-
VF ACLS algorithm
- shock, shock, everybody, shock, AMEN!
- shock, CPR, shock, CPR, epinephrine (1mg q 3-5min), shock, amiodarone (300mg, 150mg)
- defibrillation: 120-200J
-
VT ACLS algorithm
- shock, shock, everybody, shock, AMEN!
- shock, CPR, shock, CPR, epinephrine (1mg q 3-5min), shock, amiodarone (300mg, 150mg)
- defibrillation: 120-200J
-
asystole ACLS algorithm
CPR, epinephrine (1mg q3-5min)
-
PEA ACLS algorithm
CPR, epinephrine (1mg q3-5min)
-
H's and T's
- Hypovolemia
- Hypoxia
- Hydrogen ion (acidosis)
- Hypo-/hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade, cardiac
- Toxins/Tablets
- Thrombosis, pulmonary
- Thrombosis, coronary
-
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
-
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)
-
right coronary artery circulation
- SA node
- AV node
- inferior wall of LV
-
left coronary artery circulation
- WIDOW MAKER
- anterior wall of LV
-
diastole
ventricular relaxation/filling
-
systole
ventricular contraction
-
depolarization
polarized cell is reduced to a less negative value
-
repolarization
cell returns to resting polarized state
-
SA node conduction
- rate=60-100bpm
- accounts for atrial kick
-
AV node conduction
rate=40-60bpm
-
lead selection: lateral wall
I, aVL, V5, V6
-
lead selection: inferior wall
II, III, aVF
-
lead selection: anterior wall
V1-V4
-
lead selection: posterior wall
V1-V4
-
lead placement
- right: clouds over grass
- left: smoke over fire
- center: chocolate near my heart
-
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
-
PR interval is
- time:
- boxes
- prolonged=
- time for the atrial impulse to reach the ventricles
- - 3-5 small boxes
- - prolonged=delayed conduction through AV node=atrial hypertrophy, ischemia, etc.
-
QRS complex represents
- time:
- # boxes
- ventricular depolarization
- - time: 0.04-0.12 sec
- - 1-3 small boxes
-
ST segment represents
- elevated=
- depressed=
- ventricular repolarization
- - elevated=myocardial injury
- - depressed=myocardial ischemia
-
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
-
QT interval represents
- time:
- # boxes
- total duration of ventricular systole
- - time: 0.35-0.40 sec
- - 9-10 small boxes
-
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
-
EKG rate calculation
- 300, 150, 100, 75, 60, 50
- boxes: 30, 10, 5, 3, 2
-
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
-
bradydysrhythmias do what?
- to diastole
- to coronary perfusion time
- decrease myocardial oxygen demand
- - diastole=prolonged
- - coronary perfusion time=prolonged
-
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)
-
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
-
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
-
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)
-
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)
-
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)
-
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
-
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
-
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
-
sxs hypokalemia
weakness, lethargy, PVCs
-
foods high in K+
tomatoes, beans, prunes, avocados, bananas, strawberries, lettuce
-
sxs hypomagnesemia
weakness, ventricular irregularities
-
foods high in Mg
green leafy vegetables, nuts, dried peas, beans, whole grains
-
respiratory failure=
inability of cardiac and pulmonary systems to maintain adequate exchange of oxygen and carbon dioxide in the lungs
-
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
-
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
-
-
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
-
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
-
CPAP=
- invasive vs noninvasive
- how it works
- =continuous positive airway pressure
- - noninvasive
- - constant pressure applied to keep the alveoli open
-
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
-
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
-
controlled mandatory ventilation
- pt with no spontaneous effort
- pt receives a set Vt at a set rate
-
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
-
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
-
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
-
pressure support ventilation
augments spontaneous breathing with added pressure to overcome resistance of ET tube
-
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
-
tidal volume (Vt)
- the amount of air delivered with each preset breath
- usually 6-7ml/kg
-
fraction of inspired oxygen (FiO2)
percentage of oxygen delivered each breath
-
sigh
- breath that has greater Vt than the preset Vt
- 1.5-2.0x the Vt
-
low pressure alarm
- indicates a loss of pressure
- i.e. disconnect or leak in the system
-
high pressure alarm
- indicates increased pressure
- i.e. blockage - sputum, condensation of fluid, coughing, pneumothorax, etc.
-
some complications of mechanical ventilation
barotrauma, R main stem intubation, accidental extubation, tracheal damage, acid/base imbalance, infection, DVT, PE
-
emergency items to have at bedside with mechanical ventilation
- suction equipment
- Ambu bag
- extra trach tube
- 10cc syringe to check ET tube cuff
-
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
-
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
-
ABCDE bundle
- Awakening and Breathing Trial Coordination - daily spontaneous breathing trial to promote earlier extubation
- Delirium assessment and management
- Early exercise and mobility
-
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
-
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
-
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
-
hemodynamics provide information about
- vascular capacity
- blood volume
- pump effectiveness
- tissue perfusion
-
things to know about hemodynamic procedure
- pressure monitoring system
- slow drip heparinized saline solution
- phlebostatic axis - 4th intercostal space, midaxillary line
-
cardiac output=
cardiac index=
SVO2=
- CO=4-8L/min
- CI=2-4L/min
- SVO2=60-80%
-
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
-
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
-
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
-
initial stage of shock
- BP
- HR
- labs
- 1st stage
- BP: MAP dec 5-10 from baseline
- HR: slight increase
- labs: inc lactate
-
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
-
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
-
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)
-
sepsis=
clinical signs of SIRS + definitive evidence of infection
-
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
-
septic shock=
severe sepsis with acute circulatory failure and persistent hypotension, despite adequate volume resuscitation
-
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
-
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
-
ABG values:
- pH
- PCO2
- HCO3
- pH: 7.35-7.45
- PCO2: 35-45
- HCO3: 22-26
-
normal ranges:
- APTT
- PT
-
anticoagulation therapeutic ranges
- heparin
- coumadin
- heparin: APTT 60-75
- Coumadin: PT 18-24
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