses; hypotension and arrhythmias, ofter tachycardia
What are the clinical findings of Neurogenic shock?
Hypotension; may be accompanied by profound bradycardia due to loss of the cardiac accelerating nerve fibers from the sympathetic nervous system at T1-T4. The skin is warm and dry or clear west lines exists, above which the skin is diaphoretic; priapism due to peripheral nervous system stimulation