What combination of blunt forces can occur coup-contrecoup injury?
Blood loss of a significant degree.
Solution of choice to replace fluid loss from exsanguinations?
- Lactated Ringers or Plasmolyte IV flud
- Packed RBCs
Treatment of an open pneumothorax.
- Sterile occlusive dressing taped on 3 sides
- Chest tube ASAP
What action should the nurse do it a missile is impaled in the body?
- Leave it in place.
- Protect from displacement.
What is never used to treat hypotension when in hypovolemic shock?
What IV fluids are best to correct hypotension in hypovolemic shock when large amounts of IV fluids are needed?
- -Lactated ringers or Plasmolytes
Examples of PPV.
Manifestations of flail chest.
Uncoordinated, papadoxical movement of flailed section of chest
d/t 2+ consecutive broken ribs
What can precipitate and relieve Vena Cava Syndrome?
- Precipitate -- supine position
- Relieve -- left-lateral
Best predictors of poor patient outcomes in traumatic injuries.
- Inreased lactic acid.
- Decreased base levels.
What actions occur during "E" phase of primary survey?
- Heat concervation.
- Transfer to an appropriate level trauma center.
Types of traumatic injuries causing partial or complete airway obstruction.
- Maxillo-facial fractures.
- Crushing of larynotracheal tree.
What to monitor to evaluate the status of splenic injuries?
Trend H & H.
Elevaed lactic acid and decreased base levels represent, what?
- Severity of tissue ischedmia.
Assessments to be included during "C" phase of primary survey?
- Strength, rate, rhythm and symmetry of pulses.
- Capillary refill.
- Skin tempature.
- Level of consciousness.
Manifestations of tension pneumothorax.
- Absent breath sounds.
- Neck vein distention.
- Tracheal deviation.
- Pulsus paodoxus.
Decrease in systolic BP and HR with inspiration.
Treatment for tension pneumothorax.
- Emergent needle thoracotomy.
- Chest tube.
What type of blood is given in an emergent traumatic injury?
Name 4 intra- and postop complications for traumatic injuries.
- Metabolic acidosis.
- Intraabdominal compartment syndrome.
Procedure performed to aspirate fluid from pericardial sac in cardiac tamponade.
Manifestations of cardiac tamponade.
- Beck's triad.
- Pulsus paradoxus.
- Elevated RA pressure.
- Muffled heart sounds.
- Needle cricothyroidotomy.
- Surgical cricothyroidotomy.
- Emergency tracheostomy.
Area of body which large amounts of clood could collect without overt signs of blood loss.
- Pelvic regions.
What interventions should the nurse do following endotracheal intubation?
Obtain an order for naso- or OG tube to decompress the stomach.
What to use autotransfusions to replace loss of blood for?
Massive hemorrhagic chest trauma
Primary goal of "B" phase in primary survey.
Phase in trauma care that focuses the attention on identification of life-threatening injuries.
Actions that need to occur immediatly after ET intubation to confirm placement.
- Ausculatate all lung fields.
- Portable CXR.
2 injuries from shearing force in blunt trauma.
- Aortic tearing.
Traumatic injuries in which pulsus paradoxux can monifestate.
- Tension pneumothorax.
- Cardiac tamponade.
Location of LeForte fractures.
Greatest risk with this type of fracture?
Why not use nasopharyngeal airway with basal skull fracture?
Can enter cranial vault causing brain injury.
Leading traumatic injury requiring medical attention.
Airway for: unconscious, no gag reflex.
Airway for: conscious patient
Airway for: conscious, basal skull fracture or cribriform
3 things that can increase tissue deformation and displacement in penetrating injuries.
- Change in trajectory.
- Blast effect.
Begins after life-threatening injuries have been addressed
What occurs during secondary survey?
- Emergent - trauma, MI, PCI alert
- Urgent - serious, non-lifethreatening - COPD
- Non-Urgent - episodic - UTI
- Fast-track - minor, acute - breaks, stitches.
Types of blunt trauma forces
Coup-contrecoup sheering injuries.
- Occurs at C7 and T1.
- Because C7 is the lowest mobile and T1is the highest immobile part.
#1 affected organ with blunt force injuries.
ET tube is in esophagus
Symptoms of hypovolemic shock.
- Scale used during primary survey to determine LOC.
- V-response to Verbal stimuli
- P-response to Painful stimuli
Ability to move air in and out of lungs
Gas exhange at the cellular level
O2 in - CO2 out
Reasons for ventilation
- Acute ventilatory failure.
- Pulmonary mechanics.
Acute ventilatory failure.
- Can't move CO2 out
- =acute respiratory acidosis
- = increase CO2, decrease pH
Insufficient O2 in blood
Supplies for intubation
- ET tube
- 10mL syringe
- Pulse Ox
Pre-intubation duties and care
- Call anesthesia and respiratory.
- Confirm patients wishes with family.
- Set up suction.
- Oral care -- remove dentures.
Post-intubation duties and care
- Secure ET tube.
- Document placement.
- End-tidal CO2.
- Patient and family needs.
Used if patient will be intubated for a long period of time.
Improves patient comfort.
Negative pressure ventilation.
(-) pressure in lungs causes air to be sucked in.
Positive pressure ventilation
Air being pushed into lungs.
- Most common.
- Delievers a preset Volume of air.
- Pressure will vary.
- Deliever preset Pressure.
Tidal Volume (TV)
Amount of air delievered to lungs with one breath in mL's
Precentage of O2 in inspired air.
Rate setting on vent.
- # of breaths/min give to patient.
- Can be patient or vent controlled.
- Keeps alveoli inflated during expiration.
- Will increase O2 to blood by keeping more surface area on copullary wills.
- Barotrauma, decreased CO2
Peak airway pressure
Pressure required to deliever volume of air.
- Healthy lungs - 20 cm H2O
- Goal - <40 cm H2O
Assist control ventilation
- Guaranteed set # of breaths/min at set TV.
- Any additional attempts to breathe, are assited at set TV
Advantages and disadvantages of Assist controlled ventilation.
- Advantage - allows respiratory rest
- Disadvantage - hyperventilation
- guaranteed set # of breaths/min @ TV.
- Any additional attempts ot breathe, are at TV that patient sets
Advantages and Disadvantages of S-IMV
- Advantages - exercise of repiratiory muscles
- Disadvantages - Potential for fatigue
- No set rate or TV
- Pt generated thier own, only a source of O2.
- Used for weaning.
High pressure alarms
-secretions, coughing, kinked tube
Low pressure alarms
- Pushing against little or no reisistance
- Disconnection or leak
- check tubing, connections
Complications of mechanical intubation
- CV - decreaed CO
- Plumonary - O2 toxicity, VAP, barotrauma
- GI - stress ulcer
What complications are possible when large amounts of NS is given to a patient with hypotension in hypovolemic shock?
Hyperchloremic acidosis d/t large amounts of chloride.
What question is important to ask prior to assessing a patient with a traumatic injury?
"What was the mechanism of injury?"
Name 3 predictable traumatic injuries that can occur from using both a lap belt and shoulder harness in a motor vehicle crash?
- Pulmonary contusion
- Chest wall contusion
- Small bowel contusion
What triage classification would you as a nurse, give a patient with a temp of 100.5, productive cough, SaO2 of 93% on 3L of O2?
Non-life threathening; Urgent, serious health.
Name the principle phases of trauma care according to Advanced Trauma Life Support.
- Primary survey
- Resusciation (along with primary survey)
- Secondary survey
What nursing actions occur during "D" Phase of the primary survey?
Quick neuro assessment using the AVPU scale.
Where is the most common location for a coup-contrecoup shearing injury to occur?
Between C7 and T1
What type of blunt injury are pregnant women at greatest risk to incur?
Blunt abdominal trauma.
What type of complications could cause death during the 3rd peak or trimodal distribution of trauma-related deaths?
- Systemic inflammatory response syndrome
- Multiple organ dysfunction syndrome
- Acute respiratory syndrome
What method of establishing an airway is contraindicated in traumatic injuries?
What type of airway is contraindicated if there is suspician of a cribriform plate fracture or basal skull fracture?
Name 3 methods used to confirm the adequacy of ventilation and oxygenation.
What diagnostic tool is used to diagnose the presence of slpeen or liver injuries in traumatic injuries?
What is the major complication of liver or spleen injuries?
Name 2 metabloic phased to stress injury that occur when the body is attemping survival and recovery.
- Ebb phase - 24-36hrs
- Flow phase - after 36hrs
What shock state is present in traumatic injury when there is acute blood loss or fluid shifts?
Classic clinical manifestations of hypovolemic shock?
Paradoxical, uncoordinated respiratory movement.
Worrisome complications that can occur with flail chest.
How is flail chest treated?
- High Fowler's
- Adequate pain medication
- Stabilization of rib fractures
What triage classification would you give a patient with fracture ankle, alert, stable vital signs?
Fast track; Minor acute
Waht is the cause of cardiac tamponade?
Blunt or penetrating trauma causes pericardium to fill with blood restricting myocardial contractility.
What is the primary goal in "A" phase?
Maintain the patency of the airway and cervical spine immobilization.
What is a potential complication that can occur if a missle is removed from the body?
What airway is recommended for a conscious patient without suspicion of basal skull fracture or cribiform plate fracture?
What methods of establishing an airway are approved in traumatic injuries?
- Chin lift
- Modified jaw thrust
The temporary space that is created by displaced tissue from a penetrating missile.
Complications that can occur following rib fracture(s).
What ribs are at greatest rish to fracture?
What triage classification would you give a patient with a fall from a standing position, on Coumadin, hit his head and an altered LOC?
Emergent; Highest priority; Life-threatening.
What emergency surgical intervention is performed to locate hemorrhaging great vessels in hemorrhagic chest trauma?
Open resuscitative thoracotomy
Blunt force that involoves and increase in the velocity of a moving body or structure.
What criteria is used by a nurse to triage ETC patients?
- Based of severity of injury or health problem.
- Based on immediacy of the treatment.
What is the name for the collateral damage to the surrounding vessels, nerves, and organs of tissues from a penetrating missle?
How is the velocity of a missle related to the degree of tissue and organ damage?
The greater the velocity the greater the tissue and organ damage.
Upon initial contact in caring for a patient on a ventilator, what nursing actions should occur?
- 1. Ausculatate all lung fields for breath sounds.
- 2. Note demarcation line of the ET tube at the lip.
- 3. Confirm ventilator settings.
Blunt force that involoves being pressed or squeezed by force.
What does canopgraphy measure?
- End Tital Volume (EtCO2)
- Gives objective confirmation of ET tube placement.
EtCO2 <35 mm/Hg?
ET tube may be in the espohagus
Why is an elderly trauma patient have limited organ function when faced with a physiologic challenge?
Limited physiologic reserve.
What factors could delay or alter an accurate neuro evelaluation of a trauma patient during the primary survey?
Use and abuse of impairing substances.
Limited longitudinal stretch or stress upon a tissue or organ that can occur in a traumatic injury.
Monifestations of Tension and Open Pneumothorax
- Midline treachea
- Abset breath sounds on the affected side
- Pulsus parodoxis
- Decreased venous pressure
- Increased intrathorasic pressure
- Chest pain
Tension pneumothorax vs. Open pneumothorax
- Tension - damage of the lung causing air to ecsape from the lung into the pleural cavity.
- Open - penetration of the skin casing air from the atomosphere to enter the pleural cavity.
Treatment of tension vs. open pneumothorax
- Tension - needle aspiration, chest tube
- Open - occlusive dressing taped x3, chest tube, surgery prn.
-How to prevent?
- ->80% FiO2 for over 48hrs
- -Can damage endothelium
- -Increased PEEP and decreased FiO2
- Interventions designed to prevent complications of mechanical ventilation.
- -HOB >30
- -Prevention of stress ulcer
- -DVT prophylaxis
- -Sedation vacation
- -Oral care Q4
- -Weaning trial
- Richmond Agitation Scale
- -MD sets target score
- -RM tries to match by adjusting sedation.
Complications of artifical airways
- Insertion trauma
- Cuff trauma
- Vocal cord paralysis or damage
- Swallowing dysfunction
- Tracheoesophagheal fistula
Nursing Diagnoses for mechanical ventilation
- Ineffective Airway Clearance
- ---suction prn
- Impaired Gas Exchange
- ---monitor CO2 and pH
- Ineffective Breathing Pattern
- ---tachy, brady, dysynchrony, anxiety
- Alteration in Cardiac Output
- ---d/t increased PEEP
Rapid Shallow Breathing Index (RSBI)
- Used to assess a weaning trial.
- RR / TV = RSBI
- Target: <100
- Monitor for stridor
- Assess breath sounds
- Chest PT
- Cough and deep breathing
- Swallowing evaluation
Your ventilated patient seems to be in distress. Her SaO2 is 84%, she is cyanotic and diaphoretic. What to do first?
Bag patient with 100% O2
- -onset - 5min
- -duration - 4-5hrs
- -dosage - 2-4mg IV Q4
- -onset - 15min
- -duration - 4-5hrs
- -dosage - 0.2-1mg IV Q2-3
Morphine vs Dilaudid
Dilaudid is 7x's stronger than Morphine
- -dosage - 50mcg-100mcg
- *useful for procedures
Opaite reversal agent
- Will reverse all effects of opaites, including pain
- -onset - Rapid
- -duration - 4hrs
- -dosage - weight based - 1-4mg
- -onset - slow - 10-20min
- -duration - 12hrs
Benzodiazepine reversal agent
Reversal agent for Benzo's
Reversal agent for opiates
- General anaesthetic
- White in color - dissolved in lipids
- -onset - 2 min
- -duration - 2-5min
- Heart failure
- Metabolic acidosis
- Renal failure
-how to test?
- Drug-induced paralysis
- Paralyzes skeletal muscles
- Must sedate and analgesia
- -Test with peripheral nerve stimulator
Assessment and non-verbal cues of pain
- Facial expression
- Body language
- Muscle tension
- Compliance of vent.
- Scale used for non-verbal pain assessment
Visual Analog Scale
0-10 face scale used for pain assessment
When is the spinal cord considered unstable?
- When there is a lack of vertebral support
- When there is a lock of ligament support
- When there are 2+ damaged vertebral columns
Where is the beginning and end of the spinal cord?
- Starts at foreamen magnum
- Ends at L1 or L2
If the spinothalamic tract was injuried in an incomplete spinal injury, how might the patient present?
- Unable to differentiate temp. below the level of injury
- Altered and/or increased pain below the level of injury
What is the most common reason for a laminectomy?
Neural impingement stenosis
How are spinal cord injuries classified according to ASIA (American Spinal Injury Association)?
- According to the level of vertebral injury.
- If it is complete or incomplete
What type of spinal cord injury results in the absence of all motor and sensory function below the level of injury?
Complete spinal cord injury
What is the name of the spical cord injury id damage to the spical cord occurs between T2 anf L1?
What type of incomplete spinal cord injury results in spastic muscles and exaggerated tendon reflexes below the level of injury?
Upper motor neuron injury
What level of vertebral spinal cord injury results in loss of phrenic nerve innervations with the diaphragm?
Would a patient with complete coup-contrecoup shearing spinal cord injury be concidered a tetraplegic or paraplegic?
When does the primary spinal cord injury occur?
At the time of impact
Where should a nurse being a motor assessment when evaluating the motor functioning of a spinal cord injury?
At the head and compare left to right
What does it indicate if there are the presence of reflexes below the level of injury?
- Upper motor neuron injury
Who are at greater risk for the ocurrence and severity of shock states in spinal cord injuries?
- The higher the injury.
- The greater the autonomic nervous system dysfunction.
- Greater the occurence and severity of the shock state.
When do you know that spinal shock has ended for a patient with an incomplete upper motor neuron spinal cord injury?
Return of relexes below the level of injury
How do you treat spinal shock?
At what vertebral level of incomplete spinal cord injury does an upper motor neuron injury occur?
At or above T12
What is the name for the clinical state in spinal cord injuries that is marked by massive vasodilation, hypotension and bradycardia?
What is the rold of the nurse when turning a spinal cord injury patient
Cervical spine immobilization
Why does spinal shock occur?
Autonomic nervous system is in dysfunction
What spinal tract is injuried in an incomplete spinal injury if the patient has altered or increased pain levels?
What type of bladder function does a patient with an incomplete upper motor neuron have?
Spastic neurogenic bladder
What type of incomplete spinal cord injury results in hyporeflexia responses and flaccidity below the level of injury?
Lower motor neuron injury
What type of spincal cord injury causes loss of motor and sensory function of the arms, trunk, legs and pelvic regions?
When does the secondary spinal cord injury occur?
Within a few minutes of the impact
How is neurogenic shock treated?
- IV fluid resusicitation
Name examples of non-surgical stabilization methods used in spinal cord injuries.
- Cervical tongs with traction
- Halo traction
- Spinal braces
What type of spinal cord injury can be stabilized with a halp traction?
What is the name given to a spinal cord injury that involves injury from C1 - T1?
What medication is given as a 24 hour infusion in the early stage of care of the spinal cord injury patient to improve neurological outcome and minimize the effects of secondary spinal cord injury inflammations?
Where should a nurse being a sensory assessment when evaluating function of a spinal cord injury patient?
- At the feet
- Comparing the left to the right
What dies the presence of perineal reflexes indicate when there is a spinal cord injury?
Incomplete involving upper motor neuron injury
When does spinal shock occur?
Within 30-60 minutes of primary injury
What type of pulmonary complications are SCI patients at risk for which could cause impaired respiratory effectiveness?
What spinal tract is injured, if the patient presents with altered or exaggerated sensations to touch and vibrations?
Posterior or dorsal spinal tract
What is the etiology or reason that a secondary spinal cord injury occur?
d/t vascular injury to the injured spinal cord
At what vertebral level does a lower motor neuron injury occur?
What is the best way of mobilizing secretions in a SCI patient?
- Frequent turning
- Log rolling
- Chest PT on bed
Name the perineal reflexes that are assessed in SCIs.
- The anal wink
- The bulbocavernosus reflex
Why is suctioning to be avoided unless necessary and only then is done with extreme caution in patients with spinal cord injuries?
Suctioning can cause bradycardia and asystole
What type of SCI results in preservation of some degree of sensory and/or motor impulses below the level of injury?
What spinal tract is damaged if the patient is not able to differentiate temperature changes below the level of injury in an incomplete spinal injury?
What vertebral level of spinal cord injury will result in the patient be dependent upon a ventilator to breathe?
Describe the reflex function seen in an upper motor neuron incomplete SCI.
- Spastic reflexes
When does spinal shock end?
How does hypovolemic shock and neurogenic shock differ?
- Hypovolemic shock - atrial hypotension and tachycardia.
- Neurogenic shock - atrial hypotension and severe bradycardia.
What is the purpose of manual or surgical stabilization of SCI?
- Prevent worsing deformities.
- Maximize recovery.
Name the 3 examples of secondary SCIs.
- Ischemia injury.
- Elevated intracellular Ca+ ions resulting in destruction spinal cell membrance injury.
- Inflammatory injury.
What type of bladder function does a patient with an incomplete lower motor neuron SCI have?
Acontractile bladder (dribble at a continuous rate)
How does the SCI patient present when in spinal shock?
Loss of motor and sensory function below the level of injury.
If the corticospianl tract was injured in an incomplete SCI, how might the patient present?
Weakness or an altered ability to move the muscles voluntarily below the level of injury.
What type of SCI results in loss of motor and sensory function of the lower extermities, but still has upper extremity functioning?
How do you assess for the presence of the bulbocavernosis perineal reflex?
Tugging the foley catheter and checking for contraction of the anal sphincter
Describe the type of relex activity seen in an incomplete lower motor neuron SCI.
If the patient presents with ataxia, what spinal tract has been injuried in an incomplete SCI?
The posterior or dorsal spinal tract due to altered proprioception.
Why is Methylprednisolone 24 hour infusion given in the early stages of care to a PCI patient?
- Improve neurological outcomes
- Minimize effects of secondary inflammation injury
What conditionl in SCI is treated with IV fluid resuscitation, atropine and voasopressors?
What should the nursing diagnosis be for any SCI involving the cervical vertrae?
Actual or Risk of impaired ability to breathe without a vent.
What is the name for the clinical condition in SCIs that are marked by temporary complete loss of sensory and motor loss of funcioning below the level of injury in incomplete SCIs?
What can delay an MD from being able to assess the true extent of a SCI?
- Inflammation from secondary SCI
- Spinal shock
Would a patient with a T6 thorasic SCI be concidered a tetraplegic or paraplegic?
How would a patient with an incomplete SCI present?
Preservation of some sersory and/or motor function
What clinical finding would a nurse assess when a patient with a SCI is in spinal shock?
- Absence of all reflex activity
What spinal tract is injured in an incomplete SCI if the patient has weakness in his ability to voluntarily move his muscles below the level of injury?
What is a complication of treating neuorgenic shock with fluid restriction?
How should bradycardia due to suctioning be treated in a patient with SCI?
- Stop suctioning
- IV atropine
Loss of thermoregulation in SCI
What is the name of the nerve that can be damaged with a cervical SCI that can result in impaired or absent disphragmatic innervation?
Clinical condition in patients with a SCI at or above T6 that is manifestated by severe hypotension and bradycardia.
Why does poikilothermia occur in SCI?
interruption of the signaling between the spinal cord and the hypothalamus thermoreceptors
What part of the spinal cord is damaged if the patient is a tetraplegia?
C1 to and including T1
What type of metabolic state occurs in SCI?
Hypermetabolic d/i increased energy expenditures
What could a paralytic ileus occur in the first few days following a SCI?
d/t the effects of spinal shock
What is the #1 reason for mortality after SCI?
What level of vertebral SCI is more prone to have occurence of neurogenic shock?
SCI at or above T6
What causes neurogenic shock in SCI?
d/t sudden loss of sympathetic stimulation to the blood vessels cause bradycardia and massive vasodilation and venous pooling.
Would a patient with a C1-C3 cervical SCI be concidered a tetra- or para-?
occur is patients with SCI where there is ectopic overgrowth of the bones below the level of injury
Autonomic Dysreflexia (AD)
Life-threatening emergency in SCI patients marked by accelerated HTN from amplified response from the autonomic NS
Why do shock states occur in SCIs?
Autonomic NS is disorganized
What vertebral level of injury in SCI have the ocurrence of AD?
at or above T6
What can heterotopic ossification in SCI result in?
limitation of joint mobility
What joint is primarily affected in heterotopic ossification?
Is neurogenic shock in SCI marked by vasodilation or vasoconstriction?
What is 3 actions by the nurse when a patient is experiencing AD?
- Elevated HOB
- Finds the trigger and correct it
- Administer IV and HTN meds
Name some classic manifestations during impending or actual AS.
- Accelerated HTN - 200+/100+
- Severe headache
- Flushing of face
- Blurred vision
- Feeling of doom
Common trigger of AD?
What method should a nurse change a position in a SCI patient?
What measures are effective in helping the patient with SCI tolerate position changes?
- Abdominal binder
- Compression stockings
What long-term intervention occurs for patients with tetraplegic SCI to improve QOL d/t bladder incontinence?
What type of motor neuron injury has better results in bladder and bowel training in SCI?
I a satisfying sexual relationship possible following a SCI?
- Arousals and orgasms take longer
- Ejaculation can be stimulated by devices for future insemination
What medications are effective in controlling phantom or central pain?
- Anti-seizure (Neurontin)
- Anti-depressants (Lyrica)
Corticospinal tract transmits...
Spinothamlamic tract transmits...
Pain and temperature
Dorsal tract transmits...
sensation of vibration, propioception, touch, fine touch, pressure and texture
Complete severing between C1 and T1
Complete severing between T2 and L1
- Decrease circulation
Elevated Intracellular Calcium
- Damage to cell membrane
- Neuronal cell death
- Infiltration of leukocytes
- Swelling of the injured spinal cord
- Days to weeks
Upper Motor Neuron Injury
- Incomplete SCI at or above T12
- -HYPERreflexia or spastic
Lower Motor Neuron Injury
- Incomplete SCI below T12
- HYPOflexia or flaccid
Volume of blood filling the ventricles at the end of diastole
S/S of increased (R) heart preload.
(Right side is backing up)
- Hepatic engorgement
- Peripheral edema
- -->Same as fluid overload
S/S of decreased (R) heart preload.
(Right side not getting enough)
- Poor skin turgor
- Dry membranes
- Orthostatic hypotension
- Flat jugular veins
- -->Same as dehydration
S/S of increased (L) heart preload
(Left side backing up)
- S3, S4
- -->Pulmonary symptoms
- The bigger the stretch --> the bigger the squeeze
- Increased preload --> increased stretch, therefore --> increased CO
The pressure the ventricle must generate to overcome resistance.
(systemic vascular resistance)
- Simultaneously assesses hemodynamic parameters
- -PA systolic and diastolic pressures
- -Wedge pressure
- -CVP (central venous pressure)
Normal RA pressure
Normal RV pressure
- 20-30 (systolic) 2-8 (diastolic)
- 4-8 Liters
- Calculated by HR x SV
Normal Wedge pressure
Normal PA pressure
- 20-30 (systole)
- 8-15 (diastole)
- Measures fluid status
- Normal 2-6
- Measure pressure in PA
- Reflects the state of RV and lungs
- Normal 20-30/8-15
- Balloon obstructs PA allowing LV pressure to be measured
- Normal is 4-12
Measuring CO using a Swan-Gantz catheter
- Inject NSS into catheter, travels thru heart. Temp is measured when cool blood passes by the thermistor.
- CO is calculated by how much blood is being pumped by knowing how fast it takes for the cooled blood to pass thru the heart.
- CO x BSA
- More accurate than CO
- Produce arterial vasodilation
- Sever drop in BP
- Low SVR (below 600)
- Increased HR and contractility
- Increased CO (over 10)
- Heart loses pumping ability
- Severe decrease in BP
- Decreased CO (less than 3)
- Causes vasoconstriction
- Increased SVR (over 1600)
Septic vs. cardiogenic shock
- Septic -- Increase CO
- Decreased SVR
- Cardiogenic -- Decrease CO
- Increased SVR
Know RA, RV, CO, CI, SVR, CVP, PA, Wedge
- RA - 2-6
- RV - 20-30/2-8
- CO - 4-8
- CI - 2.4-4
- SVR - 800-1200
- CVP - 2-6
- PA - 20-30/8-15
- Wedge - 4-12
Why would a patient need an A-Line?
- Hemodynamically unstable
- Serial blood gases needed
- At baseline - diastole
- At peak - systole
- Dichrotic notch - marks the closing of the aortic valve
Tranducers with A-Lines
Transducers with a Swan
- Must be at the level of the catheter.
- Must be level with 4th intercostal space, midaxillary line.
Medications and A-lines
Never inject medications thru an A-Line.
Removal of A-Lines
Apply pressure x5 minutes
SA node --> AV node --> Bundle of His -->(L) and (R) bundle branches --> Purkinje fibers
- Q is first down segment
- R is first up segment
- S is down segment FOLLOWING an R
- *no R, no S*
Causes of Dysrythmias
- Fluid volume
- Body temp
NSR with HR <60 bpm
Treatment of Sinus Brady
- *Treat only if symptomatic*
- Meds - Atropine Sulfate
- Temp PPM?
Treats symptomatic brady
NSR with HR >100 bpm
Causes of Sinus Tachy
- Always has a cause - anxiety, pain, fever, activity, dehydration, HF
- Treat cause, treat tachy
- No meaningful P-wave
Causes of A-Fib
chaotic firing of myocardial cells
- HR >250 bpm
- Sawtooth p-wave
Treatment of A-Fib and A-Flutter
- Control rate
- BB or CCB
- HR 150-250
- Always regular
Treatment of SVT
- Valsalva maneuver
- AdenosineCCB, BB
Early atrial depolarization
Causes of PACs
stress, anxiety, fatigue, infection, etc.
- Early ventricular contraction
- Can be bigeminy, trigeminy, couplets, triplets
Causes of PVCs
Treatment of PVCs
Treat the patient not the rhythm
Causes of Ventricular Tachycardia
- Cardiac disease
- Electrolyte imbalance
Treatment of V-Tach
- With a pulse - Amio
- Pulseless - CPR
- Will always be unconscious
- #1 cause is an MI
1st degree AV block
PR interval >0.20
2nd degree AV block Mobitz Type I
- PR interval progressively increased until QRS is dropped
2nd degree AV block Mobitz Type II
- Some beats conducted, some not
- Some P's with no QRS
- respuires PPM
3rd deree AV block
- No communication between atria and ventricles
- All P's evenly spaced, all QRS's evenly spaced
Causes of 3rd degree AV block
- Medication - Dig toxicity
Treatment of 3rd degree AV block