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nu568 monitor thermal gas

Who issues regulation for handling transportation and storage and disposal of cylinders USDOT, CGA, and NFPA
oxygen is in what state at room temp gas
oxygen is refrigerated to maintain what state liquid
manifolds redude pressure of cylinder from what to what? 2000 psi to 50psi
service pressure of oxygen is what 2000psi
critical temp of oxygen -119C
capacity of Ecylinder 660liters
is even of loss of pipelie pressure 1. fully open E cylinder, and use low FGF. 2. if not fully open, flow ends before its empty. 3. hoses to pipeline are disconnected
at 1000psi of O2 how many liters are left? 330L
adiabatic means what no heat loss to atmosphere
Nitrous oxide PSIG, LIters, and temp 1600Liters, 745 psig, stored as liquid critical temp 36.5C
N2O is easily compressible without a large incrase in tank pressure T or F True
what is a rupture disk is emergecny relief valve to prevent explosion, will rupture at 3300 PSI. E cylinder them self can withstand 5000psi
woods metal metls at 158F , ventilates gas into air
volume of N2O is what to cylinder pressure not proportional
what what liter of N2O will nitrous be expended 400L
what is tare weigt empty wieght
energy to convert liquid to gas endothermic
how do you crack a cylinder slowly
how to determind residula volume of N2O weigh the cylinder.
medical air made from compressors
crtical temp of medical air -146.6C, pressure falls proportional to tank content
medical air cylinder 660L and 1900psi yellow
pipeline constructions seamless copper tubing, 1993 NFPA made stricter standards against contaminants.
DISS connectore help prevent connection errors TRUE
how far apart are the O2 lines are labled every 20 feet, every story of a building, and entering each OR
installation of anesthesia gas system copper only, certified installer, 48 hour pressure test,
Yellow PSI L PIN 1900psi 660L 1,5
Green PSI L PIN 1900psi 660L 2,5
Blue PSI L PIN 745psi 1600L 3,5
H cylinders hold about 6900 liters so at 3/l min you can run it for how long 38hours
central vacums contain what to prevent system contamincation Traps.
what happens if you bypass a trap may shut down system for terminal cleaning, upto 24 hours.
O2 shut off valves AKA zone valves
gas tubing in OR present three diff ways gas colums, hose drops, articulated arm BOOM
compressed nitrogen not for patients, BLACK in color, commonly in H cylinder, 660L at 200psi
what seamlessly selects the supply tank with apreoate pressure and swtitches from central supply to tanks manifold system
carbon dioxide insulfation gas, Grey tanks, CGA says color code, but not all do. not mandated by FDA.
testing anesthesia gas circuits 1. pressure test, 2. test for cross connections. 3. pipeline purge using cheese cloth. 4. standing pressure test after walls are closed. in accordance with ASSE 6000
what type of burn is prevalent among small children scald injuries
chemical burn degree depends on what type of chemical, concentration and duration of exposure
what causes death in burn pts not the thermal toxic damage, but the shock state following by potential sepsis.
what systems can be affected by burns all can be affected
Burn degree 1st, sunburn 2nd. partial thickness 3rd. all epidermus white sluffing off. 4.muscle fascia bone burn.
estimation of body percent burned the rule of nine
rule of nine breakdown adult head and each arm 9. front 18 back 18, circumfrance of each leg 18
rule of nine with babies head 18, arms 9 each, front 18 back 18 and legs are 14 each
is the rule of nine definitive no, just a good estimate
lund and browder chart more accurate burn injury quantification, esp for pediatric.
burn formula and if greater than what is predictive with high mortality rate age + %TBSA of burn >115 then the mortality is great than 80%
how can mortality of burn victim be doubled if there is an inhalation injury with thermal burn
4 types of burns chemical, electrical, thermal, and inhalational
treatment of chemical burn large amount of water flush, noxious fumes can also cause serious injury.
electrical burns depends on voltage, duration. point of entry is not the point of exit and not always appartent.
electrical burn damages what bones, blood vessel, muscle, nerve
muscle damage from electrical burn can cause myoglobinemia which leads to renal failure.
thermal burns from ages of what to what is normal 1-4
what is the second leading cause of accidental death fire
scald burns in children are one of the most common injuries that result in what abuse
with thermal injury what should always be suspected untill ruled out inhalational burn both upper and lower
dry air at what temp and steam at what temp can cause damage dry at 300C and steam at 100C
lower airway injury from soot and particles, airway mucosa makes acidic and alkali substances, which results in INCREASED capillary permeability.
signs of inhalational injury hoarseness, sore throat, dysphagia, hemoptysis, tachypnea, accessory muscles, wheezing, carbon in sputum, and or elevated carbon monox
three phases of treatment 1. resuscitative, 2. debridment and graft 3. reconstructive
Resuscitative ABC, and coexisting trauma, all at risk for pulmornay injury,
how to diagnose airway injury history physical, direct visualization, CXR normal in early phase unless aspirations, intubation even if not showing signs of decompensation.
why intubate early because once edea sets in, very hard to intubate, especially after fluid resusication has occured. children no cuff, and one size smaller than norm, naso for kids is better tolerated.
if burn injury great thatn 24 hours what can NOT be used succinocholine
upregulations of acetylcholine can cause what if succs is given increase of K from muscle, resulting in hyper K and possibly cardiac arrest
what determines the K release in a burn patient if succs is given the size of the burn
burn patient have a what sensitivity to NDMB decreased, due to increased nicotinic acetylcholine receptors and change in volume of distribution. may need two or three times the dose
best intubation if when a patient is awake
carbon monoxide poisoning any burn patient in enclosed space, is at risk for CO. 50-60 % die from CO poisening.
symptoms of CO poisoning depends on what carboxyhemoglobin level
CO affinity to heme is 200 times that of Oxygen, tissue beceomes acidotic ABG normal arterial oxygen tension but decreased total oxygen content.
carboxyhemoglobin level of what kills greater than 60
a shift to the what is seen with CO toxicity shift to the left
pulse ox is a good measure of CO poisoning? NO, pulse ox can not tell difference
Treatment of CO includes oxygen at 100% face mask. Shortens half life of CO from 4 hours, to 40 min.
upon securing airway, and other life threatening injury pt given fluid, include blood. need to maintain renal function.
Fluid losses are great in the first 12 hours and stabilized after 24 hours
edema and or third spacing causes what depletion of plasma volume, increase in extracellular fluid and shows up as HYPOVOLEMIA and BURN INDUCED EDEMA
inflamation and edema can occur localy or systemically why depends on the size of burn.
fluid resuscitation formular 2-4ml/kg x BSA for adults. 3-4 for children. NSS for adults, LR for children under 3yrs.
what type of fluid should be given according to american college of surgens commitee on trauma cystalloid.
why are colloids not given within the first 24 hours they wont stay in vascular.
after the first 48 hours patient goes into what state of metabolism hypermetabolic hyperhemodynamic phase
hypermetabolic state is manifested by hyperthermia, tachypnea, tachycardia, increased catecholamine, increased Oxygen, increased basal metabolic rate. stays for weeks, till wound healing starts.
cardiovascular system after burns edema, third spacing due to disrupted endothelium, shock 24-36 initial hours, HALL MARK IS DECREASED Cardiac Output. initially compensated.
inflamatroy syndrome in burn patiens increased CO, tachycardia, and reduction in SVR, 24-35 hours post burn. Initial burn hours, decreased CO and increased SVR.
in hypermetabolic state patient shows increased consumption of what oxygen and production of CO2
children weeks after burn injury become hypertensive, increased catecholamine production, activation of renin-angiotensiin
Pulmonary system and burns may decrease, FRC reduced, chest wall compliances decreased. edema, eschar formation,
If no inhalational are lungs still compromised yes, plasma oncotic pressure decreases, results in pulmonary edema.
Immune system and burn susceptible to infection, altered immune system starts hours after burn, Leukocyte activity is depresses as well as humoral and cellular response.
prime medium for bacterial growth is the burn eschar
which bacteria increases mortality gram negative bacteria, septic, pneumonia, require prolonged mechanical vent
death after burns, most deaths is attributed to 100% infection in children, and 75% in adults.
Renal and burns ARF is a serious injury, increases mortality. glomerular filtration alteration, due to intravascular depletion, decreased CO, and increased catecholamine
renin-angiotensin release what and it does what ADH and conserve sodium and water.
electrical burns and renal myoglobinemia, can damage the renal tubules and impair function
what do we give to protect the renal system bicarb
bicarb in renal system in burn patients prevents what myoglobin casts formation
how soon after burn can ARF occur 2-3 weeks
damage to renal arencyma occurs from myoglobinuria, rhabdomyonecrosis and or hemoglobinuria due to hemolysis.
what blood product can be given to protect renal in burns FFP, contains haptoglobin, binds free hemoglobin.
GI and burns with a 40% burn pt has a 132% higher basal energy espendature. for sepsis is 79% increase and major surgery is 25%
burn patients and prevention of catabolism what is more nurtietionaly available carbs are better than fats. Insulin not functioning, need blood sugars.
what is better for protein fats or carbs in burn patients carbs
enteral feeding before surgery stop the night before
intubated patients and enteral feeding may continue feeding. Un-intubated stop 4 hours before.
NG tube should be what once in OR suctioned and RSI should be in order.
if patient is on parenteral hyperalimentation continue through out surgeory and line should not be used for anesthetic
20% TBSA burn or more can cause what in GI illeus, gastric and duodenal ulcers can occur called Curlings ulcer.
what is curlings ulcer gastric and duodenal ulcers cause by burn. ie stress ulcer from burn
treatment of curlings ulcer H2 blockers and antacids. these patients have increased infection of pseudomonas of lung. H2 blockers end in -tidine
burn patients and changes in plasma protein decreased albumin and increased alpha-1 gylcoprotein
decreased albumin affects what drugs how albumin/plasma binding of drugs like benzo, phenytoin, salicylic acid is decreased. ie need LESS drugs. larger volume of volume distribution.
drugs bound to alpha1-glycoprotein need more drugs, eg lidocaine, Demerol, propofol
volume distribution of drugs in burns is affected by extracellular fluid volume and Protein binding. these effect how drugs work in body and how much you need to give.
In hypermetabolic state CO increases to kidney and liver causing increased drug clearance.
Surgical debridment and skin grafting restore skin integrity, ealier eschar is removed and less chance of infection. other advocate waiting 1-3 weeks after injury.
before surgery pt must be what stable and fluid resuscitated.
surgical limited to how much of body 20% at a time. otherwise hemodynamics and coagulation status must be considred.
what preop test are important before surgery acid-base, electrolyte, ABG, CXR, chem panel, CBC, EKG, airway eval, coags
what electrolyte imbalance might be seen with burn HyperKalemina, hypercholeremic , Na, Cl
tpoical antibiotics like Mafenide acetate inhibits carbonic anhydrase which causes hyperchloremic acidosis
silver nitrate aka silvadine decreases what Na, Cl, and K levels.
electrolyte imbalances with burns can be seen with what “procedures” surgical time of 2-3 hours and core temp 35C or blood loss of 10 units PRBC
Grafts in burn patients can use own skin or other type of grafts if own skin is not available
pre-op eval of burn pts medical hx, lab, physical, lungs, airway, resp compliance. know type of burn, and TBSA% and location of burns. surigcal intentions. alot to consider when giving anesthesia to them.
other pre-op considerations for burns monitors, core temp, airway, invasive lines, sedation, analgesia all must be considered.
pre-op oral assessment if not intubated, awake fiberoptic should be considered. no tape, consider cloth to hold ETT.
hypothermia and burn great risk for hypothermia, warm fluids, bair hugger, warm OR, humidifiers if possible.
detriment bloody considerations gauze may be soaked in epi and neo to vasoconstrict. this can cause tachycardia. elevation in BP. Instead use THrombin soaked sponges instead.
Thrombin soaked sponges an alternative to epi and neo soaked for detriment.
all blood products should be immediately be available to you T or F True
in burn patients what is of utmost importance VIGILANCE and careful planning. survery the surgical field, do not rely on surgeon for blood loss.
Burn patients and anesthetics go slow, titrate, regional is debatlable during reconstructive phae. (infections, hypovolemia, vasodilation)
Inductions drugs and burns standard induction is ok to use. Succs becareful, sodium thiopental, propofol and etomidate all can be used but know downfall to fix it.
what has a greater negative ionotropic effect than sodium thiopental and etomidate propofol
ketamine is a good hemo-stable drug, some analgesia for burns True
if no IV in ped, then what VAA can be used Sevo, keep in mind cardio vascular depressant effect of VAA and if pt is NOT fluid resuscitated.
non-depolarizors can be used in burns but need redosing, increase in postjunctional acetylcholin receptores becareful about succs
in burn pts need more opiods due to activation of endogenous opoid pathways., PCA over IM. Morphine, fentynl and sufent are all ok intraop
what opioid is good for dressing change remifyntanel
why NSAIDS not a good idea for burn pt when changing dressing prevention of thromboxin A, faiiure of platelet aggregation.
if to be extubated in OR need full spontatnous breaths, niff of -30, follows all directions, all properly reversed. adequate tidal volume, good RR
what is monitored by anesthesia BP(invasive and non) EKG
respiratory system monitors precodal and esophageal stetchescopes. Pulse oximetry, end tidal CO2, and anesthetic analysis.
Neurological systems EVP by neurophysiologist, BIS and perfipheral nerve stimulators.
We keep an an eye out for renal urin ouput, temp.
vital signs are HR, BP, EKG, Pulse Ox, End tidal CO2, Temp (for GA and peds mac)
Rhythmic contraction of left vent ejects blook in vascular system results in pulsitile arterial pressure.
Peak pressure generated during systolic contraction
trough pressure during diastolic relaxation
MAP, Mean arterial pressure, average pulse cycle SBP +2(DBP)/ 3
PULSE PRESSURE is the difference between the systolic and diastolic pressures
radial artery systolic pressure is usually higher than aortic systolic pressure
aortic root has the lowest SBP and narrowest pulse pressure. TRUE
the dorsalis pedis has the highest SBP and widest pulse pressure
Pulse pressure = SBP-DBP
Non invasive blood pressure inflation of BP cuff, artery partially collapsed, as released Korotkoff sounds, audible distal third of BP cuff
BP cuff size too small high BP, too big low BP. too narrow most significant error.
width of the cuff should be how much greater than diameter of extremity 20-50
automatic bp cuff based on oslometric q3 to q5 min
BP should be viewed as an indicator not a measure of end organ perfusion
Gold standard of blood pressure Invasive arterial blood pressure
reasons for Aline cardiovascular instability, fuild shift, intracranial surgery, CV disease, LVH, valvular disease, diabetes, cardiac arrest
reasons for Aline direct maipulation of cardiovasular, surgery, vascular surgery, deliberate, hypoten, deliberate hypothermia, obesity, frequest Arterial samples
technique of invasive arterial line insertion percutatneous arterial cannulation of radial, dorsiflexion, secure wrist, palpate, mark, sterile technique
sterile A line technique gloves, prep, skin wheal 1% insert 30-45deg upon flash drop angle to 10 to 30deg
Trans-arterial or through arterial through artery, pull back flash remove stylet and advance, use guide wire or 3cc syringe to advance catch.
Seldinger technique over wire technique
Pressure transducer IBP tubing non compliant, fluid filled, transducer used,
Transducer are based on strain gauge principle. crystal stretched and electrical resistance is changed.
mechanical characterstics of transducer system is based on two parameter natrual frequency and damping coefficient
Natural frequency the frequency at which the system will resonate or ring
Damping coefficient which describes the tendency of the apparatus to extinguish oscillations through viscous and frictional forces.
Natural Frequency of Arterial Pulse= 16 -24 Hz
Natural Frequency of Transducer = 1 to >200 Hz
addition of arterial extension tubing, extra stopcocks, air bubbles all can lead to damping effect
Overdamping____estimastes systolic pressure under estimates
underdamping leads to ____ and reads a falsly____ overshoot and reads falsely systolic pressure
Underdamping will over shoot or ringing the image lookslike one or more “step offs”
damping underestimating the systolic pressure, slurred stroke absent dichroitic notch
damping coefficient of ___is optimal, and can be determined by examining tracing oscillations after a high-pressure flush 0.6 to 0.7 on a scale of 1
Air bubbles in the tubing runs the risk of flushing the air bubbles ___ into the arterial tree, possibly causing a cerebral air embolus RETROGRADE
baseline drifts, requires periodic re-zeroing
Usually at the level of the RIGHT ATRIUM Known as Phlebostatic axis
The zero reference point of the transducer is the TIP of the stopcock.
ischemia may be reduced by presence of collateral blood supply
___is meant to identify a patient’s risk for ischemic complications during or after radial artery catheterization allen’s test.
5% of patient have incompetent palmer arches and lack collateral blood flow
allen’s test determins adequecy of ulnar collateral circulation in case of radial thrombosis
Technique for Allen’s Test 1. make a fist to exanguinate hand 2. occlude radial and ulnar artery with fingertip pressure 3. relax blanched hand. release ulnar. 4. collateral is good if pink 5 seconds thumb
allen’s test if thumb does not occur within 10 seconds not good collateral.
Alternative site for arterial bp monitoring ulnar, brachial, axillary, fermoral (next most common) dorsalis pedis, posterior tibials, head superficial temp artery
complications of arterial catheterization hematoma, loss of digit, bleeding, thrombosis, infection, vasospasm, skin necrosis, nerve damage
Dicrotic notch seen at apex of waveform of A line and represents closure of aortic valve.
square wave test flush no more than 2- 3 seconds. should return to normal after 2 seconds.
Anacrotic limb “The rise” first phase of arterial pulse cycle, ventricles eject blood into arterial tree. arterial pressure rises to end systole.
steepness of ascending phase affected by HR, increases SVR, vasopressor, norepi, vasodialator less steep.
systolic notch not normal, aortic insufficiency, stenosis, hypertrophic obstructive cardiomyopathy. OVERESTIMATE systolic BP
Descending limb of Aline pressure falls to that of end diastolic pressure. Has dicrotic notch.
Dicrotic notch occurs at any point of fluctuation in pressure during descending arterial limb. aortic and pulmonary valves snap shut causing pressure reverberations.
Dicrotic notch ie aortic valve closure
Incisura deep notch at surface ie when it comes to Aline dicrotic notch
flat or non existing dicrotic notch dyhydrated,
low dictorotic notch high pulse pressure, spetic shock ie low diastole
flat notch present in cardio pulmonary valve insufficiency
the rate of fall off or fall of end systole to early diastole changes in relation to SVR
what does the upstroke of arterial waveform represent ventricular contraction
what does the down stroke of arterial wave form represent SVR
what does the area under the curve represent MAP
what does respiratory variation represent pt is dry
lead what has the greatest Pwave voltage tracing lead II, it parallels the atria.
lead V lies where 5th intercostal space mid axillary,
lead V use for detecting anterior lateral wall ischemia. a true lead V needs 5 leads
electrocautery, lead, cable and patient movent can@ simulate dysrhythmias
how many patient scheduled for cardiac surgery have risk factor for CAD 1/3
No universal criteria for ischemia TRUE
ST segment analysis is more sensative than holter in detecting ischemia
ST analysis STdepressression greater than 1mm, greater than 1mm sloping or down sloping from J point, 1mm or greater ST elevation, are all worthy for ischemia
transmural ischemia ST elevation greater than 1mm
subendocardial ischemia down ST depression
who cant get PA RIJ hypovol, hypoten
why RIJ over Left Left has thoracic duct
what is thoracic duct lymph empties into it
technique for PA RIJ seldinger, over wire, trendelinburgh, sternocleidomastoid and clavicle, facing opposite nipple
characteristic pressure waveforms of monitor A C X V Y
positive deflection of PA A C V
negative deflection of PA X Y
CVP monitoring helpful in dx and treating cardiac tamponade
cardiac tamponade and CVP diastolic pressure equalize and CVP become monophasic
characteristic of significant cardiac constriction and tamponade CVP=RVDP=PDP=PAOP(wedge)
The postive deflections A atrial contraction, correlates with PR interval
the positive deflections C represent ventricular contraction, bulging of tricuspid valve into atria, follows onset of QRS on EKG
the positive deflections V represents pressure buildup from venous return until AV valve opens. follows T wave on EKG
negative deflictions X atrial relaxation
negative defrlection Y early ventricular filling, opening of tricuspid valve.
CVP is proportional to preload of the right heart, PCWP is proportional to preload of left side of heart.
canon a waves on CVP result from atrium contracting against closed tricuspid valve. for example in junctional retrograde atrial antegrade vent depol
RA reading 2-6
RV reading 25/2-6
LA reading 2-12
LV reading 100-140/2-12
A-LA pressure during atrial contraction, PR interval
C-LA ventricular constant follow onset QRS, or bulging of tricuspid valve into RA
V-LA represents buidling up from venous sys untill AV valve opens, follows T waves
X wave atria relax
Y wave early vent filling
cardiac index= cardiac output/BSAm2
normal CO= 5-6L/min
Normal CI= 2.8-3.8
swan ganz aka pulmonary artery catheter first described by letegalo and rhan in 1953. Used by Swan and Ganz in 1970.
the PAC is balloon tipped, flow directed, multilumen can measure CVP, PAP, PCWP,
PAC’s also measure cardiac output by thermo dilution technique.
PAC capabalities fiberoptic measurement of mixed venous and oxygen sat, cadiac pacing, Volume/venous infusion port,
PA catheters are indicated cardiac surgery, heart and lung and liver Tx, guide resuscitation in trauma, major blood loss, multiple organ system injury.
PAC indication cont poor LV, EF less than 40%, CI less than 2L/Min/m2, recent MI, ischemic disease, Pulm HTN, shock, sepsis, large volume shift, cross clamping of abd or thoracic aorta.
PAC outside of OR diagnosis and treatment of intra-cardiac shunt, sepsis, Pulm HTN, ARDS, cardiac tamponade, volume delivery, high risk surgical patients, and shock
equipment for PA catheter insertion percutaneous introducer ie Cordis, pressure transducer, mornitor capable of displaying waves,
Fluoroscopy, may be needed with anomolies of greater veins, RA or RV, or PA
any contraindications for PAC insertion NO ABSOLUTE CONTRAINDICATIONS
relative contraindications severe coagulopathies, thrombocytopenia, prosthetic right heart valve, endocardial pacemaker, infection or tissue breakdown at insertion site.
PAC and LBBB may be contraindicated becaue it may cause a RBBB and then a Complete hear block. Have PA pacer and good to go.
complications with PAC during venous access, while in place air embolism, arrythmia. carotid artery cannulation aka BIG RED, pneumothorax
when inserting a PA catheter and you have arrythmia you should push past it.
complications with PA catheters dysrhythmia 70% pt, may need lidocaine 13%, INTRAPULMONARY HEMORRHAGE SECDONDARY TO PULMONARY ARTERY RUPTURE, pulm infarc, embolis, sepsis
most serious complication of PA catherterization pulmonary artery rupture
pulmonary artery rupture rapid hypotension, hemoptysis, reveral of anticoag, leave PA in place CALL THORACIC surgreon, place DL tube
a double lumen tube is needed to isolate injured lung. possible emergent lobeectomy or pneumonectomy
common site for insertion of PAC RIJ, align with superior vena cava and right atrium. Second best site, left subclavian.
LEFT IJ and right Subclavian for PAC not good, due to thoracic duct and serious turns required to gain access to PA
wedge pressure when and what evaluate LV preloading, and LVEDP, left vent end dias pressure, after the A wave but before the C wave. taken at end expiration
we want a wedge pressure of greater than 60mmHg
PAC is calibrated to atmospheric pressure
Zones of west 1. PA>Pa>Pv 2. Pa>PA>Pv 3. Pa>Pv>PA
zones of west are anatomical or physiological physiological, move with position of lung.
PAOP should be less than PAD “drop Off”, if higher then not in zone 3. Pa>Pv>PA

Created by: Rooz