Clinical Simulation.txt

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artxlife
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76872
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Clinical Simulation.txt
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2011-04-03 03:03:17
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Respiratory Therapist
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SImulation Diseases
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  1. EMPHYSEMA
    • Distention of the alveoli resulting in rupture and loss of elasticity of the lung.
    • Bedside Assessment:
    • Smoker
    • Dyspnea Grades
    • Increased Hb/HCT
    • Barrel Chest, Increased AP Diameter
    • Accessory Muscle Usage
    • Cyanotic
    • Clubbing
    • Secondary Assessment:
    • Hyperlucency with Diminished Vascular Markings and Flattened Diaphragm
    • FCRA c Mod to Sev Hypoxemia
    • PFT - Decreased DLco, Decreased Flows (FEF 25-75% and FEV1/FVC)
    • Tx/Management
    • Low Flow Oxygen Therapy
    • Antibiotics
    • Rehab and Home Care
    • Comprehensive Respiratory Care - Bronchodilators, MDI, Aerosol Nebulizers
    • Perhaps trans-tracheal oxygenation
    • Nicotine replacement therapy may help to quit smoking
  2. CHRONIC BRONCHITIS
    • Productive cough for 3 months out of the year for 2 or more consecutive years.
    • Bedside Assessment:
    • Smoking Hx c Chronic Infections
    • SOB
    • Productive Cough c Purulent Sputum
    • Secondary Assessment:
    • May Exhibit an Emphysema Pattern
    • Hypoxemia c Normal to Slightly Increased PCO2 levels
    • Decreased Flows (FEV1, FEF 25-75%)
    • Tx/Management
    • Good Bronchial Hygiene (CPT)
    • Antibiotics
    • Bronchodilator Therapy
    • Oxygen
  3. BRONCHIECTASIS
    • Abnormal dilation of bronchi secreting large amounts of purulent secretions.
    • Bedside Assessment:
    • Hx of Reccurent Gram Negative Infections
    • Clubbing
    • Hemoptysis
    • 3 Layer Sputum
    • Secondary Assessment:
    • Bronchogram - BEST DIAGNOSTIC TEST Shows "A Tree In Winter Pattern"
    • Decreased Flows (FEV1)
    • Tx/Management
    • Good Bronchial Hygiene (CPT)
    • Antibiotics
    • Aerosol Therapy c Bronchodilators
    • Surgical resection of involved segments is an option
  4. SLEEP APNEA SYNDROME
    • Apnea during sleep for periods of more than 10 seconds.
    • CENTRAL APNEA - Respiratory Stimulants, Diaphragmatic Pacemaker
    • OBSTRUCTIVE - Weight Loss, Nasal/Mask CPAP, BiPAP, Oral Surgery, Tracheostomy
  5. ASTHMA
    • Form of respiratory distress, normally due to bronchospasm and inflammation. Most common mechanism is allergy, others include: stress, exercise, cold exposure, infection and inhaled irritants.
    • PFT - DLco normal, Pre and Post Bronchodilator Improvement (15% or more)
    • Tx/Management
    • Low Flow Oxygen Therapy If In Distress
    • Aerosol Nebulizer With Bronchodilators
    • IV Aminophylline Drip
    • Consider inhaled steroids, cromolyn sodium, leukotriene modifiers
  6. STATUS ASTHMATICUS
    • Sustained asthma attack unresponsive to bronchodilator therapy for 24 hours.
    • Bedside Assessment
    • Pulsus Paradoxus
    • TxManagement
    • Oxygen Therapy (100%), continuous beta2 agonist nebulization, Steroid Therapy
    • Subcutaneous Epinephrine - 1 ml of 1:1000 Solution Given Every 20 to 30 Minutes For Three Consecutive Times, if needed
    • If No Improvement c Rapid Progression to Ventilatory Failure, THEN: INTUBATE, VENTILATE AND SEDATE
  7. RIB FRACTURES / FLAIL CHEST / CHEST TRAUMA
    • This can involve any type of trauma, unintentional / accidental or intentional (such as surgery).
    • Bedside Assessment
    • Severe Chest Pain
    • Paradoxical Chest Movement - FLAIL CHEST
    • Possible Pneumothorax (hyperresonance, tracheal shift)
    • Tx/Management
    • Therapy To Improve Ventilation - Incentive Spirometry, IPPB, deep breathing, cough
    • Closely Monitor ABG's For Ventilatory Failure
    • Ventilatory Failure - INTUBATE, SEDATE, VENTILATE (may have to paralyze)
  8. PNEUMOTHORAX / HEMOTHORAX
    • Air or blood trapped in the pleural space.
    • Tx/Management
    • If PNEUMOTHORAX Is Greater Than 20% - Insert Chest Tube
    • In HEMOTHORAX - Thoracentesis or Chest Tube To Drain Fluid
    • A tension pneumothoraxay require insertion of a large bore needle to release the pressure
  9. THORACIC SURGERIES
    • Tx/Management
    • Involves Management And Troubleshooting Of CHEST TUBES
    • Therapy to Improve Ventilation:
    • a. Imcentive Spirometry
    • b. IPPB / CPAP mask
    • c. Continuous Ventilation
    • May involve less than ideal (< 10 mL/kg) mechanical Vt in patient's c a pneumonectomy or lobectomy
    • Fluid Therapy - Treat hypovolemic shock
  10. HEAD TRAUMA / SURGERY
    • Tx/Management
    • Maintain PaCO2 Levels Between 25-30 Torr
    • Administer Mannitol to reduce ICP to less than 20 cmH2O
    • Keep PO2 Levels Near 100 TORR
    • Set Low Pressure / Exhaled Volume Alarms - Patients OFTEN ARE SEDATED c Barbiturates
    • Minimize MAP by keeping PEEP and peak pressures low on ventilator
    • If closed-head injured patient has grand mal seizure, establish the airway and treat c Dilantin
  11. NECK & SPINAL INJURY / SURGERY
    • TxManagement
    • In a Code Situation
    • a. Modified Jaw Thrust
    • b. Femoral Pulse (If neck brace is in place)
    • Intubation:
    • a. With a Bronchoscope Is PREFERRED
    • b. Blind Nasal Intubation
    • Support Ventilation, Oxygenation, Circulation and Perfusion as necessary
  12. ACUTE RESPIRATORY DISTRESS SYNDROME
    • An illness or injury acutely affecting the lung compliance including a variety of contributing factors.
    • Secondary Assessment
    • ABG - Refractory Hypoxemia
    • Decreased Compliance
    • TxManagement
    • Treat underlying cause
    • Incease FiO2 to .60 Then Add CPAP / PEEP
    • Titrate FiO2 To Below .60 Then Reduce CPAP / PEEP when patient improves
    • Consider Pressure control ventilation, IRV, APRV, HFJV
  13. ABDOMINAL SURGERY / PRE-POST OPERATIVE PATIENTS
    • Tx/Management:
    • POST-OPERATIVE CARE:
    • Conscious Patients - Incentive spirometry Every Hour
    • Unconscious Patients - IPPB
  14. LARYNGECTOMY
    • Surgical removal of the larynx. Performed to treat cancer of the larynx.
    • With only vocal cord involvement, the temporary tracheostomy is closed within days after removal of the cords. With more radical involvement, the entire larynx may be removed along with the epiglottis and thyroid cartilage. In this case the tracheostomy becomes permanent.
    • NOTE: Keep in mind, there is no longer any connection between the upper amd lower airways, and the patient has a permanent stoma opening. The patient can not be orally or nasally intubated. Must ventilate through laryngectomy tube, or insert a E-T tube through the laryngectomy opening
    • Tx/Management
    • A cool aerosol will help to keep secretions thin in the early post-op period
    • The laryngectomy tube is removed after three to six weeks, at that time the tracheostomy is considered stable and permanent
    • Tube feedings at first, oral liquids after one week. ALL TO PREVENT ASPIRATION
    • Use meticulous suctioning technique
  15. NEUROLOGICAL / NEUROMUSCULAR
    With all of the following disorders in this category, ALWAYS Monitor: TIDAL VOLUME, VITAL CAPACITY, AND MAXIMUM INSPIRATORY PRESSURE. If They Fall Below Acceptable Values INSTITUTE MECHANICAL VENTILATION
  16. MYASTHENIA GRAVIS
    • A descending paralysis - moves from the MIND to the GROUND
    • Bedside Assessment
    • Common Symptoms:
    • a. Eyelid Drooling (Ptosis)
    • b. Double Vision (Diplopia)
    • c. Difficulty Swallowing (Dysphagia)
    • Secondary Assessment
    • TENSILON CHALLENGE TEST TO DIAGNOSE AND MONITOR THERAPY
    • a. If VT, VC, MIP and Weakness Improves with Tensilon:
    • IT IS REFERRED TO AS A MYASTHENIC CRISIS
    • (Indicating MORE Of This Type Of Drug Needs To Be Given)
    • b. If VT, VC, MIP and Weakness Worsens With Tensilon:
    • IT IS REFERRED TO AS A CHOLINERGIC CRISIS
    • (Indicating TOO MUCH Of This Type Of Drug Has Been Given)
    • ATROPINE will reverse this Cholinergic Crisis
    • Tx/Management
    • Closely Monitor Vt, VC, MIP
    • AS VITAL CAPACITY APPROACHES TIDAL VOLUME, INTUBATE & VENTILATE
    • Maintenance Drug Therapy (anticholinesterase therapy) Including:
    • a. Prostigmine (Neostigmine)
    • b. Pyridostigmine (Mestinon)
    • Bedside restriction and soft diet to reduce symptoms
  17. GUILLAIN-BARRE' SYNDROME
    • An ascending paralysis - moves from the GROUND to the BRAIN
    • Bedside Assessment
    • Recent Flu like symptoms
    • Secondary Assessment
    • Spinal Tap - Increased Protein Level in CSF
    • Plasmapheresis
    • Tx/Management
    • Closely Monitor - VT, VC, MIP
    • Give O2 as necessary
    • Mechanical Ventilation:
    • AS VC APPROACHES VT, INTUBATE & VENTILATE
    • Bronchpulmonary Hygiene Therapy - to mobilize secretions
    • Anti-inflammatory and immunosuppressive agents
    • Anti-coagulants to prevent thrombus formation and embolism
    • Plasmapheresis for severe cases
  18. DRUG OVERDOSE
    • Hx is often the most significant finding.
    • Tx/Management
    • PLACEMENT OF AN ARTIFICIAL AIRWAY IS THE NUMBER 1 PRIORITY
    • Mechanical Ventilation If In Ventilatory Failure
    • Naloxone (Narcan) To Reverse Narcotic Overdose
  19. POLIOMYELITIS / TETANUS/BOTULISM / MUSCULAR DYSTROPHY
    • Bedside Assessment
    • Previous Admissions for Disease - Poliomyelitis, Muscular Dystrophy
    • Current Therapy at home - Poliomyelitis, Muscular Dystrophy
    • Secondary Assessment
    • Decreasing Vt, VC, MIP
    • Watch for Ventilatory Failure
    • Tx/Management
    • Closely Monitor Vt, VC, MIP
    • AS VC APPROACHES Vt, INTUBATE & VENTILATE
    • Mechanical Ventilation
    • With Tetanus/Botulism - May have to paralyze the patient to get a relaxed jaw for intubation. (Curare)
  20. CONGESTIVE HEART FAILURE / PULMONARY EDEMA
    • When the cardiac output is insufficient to meet the needs of the body's demand.
    • Bedside Assessment
    • Pink Frothy Secretions
    • Diminished With Fine Rales
    • Secondary Assessment
    • Fluffy Infiltrates Or Butterfly Pattern
    • Increased PCWP, PAP, CVP
    • Tx/Management
    • EMERGENCY - ADMINISTER 100% OXYGEN IMMEDIATELY
    • IPPB With 100% Oxygen And Ethyl Alcohol
    • Diuretics - Furosemide (Lasix)
    • Inotropic drugs - digitalis or digoxin if cardiogenic pulmonary edema (Increased PCWP and PAP)
    • IF NO IMPROVEMENT WITH PROGRESSION INTO VENTILATORY FAILURE - THEN INTUBATE & VENTILATE
  21. CHEST PAIN / MYOCARDIAL INFARCTION
    • Often the history is the most significant finding.
    • Secondary Assessment
    • Significant Q Waves And S-T Segment
    • Tx/Management
    • START OXYGEN THERAPY IMMEDIATELY AT 100%
    • Closely Monitor Vital Signs
    • Treat Arrythmias:
    • a. PVC's - Lidocaine
    • b. Bradycardia - Atropine
    • c. Pulseless Ventricular Tachycardia OR Fibrillation - Defibrillate
  22. SHOCK
    • A reduction in blood flow to the tissues that is inadequate to sustain life.
    • Bedside Assessment
    • Clammy, Pale, Cyanotic
    • Tx/Management
    • START OXYGEN THERAPY IMMEDIATELY AT 100%
    • Closely Monitor Vital Signs
    • TREAT UNDERLYING CAUSE AND WATCH FOR VENTILATORY FAILURE
    • Administer IV fluids, blood transfusion for anemia
  23. PRE/POST OPERATIVE HEART SURGERY
    • Tx/Management
    • POST-OPERATIVE CARE:
    • Conscious Patients - Incentive Spirometry Every Hour
    • Unconscious Patients - IPPB or CPAP mask
    • IF CPR REQUIRED, DO NOT HESITATE TO PERFORM
    • Ventilator Weaning
  24. PULMONARY EMBOLI
    • A circulatory problem involving obstruction of the pulmonary artery.
    • REFERRED TO AS A DEADSPACE DISEASE: (VENTILATION WITHOUT PERFUSION)
    • Bedside Assessment
    • Sudden Onset, Prolonged Bedrest, Trauma, Venous Stasis
    • Severe Chest Pain
    • Wheezes And Rales
    • Secondary Assessment
    • Ventilation Normal, Perfusion Abnormal
    • Decreasing PeCO2 c normal PaCO2
    • Tx/Management
    • Administer Oxygen Therapy at 100%
    • Anticoagulation Therapy - Heparin / Coumadin
    • Closely Monitor Vital Signs And ABG's
    • Coagulation studies
  25. Arrythmias
    • Many different types: Ventricular more life threatening than atrial
    • Bedside Assessment
    • Blood Pressure - Low, may be in shock
    • Secondary Assessment
    • ECG is definitive and is necessary to determine the arrhythmia.
    • Tx/Management
    • Treatment depends on the specific problem
    • Give plenty of oxygen. Up to 100% - Consider it a cardiopulmonary emergency
    • Oxygen is often enough to treat occasional PVCs
    • Ventricular fibrillation and pulseless ventricular tachycardia - Defibrillate at no greater than 360 joules
    • Atrial flutter, fibrillation and ventricular tachycardia with a pulse are not immediately life threatening. Perform synchronized cardioversion starting at 50 joules
    • Antiarrythmic drugs should be given as necessary
    • a. Bradycardia - Atropine
    • b. Tachycardia - Oxygen
    • c. PVC's - Lidocaine
    • d. Asystole - Epinephrine
    • CPR - Must know the standards and steps for obstructed airway and cardiopulmonary arrest. Often included in a part of another disease process
  26. CROUP (LARYNGOTRACHEOBRONCHITIS)
    • A VIRAL INFECTION involving the upper and lower respiratory tract that causes subglottic edema.
    • Bedside Assessment
    • Recent cold that developed GRADUALLY into a Barking Cough over 2-3 Days
    • Age 6 Months To 3 Years
    • Stridor
    • Secondary Assessment
    • Lateral Neck X-ray - Haziness In The Subglottic Region (Below The Glottis), Steeple Sign, Pencil-Point, Picket Fence
    • Tx/Management
    • Oxygen Therapy in a Tent at 30-40% (FIRST)
    • Aerosol Nebulizer Treatments With Racemic Epinephrine
    • High Humidity Therapy (Mist Tent)
    • Criteria For Intubation:
    • a. Lethargic
    • b. Severe Stridor At Rest
    • c. Diminished Breath Sounds
    • d. Extreme Accessory Muscle Usage
    • Criteria For Extubation:
    • a. Childs condition is stable
    • b. Once you can hear an air leak around the tube (swelling has gone down)
  27. EPIGLOTTITIS
    • A severe BACTERIAL INFECTION of the epiglottis and surrounding tissues usually caused by Haemophilus Influenzae (gram negative bacteria)
    • IT IS AN IMMEDIATE EMERGENCY
    • Bedside Assessment*
    • SUDDEN Onset Within The Last 6-8 Hours
    • Age - 3 to 11 Years
    • Lifeless, Drooling, Hoarseness, Muffled Cough, Inspiratory Stridor
    • Difficulty Swallowing (Dysphagia)
    • High Fever (Should Be Measured Axillary or via Tympanic Avoid Stimulating The Child)
    • AVOID ANY UNNECESSARY STIMULATION OF THE CHILD
    • *NOTE - DIAGNOSIS SHOULD BE MADE AT THE BEDSIDE
    • *Lateral Neck X-ray - ONLY AFTER AN ARTIFICIAL AIRWAY IS IN PLACE will show Supraglottic Swelling (Above the Glottis) or Thumbprint Sign
    • *NOTE - NOT NECESSARY FOR DIAGNOSIS
    • Tx/Management
    • 1st Priority - Establish an Airway
    • a. Endotracheal Tube
    • b. Tracheostomy if unable to intubate
    • Oxygen Therapy 30-40%
    • Antibiotics
    • EXTUBATION - After 3-4 Days (ONCE SWELLING IS GONE)
    • Sedate & Restrain
  28. CYSTIC FIBROSIS (MUCOVISCIDOSIS)
    • An inherited, genetic disorder involving the exocrine glands.
    • Secondary Assessment
    • Sweat Chloride Level (Sweat Test) -> 60 mEq/L
    • (THE MOST RELIABLE DIAGNOSTIC TEST)
    • Tx/Management
    • Aggressive Bronchopulmonary Hygiene - Bronchodilator And Mucolytic Aerosol Therapy With Postural Drainage And Percussion
    • Low Flow Oxygen
    • Antibiotics (Tobramycin etc.) For Infection - Staph and Pseudomonas are the most common
    • Pulmozyme
  29. BRONCHIOLITIS
    • Bedside Assessment
    • Age 3 months to 3 years (even younger)
    • Low Grade Fever
    • Audible Wheezing, Rhonchi And Rales
    • Secondary Assessment
    • Hyperlucency With Scattered Infiltrates
    • Tx/Management
    • Ribavirin Aerosol - Given via Small Particle Aerosol Generator (SPAG) for RSV infection. RSV most common cause. Will need scavenger system, filters, mask, etc.
  30. FOREIGN BODY OBSTRUCTION
    • Highest incidence among children between 6 months and 3 years. A major cause of death in the home.
    • Bedside Assessment
    • SUDDEN ONSET, Survey the Scene For Pieces of Food or Missing Objects (Coins, Beads and Marbles)
    • Violent coughing, dyspnea, retractions, restlessness
    • Vary from completely absent to rhonchi to frank wheezing - sometimes unilateral wheezing
    • Secondary Assessment
    • Inspiratory & Expiratory Films - Indicating Air Trapping, Hyperinflation & Unequal Ventilation
    • NOTE - MAJORITY OF ASPIRATED OBJECTS ARE RADIOLUCENT AND CANNOT BE SEEN ON CXR - Such as food items
    • Tx/Management
    • BRONCHOSCOPY
    • Postural Drainage and Percussion
    • Aerosol Therapy With Bronchodilators
  31. TOXIC SUBSTANCE INGESTION
    • Tx/Management
    • Maintenance of an Airway - INTUBATE when aspiration is possible
    • Supportive Therapy - IV Fluids, Gastric Lavage, Antidote (acetylcysteine for Tylenol, Narcan for narcotics, etc.)
    • WATCH FOR VENTILATORY FAILURE - VENTILATE
    • For injestion of kerosene or gasoline, insert an NG tube and dilute with water. Do not induce vomiting
  32. DELIVERY ROOM CARE
    • Initial Care
    • Airway - Cleared 1st with Bulb Syringe (Mouth is Cleared First Followed by Nose)
    • Dried and Kept Warm
    • Bedside Assessment
    • 1 - Body Pink Extremities Blue
    • 1 - < 100 / min
    • 1 - Grimace
    • 1 - Some Flexion of Extremities
    • 1 - Slow, Irregular Weak Cry
    • 4 - 6 Stimulate, Warm, Administer Oxygen
  33. INFANT APNEA / SUDDEN INFANT DISTRESS SYNDROME
    • Apnea caused by immature neurologic control of ventilation resulting in death.
    • Bedside Assessment
    • Sibling Deaths
    • Periodic Cyanotic Spells, Apnea
    • Premature
    • Cold Air On Baby's Face
    • Secondary Assessment
    • Abnormal Moro and/or Babinski Reflex
    • Tx/Management
    • O2 Therapy 30-50%
    • Teach Parents CPR
    • Send Infant Home with an Apnea Monitor
  34. MECONIUM ASPIRATION
    • Bedside Assessment
    • Post-term Infant > 42 Weeks
    • Stained with Meconium, Grunting, Retractions, Cyanosis, Nasal Flaring and Asphyxia
    • Low Apgar Scores
    • Secondary Assessment
    • Patchy Densities Bilaterally with Widespread Atelectasis
    • Tx/Management
    • FIRST PRIORITY IS TO SUCTION THE AIRWAY (Even when only the baby's head has emerged). SUCTION THE OROPHARYNX BEFORE THE NOSE
    • Repeated Intubation & suctioning until adequately cleared
    • Intubate and Resuscitate if indicated by APGAR score
    • Mechanical Ventilation - ABG
    • Aggressive Chest Physiotherapy - CPT and Suction
  35. CONGENITAL HEART DEFECTS
    • Bedside Assessment
    • May be Premature
    • Cyanosis not reversed by 100% O2
    • Heart Murmur
    • Coarctation of the Aorta - Hypertension in the Upper Extremities VS Hypotension in the Lower Extremities
    • Secondary Assessment
    • CXR - possibly an enlarged heart, Egg-shaped heart c Transposition of the Great Vessel, and a Boot-shaped heart c Tetralogy of Fallot
    • Echocardiogram is the most important diagnostic test to identify cardiac defects
    • a. Tetralogy of Fallot (egg-shaped) - overriding aorta, pulmonary stenosis, ventricular septal defect, and right ventricular hypertrophy
    • b. Transposition of the Great Vessels (boot) - aorta is switched c pulmonary artery (aorta rises from the right ventricle and the pulmonary artery arises from the left ventricle)
    • c. Patent Ductus Arteriosus - failure of the ductus arteriosus to close most often results in a left-to-right (increased pulmonary blood flow). However, if the pressure in the right ventricle is greater than the pressure in the left ventricle, blood will flow from right-to-left across the ductus (shunt effect)
    • d. Coarctation of the Aorta - a constriction (narrowing) in the aorta
    • e. Atrial Septal Defect - opening in the atrial septum
    • f. Ventricular Septal Defect - opening in the ventricular septum
    • g. Truncus Arteriosus - combined pulmonary artery and aorta
    • Pre and Post ductal blood gas studies
    • a. If the pre-ductal (right radial artery) PO2 is > 15 mmHg higher than the post-ductal (umbilical artery) PO2, then the patient has a patent ductus arteriosus with a right-to-left shunt
    • b. Could also be assessed using two transcutaneous monitors. One placed on the upper right thorax (pre-ductal) and the other on the lower left thigh or left abdominal region (post-ductal)
    • Tx/Management
    • Oxygen - Maintain PaO2 levels > 60 torr
    • Watch for ventilatory failure - intubate & ventilate
    • Supportive Care prior to surgery to correct the defect
  36. INFANT RESPIRATORY DISTRESS SYNDROME
    • A reduction in lung volume due to a lack of surfactant production.
    • Bedside Assessment
    • Gestational Age < 38 Weeks
    • LOW APGAR SCORE
    • Onset of symptoms usually present at birth or a few hours after birth
    • Nasal Flaring, Grunting, Retractions, Cyanosis
    • Secondary Assessment
    • CXR - Reticulogranular Infiltrates, or Honeycomb Appearance, or Ground Glass Appearance
    • Unresponsive to Increased FiO2
    • L/S Ratio - Less than 2:1 (Decreased)
    • Tx/Management
    • Maintain PaO2 Levels > 60 Torr
    • Treat Hypoxemia with Oxygen via oxyhood then CPAP
    • WATCH FOR VENTILATORY FAILURE - INTUBATE, VENTILATE WITH PEEP
    • SIMV
    • Inverse I:E Ratio
    • Surfactant Therapy (Exosurf, Survanta)
    • Procedure for surfactant administration - instill 2-5 ml/kg, divided in 2-4 doses and manually ventilate. After each dose rotate infant to the right or left for 30 sec.
  37. BRONCHOPULMONARY DYSPLASIA
    • A chronic lung disease that develops in newborns as a consequence of treatment of IRDS with oxygen and positive pressure ventilation.
    • Patient Assessment
    • Premature infant who requires mechanical ventilation and doesn't improve
    • Continued need for high oxygen (FIO2) concentrations
    • Usual signs of respiratory distress (tachypnea, retractions)
    • Secondary Assessment
    • ABG hypoxemia and hypercarbia
    • CXR initially resembles IRDS, then hyperinflation with areas of fibrosis
    • Tx/Management
    • Supportive care to relieve symptoms of respiratory distress and heart failure.
    • Maintain blood gas values: PaO2 55-70 mmHg, PaCO2 45-60 mmHg, and pH 7.25-7.40.
    • Maintain the lowest FIO2 possible
    • Minimize mean airway pressure
    • Weaning should be done gradually by decreasing the ventilator rate as tolerated.
    • Extubation can be done at rates between 5-15 breaths/min.
    • 7. Avoid endotracheal CPAP, because of the increased airway resistance and work of breathing that can be created
    • 8. Bronchodilator therapy
  38. TRANSIENT TACHYPNEA OF THE NEWBORN (TTN)/TYPE II RDS
    • Condition with symptoms similar to mild RDS. Occurs within 24-48 hours after birth and is self limiting. More common in full-term infants born via C-section. Develops as a result of delayed absorption of fetal lung liquid.
    • Patient Assessment
    • Tachypnea - rates 100-150/min.
    • Born at or near full term
    • Appropriate weight for gestational age
    • Accumulated secretions
    • Depressed swallowing and cough effort
    • Good APGAR scores
    • Later development of cyanosis, retractions, nasal flaring and grunting
    • Secondary Assessment
    • ABG mild hypoxemia with respiratory and metabolic acidosis
    • CXR initially normal, after 12 hours pulmonary congestion appears.
    • Tx/Management
    • Supportive care to relieve signs of respiratory distress
    • O2 via oxyhood
    • CPAP
  39. CONGENITAL DIAPHRAGMATIC HERNIA
    • Caused by failure of the diaphragm to close properly. 85% occur on left side.
    • Patient Assessment
    • Respiratory distress at birth
    • Breath sounds absent on affected side
    • Scaphoid abdomen, barrel chest
    • Secondary Assessment
    • ABG hypoxemia, hypercarbia, acidosis
    • CXR loops of bowel seen in chest, mediastinal shift toward the unaffected side.
    • Tx/Management
    • Nasogastric tube to decompress stomach and intestines
    • Avoid bag-mask ventilation
    • Low ventilating pressures after intubation
    • Surgical repair
  40. EXPOSURE (HYPOTHERMIA)
    • Body Temperature Falls Below Normal.
    • Bedside Assessment
    • Hx - Homeless, Found lying in the street shivering
    • Lethargic, Unconscious
    • Vital Signs:
    • a. Temperature - < 36.0C (98.0F)
    • b. Pulse - Bradycardia
    • c. Respirations - Bradypnea
    • Secondary Assessment
    • ARTERIAL BLOOD GASES - ANALYZED AT 37.0C (98.6F)
    • IF PATIENT'S BODY TEMPERATURE LESS THAN 37.0C (98.6F), then the patients actual values will show:
    • pH - INCREASED
    • PCO2 - DECREASED
    • PO2 - DECREASED
    • EXAMPLE - ABG'S ANALYZED AT 37.0C (98.6F) RESULTS ARE:
    • pH - 7.32
    • PCO2 - 53 TORR
    • PO2 - 67 TORR

    • PT'S BODY TEMPERATURE IS 35.0C (95.0F) TEMPERATURE CORRECTED RESULTS:
    • pH - 7.40
    • PCO2 - 45 TORR
    • PO2 - 59 TORR

    • Tx/Management
    • WATCH FOR DIFFERENCES IN TEMPERATURES - ANALYZED & ACTUAL
    • O2 40-100% via Heated Aerosol (core warming)
    • WATCH FOR VENTILATORY FAILURE - INTUBATE & VENTILATE
    • DON'T GIVE UP - RESUSCITATE UNTIL BODY TEMPERATURE NORMAL AGAIN
  41. INFECTIOUS DISEASE / PNEUMONIA
    • Bedside Assessment
    • Vitals increased, increased WOB, dyspnea, cough
    • Breath sounds decreased over affected area
    • Dull percussion sound
    • Decreased pulse oximetry readings.
    • Secondary Assessment
    • WBC
    • a) increased WBC = bacterial
    • b) decreased WBC = viral
    • Sputum culture and sensitivity (C&S) or Gram Stain
    • Acid-Fast Stain for mycobacterium (TB)
    • ELISA Test for HIV
    • Tx/Management
    • O2 30-60%
    • Bronchial Hygiene Therapy
    • a) CPT
    • b) Hyperinflation
    • Antibiotic or Antiviral agents
    • Watch for Ventilatory Failure
  42. BURNS / SMOKE INHALATION / CO POISONING
    • May lead to complete airway obstruction. Should be expected in the presence of any type of fire (ie. burning leaves, trash fire, kitchen fire).
    • Bedside Assessment
    • Hx - Fireman pulled from a burning building, Found sitting in garage with car running
    • Anxious, Burns, Retractions, Stridor, Hoarseness
    • Alert, Confused, Unresponsive
    • "CHERRY RED" (SUSPECT CO POISONING)
    • Rales, Rhonchi and Wheezes
    • Vital Signs:
    • a. Pulse - Tachycardia
    • b. Respirations - Tachypnea, Grunting, Labored
    • c. Temperature - Hyperthermia (NOT ACCURATE IF IN FIRE)
    • Secondary Assessment
    • COHb Levels - Normal 1-3%; Smoker 5-10%; > 20% TREAT WITH OXYGEN THERAPY AT 100%
    • ABG Normal PO2, Decreased Sat., Decreased PCO2 INITIALLY LATER - MAY DEVELOP METABOLIC ACIDOSIS
    • CXR Initially clear, Later may develop Pulmonary Edema, or ARDS
    • Tx/Management
    • With Burns around FACE - if in SEVERE Distress - INTUBATE IMMEDIATELY
    • IF CO POISONING SUSPECTED - ADMINISTER 100% OXYGEN (DON'T WAIT FOR COHB LEVEL)
    • Continue 100% Oxygen Therapy until CO level is < 10%
    • Put ALL Burn patients in protective (reverse) isolation
    • WATCH FOR RESPIRATORY FAILURE - INTUBATE & VENTILATE
    • Watch for infections and dehydration.
    • Hyperbaric oxygen therapy
  43. NEAR DROWNING
    • An acute respiratory insult that often leads to the development of complications.
    • Bedside Assessment
    • Hx - Swimming pool accident, Boating accident
    • Confused, Unconscious, Comatose
    • Cyanotic, Pallor
    • Vital Signs:
    • a. Temperature - Hypothermia
    • b. Respirations - Absent, Shallow, Labored
    • c. Pulse - Absent, Tachycardia, Bradycardia
    • d. Blood Pressure - Hypotensive
    • Secondary Assessment
    • CXR Diffuse Bilateral Alveolar Infiltrates
    • ABG Metabolic and Respiratory Acidosis
    • CBC, Hb, Hct., Electrolytes
    • Hemodynamics - CVP, PAP, PCWP
    • Tx/Management
    • 100% Oxygen
    • WATCH FOR VENTILATORY FAILURE - INTUBATE & VENTILATE
    • NOTE - If Suspected NECK INJURY Requires Intubation - Intubate via BRONCHOSCOPE OR BLIND NASAL INTUBATION
  44. DIABETIC / RENAL FAILURE
    • Bedside Assessment
    • Hx - Previous Admissions for Diabetes
    • Alert, Lethargic, Confused, Comatose, Unresponsive
    • Scattered Rales (Renal Failure)
    • DIABETIC May Have Kussmaul's (Increased Respiratory Rate, Increased Depth, Irregular Rhythm)
    • Pedal edema - Renal Failure
    • Secondary Assessment
    • ABG - Metabolic Acidosis
    • Urine Output - < 500 ml/day (Renal Failure) Normal 1000 mL/day
    • Blood Glucose Level - > 160 mg (Diabetic) Normal 80-120 mg
    • Tx/Management
    • Renal Failure - Carefully monitor I&O, Electrolytes, Watch for signs of CHF and TREAT
    • Diabetic - Closely monitor blood glucose levels, ABGs, Watch for signs of Respiratory Failure and TREAT
  45. PICKWICKIAN SYNDROME / OBESITY
    • WATCH FOR SLEEP ANEA
    • Must use IDEAL BODY WEIGHT when initiating mechanical ventilation.
  46. ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
    • Often the history is the most significant initial finding.
    • Bedside Assessment
    • Hx- Weight Loss, Persistent Fever or Diarrhea, Night Sweats (Nocturnal Diaphoresis), Frequent Herpes Simplex Infections, Homosexuality, Drug Abuser
    • Malnourished, Pallor
    • May have Signs & Symptoms of Pneumonia
    • Secondary Assessment
    • A POSITIVE HTLV-III OR Human Immunodeficiency Virus (HIV) via ELISA TEST
    • BRONCHOSCOPY for Tracheal Washings or Lung Biopsy - Shows PNEUMOCYSTIS CARINII
    • NOTE - DO NOT ORDER A CULTURE AND SENSITIVITY (Pneumocystis Carinii CANNOT GROW OUTSIDE THE BODY)
    • USE UNIVERSAL PRECAUTIONS
    • Pneumocystis Carinii Pneumonia is Treated/Prevented with PENTAMIDINE AEROSOL THERAPY. Most commonly a monthly treatment.
    • Special Considerations Include:
    • a. Masks Worn by Personnel Administering Therapy
    • b. One Way Valves and Filters
    • c. Closely Monitor Vital Signs
    • d. Administer Therapy in Semi-fowlers Position (In Bed)
    • e. Given in a special room or chamber to direct room ventilation to the outside
    • TB is endemic in this population
    • a. Positive acid fast stain (mycobacterium) in sputum confirms active TB
    • b. Respiratory Isolation
    • c. INH, rifampin, ethambutal, streptomycin (18-24 months)
  47. POISONING

    Swallowed Poisons
    • In general, the rule of thumb is to induce vomiting EXCEPT under the following conditions:
    • 1. Swallowed corrosive poison (strong acid or alkali)
    • 2. Swallowed petroleum product (gasoline, kerosene or lighter fluid)
    • 3. Swallowed iodine or strychnine
    • 4. If victim has convulsions, is in a coma, or is unconscious
    • Induced vomiting can be accomplished by using syrup of Ipecac.
    • Activated charcoal - An absorbent that is given when there is no specific antidote or when the nature of the poison is unknown. This substance is given in doses of 10 times the estimated ingestion dose of poison, mixing 2-4 tablespoons to an 8 ounce glass of water. Should be given after the syrup of Ipecac, but is not useful in alcohol and insecticide poisoning.
  48. KEROSENE POISONING
    • A toxic condition caused by ingestion of kerosene or the inhalation of its fumes.
    • Patient Assessment
    • Drowsiness, fever tachycardia, tremors, coughing and choking, possible vomiting followed by cyanosis, breath holding and persistent coughing.
    • CNS symptoms include lethargy, coma and convulsions.
    • Severe pneumonitis if aspirated.
    • Tx/Management
    • Vomiting should NOT be induced (syrup of Ipecac) for ingested or aspirated kerosene.
    • Tx for Ingestion - may include 1 or 2 ounces of vegetable oil to prevent absorption of the kerosene if the stomach. Gastric lavage with copious amounts of water, a 3% sodium bicarbonate solution or normal saline. This is performed to remove the stomach contents and wash out any remaining poison.
    • Treatment for inhalation - includes oxygen and ventilatory assistance if necessary.
  49. PETROLEUM DISTILLATE POISONING
    • A toxic condition caused by the ingestion or inhalation of a petroleum distillate (i.e., fuel oil, lubrication oil, model airplane glue, and various solvents).
    • Patient Assessment
    • Nausea, vomiting, chest pain and dizziness.
    • Severe depression of the central nervous system.
    • Severe or fatal pneumonitis may occur if the substance is aspirated.
    • Tx/Management
    • Induced vomiting is contraindicated, because of risk of aspiration of a toxic substance.
    • Gastric lavage may be indicated as well as other supportive therapy (i.e. oxygen, ventilatory support - see kerosene poisoning).
  50. PERIPHERAL VASCULAR DISEASE (PVD)
    • An abnormal condition that affects the lymphatic vessels and the blood vessels outside of the heart. Examples of PVD are arteriosclerosis and atherosclerosis.
    • Patient Assessment
    • Different kinds and degrees of PVD are characterized by a variety of signs and symptoms, such as numbness, pain, pallor, elevated blood pressure, impaired arterial pulsations.
    • PVD in association with bacterial endocarditis may involve emboli in terminal arterioles and produce gangrenous infarctions of various distal parts of the body, such as the tip of the nose, pinna of the ear, the fingers and toes.
    • Large emboli may occlude peripheral vessels and cause atherosclerotic disease.
    • Tx/Management
    • Tx of severe cases may require amputation of gangrenous body parts.
    • Less severe peripheral vascular problems may be treated by elimination contributing factors, especially cigarette smoking, and by the administration of various drugs, such as salicylates and anticoagulants.
  51. INFANTS
    A. Pulse
    B. RR
    C. BP
    D. Birth Weight
    E. APGAR Score
    • A. 110-160 beats/minute
    • B. 30-60 breaths/minute
    • C. 60/40 mmHg
    • D. > 3000 gm
    • E. Done at 1 and 5 minutes
    • 7-10 Normal
    • 4-6 Poor
    • 0-3 Emergency
  52. ARTERIAL BLOOD GASES
    A. Vd/Vt
    B. CaO2
    C. CvO2
    D. C(a-v)O2
    E. Qs/Qt
    • A. 20-40%
    • 40-60% (ventilator patients)
    • B. High Teens
    • C. Low Teens
    • D. 4-5%
    • E. 5% Normal
    • 10-20% Tolerate
    • 20-30% Life Threatening
    • Qs/Qt increase = increases PEEP
  53. HEMODYNAMICS
    1. BP
    2. MAP
    3. CVP
    4. PAP
    5. PCWP
    6. CO or QT
    7. CI
    • 1. 120/80 mmHg
    • 2. 93-96 mmHg
    • 3. 2-6 mmHg (4-12 cmH2O)
    • 4. 25/8 mmHg (mean 14)
    • 5. 4-12 mmHg
    • 6. 4-8 L/min
    • 7. 2.5-4.0 L/min/m2
  54. MECHANICAL VENTILATION
    A. Spontaneous Measurements
    Vt
    VC
    f
    Ve
    MIP

    B. Initial Ventilator Parameters
    *TWO MOST IMPORTANT SETTINGS ARE TIDAL VOLUME AND RATE
    1. Vt
    SET AT ABOUT 10 mL/kg (8-12 mL/kg ideal body weight)
    2. Respiratory Rate
    SET AT ABOUT 10 Breaths/Minute (8-12 range)
    3. Ventilation Mode
    *DO NOT RULE OUT AN ANSWER BECAUSE OF THE MODE
    ANY MODE IS FINE
    EXAMPLES: CONTROL , ASSIST/CONTROL OR SIMV/IMV
    *NORMAL SIMV OR ASSIST/CONTROL IS PREFERRED
    4. FiO2 and PEEP
    a) No Information About Prior O2 or Patient on Room Air.
    b) Patients Was On Oxygen and/or CPAP (elevated baseline) Before
    c) An Emergency Involving Lung Damage (CO Poisoning, Pulmonary Edema, Crushed Chest etc.)
    • Vt Normal Unacceptable
    • 5-8 mL/kg < 5 mL/kg
    • VC Normal Unacceptable
    • 65-75 mL/kg < 10 mL/kg
    • (10 X Vt) (< 2 X Vt)
    • f Normal Unacceptable
    • 8-12 bpm < 8 bpm
    • > 20 bpm
    • Ve Normal Unacceptable
    • 5-6 L/min > 10 L/min
    • MIP Normal Unacceptable
    • -80 cmH2O < -20 cmH2O

    • a) 0.40-0.60
    • b) Same FiO2 and/or PEEP (elevated baseline)
    • c) 1.0 (100%)
  55. INFANTS
    Time Cycled / Pressure Limited Ventilators

    MODE
    RATE
    PRESSURE
    FiO2
    PEEP LEVELS
    FLOW
    I-TIME
    *NOTE - Patient Already Receiving Oxygen & CPAP Should Start At THE SAME LEVEL
    • MODE IMV/SIMV
    • RATE 20-30 bpm
    • PRESSURE 20-30 cmH2O
    • FiO2 Same as adults
    • PEEP 2-4 cmH2O (Increased in Increments 1 or 2 with maximum levels around 8 cmH2O)
    • FLOW 5-6 L/min
    • I-TIME .5-.6 sec

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