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Test 3

Shock/MODS/ARDS/Triage/Chest Tubes/VENTS/ABGS/TRAUMA

TermDefinition
Diastolic Dysfunction in Cardio Shock Inability for heart to fill during diastole- Cardiomyopathy, Tamponade
Systolic Dysfunction in Cardio Shock Inability for heart to pump forward - MI, HTN, Blunt, Stenosis, tension pneumo
What is shock? Syndrome ↓tissue perfusion and impaired cellular metabolism imbalancing the supply and demand for o2 and nutrients.
Cardiogenic Shock Diastolic or Systolic dysfunction ↓CO
Cardo Shock Hemodynamics ↑HR, ↑SVR, ↑PAWP >20, ↑CVP / ↓BP, ↓CO Cardiac Index <2.1L
Cardio Shock- what your patient will look like "HEART FAILURE" Tachy, Hypotensive, Narrow Pulse Pressure, ↓Cap refill, Cyanotic, Crackles, ↑NA, ↓UOP, Clammy, LOC, N/V, ↓Bowel
Cardio Shock Diagnostics ↑Cardiac Markers- troponin, EF<50, ↑Lactate, ↑BUN, CXR infiltrates,tension pneumothorax, arrhythmias
Cardio Shock Tx Tx underlying cause, Dobutamine (systolic), Dopamine, the Nitro's, Epi's, Stent, thrombolytics, IABP, Diuretics
Absolute Hypovolemic Shock Hemorrhage, fluid loss, n/v/d, diabetes
Relative Hypovolemic Shock 3rd spacing, burns
Hypovolemic Shock is Loss of intravascular fluid
Hypovolemic patient will look like... thready pulse, ↑RR, ↓CO, ↑SVR, tachy, clammy, ↓UOP
Hypovolemic Diagnostics ↓Hct, ↑Lactate, ↑Urine gravity
Hypovolemic Nursing Tx Restore volume, Stop Loss. 3:1 rule 3ml per 1ml lost, vasopressor
Cardio Shock Nursing Specific Measures O2, thrombolytics, vasodilators, increase contractility inotropes (dig or dobutamine), reduce preload diuretics, decrease afterload ACE/ Vasodilator, reduce HR BB and CCB, prepare for sx
Hypovolemic Hemodynamic Goal CVP 8-12, Map 60-65, PAWP 10-12, CI >3L
Neuro Shock is T5 or greater spinal injury- can occur 30 min - 6wks, massive vasodilation pooling of the blood, "floppy"
Neuro shock patients will look like Brady, Hypotensive, poikilothermia, ↓UOP, flaccid
Neuro Shock Tx Treat underlying cause, stabilize spine, corticoids for swelling, vasopressors, atropine, cautious fluid replacement, Dopamine, Norepi, monitor for hypothermia
Obstructive Shock is Caused by PE, Tamponade, tension pneumo, its a physical obstruction of blood flow, aortic stenosis, masses
Obstructive shock patient will look like JVD, pulse paradoux, cardiac arrest, tracheal deviation
Obstructive shock Tx PE: thrombolytics, tamponade or pneumo: mechanical decompression chest tube or needle
Anaphylactic Shock is acute massive vasodilation reaction to previous food, chemical, insect bite ect.
Anaphylactic shock patients look like hypotensive, angio edema, hives, stridor, chest pain
Anaphylactic shock Tx Epinephrine, fluid resuscitation, albuterol, antihistamine, corticoids if hypotensive, ETT
All shocks have.... DECREASED Cardiac Output- piss poor perfusion
Sepsis is 2 SIRS criteria PLUS infection
Septic Shock is Presence of sepsis PLUS ↓BP despite fluids PLUS poor perfusion
SIRS Criteria T 36-38/96.8-100.4 HR >90 RR> 20 Co2<32 WBC >12k or <4k or 10%
Risks for Septic Shock Post-op, tubes, immunocompromised, age, trauma, gram negative or positive bacteria
Septic shock patients will look like early on... EARLY- warm flushed, change LOC, ↓SVR, ↑HR, ↓BP, Hyperventilation, Hypoxemia, ↓UOP, ↓ plt
All shocks pretty much have... An increase in Lactate and Decreased UOP and Decreased CO
Septic shock patients will look later on... ↑SVR, cool mottled, paralytic ileus, ARDS/Resp Fx
3 major patho of Septic Shock Vasodilation Maldistribution Myocardial Depression
Septic Shock TX Fluid resuscitation, CVP 8-15, give 6-10L, PAWP 10-12, Hemodynamic monitoring, Vasopressor if cvp>8 norepi dopamine, antibiotics, glucose not >180, dvt and ulcer prophylaxis, corticoids if fluids not working
Nursing measures for tx septic shock O2, FLuids, increase CO (vasopressors, inotropes), obtain culture b4 antibitotics, enteral feedings
ARDS is Resp unable to supply adequete o2 or eliminate co2 leads to lung inflammation, injury, aveoli collapse...refractory hypoxemia
1. Hypoxemic vs 2. Hypercapnic 1. Pa02 <60 aka V/Q mismatch 2. PaCo2 >60 aka ventilatory
Tx for ARDS in general intubation, vent, bronchodilators, sedatives, mucolytics, dobutamine, dopamine, diuretics and anti-biotics if indicated
Causes of ARDS SEPSIS #1...COPD, pneumonia, trauma, pancreatitis, dic, burns
Diagnostics of ARDS ABGs, Cxry new bilateral infiltrates, REFRACTORY HYPOXEMIA, PAWP>18 and no heart failure
ARDS patients look like... crap
Hypoxemic Resp. failure looks like retractions/paradoxical chest, tachycardia, prolonged expiration, CYANOSIS
Hypercapnic Resp. failure looks like rapid, shallow, decreased ventilation, tripod, pursed lip breathing, decreased tidal volume, morning headache, solmnalance
Early ARDS looks like... Respiratory Alkalosis, hyperventilation, fine crackles, refractory hypoxemia
Late ARDS... White out, ratio <200 despite fi02, continual lung compliance decline, pulmonary htn, fibrosis, Resp and metabolic acidosis
Complications of Tx for ARDS SEPSIS#1, VAP, Barotrauma, Volutrauma, Stress ulcers, Renal Failure, paralytic illeus, pneumothorax
Prone Positioning in ARDS is used when pt does not respond to ↑ Pao2, also releives pressure off of the posterior aveoli
o2 toxicity can occur when FIo2 >60% for more than 48hrs
Permissive hypercapnia ventilate with smaller tidal volumes to allow paCo2 to rise slowly avoids barotrauma
Vent Bundle 1. HOB 30-45 2. Sedation Vacation dayshift 3. Peptic ulcer prophylaxis 4. Venous Thrombus prophylaxis
High levels of peep can.... can cause volutrauma and barotrauma, decrease BP, decrease CO, and preload.
Use peep cautiously in pt's with.... ICP, COPD, Pneumothorax
Good Vent Care Early enteral feedings, positioning, asepsis technique, avoid nephrotoxic drugs, sedation, full o2 prior to suctioning, if needed bag the pt
Vent Weaning CPAP, PSV, or T Piece used, siting pt up, Determine ability to breathe spontaneously sedation vacation Assess muscle, lung sounds/cxr, sustain 91%, SBT 30-120 min
ETT Cuff Maintaining proper cuff inflation Serves to stabilize and “seal” ET tube within trachea Excess volume → tracheal damage Cuff pressure 20–25 cm
ER Triage Levels are: 1. Resuscitation- immediately seen 2. Threat- seen in minutes 3. Stable "urgent" up to 1hr 4. Stable "less urgent" -may delay 5. Stable "non-urgent" delayed
Primary Survey entails.... Airway, Breathing, Circulation, Disability, Expose (injury/Stabilize c-spine) (pneumo) (central pulse) (AVPU/LOC)
Secondary Survey entails... Full assess, Give comfort, History, AMPLE (Vitals, EKG, Foley, NG, Log Roll, Tetanus
AMPLE means... Allergies, Meds, PMH, Last meal, Event
Mass Casualty Tags are... Green- Minor Yellow- Non- life threat Red- Life threat Blue- Expected to die Black- Dead
Limb Trauma 6 p's, immobilize, never realign, watch for cvompartment syndrome
Pelvic Trauma Urinary/Bowel complications, swelling, eccymosis, deformity, pain control
Abdominal Trauma Solid organs bleed out- hollow spill out gi fluids causing peritonitis, complications hypovolemia and sepsis
Abdominal Trauma tx Peritoneal lavage >10ml = positive
Abd trauma nursing interventions Airway, IV, NG, Foley, leave impaled object, no pain meds until DO, prepare for surgery
Flail Chest 2 or more fractured ribs in a segment, paradoxic movement, crepitus, affected side sucks in on inspiration, rapid shallow RR
Flail Chest Tx Airway, vent or supp o2, IV fluids, Surgery plates/screws, cpab/bipap
Rib Fx Most common ribs 5-9, atelectasis, splinting, shallow RR, complication pneumonia
Rib Fx treatment If pleura is damaged chest tube may be needed, no binding, deep breath, IS, opioids, and nerve block
Chest Tube insertion arm above head, hob 30, aseptic, connect to drainage system, CXR
Chest tubes are for... bringing back negative pressure so lung re-expands, removes air and or fluids from pleural cavity.
WET Chest tube chambers 1. Suction chamber filled w/20cm water- bubbles ok 2. Water seal chamber 2cm water- bubbles mean air leak- tidaling is normal 3. Collection chamber- never emptied.
Diff between wet and dry chest tube systems Dry suction chamber has a dial and no water is added to suction.
Chest tube Management Maintain patency, loosely coiled, below the body, report fluid >100, SQ emphysema, do not clamp (pneumo risk), do not strip, tape air leaks, keep sterile water nearby.
Chest tube complications SQ emphysema can effect airway if too much air is leaking, INFECTION, re-expansion of pulm edema, and if more than 1-1.5l is pulled hypotension
Cover sucking chest wounds with... 3 sided occlusive dressing
Removal of chest tube DC suction 24hrs prior, Inform, Medicate, Semi-fowlers or lying on unaffected side, aseptic technique by a physician, have pt bear down exhale upon removal, cover with xeroform, 4x4, and tape. Cxr and Assess lungs.
Spontaneous pneumo CP, Cough Sudden, pleurodesis can be down for chronic occurrences, chest tube, thoracentesis.
Dx of spontaneous pneumo CXR & reduction or absent lung sounds on affected side
Iatrogenic means.. a laceration/puncture occurred during a medical procedure ex: subclavian insert, thoracentesis
Tension Pneumo Trachea deviated to unaffected side, s/s JVD cyanosis, muffled heart sounds, resp distress
Tension pneumo tx needle decompression, chest tube, is an emergency as it decreases CO
Hemothorax is blood in pleura
Hemopneumothorax is blood and air in pleura
Chylothorax is lymph fluid in pleura
Vaccines available are for biological agents used in bioterrorism are.. Anthrax and Small Pox and Yellow fever
Anthrax tx Cipro, PCN, Cyclines, limited vaccine
Small Pox VIG vaccine
Botulism induce vomitting, anti-toxin not a vaccine, PCN
Plague Myacins
Tularemia Myacins, Doxy, and Cipro
Radiation Syndrome NVD, then asymptomatic, last is CV/CNS decreased blood count and GI returns.
Radiation exposure tx Remove clothing, wash skin, fluids, prevent infection, isolation.
Out of all the bio-agents two are viral in this exam.. small pox and ebola
DIC is Bleeding and clotting at the same time- not a disease- a complication. Coag overdrives, IV thrombin increases, then fibrin, and enhances plt aggregation so much that it fails to clot anymore-hemmoraging.
DIC labs ↑D-Dimer >1.37 ↑PTT & PT ↑FSP ↓ Plt ↓ Fibrinogen
Fibrin VS Fibrinogen At the same time: Fibrin increases (clotting) and Fibrinogen decreases clotting = massive bleeding and capillary permiability
DIC tx Fresh Frozen Plasma, PLT, Cryoprecipitate, Heparin Goal is to prevent massive coagulation by giving the heparin- a balancing act
Decreased Fibrinolysis microthrombi obstruct vessels
DIC patients will look like... pettichae, bruising, hemotypsis. hyoptensive, abd distension, ↓UOP, ↓decreased LOC
Solu-cortef/hydrocortisone reverses increased capillary permiability
SIRS Systemic inflammatory response to anything: infection, mechanical trauma, ischemia
First to go in MODS Respiratory
MODS is.. results from SIRS, Metabolic Acidosis, failure of 2 or more organs
Omnious sign in MODS ↑CO and ↓SVR >24 hours
MODS patients will have this.... decreased UOP, NA retention from ↑ aldosterone , abdominal displacment perotonitis, early sign ↓ LOC, warm, mottleling, 3rd spacing, ↑HR, aveolar edema decreased surfactant to ards,
MODS Tx Try to prevent sirs to mods. Hypermetabolic state increases glucose, tx hypotension, O2 PPV VENT, enteral nutrition, appropriate support of failing organs
ABG compensation rule Full comp the ph will be normal Partial comp the ph will be abnormal if both metabolic and respiratory are out of range and the ph is normalizing, some kind of compensation is going on.
Normal Labs BUN 7-20, PT 11-14, Lactate 0.1-1, Plt 100-450, Creat 0.6-1.35, CVP 8-12-15, PAWP 8-12, HGB 12-15, HCT 35-50, Albumin 3-5
Complications in PEEP once more... SQ emphysema and Spontaneous Pneumothorax
Botox No vaccine, not contagious
If there is no tidaling ... check if the pt is connected to suction, check for blockage, lung may have re-expanded.
Anthrax can cause N/V Ascites, Shock widened mediastinum, black ulcer
Plague Flea bites and contaminated meats, bloody sputum high fever chills, lymph node swelling.
Tularemia rabbits and ticks, weightloss, pnemonioa, sore throat
Created by: matthew0116