CRITICAL CARE EXAM 1

• Most common opiate
• Onset - 5 mins
• Duration - 4-5 hours
• Dose - 2-4 mg IV Q4H

• Onset - 15 mins
• Duration - 4-5 hours
• Dose - 0.2-1 mg IV !2-3H
• Reversal - Narcan - .1-.2mg IV @ 2-3 min intervals

• Synthetic opiate analgesic 
• Dose - 50mcg-100mcg (.05-.1mg)
• Duration - .5-1 hour (IV)

• Nonopiods
• Do not exceed 2g in 24H

Adjustment of a drug for an individual level to provide the greatest comfort to the patient with min side effects

• Benzodiazepine
• Duration - 4H
• Dose - Weight based (1-4mg)

• Romazicon (flumazenil)
• .2mg every min
• Max 4 doses

• Benzodiazepine
• Duration - 12H
• S/E - seizures

• Romazicon
• .2mg -1mg max IV

• Onset - 2 mins
• Duration - 2-5 mins
• Metabolized in liver ; excreted in kidney
• NO reversal agent

• Cardiac failure
• metabolic acidosis
• rhabdomyolsis
• renal failure

• Patients response to vent
• restlessness
• LOC
• VS
• RASS

• Sedation scale
• +4 - -5
• Target Score - MD determined
• Actual Score - RN assessed

• Drug-induced paralysis
• Paralyzes skeletal muscle ONLY - not brain
• S/E - Tachycardia, HTN

• Neuromuscular block
• onset - 3 mins
• duration - 30-40 mins

• Neuromuscular block
• onset - 2-3 mins
• duration - 45-60 mins

• 1. Falls
• 2. Stuck by person or object
• 3. Transportation related injury

Mechanism of injury?

• 1. Blunt
• 2. Penetrating

• NO skin interruption
• covert injury

• 1. velocity of energy transmission
• 2. surface area of injury
• 3. elasticity of tissues impacted

• Sliding of body structures in the opposite direction upon impact from blunt force
• **Coup-contrecoup chearing C7-T1
• **Aortic Tearing

• Increase in the velocity of a moving body or structure 
• increased tissue/organ damage with greater velocity
• Example : hitting steering wheel in MVA

• Decreased in velocity of a moving object
• force impedes forward movement of person

• Not a force
• limited longitudinal stretch or stress upon a tissue or organ
• Example: AC dislocation

• Organ or tissue is squeezed or pressed by force
• Example: heart and lungs between the chest wall
• Example: Bowel,liver, or spleen between spine and seatbelt

#1 organ injured in blunt force trauma

• Transmission of energy from a moving object into the body tissues
• disrupts skin integrity 
• DO NOT REMOVE OBJECT

damage to surrounding area

• 1. Primary survery
• 2. Resuscitation 
• 3. Secondary survery

Primary and resuscitation occur together!

• Identify life-threatening injuries and intervene simultaneously 
• ABCDE approach

Maxillofacial Fx - highest cause of airway obstruction

• 1. Nasopharyngeal 
• 2. Oropharyngeal

• Conscious patient
• used when c-spine cannot be hyperextended
• Contraindications - Cribriform Fx or Basal skull Fx

• Endotracheal Tube
• Unconscious patient
• can cause aspiration in conscious patient

• Measures end tidal CO2
• Normal - 35-45 mmHg

Clinical state of inadequate circulation

• Caused by acute blood loss from injury
• Most common traumatic shock
• shifting or loss of fluids from intravascular space

• 1. Mild to marked tachycardia
• 2. Hypotension
• 3. Tachypnea and anxiety

• Extreme hemorrhage
• ALWAYS = hypovolemic shock

• First Peak - Dead at the scene
• Second Peak - within 2 hours
• Third Peak - Within days to weeks

• Done with primary
• Exsanguination resuscitation - 14G-16G IV - 2L LR or plasmolyte

• Lack of bony support due to 2+ rib Fx
• complications - hypoxemia, PNA

• Caused by blunt force trauma
• Trapped air
• Plusus Paradoxus
• Neck vein distension
• Absent breath sounds on affected side

• Needle Asp
• Chest Tube

• Drop in SBP by 10mmHg or more upon inspiration 
• Seen in tension pneumo and cardiac tamponade

• Penetrating chest wall injury
• appears same as tension pneumo

• Sterile dressing taped on 3 sides
• Chest Tube
• Sx

• Accumulation of >1500cc of blood in chest cavity
• autotransfusion used
• CT placed 
• Sx

• Caused by blunt or penetrating trauma
• pericardium fills with blood
• impedes venous return

• Becks Triad - Increased RAP with neck vein distension
•                 - Hypotension
•                 - Muffled heart sounds
• Pulsus Paradoxus
• PEA

Procedure where fluid is aspirated from pericardium

• 1. Hemodynamic Monitoring 
• 2. Decrease in lactic acid levels
• 3. Raise base levels

• 1. Initial Operation - control source of bleeding
• 2. Resuscitation - In ICU for trauma resuscitation
• 3. Definitive Resuscitation - Back in OR within 72H
• Complications: Intraabdominal compartment syndrome

Body response to traumatic injury

• Metabolic Response to Stress Injury
• 24-36H
• Decreased O2 consumption
• Decreased body temp

• Metabolic Response to Stress Injury
• After 36H - Recovery State
• Increase in body temp
• Protein breakdown - catabolic state
• think high energy, high use of O2

Ability to move air in and out of lungs

Gas exchange at cellular level

• Patient unable to move air in and out
• acute resp acidosis 
• Increased CO2 (>50) - because they cant exhale 
• Decreased pH (< 7.30) - Acidosis

• PO2 (<60)
• O2 sat 88%

• Example: ALS d/t paralysis of muscles
• Obstruction, decreased compliance, weak pulmonary muscles

• 1. Auscultate
• 2. etCO2
• 3. CXR

• Prolonged needs for airway
• Prevents skin breakdown around mouth

• "Iron Lung"
• Diaphragm goes down...lungs go out

• Delivers a preset volume of air to lungs
• pushes certain amount of air
• most common setting

• Delivers a preset gas pressure to lungs
• keeps pushing air until pressure is achieved

• Amount of air delivered to lungs in one breath
• 5-12mL/Kg (500-800mL)

Damage to alveoli

• % of O2 inspired gas
• Room air - 21%
• Usually starts at 30%

Keeps alveoli inflated during expiration

• Pressure required to deliver volume of air 
• Normal - 20cm H20
• Goal - < 40cm H20
• Increased peak = decreased lung compliance
• Decreased peak = improving status 
• Highest amount of pressure it takes to push air into lungs determines how healthy lungs are

• Patient guaranteed to get certain amount of breaths per min
• Additional inspiratory breaths are assisted at set tidal volume
• Patient can become alkalotic from breathing off to much CO2

• Patient gets guaranteed amount of breaths 
• machine does not assist with patient attempting to take their own breath
• setting used to wean patient from vent

• no RR or TV preset 
• Patient generates their own Rate and Tidal volume
• Just gives a source of O2, does not provide breaths

• Overcomes increased airway resistance
• little bit of pressure that stays in the vent circuit all the time
• decreases work of breathing

• Indicates resistance in the circuit
• Usual Causes are : Secretions, coughing, biting on ET tube, high lung compliance

• Indicates a disconnection or leak in the system
• check tubing and make sure everything is connected

• Decreased CO, preload, SV
• Heart cant fully expand when lungs are over inflated

• Changes in flow of gas
• O2 toxicity
• R/O VAP, barotrauma

• Decreased perfusion
• Rare

• Stress Ulcers!!
• Very Common
• Vented patients need to be on PPI or H2 blocker!

• Decreased flow to head
• Increased ICP

• Risk with > 80% FiO2 for > 48H
• Damages endothelium
• Use min O2 to obtain acceptable PaO2%
• Add PEEP - PEEP will increase O2 consumption and decrease % of O2 needed

• Increased intrathoracic pressure over distends lungs and prevent cardiac filling
• Lungs very expanded = increased pressure on heart = hard time filling and pumping = decreased CO

• Assess readiness to wean (RTW)
• All patient parameters must be optimized
•   - < 50% FiO2
•   - PEEP < 5
•   - Optimal Nutrition
•   - Afebrile
•   - No GI Bleed
•   - Stable hemodynamics
•   - Mental Status

Removed from vent and placed on T piece, Trach collar, serially increase time off vent

• More common
• usually CPAP setting

• Remain attached to vent
• provides oxygenated air

• Patient starts with high number of breaths
• over time breaths are decreased
• this setting often used with a difficult to wean patient

• Increased TV and Decreased RR
• Rapid shallow breathing index
• Target - < 100

Stridor, laryngospasms

• Assess breath sounds
• humidified air
• Pulm Hygiene
• Swallowing eval

Forces air into lungs as you breathe on your own

• Gastric distention
• Aspiration - Keep NPO
• Hypoventilation
• Skin irritation
• Nasal problems
• Conjunctivitis 
• Removal/ non-compliance

• 1. Protection
• 2. Structure/support

• 1. Lack of vertebral support
• 2. Lack of ligament support
• 3. 2+ damaged vertebral columns

• 31 pairs of nerves
• Begins at foramen magnum
• *Ends at approx L1-L2

• Originate at cerebral cortex
• Carries motor signals from brain to the end of the spinal cord
• convey impulses for voluntary movement

• Originate in brain stem
• connects upper motor neuron by synapses
• branch out as spinal nerves
• innervate with skeletal muscle

• Protective layer around brain and spinal cord
• 1. Dura Mater - Outermost 
• 2. Arachnoid - Middle Layer
• 3. Pia Mater - Innermost
• CSF = Subarachnoid Space**

• Inner region
• Motor activity is transmitted from brain to body
• sensory messages are related from the body to the brain

• 3 Tracts
• 1. Corticospinal - transmits motor activity
• 2. Spinothalamic - transmits pain and temp
• 2. Posterior (dorsal) - carries sensations of vibration, proprioception, touch, fine touch, pressure and texture

• 1. MVC
• 2. Falls
• 3. Violence
• 4. Sports

Decompression that alleviates pain from neural impingement stenosis

Removal of all or part of the damaged disc

• 1. Location
• 2. Incomplete or Complete

Lack of sensory and motor function below the level of injury

• Preservation of some sensory and/or motor function below the level of injury
• altered sensory and/or motor function
• range of degree preservation

• Formally known as Quad
• Complete severing of SC between C1 and T1
• Probably no bowel or bladder function

• Complete severing of SC between T2 - L1
• Possible bowel and bladder training

• Upper motor neuron injury
• spasticity of muscles
• exaggerated tendon reflexes
• spastic neurogenic bladder
• anal sphincter will respond

• Lower motor neuron injury
• hypotonation
• hyporeflexia
• flaccidity
• acontractile bladder and bowel

• Can be fatal
• Loss of phrenic nerve
• vent dependent 
• tetraplegia

• Common diving injuries
• risk of vent support

Coup-contrecoup shearing injury

T-L junction most common site

Occurs at the moment of impact

• Hyperflexion
• hyperextension
• flexion-rotation
• compression

Occurs within mins of primary injury

• 1. Ischemia
• 2. Elevated Intracellular Calcium 
• 3. Inflammatory Processess

• Decrease in circulation to injury site 
• vasospasms
• edema
• hypoperfusion
• neuronal death

• Accumulation of calcium ions in injured cells
• demyelination and destruction of cell membrane
• damage to the cell membrane
• neuronal death

• Infiltration of leukocytes at the site of injury
• swelling of the injured SC
• Swelling can take days to weeks

• Assess strength and movement
• ALWAYS begin at the end
• Lower extremities assessed last

• Checking for exact points of normal sensation
• ALWAYS start distally and move proximally

• Complete SCI - absence of deep tendon reflexes below the level of injury
• Incomplete SCI - Presence of reflexes below level of injury

• If present - Possible bowel and bladder training
• upper motor neuron injury

• 1. Absence of all reflex activity
• 2. Flaccidity 
• 3. Loss of all neurologic activity below the level of injury

Unable to classify SCI as complete or incomplete until shock resolves

• 1. Return of deep tendon reflexes
• 2. Spasticity and hyperreflexia
• 3. Clonus - muscular spasm
• 4. Increased muscle toen
• 5. Return of perineal reflexes

• Occurs in SCI at or above T6; within 30 mins of SCI
• Sudden loss of sympathetc stim to blood vessels = bradycardia
• massive relaxation and vasodilation of vessels = severe hypotension
• loss of vasoconstrictive effects = pooling of blood
• unable to regulate temp = poikilothermia
• **Severe arterial hypotension with bradycardia = classic neurogenic shock**

• 1. Fluid resuscitation
• 2. Vasopressor
• 3. Atropine

Hypovolemic Shock!

• Methylprednisolone
• Min inflammation
• 24H infusion
• D/C if symptoms resolve
• can increase risk of PNA, sepsis, GI bleed, electrolyte imbalance, delayed healing

• Atropine
• SCI pts increased R/O bradycardia/asystole during ET tube manipulation, suction, NGT insertion

• **Leading cause of mortality and morbidity in SCI
• Predisposing factors : Venostasis and transient hypercoagulable state

• Ectopic overgrowth of bone below level of injury
• Manifestations : loss of ROM and localized swelling, warmth and fever
• Hip most common
• Preventative measure - Indomethacin

• Life-threatening medical EMERGENCY
• SCI at or above T6
• Overstimulated autonomic nervous system

• BLADDER DISTENTION
• bowel impaction
• stim of anal reflex
• pain
• temp change
• ingrown toenail
• tight clothes
• UTI
• uterine contraction

• **HTN - Any SBP > 40 mmHg over baseline
• profuse sweating
• goose bumps
• sudden HA
• blurred vision
• anxiety / doom

• LOWER BP
• HOB 90
• loosen clothing
• relieve bladder
• facilitate defecation
• pain meds
• anti HTN meds

Vena Cava --> RA --> Tricuspid valve --> RV --> PA --> LA --> Mitral valve --> LV --> Aorta --> out to body

Pressure in atria exceeds resistance in ventricles = opening of tricuspid and mitral valves

LV prefilling

20-30%

Two ventricles exceed the resistance of outflow vessels = valves closing = S1 heart sounds

• "filling the tank"
• the volume of blood filling the ventricles at the end of diastole

• JVD
• ascities
• hepatic engorgement 
• edema
• * signs of fluid overload

• Poor turgor
• Dry membranes
• orthostatic hypotension
• Flat jugular veins
• * signs of dehydration

• Dyspnea
• Cough
• 3rd and 4th heart sounds

• Force of contraction of cardiac muscles is dependent on the stretch of cardiac muscle fibers
• force of ventricular contraction is dependent on preload
• Bigger stretch = bigger squeeze *

• Measure of work or resistance
• amount of resistance that push against aortic valve
• Increased afterload = increased O2 need
• Increased afterload = increased work of the heart
• measured by SVR - directly related to arterial dilation and contraction
• Dilation = Decreased SVR
• Contraction = Increased SVR
• Normal SVR - 800-1200**

• Squeeze
• ability of the cardiac muscle fibers to shorten in length

• Agents that affect contractility
• Positives - increase
• negatives - decrease

Measurement and interpretation of invasive hemodynamic parameters to determine cardiovascular functions and regulate therapy

• Most invasive critical care monitoring catheters
• Simultaneously assesses several hemodynamic parameters
• Inserted in IJ, subclavian or femoral

2-6

20-30/2-8

2-30/8-15

800-1200

• Measures filling pressures in the Right heart
• Normal 2-6
• Low CVP = hypovolemia , dehydration
• High CVP = fluid overload

• Reflects RV and lung
• Normal 20-30/8-15
• Low PA = hypovolemia
• High PA = fluid overload, mitral stenosis, COPD, Pulm embolus, Idiopathic Pulm HTN

• Reflects BP in LV at end-diastole
• Measure of LV preload
• Low wedge = hypovolemia
• High wedge = fluid overload,MI, cardiogenic shock, CHF
• Normal 4-12

• Amount of blood ejected by the heart per minute
• Normal = 4-8L/min
• CO= HR x Stroke Volume
• CO is partially dependent on body size of individual

• Amount of blood ejected per beat
• Normal 50-100cc

• CO divided by body surface area
• Normal = 2.4-4L/min
• CI < 2.0 = Shock

• Endotoxins produce massive arterial vasodilation
• Severe decrease in BP
• Decreased SVR (<600)
• Increased CO (>10)

• Heart loses pumping ability
• Severe decrease in BP
• Increased SVR (>1600)
• Decreased CO (<3)

• 3cc/hr - keeps line open and clear
• filled to 300 of pressure

Dichrotic notch signals closure of the aortic valve - beginning of diastole

• Ensure that all connections are tight
• Kinked a-line will result in a dampened waveform
• maintain the transducer level with tip of the catheter
• NEVER INJECT MEDS INTO A LINE

Cells will not respond to any further stimulation

• cells will respond to a stronger than normal stimulus
• R on T phenomenon

< .12

.12-.20

• Start of conductive system
• typically determines HR

Receives from atria and transmits thru the ventricle thru purkinje finbers and breaks into bundle branches

• < 60 bpm 
• may or may not be symptomatic 
• Atropine - .5mg IV q3-5 mins ; max 3 mg

• > 100 bpm
• always has a cause
• Fix the cause, fix the rhythm
• Beta blockers, calcium channel blockers

• Irregularly irregular 
• no meaningful P waves
• No effective contraction = atria quivers

• > 250 bpm
• Saw tooth P waves

• Diltiazem and Amiodarone
• Beta blockers and Digoxin
• anticoagulate

• 150-250 bpm
• always regular
• Valsalva or adenosine

• O2
• IV
• cardiac monitoring
• vagal maneuvers
• adenosine

• Adenosine
• calcium channel and beta blockers
• cardioversion

• Early atrial depolarization before next scheduled sinus beat
• usually asymptomatic

• QRS is wise and bizarre
• T wave is opposite to QRS

• Fatal
• Significant cardiac disease
• quick regular rhythm

• Amiodarone
• lidocaine
• Mag
• Potassium
• cardiovert

• CPR
• Defib
• EPI
• vasopressin
• amiodarone
• lidocaine
• resuscitation

• Always fatal unless terminated
• no organized depolarization = no contraction = no perfusion

• A-V node conduction delay
• PR > .20
• Least serious

• PR lengthens until QRS is dropped, than starts again
• less serious
• treat symptoms

• PR constant
• some beats are conducted and some arent
• more serious
• atropine, dopamine and Epi
• pacer

• No communication between atria and ventricles
• no realtionship between P waves and QRS
• P waves and QRS are on time but the do not work together