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Critical Care I


Balance of Fluids & Electrolytes Homeostasis
is vital to neuromuscular function and acid based balance Electrolyte balance
Inflammation and decreased protein cause Fluid shifts
Fluids are drawn to Na+ and glucose
Decreased concentration to increased concentration (cell -> Vasc. space) Osmosis
Increased concentration to decreased concentration (vasc. space -> cell) Diffusion
Pulls fluid in Osmotic pressure
Push fluid out Hydrostatic pressure
Decreased BP, Hypovolemia, Hyponatremia, Hyperkalemia cause: Adrenal gland to secrete aldosterone; Kidney retains H2O & Na+, Excretes K+
The concentration of fluid that affects the movement of water between fluid compartments Osmolality
The higher the osmolality the greater the pulling power of water. (_______ pressure) Osmotic
Drawn to H+ ions Chloride
Maintain acid balance Bicarbonate
Move fluids into diff. spaces Intravasc. -> ICF/ECF Crystalloids
D5 & H2O: Iso in bag, _____ in body. Body metabolizes sugar, H2O is _____. Hypotonic
Hypotonic solution Cells grow
Isotonic Solution Volume Expansion
Hang Blood Hang ISO
D5 1/2 NS ________ in bag ________ in body Hyper Hypo
Hypertonic solution Cells Shrink
Contain proteins (ex. albumin) that remain intravascular and pull fluid from cells & interstitial space (very high osmotic pressure) Colloid
Interstitial edema, +2 pitting edema Swollen legs -> fluid in interstitial spaces Second Spacing
M: 37 - 49 F: 36 - 46 Hematocrit (HCT)
8 - 22 mg/dL Blood Urea Nitrogen (BUN)
135 - 145 mEq/L Na+
70 - 110 mg/dL Glucose
Fluid accumulates where fluid is not normally at in large amounts: anasarca Third Spacing
Give colloids + diuretics to get the fluid back where it belongs Third Spacing
98 - 106 mEq/L Chloride (Cl-)
8.5 - 10 mg/dL Calcium (Ca+)
3.5 - 5.0 mEq/L Potassium (K+)
1.3 - 2.1 mEq/L 1.6 - 2.6 mg Magnesium (Mg+)
1.7 - 2.6 mEq/L 2.5 - 4.5 mg Phosphate (PO4-)
275 - 295 mOsm/kg Serum Osmolality
M: 14 - 18 gm/dL F: 12 - 16 gm/dL Hemoglobin (Hgb)
First line med for V-tach Amiodarone
2nd line med for V-tach Lidocaine
Shockable??? V-tach V-fib
Unstable, pulseless V-tach Call Help Call Code Start CPR D-fib Epinephrine Vasopressin Amiodarone Lidocaine Resuscitation
Stable V-tach w/pulse Amiodarone Lidocaine Mg+, K+ Sync Cardiovert
HR >180 Acute MI, CAD, Cardiomyopathy, Heart Failure, Valvular disease K=, Mg+ imbalance Artifact - Ck. Pt. V-Tach
Amiodarone Lidocaine Antiarrhythmics
40 - 60 bpm No P wave - No Atrial Kick Always Regular Junctional Escape
HR 150 - 250 bpm Always Regular May or may not see P waves Drug of choice: Adenosine Superventricular Tachy (SVT)
O2 IV access Heart monitor Vagal maneuvers Adenosine Stable SVT Treatment
ADENOSINE - Chest pain, Dropping BP, other distress Ca+ Chan Blocker Beta Block Cardiovert - LAST RESORT Unstable SVT Treatment
Control HR & Rhythm Diltiazem Amiodarone Digoxin Atrial Tachy Treats
Sinus Node Disease Meds (Beta Blocks) Hypoxia Athletes Sinus Brady Causes
O2 IV Access Atropine Sulfate(if symptomatic) Continuous Monitoring Sinus Brady Treats
Blocks PNS to Increase HR anticholinergic Atropine Sulfate
"Early" Atrial depolar Usually Asymptomatic Treat the cause PAC - Premature Atrial Contraction
Stress, anxiety, fatigue, infection, lack of sleep, meds, cafiene, Heart failure, Electrolyte imbalance, MI PAC causes
Chaotic firing of Atrium - No Pattern Irregularly - Irregular No meaningful P waves Loss of Atrial Kick Decrease C.O. 20 - 30% A-Fib
Amiodarone A-fib (treats arrhythmias)
HR 100 - 150 ALWAYS has a cause: anxiety, pain, fever, activity, dehydration, Heart fail, anemia FIX CAUSE -> FIX RHYTHM Sinus Tachy
FIX CAUSE -> FIX RHYTHM Give O2 Beta Blocks (lopressor) Ca+ Chan Blocks (Decrease HR) Sinus Tachy Treats
Beta Blocker - Decreases HR Lopressor
HR>250 bpm - SAWTOOTH Conduction Ration P:QRS -> 4:1 A-Flutter
Cardioversion Ca+ Channel Blocks Beta Blocks Digoxin A-Flutter Treats
Ideal RASS Score -2: Lt. Sedation - Briefly awakens w/eye contact to voice (<2 secs)
HOB > 30* Prevent Stress Ulcer DVT Prophylaxis Sedation Vacation Oral Care q2hrs Weaning Trial Vent Bundle
Low Pressure Alarm Leak in Line or disconnection
High Pressure Alarm Resistance in circuit: Kinked Tube Pt. Biting Tube
AIR IN Amt air delivered to lungs -> 1 breath 5-12 mL Tidal Volume
3-5 cm H2O > 20 + Dmg can occur Keeps Alveoli inflated during expiration PEEP
Hyper inflated lungs take space from Heart -> Heart can't fully open and close -> Increases PEEP -> Increased PEEP -> Decreased C.O.
Assist Control Vent (set # of guaranteed breaths) CPAP to wean from vent (Pt breathes on own -> alarm for Apnea)
Coumadin Reversal Fresh Frozen Plasma
Left Heart Failure Manifestations? Decreased C.O. -> Weak peripheral Pulses
Electrical CHAOS!!! Vents wiggle -> No Squeeze -> No Pulse -> Pt. Always Unconscious #1 Cause: Acute MI D-Fib w/in 5 mins or DEAD! SHOCKABLE!!! V-Fib
#1 Cause of V-Fib Acute MI
Hypo & Hyperkalemia can cause: V-Fib
Hypovolemia Hypoxia Hypoglycemia Hypothermia V-Fib Causes
Conduction problem in the AV Node AV Blocks
A-V Node Conduction Delay PR >.20 Usually age, Asymptomatic & Benign 1st* AV Block
Mobitz I (Wenkebach) Mobitz II 2nd* AV Block
PR Lengthens PROGRESIVELY Less Serious Treat Symptoms AV Node can't keep up - usually temporary and fixes itself Mobitz I (Wenkenbach)
PR same & constant More Serious Some QRS's Drop Mobitz II
MI AV Node/Bundle Branch disease More serious than Type I AV Block Type II
Atropine Dopamine Epinephrine Temporary Pacemaker, if unstable AV Block Type II - Treatments
AV Node can't keep up _-> P progressively lengthens until QRS drops off -> Starts over -> Temporary, No treatment Mobitz I (Wenkenbach) 2nd* AV Block
P wave w/o QRS -> usually rqrs. Pacemaker (if unstable) -> Atropine, Dopamine, Epinephrine Mobitz II 2nd* AV Block
Complete Heart Block Decreased C.O. LOC, Syncope, can progress to Asystole SERIOUS!!! 3rd* AV Block
Atria <- No Communication with -> Ventricle ALWAYS more P's than QRS's AV Block Type III
Meds: Digitalis toxicity Degenerative Heart Disease Acute MI Myocarditis 3rd* AV Block Causes
Treat symptoms Usually gets perm. pacemaker Atropine, Dopamine, Epi. - while awaiting pacemaker 3rd* AV Block Treats
One of the 2 Bundle Branches is blocked Wide QRS >0.12 12 lead EKG -> determine R or L Not treated unless acute Bundle Branch Blocks (BBB)
Causes Acute conditions - MI or Heart Fail Increased HR Bundle Branch Blocks (BBB) Temporary
Causes: Infarct of Bundle Branch Congenital Heart Disease Rheumatic Heart disease Cardiomyopathy Severe aortic stenosis Any heart disease causing scarring of conduction system Bundle Branch Blocks (BBB) Permanant
Pt: HR 40, Sinus Rhythm, SOB, Chest pain, BP 87/60 Symptomatic Bradycardia Give Atropine 1 mg IV to increase HR
Pt: Heart beating out of chest, diaphoretic, Tachypneic, BP 70/40 Heart Monitor: SVT Valsalva & 3 doses Adenosine - NOT working Immediate action?? Unstable SVT Valsalva & Adenosine Failed... Prepare for Synchronised Cardioversion
8 hrs. post CABG: Report what? Mediastinal drainage of 100 mL/hr T: 98.8* BP 160/80 K+ 3.8 Increased BP -> Increased Vascular pressure may cause bleeding @ incision sites
35 - 45 PaCO2
22 - 26 HCO3-
Necrosis of Heart Muscle do to lack of O2 Decreased O2 & Increased Demand MI
Peripheral Edema Jugular Vein Distension Ascites Heptomegaly Fatige R Sided Heart Failure
Tachycardia Dyspnea Decreased Cerebral perfusion SOB, Wt Gain, Confusion L Sided Heart Failure
CHEST PAIN?? M.O.N.A. Morphine O2 Nitro Aspirin
Congestive Heart Failure UNLOAD FAST Upright Nitrates Lasix O2 Ace inhibitors Digoxin Fluid Restrict Afterload Decreased Sodium restiction Test (Dig, ABG, K+)
Block Beta Receptors in Heart: Decrease HR, Force of contraction, Rate of AV Conduction Beta Blockers
Bradycardia, Lethargy, CHF, Depression, GI Disturbances, Decreased BP Beta Blockers S/E
PropranOLOL (Inderal) AtenOLOL (Tenormin) MetroprOLOL (Lopressor) Beta Blockers
Created by: lost little girl