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97 Cards in this Set

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What items are generally inventoried during respiratory assessment?
Level of consciousness, airway injury, chest wall movement, retractions and breath sounds
What are the indications for BVM?
What should be performed if a patient is apenic, has inadequate TV by exam/labs or poor ventilation, or to reduce the patients work of breathing?
What are the consequences of too vigorous BVM?
If this is performed too vigorously, it can cause hyperventilation leading to alkalosis, and gastric distention leading to aspiration.
What are the risk factors for difficulty performing BVM?
Old, fat, bearded, toothless, and a history of OSA.
What adjuncts should be used if a patient is both difficult to BVM and difficult to intubate?
An LMA or Combitube should be used if a patient is difficult to do what two things?
What are the indications for intubation?
What should be performed if the patient needs respiratory protection, relief of an obstruction, needs mechanical ventilation or needs hyperventilation to prevent intracranial hypertension, or is generally in respiratory failure or shock?
What anatomic considerations should be assessed before a patient is intubated?
Neck flexibility, face structure (micrognathia) mouth opening (three fingers), mallampati score (less than 3), thyromental distance (three fingers)
What induction agents are used for intubation?
Fentanyl (analgesic), Midazolam (amnestic) Etomidate (hypnotic), Lidocaine (blunts sympathetic response to tracheal irritation)
When is RSI used?
What technique for intubation should be used when there is an increased risk of aspiration and an easy intubation is anticipated?
What are the contraindications for succinylcholine?
What neuromuscular blocking agent should not be used in the setting of ocular injury, head injury, hyperkalemia, burn and crush victims (due to hyperkalemia), UMN lesions or muscle disease?
What is the basic procedure for RSI?
Assess, preoxygenate, induce and paralyze, intubate is the outline for what technique?
What are the appropriate energies for monophasic and biphasic diffibrilation?
360J and 200J are the appropriate energies for what, respectively?
What labs should be drawn during a Cardiopulmonary resuscitation?
Glucose, potassium, iCalcium, magnesium and an ABG should be drawn for what emergency procedure?
What are the signs of impending respiratory arrest?
tachypnea trending towards bradypnea, paradoxical abdominal breathing and decreasing alertness are signs of what?
What are the possible etiologies of respiratory arrest in an intubated patient?
Barotrauma (tension pneumothorax), respirator disconnect, or displacement of the ET tube.
What is the correct treatment for a patient in respiratory distress (intubated), hypotensive and possibly in PEA, and showing signs of increased airway resistance among other signs( ipsilateral breath sounds, JVD, tracheal deviation)?
Needle thoracostomy without waiting for radiographic diagnosis is appropriate in what setting?
What are the proper responses to intubated and non-intubated patients who have arrested?
Intubated patients should be disconnected and manually ventilated, and non-intubated patients should be intubated in what event?
What are the three forms and salient features of respiratory failure?
hypoxemic (PaO2 less than 50-60 and P(a-A)O2 greater than 20, or SaO2<90% despite FiO2>0.6), hypercapnic (PaCO2 greater than 50, acidosis) and mixed are forms of what?
What are a few common causes of acute respiratory failure and what type of failure are they?
COPD exacerbation (hypercapnic), TBI (hypercapnic), decompensated CHF (hypoxemic), pneumonia (hypoxemic) and ARDS (hypoxemic)
What is a normal P(a-A)O2 ratio for adults?
&lt;20mm
How does P(A-a)O2 gradient help with the interpretation of hypoxemic respiratory failure?
A normal value for this result suggests that there is no V/Q mismatch (the parechyma is normal).
What is the physiologic variable that accounts for hypercapnic respiratory failure? What is the equation that determines it?
Minute Alveolar Ventilation, which is determined by respiratory frequency times the product of tidal volume minus physiologic dead space.
What are some situations which affect the physiologic variables that determine minute alveolar ventilation?
Decreased tidal volume or respiratory rate can be caused by drug overdose, muscle fatigue.
Increased physiologic dead space may be caused by hypovolemia, PE or decreased CO.
Describe the nature of the V/Q mismatch which causes hypercapnic respiratory failure?
This type of respiratory failure occurs when gas flow in the lungs (V) is adequate, but blood flow (Q) is not.
Describe paradoxical abdominal breathing.
This breathing pattern occurs when the chest wall moves outward, but the abdominal wall moves inward.
When selecting a supplemental oxygen delivery system, what should be considered?
The delivery system must match the patient's demands. e.g. A tachypneic and hyperpneic patient requires a high-oxygen high-flow device
What is the flow rate and max FiO2 of a nasal cannula?
This delivery system delivers oxygen at 0.5L/min to 5 L/min, and has a max FiO2 of .4
What is the flow rate and max FiO2 of venturi masks (aka air entrainment mask)? What is the advantage of these masks?
This O2 delivery system delivers oxygen at high flow, and has a max FiO2 of .5. These systems can be precisely calibrated for an FiO2 of 0.24 to 0.5.
What is a common situation where the use of a Venturi mask is optimal?
COPD patients require the precise calibration of FiO2 of these masks, in order to maintain minute ventilation.
What is an aerosol mask used for? How is it calibrated?
An aerosol mask mixes a nebulizer with O2 and room air in a venturi mask. If the vapor from the nebulizer disappears completely from the mask, the nebulizer rate is too low.
What is the flow rate and max FiO2 of a reservoir mask? How is it calibrated?
This O2 delivery system is high flow, and has a max FiO2 of 0.6 to 0.9. It is calibrated by ensuring the reservoir remains at least partially full.
What classes and examples of medications are used in acute respiratory failure, especially those with an obstructive component?
B2-agonists (albuterol, metaproterenol, terbutaline and epinephrine), Anti-cholinergics (Ipratroprium), Coritcosteroids and antibiotics.
In what situations are inhaled anticholinergics useful?
Ipratroprium and tiotroprium have more consistent bronchodilatory effects on COPD patients than asthma patients, although ipratropium has an additive effect when given with B2-agonists to asthma patients.
What is the general indication for positive pressure ventilatory support? What are the two general categories of PPV?
This should be used if respiratory failure cannot be controlled by oxygen supplementation. The two types are non-invasive and invasive.
What are some specific indications for PPV?
ventilation abnormalities (respiratory muscle abnormalities, decreased drive, increased airway resistance), oxygenation abnormalities (hypoxemia, need for PEEP, excess work of breathing), need for sedation, need to decrease O2 consumption, prevention of atalectasis (increase recruitment)
What patient criteria suggest that NPPV is optimal?
The patient must be stable, alert (able to control secretions), cooperative (able to coordinate breathing with ventilator) and whose condition is expected to improve in 2-3 days.
What conditions are likely to respond to NPPV?
This ventilatory modality is useful in both hypoxemic and hypercapnic respiratory failure. Specific hypoxemic conditions include cardiogenic pulmonary edema (hemodynamically stable), Pneumocystis PNA, the immunocompromized. Specific hypercapnic conditinos include COPD, Asthma or CF exacerbation. Additionally, patients who would benefit from PPV, but are unable to be intubated.
What are some contraindications for NPPV (not relating to patient cooperation or duration of disease)?
Severe cardiopulmonary instability- due to cardiac or respiratory arrest, hemodynamic instability, MI or arrhthmias, severe hypoxemia, severe encephalopathy.
High risk for aspiration- active upper GI bleed, inability to protect airway or significant agitation
Facial trauma
What are the initial settings that should be used in NPPV?
Mode: Spontaneous; Trigger: Max Sensitivity; FiO2: 1 EPAP: 4-5 cmH2O; IPAP: 10-15cmH2O; Backup Rate: 6 min
What is the maximum recommended IPAP? Why?
20 cmH2O. Gastric distention is more likely above 20.
What are the goals for NPPV?
RR less than 30, VT>7mL/kg(ideal), improved gas exchange, comfort
What is the algorithm for the use of NPPV?
Assess candidacy for NPPV. If a candidate, attempt for 1-2 hours and reassess using ABG, vitals, exam. If improvement is noted, continue for 4-6 hours and assess whether respiratory goals are acheived. If no improvement at 2 hours or goals not achieved at 6 hours, intubate (or continue NPPV as directed by AD)
What steps should be taken to prepare for NPPV?
Consider if intubation is a better option, get an initial ABG, put the head of the bed at 45deg, dry-fit the mask before securing
Define cycling and triggering wrt mechanical ventilation.
cycling is the changeover from inspiration to expiration, triggering is the changeover from expiration to inspiration.
What is CMV (aka AC) ventiation?
AC or CMV is volume-cycled or time-cycled (with pressure control) where minimum Vt or Pressure is delivered at a minimum rate. Spontaneous breaths above the preset rate are fully supported by the ventilator.
What are some advantages of CMV/AC?
The work of breathing is decreased compared to spontaneous breathing and the patient can increase respirations if necessary
What are some disadvantages of CMV/AC?
Hyperventilation may occur for respiratory or nonrespiratory reasons (anxiety, pain, irritation) and auto-PEEP may develop (aka dynamic hyperinflation)
What is auto-PEEP?
Steadily increasing positive end expiratory pressure due to the patient's inability to fully exhale the previous breath.
Why is auto-PEEP dangerous?
dramatically increased airway pressures predisposing to barotrauma, and limit venous return thus decreasing cardiac output
AC volume control has what advantages and disadvantages?
This subset of AC ensures a full volume is delivered, but may cause excessive pressures
AC pressure control has what advantages and disadvantages?
This subset of AC limits peak pressures and allows the patient to control flow rates, but does not ensure a consistent tidal volume.
How is PSV Calibrated?
This mode of ventilation is calibrated using VT, 6-10mL/kg. Pressure calibration can also be used to control spontaneous breathing and minute ventilation.
What is PSV? What variables are patient controlled?
This flow-cycled mode of ventilation delivers O2 at a preset pressure to assist patient generated spontaneous breaths. Patients control inspiratory time, inspiratory flow and tidal volume.
When is PSV used primariy?
In the weaning process.
What is SIMV? What mode is frequently combined with this mode?
This mode of ventilation delivers a present number of volume or time cycled breaths (similar to CMV) but does not assist with spontaneous breaths. PSV is frequently combined with this mode to augment the spontaneous breaths.
What are some advantages and disadvantages of SIMV?
Using this mode interferes less with cardiovascular function (by allowing the patient to generate negative inspiratory pressure and thus increase venous return). However, the work of breathing is increased in this mode.
What ventilator settings affect PaO2? PaCO2?
FiO2 and Mean airway pressure (traditionally controlled by PEEP) affect this variable. Respiratory rate, dead space and tidal volume affect this other variable.
What general goals are sought when administering good ventilatory support?
adequate oxygenation/ventilation, reduced work of breathing, ventilator synchrony and avoiding high inspiratory pressures.
What are the general steps for initiating mechanical ventilation?
1) select a familiar mode of ventilation 2) titrate FiO2 based on SpO2 3) Set VT based on expected lung compliance 4) Calibrate RR and MV based on pH 5) Set PEEP based on need for recruitment 6) Set trigger sensitivity 7) Adjust settings to avoid auto-PEEP
What tidal volumes are recommended in patients with normal lung compliance? What about patients with decreased lung compliance?
8-10mL/kg for normal lung compiance, 6mL/kg for decreased lung compliance (ARDS)
What type of respiratory failure is associated with ARDS/ALI? What is the basic mechanism?
Hypoxemic, due to the shunt created by inadequate gas diffusion
What are the PaO2, Pplat, VT and pH goals in resuscitating a patient with ARDS/ALI?
PaO2 should be maintained between 55-80mmHg, Pplat should be less than 30cmH2O, Vt should be at 6mL/kg(predicted body weight) but may be lower to accommodate higher PEEP, and pH can be as low as 7.15.
What is the accepted strategy for initiating mechanical ventilation in ARDS?
Start at 8ml/kg and decrease by 1ml/kg over 4 hours to 6ml/kg. If Pplat is greater than 30, decrease VT by 1ml/kg to 4ml/kg or until pH reaches 7.15. If Pplat is less than 25 at VT 4ml/kg, increase Vt to Pplat 25 or VT of 6. If Pplat is less than 30 and VT is greater than 6 and cannot be lowered, leave it.
What are the optimal PEEP settings in ARDS? How should they be acheived?
8-15cmH2O is ideal PEEP for this respiratory condition. PEEP should be started at 5cm and titrated up in increments of 2.
In what ways does intubation help myocardial ischemia and heart failure?
Patients with myocardial ischemia benefit from the decrease in the work of breathing, which increases availability of oxygen for cardiac muscle. Patients with heart failure benefit from increased thoracic pressure, which decreases afterload through decreasing ventricular filling and juxtacardiac pressure.
What are recommended methods of modalities for monitoring for complications and outcomes mechanical ventilation?
1) CXR after intubation and with any change in status, 2) ABG initially and incrementally, 3) Vital signs, including pulse ox, and observation 4) monitor Pplat 5) ventilator alarms
What are 4 conditions associated with intubation which present as hypotension and how are they treated?
Tension pneumothorax (needle thoracostamy), positive intrathoracic pressure reducing cardiac output (fluid resuscitation), Auto-PEEP (increasing RR or decreasing VT) and MI
What two variables determine oxygen delivery?
Oxygen content of arterial blood and cardiac output.
What variables determine oxygen content of arterial blood? How low will this value drop in stressed tissue?
hemoglobin saturation, mostly. To 20%
What individual values make up cardiac output?
Heart rate, preload, afterload and contractility.
How are the cardiac output variables assessed?
Heart rate and rhythm- palpation, ECG, pulsox; Preload- JVD, liver enlargement, edema, CVP (right), dyspnea, pulmonary edema, PAOP (left); Afterload- MAP, SVR; Contractility- Echo, EF
How does the frank-starling curve relate to preload?
The frank-starling curve demostrates that a greater preload leads to a greater stroke volume.
What two lab values help indirectly determine oxygen balance?
ScvO2 and lactate levels.
What is the difference between SvO2 and ScvO2?
SvO2 is measured at right ventricle, ScvO2 is measured at IJ or subclavian and is normally 2-3% lower than SvO2, but can be as much as 7-8% lower in shock due to greater gastrointestinal desaturation.
what are normal values for SvO2 and Lactate? What causes these values to be altered?
SvO2 should be greater than 65% and lactate should be less than 2. decreased SvO2 is due to either decreased oxygen delivery (CO, SaO2, Hgb concentration) or tissue oxygen consumption. Lactate is due to tissue hypoperfusion, but also hepatic dysfunction and vasopressors.
What condition may falsely elevate SvO2?
Severe sepsis and cyanide poisoning.
When a patient's SpO2 is hovering around 92-94%, what is his SaO2?
60mmHg
What are the preferred sites of insertion of an A-line?
radial, femoral, axillary and finally dorsalis pedis. Use a 20gauge needle if more than 4 measurements in 24hours.
How is the A-line plot affected by positive pressure?
Possitive pressure decreases venous return, which drops the pressure.
What vascular phenomenon can make hypotension as measured by an A-line inaccurate?
vasoconstriction can mask hypotension or shock.
What are normal values for CVP? What does CVP estimate and at what phase of breathing is it measured?
2-8mmHg, 14-16mmHg if positive pressure ventilation. It estimates right ventricular filling pressure (pre-load) and is measured at the end of expiration
What do low and high values of CVP indicate? How is it used to guide resuscitation?
Low values of CVP indicate low intravascular volume. High values do not necessarily indicate volume overload. A CVP of 4 or less should prompt a fluid challenge (250mL), an increase in CVP greater than 5 means the patient is fluid overloaded.
How is anion gap measured, and what is a normal value? What conditions cause anion gap metabolic acidosis?
Na - (Cl+HCO3). Normal values are 10+/-4. Lactic acidosis, renal failure and DKA are common causes in critically ill patients.
How is the delta gap calculated, and what does it indicate?
Delta gap = (deviation of AG from normal) - (deviation of HCO3 from normal). A positive gap suggests a concominant metabolic alkalosis. A negative gap suggests a concominant metabolic acidosis.
what are the two types of metabolic alkaloses? What electrolyte abnormality is associated with both conditions?
Chloride deplete (hypovolemia) and choloride expanded. Hypokalemia is associated with both types.
What are common secondary brain injuries?
Hypoperfusion- global (increased ICP, hypotension or anemia) or regional (local edema or vasospasm); hypoxia (systemic, regional hypoperfusion or increased tissue consumption); electrolyte or acid/base changes; reperfusion injury with free radical formation.
What is the Monroe-Kellie hypothesis?
Since the brain is in an incompressible structure, an increase in the volume of one component results in a decrease in another component. The components consist of brain tissue, CSF, blood and lymph.
What conditions require invasive ICP measurement?
Severe TBI; SAH with coma or deterioration; ICH with intraventricular blood; Ischemic stroke; Fulminant hepatic failure; Global anoxic injury.
What is the cerebral perfusion pressure? what are normal values?
a marker for cerebral blood flow, and is calculated as MAP-ICP, normally between 60 and 100mmHg
What strategies can help minimize abnormal oxygen demands in brain injury?
Avoid fever, seizures, pain/anxiety/agitation, shivering and stimulation for 3 days.
What strategies can help promote oxygen delivery in brain injury?
Optimize systemic O2 delivery (CO and CaO2); Optimize blood pressure (too low may cause ischemia, too high may cause rebleeding); Avoid prophylactic hyperventilation; ensure euvolemia; RSI for patients with increased ICP; Nimodipine for patients with SAH.
What are important modalities in determining neuro exam?
history- coagulopathy/drinking, HTN, NSGY; physical- pupils, EOMI motor/sensory; Rads- CT
What is cushing's reflex?
Bradycardia, increased pulse pressure and systolic hypertension.
If clinical findings suggest herniation, what is the appropriate action?
Administer mannitol or hyerptonic saline, and consult NSGY.
Describe the difference in shapes with sub-dural and epi-dural hematomas
Subdural- concave, convex. Epidural convex, convex.
What drug is useful in preventing vasospasm in SAH? What class is this drug in? Dosage?
Nimodipine, a dihydropyridine CCB. 60mg q4h.
What is a common electrolyte abnormality that occurs in SAH and should be avoided? How is it treated?
Hyponatremia is common in SAH, seen as cerebral salt wasting and is treated with normal saline (as opposed to SIADH, which is treated with fluid restriction).