Barron's CCRN

"high dose" dopamine causes vasoconstriction and

(C) Increase afterload

What is the primary hemodynamic effect of:

Dopamine >10 mcg/kg/min

(A) Increase preload

(B) Decrease preload

(C) Increase afterload

(D) Decreased afterload

(E) Increase contractility

(D) Decrease contractility

Pulmonary HTN and cor pulmonale;

Mitral, aortic, or tricuspid insufficiency

What causes the S3 sound?

during diastole

When are coronary arteries perfused?

S3 heart sound

What may you hear before crackles when a patient is going into heart failure?

Variant or Prinzmetal's Angina

What is this called?

Unstable angina with transient ST segment elevation

Can occur at rest or may be cyclic (occurring at the same time daily)

troponin negative

Can be precipitated by nicotine, coke, or ETOH

RCA, inferior LV

There are changes in leads II, III, aVF....what type of MI?

LAD, anterior LV

There are changes in leads V1, V3 V3, V4

circumflex, lateral LV

There are changes in leads V5, V6, I, aVL

Low lateral LB

There are changes in leads V5, V6

high lateral LB

There are changes in leads I aVL

RCA, posterior LV

There are changes in leads V1 and V2

RCA, right ventricular infarct

There are changes in leads V3R, V4R

Marked ELEVATION of troponin/CK-MB: due to miocardial stunning when vessel opens

reperfusion arrhythmias: VT, Vfib, accelerated idioventricular rhythm (due to stunning)

resolution of ST segment deviations

Chest pain relief

What are some signs of reperfusion following fibrinolytic treatment of a STEMI?

contact the physician. Could be coronary artery re-occlusion/stent thrombosis.

Your patient just had a percutaneous coronary intervention (PCI) (stenting) less than 24 hours ago:

He is experiencing unrelenting chest pain, his EKG shows ST elevation. What should you do? What could be happening?

retroperitoneal bleeding is most likely. Give fluids/blood

Your patient just had a percutaneous coronary intervention (PCI) (stenting) less than 24 hours ago:

He is experiencing sudden low severe back pain and becomes hypotensive. What is happening?

>1 (get by dividing ankle pressure by brachial pressure on the same side)

what is a normal ankle-brachial index (ABI)?

do not elevate the affected extremity, it will decrease perfusion

Put bed in reverse trendelenburg

Your patient has PAD and just had a bypass graft. How should you care for the extremity? How should the HOB be?

torsades

prolonged QT can lead to what deadly rhythm?

Amiodarone

Haldol

Quinidine

Procainamide

Low mag, calcium, or potassium

Causes of prolonged QT

Amiodarone 150 mg IV over 10 min; Prepare for elective synchronized cardioversion.

Your patient has a pacemaker and has gone into Vtach. The pacemaker does not correct the rhythm and your patient goes unresponsive. What do you do?

1. Jungular Vein Distention

2. Ascending Dependent Edema

3. Weight Gain

4. Hepatomegaly (Liver Enlargement)

right sided heart failure

1. SOB

2. Crackles

3. Oliguria

4. Frothy Sputum

5. Displaced Apical Pulse (Hypertrophy)

*left goes away from lungs...takes your breath away

Left sided heart failure

A mechanical pump that helps the ventricles pump blood, easing the workload of the heart in patients with left ventricular heart failure, cardiogenic shock, and cardiac myopathies.

Ventricular assist device (VAD)

inflates (INCREASES CORONARY ARTERY PERFUSION)

and deflates ( DECREASES AFTERLOAD)

Inflates at dicrotic notch of the arterial waveform, beginning of diastole

Deflates before systole begins, determined by set trigger for deflation, R-wave of ECG or upstroke of arterial pressure wave

IABP

tamponade

pericarditis

long CABG can increase bleeding risk due to increased heparin dose in surgery

CABG (Coronary Artery Bypass Graft) complications

Narrowed pulse pressure (IE 82/68)

Pulsus paradoxus: excessive drop is SBP (>12mmgh during inspiration). Cardiac muscle restriction due to tamponade with inspiration, intrathoracic pressure increases thus decreasing venous return

Restlessness and agitation.

Distended neck veins (JVD), hypotension, diminished heart sounds (Beck's triad); equalization of CVP: pulmonary artery diastolic and PAOP

Signs of cardiac tamponade

4-12 mmHg

PAWP (pulmonary artery wedge pressure) (same as PAOP) normal?

hypovolemia (low PAWP, low volume)

normal is 4-12

PAWP (same as PAOP) of 1-3 mmhg means?

Hypervolemia (high volume, high PAWP)

normal is 4-12

PAWP(same as PAOP) of >12 mmhg means?

https://www.youtube.com/watch?v=i1oJ-WyTvo8

Good video for swan ganz

nose to alveoli: Air within the trachea, pharynx, larynx, bronchi, and nasal passages

Anatomic dead space is considered to be the:

PE. No blood flow past the PE, so all alveoli past it is dead space

what causes alveolar dead space?

right side. good lung down! if the right lung is down, more blood flows to it, thus increasing o2

you have a patient with left-sided pneumonia, the right lung is largely unaffected. Which position would you place them in to improve oxygenation?

0.8

=4 L ventilation/5L perfusion

normal VQ ratio

a pathologic shunt. Blood goes thru the lungs but does not get oxygenated resulting in refractory hypoxemia

ARDS is an example of what?

0-5% normal

carbon monoxide clings to Hgb and O2 cannot attach when CO is already attached. Pulse oximetry is unreliable because it just detects Hgb saturation. Thus if a patient has a CO level of 40%, they cannot have more than 60% O2 sat.

Treatment is 100% fiO2 until CO is >10% or hyperbaric

what is the normal level for carbon monoxide?

What should be considered when monitoring O2 sats?

What is the treatment for excess?

suspected pneumothorax

hemodynamic instability/life threatening arrhthmias

secretions/aspiration risks

contraindications to NIV (BiPAP/CPAP)?

Increased WOB/hypoxic respiratory failure.

Example: a patient that has pulmonary edema and can follow verbal commands.

CPAP is indicated for patients who:

Need both ventilation (IPAP) and oxygenation (EPAP)

hypoxic and hypercapneic resp failure

BiPAP is indicated for patients who:

(1) > 60% oxygen (2) inhalation of salbutamol (3) IV hydrocortisone (4) oral prednisolone

Status asthmaticus treatment

Use low rate to increase exhalation time

Use low tidal volumes to prevent auto-PEEP

Increase inspiration/expiration (I/E) ratio, often greater than 1:3-4, to allow time for optimal exhalation and prevent auto-PEEP

status asthmaticus ventilator considerations

serious airflow obstruction or pneumothorax.

Status asthmaticus---> Intubate

A silent chest may indicate

fat emboli

your patient suffered a femur fracture, they are developing petechiae and a cough, low grade fever and anxiety. What could be going on?

ALI and ARDS are the most common cause of this

noncardiogenic pulmonary edema causes?

No. Can make it worse

should steroids be used in ARDS?

limit to 30 or less

Plateau pressure in ARDS?

limit tidal volues to 4-6 ml/kg ---> permissive hypercapnea to prevent volutrauma.

Vt in ARDS?

tension, possibly life threatening. Air is unable to escape, causes

mediastinal shift,

tracheal deviation AWAY FROM AFFECTED SIDE

distended neck veins

hypotension

*other symptoms similar to regular pneumo

which is worse, tension pneumo or a regular pneumo?

tracheal deviation TOWARD AFFECTED SIDE

decreased/absent breath sounds

hypoxia

unequal chest excursion

chest pain

SOB

regular pneumo signs/symptoms?

3-5 cm above carina

ETT placement?

8-10 ml/kg, decreased in ARDS to 4-6

typical Vt?

cranial nerve IX

Swallow and gag reflex

check pupils---> oculomoter

to assess cranial nerve III, you would...

right side, ipsilateral

your patient has a head injury to the right side. You would expect a blown pupil to occur on which side?

left

your patient has a head injury to the right side. You would expect a positive babinski on which side?

positive. This means the eyes move in the opposite direction of the turn. Like a doll.

"It's good to be a doll"

your patient has a positive dolls eyes reflex. You interpret this as a _____ sign.

this is bad and abnormal. IT's also bad when the eyes don't move and stay midpoint.

Your patient's eyes move in the same direction of the turn when the dolls eyes maneuver is done.

Good! this is a positive reflex

the eyes move toward the ear with ice water being injected (oculovestibular). Good or bad?

midbrain

hyperventilation is an indication of what kind of neuro problem?

pontine problem

Apneustic breathing is an indication of what kind of neuro problem?

medulla

ataxia is an indication of what kind of neuro problem?

toward the pathology

If you patient has a left sided stroke, his eyes may deviate toward or away from the affected side?

right side, contralateral

your patient is having hemianopsia in his left eye, you know this means that he had a left or right sided stroke?

blown pupil

in an uncal herniation, what will you see first, LOC change or blown pupil on the side affected?

epidural hematoma in temporal area (uncal herniation occurs due to displacement of temporal lobe against brain stem and 3rd cranial nerve-->oculomoter)

what is the most common cause of uncal herniation?

swelling on both sides-->downward displacement of hemispheres

slight change in LOC then coma

constriction of pupils (1-3mm) then both dilate

Bil. Babinski

Causes are cerebral edema secondary to stroke or encephalopathy

what happens in central herniation?

Think P

aPneustic breathing

Pinpoint Pupils

Parasympathetic innervation

Pontine stroke S+S

to prevent elevated ICP

why is decadron given in neuro cases?

Decreased level of consciousness

first sign of increased ICP

0-10

normal ICP

CPP = MAP - ICP

how to calculate cerebral perfusion pressure?

80-100

minimum is 50

brain death is under 30

average CPP?

VERY BAD results in poor cerebral perfusion CPP= MAP-ICP

high ICP with hypotension...

1. Elevated systolic BP

2. Bradycardia

3. Irregular respirations

Cushing's triad consists of:

A waves are "awful"

"A" Waves of ICP monitoring

B waves are bad

"B" waves of ICP monitoring

C waves are common

C waves of ICP monitoring

A waves and high ICP

cerebral vasospasm results in ___ waves and ____ ICP

No! hypotonic, increased cell swelling

should you give 0.45 NS to a patient with high ICP?

No! hypotonic, increased cell swelling

should you give D5W to a patient with high ICP?

No. Hyperventilation causes alkalosis, which increases vasoconstriction which does lower ICP, but decreases cerebral blood flow

Should hyperventilation be used to decrease ICP?

-Bleeding between the dura mater and the skull

-Patient will decompensate faster RAPID symptoms

can cause UNCAL HERNIATION --->death

S+S:

headache

confusion

vomiting

ipsilateral pupil dilation usually before decreased LOC

contralateral hemiparesis/plegia

epidural hematomas

basilar fx

Check fluid coming out of nose for glucose, if positive, it is CSF

Could also put on gauze to check for clot surrounded by yellow halo---> Halo sign

NO blowing nose!

Battles sign/raccoon eyes/otorrhea

your patient with a skull fracture (you're not sure where) has lost cranial nerve I, sense of smell and has a runny nose. What do you suspect?

cerebral hypermetabolism (after 30 mins)

in status epilecticus, what is death due to?

bacterial meningitis

Low glucose in CSF

viral meningitis (60% is normal glucose)

normal glucose in CSF

8-12 mins

after how long would you reconnect vent and do an ABG for apnea test?

8-10 mins with pco2 >60 or >20 from baseline

positive apnea test for brain death

Tensilon test:

Myasthenic--> improved symptoms

Cholinergic---> increased weakness and SLUDGE

Myasthenic Crisis vs. Cholinergic Crisis

salivation, lacrimation, urination, defecation, GI upset, emesis,

miosis

cholinergic crisis S+S

SLUDGE

atelectasis LLL

left pleural effusion

--->due to elevation of left diaphragm (side of pancreas body)

bil. crackles

ARDS

---> due to phospholipase A relsease which "kills" type II alveolar cells thus decreasing surfactant.

pulmonary complications of pancreatitis

bruising in flank area (lower back area)

hemorrhagic pancreatitis

Grey Turner's sign

ecchymosis in umbilical area, seen with pancreatitis

hemorrhagic pancreatitis

Methemalbumin forms from digested blood and tracks around the abd from the inflamed pancreas

Cullen's sign

low calcium. It's used up for autodigestion.

trousseau's sign, prolonged QT, seizures

what electrolyte abnormality in pancreatitis?

Referred pain down the left shoulder;

indicative of a ruptured spleen (may also have abd distention and absent bowel sounds).

Kehr's sign

intraperitoneal bleeding

Cullen's sign + abdominal trauma. Where is the injury?

retroperitoneal bleeding

Grey Turner's sign + abdominal trauma. Where is the injury?

ruptured spleen

left shoulder pain + abdominal trauma. Where is the injury?

diaphragmatic rupture

bowel sounds in chest + abdominal trauma. Where is the injury?

disruption of GI tract

Free air on X ray