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
RIB FRACTURES / FLAIL CHEST / CHEST TRAUMA
This can involve any type of trauma, unintentional / accidental or intentional (such as surgery).
Severe Chest Pain
Paradoxical Chest Movement - FLAIL CHEST
Possible Pneumothorax (hyperresonance, tracheal shift)
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)
PNEUMOTHORAX / HEMOTHORAX
Air or blood trapped in the pleural space.
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
Tx/ManagementInvolves 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
HEAD TRAUMA / SURGERY
Tx/ManagementMaintain 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
NECK & SPINAL INJURY / SURGERY
In a Code Situation
a. Modified Jaw Thrust
b. Femoral Pulse (If neck brace is in place)
a. With a Bronchoscope Is PREFERRED
b. Blind Nasal Intubation
Support Ventilation, Oxygenation, Circulation and Perfusion as necessary
ACUTE RESPIRATORY DISTRESS SYNDROME
An illness or injury acutely affecting the lung compliance including a variety of contributing factors.
Secondary AssessmentABG - Refractory Hypoxemia
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
ABDOMINAL SURGERY / PRE-POST OPERATIVE PATIENTS
Conscious Patients - Incentive spirometry Every Hour
Unconscious Patients - IPPB
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
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
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
A descending paralysis - moves from the MIND to the GROUND
a. Eyelid Drooling (Ptosis)
b. Double Vision (Diplopia)
c. Difficulty Swallowing (Dysphagia)
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
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
An ascending paralysis - moves from the GROUND to the BRAIN
Recent Flu like symptoms
Spinal Tap - Increased Protein Level in CSF
Closely Monitor - VT, VC, MIP
Give O2 as necessary
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
Hx is often the most significant finding.
PLACEMENT OF AN ARTIFICIAL AIRWAY IS THE NUMBER 1 PRIORITY
Vary from completely absent to rhonchi to frank wheezing - sometimes unilateral wheezing
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
Postural Drainage and Percussion
Aerosol Therapy With Bronchodilators
TOXIC SUBSTANCE INGESTION
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
DELIVERY ROOM CARE
Airway - Cleared 1st with Bulb Syringe (Mouth is Cleared First Followed by Nose)
Dried and Kept Warm
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
INFANT APNEA / SUDDEN INFANT DISTRESS SYNDROME
Apnea caused by immature neurologic control of ventilation resulting in death.
Periodic Cyanotic Spells, Apnea
Cold Air On Baby's Face
Abnormal Moro and/or Babinski Reflex
O2 Therapy 30-50%
Teach Parents CPR
Send Infant Home with an Apnea Monitor
Post-term Infant > 42 Weeks
Stained with Meconium, Grunting, Retractions, Cyanosis, Nasal Flaring and Asphyxia
Low Apgar Scores
Patchy Densities Bilaterally with Widespread Atelectasis
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
CONGENITAL HEART DEFECTS
May be Premature
Cyanosis not reversed by 100% O2
Coarctation of the Aorta - Hypertension in the Upper Extremities VS Hypotension in the Lower Extremities
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)
Oxygen - Maintain PaO2 levels > 60 torr
Watch for ventilatory failure - intubate & ventilate
Supportive Care prior to surgery to correct the defect
INFANT RESPIRATORY DISTRESS SYNDROME
A reduction in lung volume due to a lack of surfactant production.
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
CXR - Reticulogranular Infiltrates, or Honeycomb Appearance, or Ground Glass Appearance
Unresponsive to Increased FiO2
L/S Ratio - Less than 2:1 (Decreased)
Maintain PaO2 Levels > 60 Torr
Treat Hypoxemia with Oxygen via oxyhood then CPAP
WATCH FOR VENTILATORY FAILURE - INTUBATE, VENTILATE WITH PEEP
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.
A chronic lung disease that develops in newborns as a consequence of treatment of IRDS with oxygen and positive pressure ventilation.
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 AssessmentABG hypoxemia and hypercarbia
CXR initially resembles IRDS, then hyperinflation with areas of fibrosis
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
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.
Tachypnea - rates 100-150/min.
Born at or near full term
Appropriate weight for gestational age
Depressed swallowing and cough effort
Good APGAR scores
Later development of cyanosis, retractions, nasal flaring and grunting
ABG mild hypoxemia with respiratory and metabolic acidosis
CXR initially normal, after 12 hours pulmonary congestion appears.
Supportive care to relieve signs of respiratory distress
O2 via oxyhood
CONGENITAL DIAPHRAGMATIC HERNIA
Caused by failure of the diaphragm to close properly. 85% occur on left side.
Respiratory distress at birth
Breath sounds absent on affected side
Scaphoid abdomen, barrel chest
ABG hypoxemia, hypercarbia, acidosis
CXR loops of bowel seen in chest, mediastinal shift toward the unaffected side.
Nasogastric tube to decompress stomach and intestines
Avoid bag-mask ventilation
Low ventilating pressures after intubation
Body Temperature Falls Below Normal.
Hx - Homeless, Found lying in the street shivering
a. Temperature - < 36.0C (98.0F)
b. Pulse - Bradycardia
c. Respirations - Bradypnea
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
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
INFECTIOUS DISEASE / PNEUMONIA
Vitals increased, increased WOB, dyspnea, cough
Breath sounds decreased over affected area
Dull percussion sound
Decreased pulse oximetry readings.
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
Bronchial Hygiene Therapy
Antibiotic or Antiviral agents
Watch for Ventilatory Failure
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).
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
a. Pulse - Tachycardia
b. Respirations - Tachypnea, Grunting, Labored
c. Temperature - Hyperthermia (NOT ACCURATE IF IN FIRE)
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
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
An acute respiratory insult that often leads to the development of complications.
Hx - Swimming pool accident, Boating accident
Confused, Unconscious, Comatose
a. Temperature - Hypothermia
b. Respirations - Absent, Shallow, Labored
c. Pulse - Absent, Tachycardia, Bradycardia
d. Blood Pressure - Hypotensive
CXR Diffuse Bilateral Alveolar Infiltrates
ABG Metabolic and Respiratory Acidosis
CBC, Hb, Hct., Electrolytes
Hemodynamics - CVP, PAP, PCWP
WATCH FOR VENTILATORY FAILURE - INTUBATE & VENTILATE
NOTE - If Suspected NECK INJURY Requires Intubation - Intubate via BRONCHOSCOPE OR BLIND NASAL INTUBATION
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
PICKWICKIAN SYNDROME / OBESITY
WATCH FOR SLEEP ANEA
Must use IDEAL BODY WEIGHT when initiating mechanical ventilation.
ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS)
Often the history is the most significant initial finding.
Hx- Weight Loss, Persistent Fever or Diarrhea, Night Sweats (Nocturnal Diaphoresis), Frequent Herpes Simplex Infections, Homosexuality, Drug Abuser
May have Signs & Symptoms of Pneumonia
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)
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.
A toxic condition caused by ingestion of kerosene or the inhalation of its fumes.
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.
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.
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).
Nausea, vomiting, chest pain and dizziness.
Severe depression of the central nervous system.
Severe or fatal pneumonitis may occur if the substance is aspirated.
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).
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.
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 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.
INFANTS A. Pulse
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
ARTERIAL BLOOD GASES
40-60% (ventilator patients)
B. High Teens
C. Low Teens
E. 5% Normal
20-30% Life Threatening
Qs/Qt increase = increases PEEP
HEMODYNAMICS 1. BP
6. CO or QT
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
MECHANICAL VENTILATION A. Spontaneous Measurements
B. Initial Ventilator Parameters *TWO MOST IMPORTANT SETTINGS ARETIDAL VOLUMEAND 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
b) Same FiO2 and/or PEEP (elevated baseline)
c) 1.0 (100%)
INFANTS Time Cycled / Pressure Limited Ventilators
I-TIME *NOTE - Patient Already Receiving Oxygen & CPAP Should Start At THE SAME LEVEL
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)