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Exam 3
Cardiac/Shock/Burns/Neuro
| Question | Answer |
|---|---|
| Stable Angina | occurs predictably with exertion and is relieved by rest and nitro |
| Variable Angina | occurs unpredictable, often at night, and is caused by coronary artery spasm |
| Unstable Angina | occurs with increasing frequency and intensity. Pain may occur at rest. High risk of MI |
| ECG changes with angina | ST depression and T-wave depression |
| Criteria for stent use for cardiac complications | 75% or greater stenosis |
| Use of nitro for angina | up to 3 times 5 minutes apart, if not relieved call 911 |
| Considerations for beta blockers | do not use with asthma patients; cause vasodilation and decreased O2 demand |
| Long-term medication for angina | calcium-channel blockers |
| Primary Goal for angina or AMI | Reduce O2 demand and improve O2 supply |
| Cardiac cripple | when patients change their ADLs due to fear of developing chest pain |
| Acute Coronary Syndrome | chest pain that lasts 10-20 minutes at rest and is not relieved by nitro. Near-complete occlusion of the artery. |
| Difference between acute coronary syndrome and AMI | ACS is near-complete occlusion with some blood flow; AMI is complete occlusion of the artery |
| Diagnostic tests for AMI and ACS | Troponin and CK-MB |
| Fibrinolytic drug action | used with AMI/ACS to break up clots causing occlusion |
| Arthrectomy procedure | removal of the arthrosclerosis build up in the arteries |
| CABG procedure | bypass the occluded area with a vessel graft from another area |
| Stable MI vs unstable MI | stable occurs progress slowly gradually leading from angina to MI; unstable occurs suddenly from rupture/spasm/clots |
| EKG changes with AMI | ST elevation and developed Q wave |
| MONA for AMI | morphine, oxygen, nitro, aspirin |
| infarct extension | cells around the infarct dying due to the release of toxins from the nearby dying cells |
| Intra-aortic balloon pump (IABP) action | temporary balloon pump in the heart to provide muscle rest |
| ventricular assist device (LVAD) action | temporary or permanent placement to decrease cardiac workload and aid with cardiac healing |
| sudden cardiac death | unexpected death within 1 hour of cardiac symptoms usually caused by V-fib |
| Heart failure | heart can't meet demands of the body |
| symptoms of heart failure | SOB, peripheral edema, ascites, loss of appetite, fatigue, cough with sputum, confusion |
| Systolic heart failure | The ventricles do not CONTRACT and PUMP blood effectively leading to DECREASED CO |
| Diastolic heart failure | The ventricles do not RELAX and FILL effectively |
| Left-sided heart failure | Fluid backs up in the LUNGS causing SOB, crackles, dyspnea, fatigue, cyanosis, and syncope |
| Right-sided heart failure | Fluid backs up in the BODY causing peripheral edema, DJV, liver enlargement, anorexia, ascites, and nausea |
| Causes of left-sided heart failure | HTN and CAD |
| Low-output heart failure | The heart has low cardiac output and cannot meet the demands of the body; Caused by CAD and HTN |
| High-output heart failure | The heart has normal cardiac output, but the body has especially high O2 demands, so the heart cannot meet the demand; Caused by hypermetabolic states |
| Classify the stages of heart failure | A = at risk; B = disease with no symptoms; C = disease with past/current symptoms; D = disease with symptoms at rest |
| Diagnosing heart failure | renal function; LFT with right-sided; ABGs with left-sided; thyroid function with high-output |
| A-lines for hemodynamic monitoring | usually in jugular vein; monitors pressures within vessels; risk of infection a bleeding |
| A-line normal rang for hemodynamic monitoring | 70-90 mmHg |
| Medications for heart failure | vasodilators and diuretics |
| Signs of pulmonary edema | SOB, cyanosis, PINK FROTHY SPUTUM |
| Treating Pulmonary edema | INTUBATION; Morphine causes vasodilation and pain control; diuretics, oxygen, and suctioning. Constant monitoring with assessment at least q 30minutes since changes occur rapidly |
| Infective endocarditis | inflammation of the endocardium; primary risk factor is DENTAL WORK |
| S&S of infective endocarditis | flu-like symptoms, malaise, heart murmur, petichiae |
| Diagnosing infective endocarditis | Blood culture (identify agent) and TEE (visualize heart valves) |
| Treating Endocarditis | antibiotics; EDUCATION & PREVENTION |
| Risks associated with endocarditis | vegetation on the valves accumulates and dislodges it can cause mobile emboli and be very dangerous |
| Myocarditis | inflammation of the myocardium heart muscle; most at risk are immunocompromised patients |
| Diagnosing myocarditis | EKG, heart ECHO, and biopsy to detect agent |
| Treating myocarditis | immune-suppressants to decrease inflammation; bed rest and O2 |
| Pericarditis | inflammation, fibrosis, and scarring of the pericardial sac. Constricts the heart causing impaired pumping ability |
| Signs of pericarditis | friction rub, tachycardia, fever, and chest pain |
| Complications of pericarditis | pericardial effusion: fills with fluid pericardial tamponade: fills with blood |
| Pericardial Tamponade | LIFE THREATENING: hallmark is pulsus paradoxus (decreased BP with inhalation; increased with exhale) |
| Treating pericarditis | Pericardiocentesis; pericardial window |
| Valvular heart diseases | valve stenosis: the valves fuse together and cannot fully open/close; valve regurgitation: the valves do not close completely and allow backflow of blood |
| Treatment of valve diseases | valvuloplasty for stenosis (cut fusion of the valves); valve replacement; symptomatic management with diuretics, anticoagulants, and vasodilators |
| Types of cardiomyopathy | Dilated: enlarged heart causing L&R HF; hypertrophic: left side is too large causing L-sided HF and a-fib; restrictive: heart becomes rigid causing diastolic HF |
| MODS | impairment of two or more organ systems as a result of uncontrolled inflammatory response to severe trauma or illness |
| Treatment of MODS | treat the underlying cause and the organ system affected |
| Shock | different types of shock caused by systemic imbalance between oxygen supply and demand |
| Calculating CO | HR x Stroke Volume = CO |
| Calculating MAP (mean arterial pressure) | CO x SVR (systemic vascular resistance) = MAP |
| normal MAP value | 70-110mmHg |
| Stage 1: Early Shock | uncompensated and reversible: HR may be elevated and VS changes will be slight. Blood loss of <500mL drop in MAP of <10mmHg |
| Stage 1: Compensated Shock | body releases epinephrine and norepinephrine causing casoconstriction; RAA pathway causes sodium and water retention to conserve fluids. Blood loss of 1000mL and drop in MAP by 10-15mmHg |
| Stage 2: Intermediate shock | MAP drops >20mmHg; fluid loss of 35-50% Pulse will be tachy and thready, body becomes hypoxic causing release of lactic acid causing ACIDOSIS and HYPERKALEMIA |
| Stage 3: Irreversible Shock | MAP is <60mmHg with >2000mL blood loss; Pulse is absent with critically low BP and CO. Tissue damage is irreversible and death is likely. |
| Neurologic changes during shock | Early: restless and anxious; Intermediate: lethargic and confused; Late: coma |
| Manifestations of Hypovolemic shock | decreased BP; increased HR, thready Pulse, RR increased, skin pallor and edema, decrease urine output, slowed cap refill |
| Cardiogenic Shock | there is no fluid loss, but the heart is unable to pump blood effectively |
| Causes of cardiogenic shock | AMI, restrictive pericarditis, cardiac tamponade |
| Manifestations of Cardiogenic shock and Obstructive shock | hyper-hypotension, HR rapid with distended veins, resp. crackles and labored, skin cyanotic and cold, dependent edema and distended veins due to increased venous pressure |
| Obstructive shock | obstruction in the heart or great vessels causing decreased blood flow throughout body despite enough fluid. Manifestations are the same as cardiogenic |
| Distributive Shock | several kinds of shock including sepsis, neurogenic, and anaphylaxis, where there is uncontrolled peripheral vasodilation |
| Septic Shock Manifestations | decreased BP, increased and thready pulse, RR deep and rapid, skin warm and flushed, decreased urine output, fever, chills, and weakness |
| Manifestations of Toxic Shock Syndrome | widespread inflammation, headache, hypotension, confusion, VD, rash, DIC, platelet aggregation and decreased blood flow |
| Neurogenic Shock | CNS disturbance causes uncontrolled vasodilation and venous blood pooling |
| Causes of neurogenic shock | *Anesthesia, CNS depressants, spinal cord injury, head trauma |
| Anaphylactic Shock | widespread hypersensitivity reaction that causes uncontrolled vasodilation and blood pooling |
| Manifestations of anaphylaxis | respiratory distress, dyspnea, bronchospasm, abdominal cramping, swelling of the hands and face, drop in BP |
| Treating SHOCK initially | Oxygen, Fluids (NS/LR), Blood products |
| Lactated Ringers Solution | used to replace plasma volume, same concentration as plasma, frequently used with burns and shock |
| Medications for treating shock | Vasoconstrictors (norepinephrine) to increase BP, Inotropes (Dopamine) to increase CO, Colloid Solutions (increase fluid volume) |
| Considerations for norepinephrine | It is infiltrates it will cause tissue necrosis |
| Considerations for inotropes | Monitor patient on telemetry, monitor I&Os, and triple check IV pump settings |
| Use of vasodilators with shock | Used with cardiogenic shock to decrease O2 demand of the heart; run IV with D5W and monitor for hypotension |
| Colloid Solutions for treating shock | (Hetastarch and Dextran) Plasma expanders to increase plasma volume; Give with LARGE-gauge needle and have EPI at bedside increase of allergic reaction |
| Things that affect burn degree | temperature, duration, and skin thickness |
| Primary concern in burn patients in the first 48 hours | Fluid Loss due to increased capillary permeability and third spacing of fluid --> HYPOVOLEMIC SHOCK |
| Layers of the skin | Epidermis (top) Dermis (nerve endings and hair follicles), under that is fat, muscle, then bone. |
| Superficial burns | damage to the epidermis; Red, tender, with NO Blistering; likely to heal on it's own |
| Partial-thickness burns | the epidermis is destroyed and there is damage to the dermis; Blistering, peeling, sloughing |
| Full-thickness burns | The epidermis and the dermis are destroyed and there is damage to underlying tissues. SKIN does NOT stretch; non-blanching, loss of feeling in area. |
| Zones of burn damage | Zone of coagulation (cell death), Zone of Stasis (cells have potential to heal/die), Zone of Hyperemia (cells will likely heal) |
| Cold water or ice burns | This causes vasoconstriction to the area and increases the area of cells that are likely to die. NEVER put ice on a burn |
| Difference between superficial partial and deep partial burns | Color and Blanching: red with fast color return = superficial partial; pale/pink with slower color return = deep partial |
| Edema r/t Burns | Small burns will lead to localized swelling; Burns >20-30% will lead to systemic swelling |
| Lab changes in burn patients | increased K+ --> HYPERKALEMIA; Na+ shift into the third space --> HYPONATREMIA |
| Primary survey of burn patients | ABCs: airway, breathing, circulation |
| Types of burn inhalation injury | above the glottis (oral and nasal); below the glottis (usually prolonged exposure to smoke and chemicals) |
| Signs of inhalation injury | SOB, wheezing,black/ashy sputum, singed nasal/facial hair, stridor, decreased LOC |
| Treating inhalation injury | 15L of Oxygen by non-rebreather, and prophylactic intubation with pulsing to replace cilia action |
| Considerations for carbon monoxide poisoning | pulse ox cannot tell the difference between O2 and CO (if O2 is reading 100% you should be concerned). Bright red conjunctiva is a sign of CO poisoning |
| Diagnosing CO poisoning | ABGs |
| CO poising treatment | non-rebreather on 100%, Vent with 100%, hyperbaric chamber (potentially, but has drawbacks) |
| Circumferential full-thickness burns | impairs circulation to limbs or torso (causing impaired respirations) |
| Diagnosing complications from circumferential burns | Check PULSES every hour; by palpation or Doppler. Increased respiratory effort, SOB, chest tightness; or diminished pulses and pale extremity |
| Treating complications from circumferential burns | Loosen ACE wraps, if not resolved within 15 minutes. Escharotomy (specific cuts in the eschar to allow increased blood flow and decrease the restrictive nature of eschar) |
| Rule of Palm | each palm is 1% TBSA |
| Rule of nines | arms, and head are 9% each, torso top/bottom & front/back and legs are 18% each |
| Most accurate way to determine burn surface area | Lund & Browder chart |
| Fluid resuscitation for burns in adults and children >40kg | 2mL x kg x %TBSA = mL/24h |
| Fluid resuscitation for burns in children <40kg | 3mL x kg x TBSA = mL/24h |
| Fluid resuscitation for electrical burn patients | 4mL x kg x TBSA = mL/24h |
| Measuring response to fluid therapy | Urine Output should be 30-50mL/h |
| AMPLE Tool | Quick history assessment: Allergies, Medications, Past hx, Last meal/drink, Events surrounding injury |
| Treating partial thickness skin burns | Biograin or Porcine (pig skin that should stick to the burn and allow for healing while providing protection) |
| Treating Full-thickness burns | removal of dead eschar and skin graft onto affected area (skin graft can be sheet or meshed) |
| Treating chemical burns initially | protect yourself; remove affected clothes, FLUSH with water, |
| Morgan Lenses | lenses that are hooked p to tubing which flushes the eyes with normal saline |
| Diagnosing electrical injuries | There will be definitive entrance and exit injuries from electrical current; there may be concurrent flame burn from a sparked fire, |
| Treating electrical injuries | If no contact injuries and no EKG changes then the patient can be discharged; if EKG changes monitor for 24 hours, if burn injuries, treat burns. Muscle fascia may need deep escharotomy to treat diminished pulses |
| Urine output with electrical injuries | urine may be red or tea colored (indicating myoglobin in the urine from muscle damage). UOP should be 50-75ml/h. |
| Sulfamylon, Silva, and Bacitracin | Sulfamylon (painful) and Silva used on full-thickness; Silva and Bacitracin used on partial-thickness |
| Caring for burns | Must be washed and debris BID with applied medications and bandages |
| Pain with burns | medicate the pain, but the patient has to be alert enough to accomplish therapy and rehab which will start on day 1. |
| Area of the brain the controls breathing and HR | Brain stem |
| ANS Sympathetic response | fight or flight |
| ANS parasympathetic response | rest and relax response |
| Cranial nerves | 12 cranial nerves that control sensory/motor/both |
| Nail bed test | press pen down on the nail bed on the toe or finger and measure patient response to pain |
| What is the lowest Glascow coma scale number | 3 (patient is in a coma) |
| Neuro assessment | Pupils, muscle strength, balance, orientation, LOC, pain response |
| AEIOU for assessment | Series of things causing changes in LOC: Alcohol, Epilepsy, Insulin, Opiates, Uremia (presentation of UTI) |
| TIPSS for assessment | Series of things causing changes in LOC: Tumor, Injury, Psych, Sepsis, Stroke |
| Normal Intracranial Pressure | 0-15mmHg |
| Complications of ICP | decreased cerebral blood flow, altered LOC, and herniation (brain herniates out the bottom of the skull) |
| Treating ICP | Manitol: diuretic to decrease ICP. Measure if it's working by monitoring I&Os and LOC; low-stimuli environment, managing HR, BP, and Temp. |
| Causes of ICP | cerebral edema (increased fluid due to injury or infection) and hydrocephalus (over production of cerebral fluid) |
| Treating hydrocephalus | VP shunt to drain excess fluid |
| Cushing's Triad | sign of ICP: increased systolic BP, widening pulse pressure, and decreased HR |
| Signs of ICP | Cushings Triad, spiked fever, headache, and projectile vomiting |
| ICP monitoring | hole in the skull with probe inserted to monitor the ICP |
| Seizure threshold | all people have a certain seizure threshold, some is higher or lower than others |
| Epilepsy | reoccurring seizures that are self-resolving |
| Simple Partial Seizure | NO altered consciousness, causes hallucinations and altered sensations. The patient will generally know when these seizures are coming on. |
| Complex Partial Seizure | IMPAIRED consciousness, characterized by REPETITIVE nonproduction activity, Amnesia is common, and may have aura |
| Generalized Absence Seizures | There WILL BE altered consciousness, Sudden, brief cessation of motor activity (lasting 5-15 seconds) |
| Tonic-Clonic Seizures | Consciousness is IMPAIRED, sudden loss of consciousness, characterized by sharp muscle contractions lasting 60-90 seconds |
| Tonic phase | Breathing may stop, pupils will be fixed and dilated. |
| Clonic phase | Hyperventilation, with altering contraction and relaxation of the muscles |
| Status Epilepticus | recurrent seizures with very short periods between seizures = MEDICAL EMERGENCY |
| Complications of Status Epilepticus | Hypoxia, Hypoglycemia, Hyperthermia, and exhaustion |
| Treating Status Epilepticus | Airway, IV Dextrose, Valium/Ativan (during seizure), Dilantin (long-term control) |
| Managing seizures | do not restrain, do not put anything in the mouth. Turn to the side if they vomit, suction if needed to clear the airway, SAFETY is the priority. Keep oxygen and suction at bedside, and pad the bed rails. |
| Antiepileptic drugs | Neurontin, Lamictal, Topamax |
| When to call a squad for seizures | first-time seizure, pregnant, or diabetic patients |
| Monitoring a seizure | what precipitated the event, how long did each phase last, what did the seizure look like? |
| TIA | mini-strokes that are self-resolving and leave no long-term damage. They are a HUGE warning sign for stroke |
| Ischemic Stroke | Occlusion of the blood supply to the brain (clots) |
| Hemorrhagic Stroke | Bleeding/rupture decreasing blood flow to the brain |
| Manifestations of Stroke | one-sided weakness, facial droop, altered LOC, sudden onset |
| FAST | Facial droop with smile, Arm drop when holding up, Slurred speech, and Time to act |
| Treating strokes | Act quickly. Clot-busters, aspirin, Fibrinolytics, surgery, and REHAB |
| TPA considerations | Clot-buster. You MUST KNOW what kind of stroke the pt is having before you give this. NEVER give to a bleeding patient |
| Focal TBI | affects a specific area of the brain; contusions and hematomas |
| TBI Hematomas | Focal injury; Epideral (outside the dural sac), Subderal (within the dural sac), Intracerebral (within the brain) |
| Treating TBI hematomas | Burr hole to drain blood and relieve pressure; intracranial are difficult to treat |
| Diffuse TBI | affects the entire brain; shaking, accel-decel, and rotation injuries, and concussions |
| TBI Contact phenomena | direct injury to the brain: hitting your head, falling injuries. |
| TBI acceleration-deceleration injury | MVA or shaking injuries; causes damage to the front and back of the brain as it hits the skull |
| TBI rotation injuries | The head rotates quickly causing whiplash and damage within the brain. |
| Manifestations of TBI | Symptoms will be related to the area of the brain affected: changes in LOC, vision changes, motor/speech/behavior changes, loss of consciousness |
| Diagnosing TBI | CT/MRI, Toxicology report, ICP monitoring |
| Treating TBI | Burr hole to relieve pressure and drain fluid, Mannitol to decrease ICP |
| Symptoms of Brain Tumors | symptoms dependent of location: headaches, seizures, vomiting |
| Diagnosing Brain Tumors | MRI, EEG, Arteriogram (detects blood supply to the tumor) |
| Treating Brain Tumors | surgery (if possible), chemo, radiation, rehab |
| Considerations for ALL neuro patients | SAFETY and Risk of Falls |
| Headaches | Tension (usually mild), Migraines (usually more severe), Cluster (usually severe targeted area) |
| Treatment for severe headaches | Calcium channel and Beta blockers, pain control (non-narcotic), decrease stimulation (dark, quiet rooms), treat nausea |
| Spinal Cord injuries | Accel-Decel injury, Hyperflexion (chin to chest), Hyperextension (backward), Axial loading (crushing injury), Rotation injury |
| Autonomic Dysreflexia | CNS signals cannot climb the spinal cord |
| Symptoms of autonomic dysreflexia | red & hot above the injury, white & cool below the injury; Severe HTN, Bradycardia, pounding headache |
| Causes of autonomic dysreflexia | pressure ulcer, fecal impaction, clogged catheter, full bladder |
| Treating autonomic dysreflexia | unkinked catheter, empty bladder, treat fecal impaction, treat pressure ulcers. TREAT UNDERLYING CAUSE |
| Consideration of spinal cord injury height | The higher up the injury the more severe the symptoms |
| Treating spinal cord injuries initially | ABCs, immobilize, steroids (decrease inflammation), vasopressors (increase BP). antispasmotics (pain and spasms), antiemetics (prevent vomiting), surgery, and traction |
| Treating spinal cord injuries long-term | Rehab, assistive devices, analgesics, stool softeners, anticoagulants |
| Meningitis (Bacterial/Viral) Symptoms | neck pain, fever, chills, nucal rigidity (stiff neck), Brudzinski's sign, Kernig's sign, ICP |
| Brudzinski's sign | when the pt puts their chin to chest; the knee will pop up |
| Kernig's sign | pt lays flat on back, flex hip at 90 degree angle and the pt cannot kick their foot out |
| Encephalitis | Infection of the covering of the spinal cord |
| Encephalitis Arbovirus | Caused by mosquitos and ticks |
| Diagnosing CNS infections | Spinal tap or Lumbar Puncture with culture of cerebral spinal fluid |
| Treating CNS infections | antibiotics/antivirals, anticonvulsants (risk of seizure), antipyretic (fever), antiemetics (nausea from ICP), treat symptoms. |
| Considerations for treating CNS infections | medications MUST cross the blood-brain barrier. ALWAY draw blood for cultures before starting antibiotics. Always start with broad abx and move more narrow. |
| Dementia | progressive degenerative disease that interferes with daily life. Treat with supportive care and SAFETY measures. |
| Alzheimer's Disease | Progressive form of dementia; manage depression, supportive and emotional care; SAFETY |
| Multiple Sclerosis (MS) | demyelinating of CNS causing DIPLOPIA, weakness, sensory loss, vision changes, and fatigue |
| Treating MS | immunosuppresants (fight autoimmune process), ACTH hormones, Rehab, and maintain as much function as possible |
| Parkinson's Disease | Decrease in Dopamine causing progressive degeneration: tremor, rigidity, facial "mask", impaired swallowing, impaired walking, and depression |
| Treating Parkinson's Disease | Dopamine agonists (Levadopa), anticholinergics (help with swallowing), Rehab to maintain function |
| Myasthenia Gravis | autoimmune disease causing chronic muscle weakness: works from EYES DOWN, weakness, tachycardia, and respiratory distress |
| Myasthenia Crisis | Due to skipping medication: causes acute exacerbation of symptoms |
| Cholinergic Crisis | Due to over-medicating: causing GI symptoms, muscle weakness, resp. distress |
| Diagnosing Myasthenia Gravis | Tensilon Test |
| Treating Myasthenia Gravis | immunosuppresants, glucocorticosteroids, anticholinesterases |
| Guillaine-Barre Disease | Demyelinating of the peripheral nervous system causing rapid ascending paralysis *EMERGENCY; The paralysis will resolve once it's treated |
| Considerations for Guillaine-Barre Disease | as the paralysis moves upward it will interfere with breathing and heart. Patient may end up intubated. Use a marker to mark the progression of the paralysis. |
| Trigeminal Neuralgia | chronic unilateral facial pain; treat with Tegretol and surgery |
| Bell's Palsy | Disorder of the 7th cranial nerve causing facial droop, and unilateral weakness; Treat with PT |
Created by:
jperrault9941
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