Urine Output
40 mL/hr.
Heart Rate (Adult)
60-100/min.
Diagnostic Chest Percussion
resonant
Breath Sounds
vesicular
Heart Sounds
S1, S2
Blood Pressure (Adult)
120/80 mmHg
Inter Cranial Pressure (ICP)
Range 90/60 -140/90 mmHg
Cerebral Perfusion Pressure (CPP)
5-10 mmHg
70-90 mmHg
Red Blood Cell Count (RBC)
4-6 mill/mm3
Hemoglobin (Hb)
12-16 gm/100 mL blood
Hematocrit (Hct)
40-50 %
White Blood Cells
5000 - 10000 per mm3
Potassium (K+)
4.0 mEq/L range 3.5-4.5 mEq/L
Sodium (Na+)
140 mEq/L range 135 -145 mEq/L
Chloride (Cl-
90 mEq/L range 80-100 mEq/L
Bicarbonate (HCO3)
24 mEq/L range 22-26 mEq/L
Creatine
0.7 -1.3 mg/dl
Blood Urea Nitrogen (BUN)
8-25 mg/dl
Clotting Time
up to 6 minutes
Platelet Count
150,000 -400,000 /mm3
Activated Partial Tromboplastin Time (APPT)
24-32 sec.
Prothrombin Time (PT)
12-15 sec.
Thrombin Time
7-12 sec.
Term Infant
38 - 42 weeks
APGAR Score
10-Jul
Temperature
36.5 0C
Heart Rate
110 - 160/min.
Respiratory Rate
30 - 60 breaths /min
Blood Pressure
60/40 mmHg
Birth Weight (Term Infant
3000 g
Dubositz Score
40
New Ballard Score (NBS)
40
Blood Glucose (Term Infant)
> 30mg/dl
L/S Ratio
2:1 or higher
capnography (ETCO2)
30 torr
3-5 %
pulse oximetry (SpO2)
93 - 97%
co-oximetry
1 - 3%
mean arterial pressure (MAP)
93 -94 mmHg
right arterial pressure
2 - 6 mmHg
4 - 12 cmH2O
right ventricle pressure
25/0 mmHg
pulmonary arteries (PAP)
25/8 mmHg
mean 13 - 14 mmHg
pulmonary capillary pressure
8-10 mmHg
pulmonary capillary wedge pressure (PCWP)
4-12 mmHg
left atrial pressure
2 - 6 mmHg
left ventricle pressure
120/80 mmHg
cardiac output
4 - 8 L/min.
cardiac index
2 - 4 L/min/m2
pulse pressure
40 mmHg
systemic vascular resistance
< 20 mmHg/L/min. or
1600 Dynes/sec/m-5
pulmonary vascular resistance
< 2.5 mmHg/L/min or
200 Dynes/sec/cm-5
Cuff Pressure
<= 20 mmHg
Pre-Term Infant
ET tubes size
2.5 - 3.0 mm
Term Infant
ET tubes size
3.0 - 3.5 mm
Adult Male
ET tubes size
8.0 - 9.0 mm
Adult Female
ET tubes size
7.0 - 8.0 mm
Oral Intubation
21 - 25 cm at lips
Nasal Intubation
26 - 29 cm at nares
Body Humidity
44 mg/L or 47 mmHg at 370C
PAO2
Varies directly with patient's FIO2
A-aDO2
5 - 10 mmHg on 21% O2
25 - 65 mmHg on 100% O2
CaO2
17 - 20 vol%
CvO2
12 - 16 vol%
C(a-v)O2
4 - 5 vol%
PaO2/FIO2
380 torr or >
Cardiac Output
4 - 8 L/min
Qs/Qt
3 - 5 %
SaO2
98%
range 95 - 100%
VD/VT Ratio
20 - 40 %
PCO2
40 torr
Range 35 - 45 torr
PaO2
97 torr
Range 80 - 100 torr
pH
7.4
Range 7.35 -7.45
Newborn Arterial Blood Gas
PaCO2
< 50 torr
Newborn Arterial Blood Gas
PaO2
>60 torr
Calibration syringe
3.0 liters
Range 2.859 - 3.105 L (+- 3.5%)
Maximum Inspiratory Pressure (MIP)
-80 cmH20
Maximum Expiratory Pressure (MEP)
+ 160 cmH2O
Vital Capacity (VC)
80% of predicted or higher
FEV1
80% of predicted or higher
FEV1/FVC
70%
FEF 200-1200
80% of predicted or higher
FEF25-75%
80% of predicted or higher
Peak Expiratory Flow Rate (PEFR)
10 L/sec or 600L/min
Airway Resistance
0.6 - 2.4 cmH2O/L/sec.
Compliance
60 - 100 mL/cmH2O
DLCO
23 mL CO/min/mmHg (STPD)
Tidal Volume (VT)
5 - 8 mL/kg
Vital Capacity (VC)
65 -75 mL/kg or 10*Vt
Respiratory Rate
12 -20 breaths/min
Minute Ventilation (VE)
5 - 6 L/min
Maximum Inspiratory Pressure (MIP)
-80 cmH2O
Static Lung Compliance
+160 cmH2O
Mean Airway Pressure (PAW)
5-10 cmH2O
Breathing Rate
adult
10 -12 bpm or every 5-6 sec
Breathing Rate
child
12 -20 bpm or ever 2 sec
Breathing Rate
infant
12 - 20 bpm or ever 2 sec
Breathing Rate
newborn
40 -60 bpm
Compression to Ventilation Ratio adult
30:2 one and two rescuers
Compression to Ventilation Ratio
child
30:2 one rescuer
Compression to Ventilation Ratio
child
15:2 two rescuers
Compression to Ventilation Ratio
infant
30:2 one rescuer
Compression to Ventilation Ratio
infant
15:2 two rescuers
Compression to Ventilation Ratio
newborn
3:1 one and two rescuers
Vd/Vt
Ventilator patients
Up to 60%
Vd/Vt
20-40%
Qs/Qt
Shut
Normal patients
3-5%
Qs/Qt
Shut
Tolerable
10-20%
Qs/Qt
Shut
Life-threatening
20-30%
Parameter
VT tidal volume
Normal
5 to 8 mL per kilogram
Parameter
Vt
Unacceptable
< 5 mL/ kilogram
Parameter
Vital capacity
Normal
65-75 ML/KG
Or 10 x VT
Parameter
Vital capacity
Unacceptable
< 10 ML/KG
Or
< 2X Vt
Parameter
Respiratory rate
Unacceptable
> 20 breaths
Or
< 8 breaths
Parameter
Minute ventilation
Ve
Normal
5-6L/minute
Parameter
Ve
Minute ventilation
Unacceptable
> 10 L/min
Parameter
Maximum inspiratory pressure
Unacceptable
< - 20 cm h2o
Parameter
maximum expiratory pressure
Unacceptable
<+40cm H20
Initial ventilator parameters phase 1
What are the two most important settings
Title volume and rate
In phase 1 ventilators where would you set the tidal volume
8-12 ML per kilogram of ideal body weight
In phase 1 ventilator parameters when would you set the title volume lower
Patients with lung disease pneumonia ARDS ALI
Infant ventilator settings
What mode would you use
IMV/SIMV
Infant ventilator settings
What rate would you set
20-30 breaths per minute
Infant ventilator settings
Where would you set the peak inspiratory pressure
20-30 cm of water
Infant ventilator settings
Where would you set the Fio2
0.40-0.60 or same
FIO2
Infant ventilator settings
Where would you set the Peep
2-4 cm of water
Increased in increments of 1 or 2 cm of water with maximum level of around 8 cm of water
Infant ventilator settings
Where would you set the flow
5-6 L per minute
Infant ventilator settings
How would you set the I-time
0.5-0.6 sec
How do you calculate volume lost two chest tubes
Deliverd Vt - exhaled Vt = loss volume
What is the formula to approximate F I O2 with a nasal cannula
20+ (4 X liter flow) = approximate FiO2
What is the formula for the duration of flow
Duration (in minutes) = gage psi X tank factor/liter flow
What is the tank factor for E cylinder
.28
What is the tank factor for h cylinder
3.14
If you hear the words lethargic somnolent or sleepy what should you consider
COPD O2 overdose or sleep apnea
If you hear the words stuporous or confused what should you consider
The patient is responding inappropriately, drug overdose, and detoxification
Semi comatose
Response only to painful stimuli
Obtunded
Drowsy state, may have decreased cough or gag reflex
Dyspnea grade V
Dyspnea at rest, shaving, dressing, etc...
When would you see venous distention
CHF
Patients with obstructive lung disease
What cheyne Stokes
Increased intracranial pressure, meningitis, drug overdose
Paradoxical pulse/pulses paradoxes
Pulse/blood-pressure varies with respiration
May indicate severe air trapping status asthmaticus or cardiac Tamponade
What is plural friction rub associated with
TB, pneumonia, pulmonary infarction, cancer
What is indicated for a plural friction rub
Steroids in antibiotics
Fluffy infiltrates
Pulmonary Adema
Butterfly/batwing pattern
Pulmonary edema
Patchy infiltrates
Atelectasis
Platelike infiltrates
Atelectasis
Honeycomb pattern
ARDS/IRDS
Diffuse bilateral radiopacity
ARDS/IRDS
Air bronchogram
Pneumonia
Peripheral wedge shaped infiltrate
Pulmonary embolus
Concave superior interface border
Plural effusion
CT scan used to diagnose
Bronchiectasis
Is spiral CT scan used to diagnose
Pulmonary embolus
Mucoid
White gray
chronic bronchitis
Yellow
Presence of white blood cells bacterial infection
Green
Stagnant sputum gram-negative bacteria
bronchiecstasis pseudomonas
Dark brown
Old blood
Anaerobic lung infection does not need oxygen
Bright red
Hemoptysis
Bleeding tumor tuberculosis
What is the most reliable indicator of pulmonary maturity even with diabetes
PG
A decrease in pet CO2 would indicate
A increase in ventilation
Or decreased perfusion dead space disease pulmonary embolism
If you have a positive test what color should the CO2 detection device change to
Yellow
Purple is poor
Troubleshooting
Loss of pressure
What would you suspect
Leak or insufficient flow
Troubleshooting
Excessive pressure
Obstruction
Or
Excessive flow
Troubleshooting
Fail to cycle into inspiration
Adjust sensitivity
Tight seal around mouthpiece
Troubleshooting
Fail to cycle off
Leak
Fenestrated trach tube open
Troubleshooting
Pressure does not rise normally
Needle reads low or negative
Insufficient flow
Interpretation of
A-aDO2
25-65
Normal value
A-aDO2
66-300
V/Q mismatch
Patient needs oxygen give up to 60%
A-aDO2
>300
Shunting
The patient will not respond the oxygen because oxygen is shunting away.
So we need to put them on CPAP if on vent use peep
PaO2/Fio2
380 or greater
Normal value
PaO2/Fio2
<200
Acute lung injury
V/ Q mismatch give oxygen up to 60%
PaO2/Fio2
<200
ARDS
SHUNT
use CPAP
Factors that control blood pressure
What can you use to increase the heart rate and strength which will ultimately increase blood pressure
Digitalis
Digoxin
Factors that Control blood pressure
What can you use to decrease the heart rate and strength to decrease blood pressure
Beta blockers to slow the heart down
Factors that control blood pressure
What can you use two cause vessel constriction to increase blood pressure
Give epinephrine to constrict the vessels
Factors that control blood pressure
What can you use two cause vessel dilation to decrease blood pressure
You can give the patient nitro nitric or nitrous to vasodilate
What should the pulmonary artery pressure be?
25/8
14
What should the pulmonary wedge pressure be?
4-12
Or
8
What should the central venous pressure be?
2-6
Or
4
What should the mean arterial pressure be?
120/80
Or 93,94
When would you notice pressure dampening
You would notice this when the monitor does not show the normal dicrotic notch which means the catheter is somehow obstructed
What can cause pressure dampening?
A blood clot or a bubble in the catheter
What three things can you do if there was a blood clot or a bubble in the pulmonary artery catheter
Aspirate
Flush the catheter with normal saline
Finally rotate the catheter
What are for immediate (24 hours) complications of a tracheostomy
Bleeding
Pneumothorax
Air embolism
Subcutaneous emphysema
What are four late complications(24-48) of a tracheostomy
Hemorrhage
Obstruction
TE fistula
Infection
When should you keep the cough inflated
If a patient is eating
Or
When the patient is on positive pressure ventilation
If you are using a fenestrated tube and decide to plug the tube you should do what three things
1 deflate the cough
2 remove the inner cannula
3 plug the tracheostomy tube
What are three indications for bronchial hygiene therapy
1) accumulated or retained secretions
2) ineffective cough
3) ciliary dysfunction
Name 8 types of patients that should receive bronchial hygiene therapy
1)Bronchiectasis
2) lung abscess
3) acute atelectasis
4) cystic fibrosis
5) COPD
6) pneumonia
7) postoperative
8) prolonged bed rest
When dealing with body positions which position is the best for hypoxic patients
Fowler
Semi-fowler
Reverse Trendelenburg
When dealing with body positions what 3 positions are best for obese patients
Fowler
Semi-fowler
Reverse Trendelenburg
When dealing with body positions what 3 positions are best for pulmonary Edema
Fowler
Semi-fowler
Reverse Trendelenburg
What is the best body position for patients with very low blood pressure
Transdelenburg
What is the best body position to prevent aspiration
Lateral flat
If a patient aspirates during postural drainage what should be done
First suction
Placing opposite position for postural drainage
What is the formula to determine catheter size
(1D size /2)*3
What would be the recommended size for patient with an 8.0 endotracheal tube
12
What are the goals of aerosol therapy
Relieve bronchospasm in mucosal edema
Provide humidity to the respiratory tract
Deliver medications
Two thin secretions that are thick and tenacious
Which device is the least effective when humidifying an artificial airway unless heated
Passover or blow by humidifier
Which type of humidifier device delivers 100% body humidity
Wick humidifiers
When using a blender with a large volume nebulizer you should set the blender at what FI O2
You should set the blender at the desired fio2
When using a blender how should you set the air entrainment port A large volume nebulizer
You should set it at 100%(closed) because you do not want to entrain room air
When would you use a SPAG device
Is used to treat RSV and a delivers the medication ribavirin to treat RSV not to be used with any other substances
When do we want to use ultrasonic nebulizers
For patients with thick and tenacious secretions
When using ultrasonic nebulizers how do we go about increasing the mist. Would we increase the amplitude or the frequency
Increase the amplitude
In what sequence would you give the patient with asthma their medications
Adrenergics
Anticholinergics
Steroid
How would you position the patient with ARDS
Prone
How would you position a patient with CHF
Fowler
How would you position a patient who was obese
Lateral fowlers
How would you position a patient with unilateral lung disease
Good Lung down
If a patient has a pre-op inspiratory capacity of 2600 ML's what should their postop goal be when using an incentives spirometer
1300 ML's
If I increase the pressure what will happen to the volume
Volume will increase
If I decrease the flow what will happen to the volume
The volume will increase because I am increasing the inspiratory time
If I increase the flow what will happen with the volume
It will decrease the volume because I am decreasing the inspiratory time
What will happen to the expiratory time if I increase the rate
It will decrease the expiratory time
If I have decreased compliance what happens to the volume
You will have a decreased volume
If a patient has increased compliance what will happen to the volume
You will have a increasing volume
Patients with obstructive sleep apnea will find relief with EPAP pressures of what
5-10 cm of water
Patients on EPAP to treat hypoxemia should be starting WITH what pressures
6-8 cm of water
What can you measure with a newborn capillary sample
PH, CO2
What should you not measure with a newborn capillary sample
Do not measure PO2 instead use the umbilical arterial line
What are the advantages of using an umbilical arterial catheter line
Constant monitoring of blood pressure
Arterial samples for ABG
And blood replacement therapy
What will happen to the displayed blood pressure if the transducer is above the catheter
The display pressure will be lower
What will happen to the display blood pressure if the transducer is below the catheter
The display pressure will be higher
Where should the transducer be for an accurate measurement
It should be level with the catheter
If the patient has their AA gradient performed and received a score of 300 what would this I tell you how would you fix it
First it would tell me that the patient is shunting.
It also tells me that the patient is not responding to oxygen because the oxygen is something away.
We need to put this patient on CPAP or Pete to open of your life into PDF of your life from collapsing
If a patient has their AA gradient performed and received a score of 66 - 300 what would that tell you
It would tell me that the patient has v/q mismatch.
This also means the patient needs oxygen give the patient oxygen up to 60%
What formula would you use to measure exhaled title volume
Minute ventilation / respirations
Formula for alveolar minute ventilation
(Vt-Vd)*RR
Formula to calculate in anatomic dead space
Approximately 1 mL per pound of ideal body weight
150 pounds equals 150 mL of Vd
Formula for physiologic dead space
Paco2-Peco2/Paco2
What is the formula for dynamic compliance
Exhaled volume/PIP-PEEP
Formula for static compliance
Exhaled volume/Plateau-PEEP
Where would you insert the needle for thoracentesis
Through the seventh or eighth intercoastal space at the site of maximal dullness
What color is transudate fluid
Is usually clear and has a light straw color
The transudate fluid is also called what
Serous fluid
transudate fluid would be associated with what
Congestive heart failure
What color does empyema pyothorax have
It has been opaque appearance
Empyema and pyothorax is also called what
Exudate fluid
Infections would produce what color on a Exudate fluid
Yellow or milky
What does Purulent Exudate fluid mean
Pus filled Exudate
Serosanguineous is what kind of effusions and they suggest what
Bloody effusions and will suggest malignancy or cancer
What is mucopurulent
Mucus and pus
What is chyle
The lymphatic exudative fluid
What does the term loculated mean
Very thick
For a PH to be considered significant for an Exudate what would the pH have to be less then
7.30
If a patient has a pneumothorax where would you place the chest tube
Anterior chest 2nd intercostal space in the midclavicular line
If the tube is to drain the fluid from the plural space where is the tube placed
Fourth or fifth intercostal space in the midaxillary line.
In a three bottle collection device which bottle controls the suction
Bottle number three
How does bottle number three regulate the suction pressure
It is regulated by the amount of water in the bottle the more water the more suction
Which bottle is considered the waterseal bottle preventing air from entering the plural cavity
It would be the middle bottle or bottle b
What happens if there is continuous bubbling in the middle bottle
It should be reported as this indicates an air leak
Since bottle B is the waterseal, if the water seal breaks would you do
Submerge the chest tube in a glass of water if the patient is receiving mechanical ventilation then leave the tube open to atmosphere air until a new system can be set up
Where do you want to set the oxygen for traumatic brain injury tumors aneurysms strokes and seizures
100% oxygen
What kind of special test do you want to perform for traumatic brain injury tumors aneurysms strokes and seizures
CT, MRI, pet scans
For traumatic brain injury tumors aneurysms strokes and seizures what do you want to do with me and airway pressures and PEEP and peak expiratory pressure
You would want to minimize Paw by utilizing low PEEP and low peak inspiratory pressures
Which medications do you want to use for traumatic brain injury tumors aneurysms strokes and seizures
Barbiturates for sedation
Mannitol to decrease ICP
Dilantin for seizures
If a neckbrace is in place where would you check the pulse
You would check the femoral pulse
How would you intubate a patient who had traumatic injury or spine deformities
Use a flexible bronchoscope
Prior to any surgeries which type of preop testing should be performed
Pulmonary function testing or basics Spirometry testing
Hyper inflation therapy
If it patient has a surgery that involves removal of the vocal chords and the larynx is also removed along with the epiglottitis in thyroid Cartlidge what should you do
The patient will have a permanent stoma therefore the patient will not be able to be orally or nasally intubated if mechanical ventilation is required insert a endotracheal tube into the laryngectomy opening
If it patient has a surgery that involves removal of the vocal chords and the larynx is also removed along with the epiglottitis in thyroid Cartlidge what should you do. What should you do about the secretions
You would want to use a cool aerosol that will help keep secretions thin in the early postop.
What are six causes of ARDS or acute respiratory distress syndrome
Aspiration
Trauma
Drug overdose
Fluid overload
Inhalation of toxins and irritants
Shock
What kind of cough is produced with ARDS
Nonproductive cough
Which type of breath sounds or heard with ARDS
Bronchial and crackles
What would you see on the chest x-ray for a patient with ARDS
Diffuse alveolar infiltrates with a honeycomb or groundglass appearance
Radiopacity
Which type of arterial blood gas will you see on a patient with ARDS
Refractory hypoxemia
Acute alveolar hyperventilation with hypoxia
Which type of pulmonary function testing results would you see with ARDS
Decreased volumes and capacities
Tidal volume residual volume FRC and total lung capacity
Which type of special tests would you want to perform on a patient with ARDS
Hemodynamic monitoring reveals elevated pulmonary artery pressure
If you were measuring hemodynamics on a patient with ARDS what would be increased
Pulmonary artery pressure or PAP
What is the first rule of thumb to treat ARDS
Treat the underlying cause
With ARDS how much oxygen do you want to use
Up to 60%
With ARDS once you 60% of oxygen what should you do next
Add CPAP or peep
When the ARDS patient starts to improve what do you titrate first oxygen or CPAP/peep
Oxygen first then CPAP or peep
If an ARDS patient develops atelectasis what should you do
Implement hyperinflation therapy such as SMI IS and IPPB
Which modes of mechanical ventilation would you consider for ARDS
Pressure control ventilation
Inverse ratio ventilation
Airway pressure release ventilation
Pressure regulated volume control
High-frequency ventilation
What is the ARDS ventilator protocol
Reduce tidal volume to 6ml/kg
Maintain plateau pressure <30 cmH20
Recruitment maneuvers
Which neurological disorder contains the neuromuscular junction that interferes with the chemical transmission of acetylcholine
Myasthenia Gravis
For patients with neuromuscular diseases, what 3 things would you look out for in case a patient went into ventilatory failure
Decreased tidal volumes
Decreased vital capacity
Decreased maximum inspiratory pressure or MIP
Which neurological disease contains drooping eyelids
Myasthenia Gravis
Which neurological disease contains double vision or Dilopia
Myasthenia Gravis
Which special tests do you want to run for Myasthenia Gravis
Edrophonium(tension Challenge test)
Electromyography
When looking at a Myasthenia Gravis patient. which type of arterial blood gas would you see and when would the PaCO2 have a ventilatory failure
Look cute ventilatory failure with hypoxemia.
Watch for ventilatory failure PaCO2 > 45
If the Vt VC and MIP and weakness improve with tensilon. what does this tell you
This is referred to as a myasthenic crisis indicating more of this type of drug needs to be given
What is the name of the drug that is given for myasthenic crisis
Niostigmine or prostigmine
If the Vt VC and MIP and weakness worsens with tensilon. what does this tell you
This would be called a cholinergic crisis indicating too much of this type of drug has been given
If the patient goes into cholinergic crisis which type of drug should be used to reverse tensilon
Atropine
While trying to treat a patient with myasthenia gravis what are some things that you should do
Bed rest restriction
Oxygen therapy for hypoxemia
Hyper inflation therapy
Pulmonary hygiene
What are some other treatment modalities for myasthenia gravis which would include drugs and other special procedures
Corticosteroids in severe cases
Adrenocoeticotropic hormone
Thymectomy
Plasmapheresis
Which neuromuscular disease contains the peripheral nervous system
Guillain barre
Which neurological disease frequently occurs after a febrile illness 1-4 weeks
Guillain barre
What is the precise cause of Guillain barre
The precise causes is unknown
What special test would you do for a patient with Guillain barre
A lumbar puncture- high protein level in CSF, abnormal electromyograph
What are some treatment options for a patient with Guillain barre
Oxygen therapy
Hyperinflation therapy
Pulmonary hygiene
Anticoagulant therapy
Physical therapy
Corticosteroids
In severe cases only what are some treatment options for Guillain barre
Plasmapheresis
For a stroke patient will kind of picture do you want to take of the brain
A CT scan or MRI
How will that intracranial pressure look with a patient with a stroke
Increased
What is the treatment therapy for a stroke patient within six hours of symptom onset drug therapy
Anticoagulation therapy
Vasodilaters
Thrombolytic therapy for acute machine stroke
When would you use mechanical ventilation for a stroke patient
1 for ventilatory failure
2 reduce intracranial pressure
What kind of electrolytes will you see with a patient with myocardial infarction
Hyperkalemia
Or
Hypokalemia
What kind of special tests would you perform on a patient with a myocardial infarction. I am not talking about scans.
Cardiac enzymes
CPK, LVH, SGOT and also troponin
How will the electrocardiogram look with a patient that has a myocardial infarction
Arrhythmias with significant Q waves in ST segment changes
How much oxygen are you going to give the patient with a myocardial infarction
100%
What is the drug therapy for a myocardial infarction
Atropine for bradycardia
Defibrillate for pulseless ventricular tachycardia or fibrillation
Nitrates for chest pain
Aspirin anti rhythmic agents
What do you do for a patient that has pulseless ventricular tachycardia
Defibrillated
How much oxygen do you give to a patient with CHF or pulmonary Edema
100% oxygen
Besides drug therapy what other decision-making protocols will you decide to use for CHF or pulmonary EDema
Oxygen at 100%
Closely monitor vital signs in place the patient in fowlers
IPPB with 100% oxygen
Which type of drugs will you use for CHF or pulmonary edema
Diuretics such as Lasix
Positive inotropic agents such as:
digitalis
digoxin
dopamine
and low-dose amiodarone
Name some positive inotropic drugs
digitalis
digoxin
dopamine
Which type of electrolyte replacements will be added to the IV bag for CHF patient or pulmonary E Dema
Potassium and sodium
What will you do for ventricular fibrillation and pulseless ventricular tachycardia
Defibrillate at 360 jewels
What will you do for atrial flutter fibrillation and ventricular tachycardia with a pulse that are not life-threatening
Perform synchronized cardioversion starting at 50 to 100 jewels
A patient that is in shock what will the drug therapy include
Vasopressors for vasogenic hypovolemia
Positive inotropic drugs such as digitalis digoxin for heart failure
Antibiotics for infection
At what age will a child most likely get croup
Six months to six years
Which child infection supports a viral infection that can cause an obstruction in the airway
Croup
For croup what will you do for mild cases
Temperature control cool the environment
Adequate hydration and humidification of inspired air
How much oxygen will you give to a patient with croup during a mild case
30 to 40% oxygen
How will you apply cool aerosol mist to a patient with croup
Facemask or tent
The patient has croup what will the drug therapy include during mild cases
Racemic epinephrine
Corticosteroids but only for patients who do not respond to cool aerosol in racemic epinephrine therapy
When would you use corticosteroids for a patient that is having a mild case of croup
only for patients who do not respond to cool aerosol in racemic epinephrine therapy
How will you know a child is having a severe case of croup
The child will have severe respiratory distress and or marked inspiratory stridor
What is the criteria for intubation for a child with a severe case of croup
The patient would appear extremely lethargic
Severe stridor or at rest
Diminished breath sounds
Extreme accessory muscle usage
What six things will you do for a child that is having a severe case of croup. No drug therapy
Temperature control cool environment
Adequate hydration in humidification of inspired air
Transfer patient to the ICU
sedate if necessary
Place on TPiece CPAP
For a child that has croup what is the criteria for extubation
Child's condition is stable
Air leak around the tube which means swelling has gone down
What childhood condition has a sudden onset within 6 to 8 hours
Epiglottitis
What kind of retractions will you see any patient with epiglottitis
Sub sternal and intercoastal retractions
What is the typical age of the child with epiglottitis
2-6 years of age
With a child with epiglottitis have a fever
Yes
How will you measure a child's fever
Axillary or tympanic to avoid stimulating the child you do not want to increase their heart rate blood pressure or cardiac output
How will the CBC appear on a child with epiglottitis
Increased white blood cells
In your decision-making for a child with epiglottitis what will be the first thing you would want to do
Endotracheal tube
Or perform a tracheostomy if unable to intubate
Transfer patient to the ICU
Today if necessary
Place on TPiece or CPAP
What drug therapy will be used for a patient with epiglottitis
AntiBiotics
For a pediatric poisoning what kinds of decisions will you make to support care
Maintain an airway intubate when aspiration is possible
Monitoring
Full resuscitation
Venous access for drug administration
Appropriate weight measurement
Toxicology screen
Once a child has been stabilized who has pediatric poisoning what are the treatment goals
Prohibit further drug absorption
Improve elimination of those drugs
Manage complications
What would you do to decontaminate the gastrointestinal tract
What did minister activated charcoal.
However this cannot be used to absorb alcohols hydrocarbons organic solvents
What is the anecdote for acetaminophen
Acetylcysteine
What is the anecdote for narcotics
Narcan
The patient that has cystic fibrosis how many times per day will you perform air clearance
Four times per day
What types of things will you do for excessive secretions in a patient with cystic fibrosis
Chest percussion and postural drainage
High-frequency chest wall compression
Would you recommend exercise for a patient with cystic fibrosis
Yes
For cystic fibrosis name three types of forced expiration techniques
Active cycle of breathing
Autogenic drainage
Huff coughing
When making decisions on a patient with cystic fibrosis what will the aerosol drug therapy include
Bronchodilator therapy
Mucolytic's such as pulmozyme
Anti-inflammatory such as Advair Flovent and Pulmicort
Which type of mucolytic will you use for a patient with cystic fibrosis
pulmozyme
Which type of anti-inflammatories will you use for a patient with cystic fibrosis
Advair Flovent and Pulmicort
And hydrating a patient with cystic fibrosis in which type of saline would you use
Hypertonic
When treating a patient with cystic fibrosis which type of inhaled antibiotics would you prefer
Tobramycin
What virus is connected to bronchiolitis
RSV
Respiratory syncytial virus
What age is RSV or bronchiolitis usually acquired
1 in 10 infants younger than two years of age
Is there any discharge with bronchiolitis if there is where would you see it
Nasal
How was a diagnosis of RSV determined
The virus is determined by its antigens in the patient's oropharyngeal or nasopharyngeal secretions
with bronchiolitis which infants are recommended for prophylaxis
-Less than two years of age who require therapy for chronic lung disease
-less then 32 weeks gestation
-infants with congenital heart disease with cardiovascular compromise
I need to know the drug therapy for Bronchiolitis. Drug therapy -what is the antibodies against RSV
Intravenous and intramuscular
Intravenous respigam
Intramuscular-synagis
Bronchiolitis most severe cases are For patients with apne, treated at the hospital, director at relieving the airway obstruction and hypoxia by utilizing what
Systemic hydration
Oxygen therapy
Airway clearance
Ribavirin aerosol
For bronchiolitis when would you use mechanical ventilation
Impending acute vent failure
For bronchiolitis what is important to know about the mechanical ventilation in regards to the respiratory rate and expiratory time
Low respiratory rates and long expiratory times
What would the action be based on this Apgar score 0-3
Resuscitatr, CPR
What would the action be based on this Apgar score 4-6
Support
Stimulate, warm, administer oxygen, assist ventilation
What would the action be based on this Apgar score 7-10
Routine care
What kind of special test would you do want a patient with apnea of prematurity
Polysomnogram
How will the vital signs look when treating a patient with apnea of prematurity
You will see periods s of bradycardia, variations in thermal regulation
when treating a patient with apnea of prematurity what are some risk factors
Prone positioning
Maternal smoking
Bottlefeeding
when treating a patient with apnea of prematurity how would you treat and manage these newborns
Oxygen therapy 30 to 50% as indicated by oximetry
-Methylxanthine
-Teach family CPR
-Send infant home with them at the monitor
Infants or newborns with meconium aspiration syndrome does it occur in full-term or postterm infants or pre-term
Full-term in postterm infants
How will the appearance of the chest look with meconium aspiration syndrome
Sub sternal retractions abdominal distention see saw movement
Patients with meconium aspiration syndrome what type of breath sounds were you hear
Wheezes, rhonchi, crackles, expiratory grunting
How will the chest x-ray appear on a new born with meconium
Atelectasis consolidation
What is the first thing you should do for an infant with meconium
Suction the nasopharynx and the oropharynx thoroughly when amniotic fluid is stained
A patient that has meconium aspiration syndrome what would you do if the infant is: vigorous, active and crying. (Pulse > 100, strong RR and a good muscle tone)?
-suction mouth and nose to clear pharynx
-warm dry and observe the infant
-apply blow by oxygen as needed
A patient that has meconium aspiration syndrome, what would you do if the infant is not vigorous (pulse<100, limp, depressed, poor tone, absent or gasping respirations) are you going to use positive pressure ventilation?
No
A patient that has meconium aspiration syndrome, what would you do if the infant is not vigorous (pulse<100, limp, depressed, poor tone, absent or gasping respirations). What are you going to visualize
Vocal chords with the laryngoscope
A patient that has meconium aspiration syndrome, what would you do if the infant is not vigorous (pulse<100, limp, depressed, poor tone, absent or gasping respirations). What would you do if you see meconium in the airway?
Intubate with the meconium aspirator and suctioned trachea
A patient that has meconium aspiration syndrome, what would you do if the infant is not vigorous (pulse<100, limp, depressed, poor tone, absent or gasping respirations). How many times will you intubate with the meconium aspirator suction the trachea?
Repeat until airways clear even if pulses low
A patient that has meconium aspiration syndrome, what would you do if the infant is not vigorous (pulse<100, limp, depressed, poor tone, absent or gasping respirations). After you have finished intubating with the meconium aspiration suctioning the trache
Intubate provide airway
A patient that has meconium aspiration syndrome, what would you do if the infant is not vigorous (pulse<100, limp, depressed, poor tone, absent or gasping respirations). List the five things that you are going to do in order!!!
-No positive pressure ventilation because you will send the meconium aspirate further down the airways
-visualize vocal chords with the laryngoscope
-intubate with the meconium aspirator suctioned trachea
-repeat until airway is clear - even if pulses low
Once you stabilize infant with meconium aspiration syndrome and transfer to the ICU which steps will you take to keep the infant healthy? (4)
-vigorous pulmonary hygiene(postural drainage percussion and suctioning)
-oxygen therapy
-mechanical ventilation for ventilatory failure
-drug therapy(steroids,antibiotics)
When you have a congenital heart defect, how does a right to left shunt present?
Cyanotic
(hypoxemia)
If you have a congenital heart defect how does a left to right shunt present?
Acyanotic
(pulmonary congestion)
With congenital heart defects what are the two causes of right to left shunts?
Tetralogy of Fallot
Transposition of the great vessels
What are the three causes of left to right shunts
-atrial septal defect
-ventricular septal defect
-Patent ductus arteriosus
With congenital heart defects what will you here on the breath sounds?
Heart murmur
What is the physical appearance of an infant with congenital heart defect
Respiratory distress
With congenital heart defects which newborn has an egg shaped heart
Transposition of the great vessels
With congenital heart defects which newborn will have a boot shaped heart
Tetralogy of fallot
What is the most important diagnostic test to identify cardiac defects
Echocardiogram
With congenital heart defects, where would you maintain the oxygen level?
Maintain the PaO2 levels between 60-80 torr
For congenital heart defects do you want to use mechanical ventilation
Yes if the new born has ventilatory failure
What is the cause of infant respiratory distress syndrome IRDS
Insufficient amount of pulmonary surfactant or depressed surfactant activity that leads to massive atelectasis in hypoxemia
What is the gestational age for a newborn that has IRDS
Less than 38 weeks
For a newborn that has IRDS how will The LS ratio appear
<2:1
newborn that has IRDS what will you see on the appearance of the chest?
Intercoastal retractions
How will the respiratory pattern appear for a newborn that has IRDS
Tachypnea and possible apnea
What will you hear for the breath sounds for a newborn that has IRDS
Bronchial or harsh, fine crackles/rales, expiratory grunting
Physical appearance for a newborn that has IRDS
-Nasal flaring
-grunting
-retractions
How will the vital signs appear for a newborn that has IRDS
-Increased heart rate
-Increased blood pressure
-Increased cardiac output
How will the chest x-ray appear on a newborn that has IRDS
-Increased opacity
-Groundglass appearance
-Air bronchograms
How will you correct hypoxemia for a newborn that has IRDS
-Oxygen with oxyhood or nasal cannula
-CPAP (4-6)
-Maintain PaO2 between 60-80 torr
For a newborn that has IRDS what kind of environment do you want to keep them in
Maintain a neutral thermal environment
For a newborn that has IRDS when should you administer surfactant
-Immediately after birth (prophylactic) in neonates 35 weeks gestation age
-Or once IRDS has been diagnosed (rescue)
Name four types of surfactant
Survanta
Infasurf
Curosurf
Pulmactant
How will you administer surfactant in a newborn that has IRDS
Instilled directly into the trachea through a 5 Fr. catheter placed into the endotracheal tube
The solution of surfactant is administered in how many portions?
4
One at a time
While administering surfactant when is the catheter removed
After each administration
During each administration of surfactant what is performed in a newborn that has IRDS
Infant or newborn is manually ventilated for 30 seconds
After the surfactant therapy is given for anewborn that has IRDS what will you be observing for as far as adverse reactions
-Barotrauma
-Apnea
-bradycardia
For a newborn that has IRDS how will you increase distribution of surfactant in the lungs
Change patient position to increase distribution of surfactant in the lungs
What kind of mechanical ventilation will you use for a newborn that has IRDS
Time cycled pressure limited ventilation with Peep for ventilatory failure
What is bronchopulmonary dysplasia
A chronic lung disease that develops in newborns as a consequence of treatment of IR DS with oxygen and positive pressure ventilation
List for common factors of bronchopulmonary dysplasia
-Low gestational age and low birth weight
-mechanical ventilation with high airway pressure
-hi oxygen concentrations
-history of IRDS
what is the appearance of the chest for bronchopulmonary dysplasia
Intercoastal retractions
What is the respiratory pattern for bronchopulmonary dysplasia
Increased > 60/ minute
What type of breath sounds will you here with bronchopulmonary dysplasia
-Wheezes
-Rhonchi
-Crackles
--Expiratory grunting
What will the physical appearance be for bronchopulmonary dysplasia
-Nasal flaring
-Substernal retractions/abdominal distention
(seesaw movement)
Does a premature infant who has bronchopulmonary dysplasia improve with mechanical ventilation
No
Do bronchopulmonary dysplasia patients have a continued need for high oxygen concentrations?
Yes
How will the chest x-Ray appear on bronchopulmonary dysplasia patient
-Groundglass pattern
-Air broncograms
-Small lung volumes
--Cardiomegaly and pleural effusion may be present
Name 14 treatments for bronchopulmonary dysplasia
-Drug therapy bronchodilators
-Avoid endotracheal CPAP because of the increased airway resistance
-M V for vent failure
-Pulmonary hygiene
-Surgical ligation of PDA
-Extubation can be done at ventilator rates between 5 & 15 breaths / min
-Monitor fluid ba
When does transient tachypnea of the newborn occur
24-48 hours after birth
What symptoms does transient tachypnea have similarities with
It has similar symptoms to the early stages of IRDS
Why is When does transient tachypnea thought to be caused?
Believed to be caused by slow absorption of fetal lung fluid
transient tachypnea is commonly seen in which type of infants
Near-term or full-term infants of normal size and gestational age
With transient tachypnea what happens with the Apgar scores
At birth the infant shows good Apgar scores and then develops respiratory distress in the next 12 hours
How is the cough in transient tachypnea
Depressed effort, excessive secretions and mucus
What is the appearance of the chest for transient tachypnea
Intercoastal retractions, nasal flaring
What is the respiratory pattern for transient tachypnea
Increased rate > than 60
What type of breath sounds will you hear in transient Tachypnea pts
-Wheezes
-Rhonchi
-Crackles
-Respiratory grunting
Describe what you will see on a chest x-ray for transient tachypnea
-Initially appears normal
-Pulmonary congestion develops 12 hours after birth
-Patchy infiltrates
-Cardiomegaly
-pleural effusion maybe present
What is the treatment and management for transient tachypnea
Cops mu
-CPAP to offset pulmonary congestion in interested she will edema
-Oxygen therapy for hypoxemia
-Pulmonary hygiene
-Supportive care to relieve signs of respiratory distress
-Mechanical ventilation for vent failure which is rare
Usually self-limiting. anat
What type of pulmonary hygiene do you want to perform on transient tachypnea
-Suctioning
-Increased bronchial hydration
-Postural drainage and percussion
For Congenital diaphragmatic hernia, are the newborns typically mature or immature
Mature
Congenital diaphragmatic hernia. Is it more common in nale or female
Males
Congenital diaphragmatic hernia appearance of the chest
-Intercoastal and substernal retractions
-Nasal flaring
-Expiratory grunting
Congenital diaphragmatic hernia
Respiratory pattern
> 60/min
Congenital diaphragmatic hernia
Breath sounds
Absent on affected side
-bowel sounds on the affected side
Congenital diaphragmatic hernia
Physical appearance
-Scaphoid abdomen
-Barrel chest
Congenital diaphragmatic hernia
Chest x-ray
-Atelectasis and complete lung collapse
-Shift of the heart and mediastinum toward unaffected side
-Hypo-plastic left lung
-Fluid and air filled loops of intestine in the chest
Congenital diaphragmatic hernia
Treatment and medical decision-making
Aid pimp
-Always an emergency
-Immediate oxygen therapy
-Do not ventilate with mask
-Prompt surgical repair is crucial
-Insert orogastric tube to decrease gas in the bowel
-May require intubation and mechanical ventilation
-Please infant on -affected side
Congenital diaphragmatic hernia
Where do you want to keep the pressures for mechanical ventilation
Use Low Peak inspiratory pressures < 30
Do you want a high-frequency or low-frequency ventilation for Congenital diaphragmatic hernia
Hi
Congenital diaphragmatic hernia
Severe cases
Ecmo
What is the temperature of Accidental hypothermia
Below 35�C in below 95�F
How are the vital signs in a Accidental hypothermia patient
Decreased heart rate respiratory rate cardiac output temperature
-Peripheral vasoconstriction
Accidental hypothermia
Arterial blood gas
Moderate to severe acidosis with hypoxemia
Accidental hypothermia
Treatment mild cases
Passive rewarming may be sufficient
-warm, dry clothes
-warm drinks
-isometric exercises to increased heat production
Accidental hypothermia
Treatment moderate
Core temperature >30�C
Active rewarming may be required
-warm water bath
-warm blankets
-heating pads
-warm oral fluids with patient is alert
Accidental hypothermia
Severe cases <30�C
Active rewarming required
Administration of:
-warm intravenous solutions
-warm gastric lavage or peritoneal lavage
-inhalation of warm gases
Accidental hypothermia
Re-warming should proceed no faster then
A few degrees per hour to avoid complications