R-R interval
Interpretation of ventricular rhythms
Quiver pattern between P waves
Atrial fibrillation described as
Ventricular arrhythmias
Thrombi are a risk in which arrhythmia
Laryngospasm
What causes stridor to be herd during auscultation
CHF congestive heart failure
JVD
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0
Time
What does the horizontal line record
0.04
Within the large blocks are 5 small boxes, what does each represent
0.5-mV
On the ECG graph what does the width of one large box represent
Atrial depolarization
The first deflection normally positive P wave indicate
Ventricular repolarization
T wave is normally a modest upward waveform
Recovery of the purkinje conduction fibers
What does the U wave represent
P-P interval
Interpretation of atrial rhythm
Count number of QRS complexes over 6 second interval & multiple by 10
...
What does each wave represent
Electrical events during one heartbeat. P wave-Atrial depolarization in response to SA node triggering. QRS Complex- Ventricular depolarization, triggers main pumping contractions(0.12sec), T Wave- Ventricular repolarization, U Wave- repolarization of the purkinjie fibers.
2. Where is each lead placed
V1 (Right) &V2 (Left) 4th intercostal space side of sternum, V3 Midway between (V2&V4), V4 (Left) 5th intercostal space at the midclavicular line, V5 (Left)Anterior axillary line, V6 Left midaxillary line same level as (V4&V5). Right & Left leg (above the ankle, below the torso). Right & left anterior between the shoulder and elbow
3. What are the different ways to count the heart rate
Count the number of QRS complexes over a 6 second interval. Multiple by 10 to determine heart rate. Count the number of small boxes for a typical R-R interval. Divide this number into 1500. Find a R wave that lands on or next a bold line. . Count the number of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes - 100, 4 boxes - 75, etc
a. Which of the different ways is the most accurate when the HR is regular or irregular
First Method- Count the number of QRS complexes over a 6 second interval. Multiple by 10 to determine heart rate.
4. What is the sequence of electrical activity
SA node, AV node, bundle of his, left & right branches and purkinjie fibers
5. What does each square represent in terms of voltage
1 small box is .1mv
a. Time
1 small box is 0.04 seconds, 1 large box 0.20 seconds
6. Which leads are bipolar
Limb leads
a. Unipolar
Precordial
7. What are some of the most significant arrhythmias to identify
Ventricular tachycardia, ventricular fibrillation, PEA, asystole
8. What chemistry results in action potential
Potassium (K+) within the nerve cell moves out and, Sodium (Na+) moves into the nerve cell and calcium (Ca+) quickly follows. Calcium's role is to strengthen the myocardial muscle contraction.
9. What is the normal length of an ECG strip
6 Seconds
10. What would you examine on the ECG strip if you were interpreting the ventricular rhythms
QRS complex, ST segment
a. Atrial rhythms
P wave, PR interval
11. What is the SA node also known as
Sinus node, pacemaker
a. AV node
Atrioventricular node, pacemaker back up
b. What rate does each node pace
SA 40-60, AV 60-100
12. Which of the rhythms you have learned are considered life threatening
Ventricular Tachycardia, ventricular fibrillation
13. What are causes for each dysrhythmia
Hypoxia, Ischemia, sympathetic stimulation, drugs, electrolyte imbalance, hypertrophy, rate, stretch the heart.
15. Why is an ECG obtained
To asses a Pt of Acute MI, a health screen for a Pt over 40, or a COPD Pt
17. Which disease process causes Right axis deviation
Left ventricular infraction, right ventricular hypertrophy
a. Left
Right ventricular infraction, left ventricular hypertrophy, ascites, 3rd trimester pregnancy.
18. With which of the arrhythmias learned causes thrombi
Atrial fibrillation & flutter fibrillation
19. If left untreated what could a run of PVC's turn into
Ventricular Tachycardia
20. Which arrhythmia is associated with the lowest CO
Ventricular Fibrillation
1. What modes of ventilation are considered pressure control modes
Pressure support, Bilevel ventilation, Pressure control ventilation, Airway pressure release ventilation, High frequency oscillation, Independent lung ventilation, Negative pressure ventilation (NPV),Positive pressure ventilation (NIV,NIPPV, NPPV)
2. What defines success or failure of NIV
Success: Improved ABG, decrease WOB & RR, increase Vt. Failure: 1-2 hours pt hasn't improved, move to intubation
4. What precautions need to be considered when choosing HFOV
Unstable cardiovascular status, acute bronchospasm, severe acidosis, pregnancy, COPD, asthma.
8. What are the formulas that can be utilized for initial settings on some modes
...
PSV: PIP-Plat/ VT or PIP-Plat
...
PCV- Pplat, PIP-EEP. Pplat-5cmh2O
...
a. How are settings changes determined after the initial settings
ABG
1. What are the six basic waveforms
Rectangular/square, Sinusoidal, ascending ramp, descending ramp, exponential
a. What are the three most commonly seen waveforms
Rectangle. Sine, descending
2. What are the common purposes of utilizing ventilator graphics
Determine PT vent synchrony, to assess effectiveness of bronchodilator, detect auto-peep
6.Describe or draw what a leak looks like on a volume waveform
Graph won't reach before the next breath.
7.Label a pressure volume loop
Expiration closer to vertical line, Inspiration closer to horizontal line.
a. What would increased compliance look like
A higher football, closer to the left
b. Decreased compliance
Lower football, closer to the right
c. Examples of disease processes that would show in increased/decreased compliance
Increased: Emphysema, Decreased: ARDS
8. What is another term for over distension on a pressure/volume loop
Beaking
10. Calculate static compliance and AW resistance
Raw = PIP-PPLAT/ V. Cstat= VT /PPLAT - PEEP
11. Define Scalar
To specify the flow, pressure, & volume waveforms against time.
12. Define Loops
Used to describe a graph of two variables plotted on the x & y coordinates.
13. What is the formula for Vt
Vt= (V X Ti)
14. What are all the ways to describe Auto peep
Intrinsic, air trapping, hyper inflation.
16. What are the three classes of Pharmacological Agents Used with Ventilated Patients
Sedative, Analgesics, paralytics
17. What short-acting, depolarizing agent is used for intubation
Succinylcholine (Anectine)
20. What are Benzodiazepines
Sedative
a. What are the effects produced from benzodiazepines
Reduce anxiety, hypnotic, muscle relaxer, anticonvulsant, anterograde amnesia
b. What drugs reverse the effects of benzodiazepines
Flumazenil (Romazicon) 0.2-1.0mg
c. What is the benzodiazepine of choice for vented pt's in the ICU
Lorazepam (Ativan)
21. What are Side Effects of analgesics
Nausea, vomiting, reduced gastric motility, respiratory depression, bradycardia, hypotension, muscle twitching, histamine release, immunosuppression, physical depression.
c. What drug reverses an analgesic OD
Naloxne (Narcan)
22. What are NMBA's & what does it stand for
Paralytics, Neuromuscular Blocking agent
a. What are the common reasons to use a NMBA with a mechanically vented pt
Pt-vent desynchrony, Permissive hypercapnia, intubation, hyperinflation not corrected, Adjunct therapy for controlling ICP, Reduction of O2 & CO2 production
b. Which is the most commonly used for prolonged paralysis with mechanically vented pt
Pancuronium (Pavulon)
what level do you set the high-pressure limit
10-15 cmH2O
2. Low and High MV (Ve)
50% above & below
3. Low and High Vt
150-200mls below & above
4. Low and High PEEP
2-5 cmH2O (low)
5. Low and High Respiratory Rate
10-15 above
6. List Patient related problems during Mechanical Ventilation
Airway, pneumothorax bed, bronchospasm, secretions, pulmonary edema, AutoPEEP, Neurological, change position, drugs, abdominal distention, pulmonary emboli.
7. List Ventilator related problems during Mechanical Ventilation
Gas source, inadequate settings, sensitivity, inadequate flows, vent-patient asynchrony, water in tubing, kinks.
8. What are the three levels of alarms during mechanical ventilation
Immediately life threatening, potential life threating, not life threating but potential source of pt harm.
9. What are examples of each level of alarms
1- Electrical power failure, 2- Circuit leak, 3- change in Ling compliance
10. What causes high pressure alarms
Kink ET, PT biting tube, ET moved/displaced, R mainstem, rupture artery. Pneumothorax, Bronchospasm, secretions
11. Low pressure alarms
Leaks
12. What alarm would you expect to find with a cut pilot balloon
Low pressure alarm
a. How would you correct this circumstance
(there is more than one possibility and think in terms of which would work more immediately until a more permanent solution corrects the problem) attach Needle syringe w/cock stop
13. What is the first action you should take when a patient is alarming
Look at PT
a. What if the patient is in distress or cyanotic
Check for patent airway, auscultate, breathing pattern,
b. What if the cause of the alarm cannot be found
Disconnect pt & start manual ventilation
14. What would a right mainstem intubation look like
Absent BS on the left, asymmetrical chest rise
15. What signs/symptoms might you expect to find with a bronchospasm
Dyspnea, wheezing, increased WOB, Asynchronous, retractions, increased PIP, Pta, Weaning
1. What is the most important prerequisite for weaning a patient off of a MV
Underlying issue is resolved.
2. What modes are considered weaning modes
CPAP, SIMV, PS
3. Describe SIMV
Mechanical breaths were synchronized to deliver during pts-initiated inspiration.
4. Describe PSV
Pt trigger, pressure limited, flow cycled, used to overcome ET resistance.
5. Describe T-Piece weaning
Air entrainment neb to control flow & FiO2, observe out flow of aerosol exiting the reservoir tube during inspiration.
7. What are considered closed loop weaning modes
Automatic tube compensation ATC, Volume targeted pressure support ventilation VTPSV, Mandatory minute ventilation MMV.
8. List three key points to Evidence-Based Weaning
Problem that caused pt to require mechanical support has been resolved; measurable criteria should be assessed to establish pts readiness for DC of mechanical support; spontaneous breathing trial
9. What are the physiological parameters required to consider a patient for weaning and potential extubation
VC >15ml/kg, Ve <10 L/min, VT >4-6ml/kg, f <25bpm, RSBI <100min/L, Breathing pattern stable, MIP/NIF <-20 to -25cmH2O.
10. What are the clinical signs and symptoms that indicate there is a problem while weaning the patient
Use of accessory muscles, nasal flaring, asynchronous breathing, diaphoretic, anxiety, tachypnea, retractions.
11. What procedures help to determine the risk of post extubation upper airway obstruction
Minimal leak test
a. Materials needed
Suction, oxygen device, ambu bag, syringe, towel, stethoscope.
13. What are the steps of extubation
Confirm orders, explain procedure to PT, semi fowlers position, suction above & below cuff, remove tape, deflate cuff, remove tube while Pt takes deep breath, ask Pt to cough & say there name, apply oxygen device, monitor pt.
14. How do you calculate RSBI
f/VT
a. What is an acceptable RSBI for a patient
<105
15. List other techniques utilized in weaning
Automode, MMV, Adaptive