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