CSE review :3

went to choose bowel sounds

abdominal trauma + surgery

when to use vinegar?

pseudomonas

when to intubate with COPD?

NIV ALWAYS regardless of ABG and then intubate. Remember initial ABG is goal for COPDers. If given initial and follow up, try and get back to the OG ABG in regards to ventilation and correct PaO2 if needed.

IPPB vs IPPV

1. IPPV

   1. when unconscious/not alert/oriented

   2. help w/ hyperventilation

   3. only for CF pt

2. IPPB

   1. requires pt to be oriented

   2. used alongside diaphragmatic breathing exercises + pursed lip breathing

   3. for atx + recruitment

what to choose when doing a PFT?

everything but pulm compliance!

when to check theophylline

when pt is being given theophylline!

what to choose for discharge recommendations?

choose ALL of the education ones

initial assessments for baby

1. ALWAYS check BP despite needing to apply cuff during an emergency

2. ALWAYS check for irritability as it is used in APGAR

3. ALWAYS choose GA despite already birthed u monkey

4. check glucose once stable

Giving O2 to babies

Remember that sometimes no O2 is better than too much O2! Do not overcorrect hypoxemia.

RDS and what to check

always check for ❤ murmurs after birth w/ RDS

when to choose transillumination?

for pneumos!

initial vent mode for babies?

ONLY PCAC MODES! NOT SIMV

1. PIP 20-30 or VT 4-6

2. RR 20-40

3. FiO2 <60% or same

4. PEEP <+7

5. flow <10

ABG

1. PCO2 <50

2. PO2 >60

medications for babies

1. PDA → indomethacin

2. Delay labor → terbutaline

3. Induce labor → pitocin

what to do with flail chest

INTUBATE on VCAC and assume ARDS (LPV)!!!! remember to allow permissive hypercapnia + hypoxemia

adjusting CXR + ETT

when tube is @5th rib, must pull back 4-5cm to correct it!

What FiO2 to set when initially intubated?

NOT 100%!!! even if they are originally on 100%, do not put them on same FiO2 UNLESS pt has brain injury.

When to chose ECG and electrolytes

when patient is stable! do NOT choose if pt is not stable and in emergent needs

how often are sleep trials done? prevention for sleep apnea?

every year!

prevention is limit caffeine and alcohol!

when to choose spinal tap?

only for MG!

when to choose lactic?

only if chronic hypoxemia!

when to check pupillary reaction?

when in a MVA despite emergency

when does tracheal deviation happen?

only with TENSION pneumos

when NOT to do NIV?

1. combative

2. decreased LoC

do NOT start without an ABG!!!! you do not know ventilatory status!!!

how to treat coughing fits? how NOT to treat?

treat w/ lidocaine! do NOT widen alarms

how to treat air trapping?

increase PEEP!

initial NIV settings?

12-15 / 4-6

how to treat PVCs?

procainamide

other causes for high peak alarm?

1. HME (secretions, nebs)

2. H2O in tubing!

VCAC and altering rate

NEVER alter RR if over breathing. if pt is over breathing and you’re given the option to increase RR or increase VT even past 8mL/kg even by the slightest amount, CHOOSE THE VT!!!! (so dumb)

weaning

1. remember that even if 1 criteria fails, do NOT wean! this includes to NOT change modes even to SIMV!

2. only gather info thats specific to weaning even if you don’t have the info before (dont choose CXR, tracheal position, CBC, electrolytes unless indicated)

neck radiographs

expensive + only done w/ complications and new trachs

asthma scoring

1. green >80%

2. yellow >50%

home therapies + post asthma attack for asthma

1. home

   1. ALWAYS choose pulm rehab and LABA w/ SABA PRN even if not that bad

   2. still give home O2 even if 88% on RA

   3. UPGRADE meds even if in yellow and already has LABA + SABA + noncompliant

   4. everyone should get social services too

2. post asthma attack

   1. can check for time consuming things like temp and PF

COPD rehab/home

1. PFTs

   1. choose DLCO and COHb

   2. N2 washout vs He dilution: careful w/ this as both are fine normally; however, N2 washout uses 100% FiO2

   3. choose bronchodilator

2. nebs:

   1. don’t give systemic steroids

   2. give incruse ellipta! ULAMA that’s great for COPD

3. scheduling:

   1. don’t schedule CXR unless life-threatening problem like CHF or pneumo

   2. if a visit was done weeks ago, don’t schedule stuff like CXR or PFT as the “doc would’ve ordered them at that time”

baby emergency birth

1. always choose ECG, umbilical cath

2. sats

   1. check pre AND post O2

   2. if given APGAR, no need to select vitals as it gives you vitals

   3. always check trans Q CO2

   4. always choose Ballard score! tells you GA

3. CPR

   1. cannot get APGAR or Silverman

   2. do NOT get any gases if just born or during CPR

   3. give epi AFTER CPR. ETT < IV, but both are fine

   4. PPV use Tpiece > self-inflating

4. intubating

   1. 3.0 ETT is right for 30wk GA, 3.5 for 40wk

   2. post intubation, choose CPR @90bpm and 100% FiO2

5. RDS

   1. don’t keep doing PPV

   2. transition to CPAP + surf ASAP

6. Mec

   1. sxn even if someone else sxn + stabilize before attempting dry, warm, stim

   2. NEVER choose surf

7. Post birth

   1. Bowel sounds

   2. right radial AND umbilical ABG

   3. echo (shows for cardiac defects)

when to check cuff pressure?

only if leak is indicated

aspiration risk

only limit diet to easy to swallow foods and don’t cut out all foods completely

tension test

always double check VT after test

how to treat increased PIP AND pplats

do RM or decrease VT until <30, both work!

lateral xray

1. for neck trauma

2. fresh trachs

3. UA obstx.

hyper/oventilating and set rate

IGNORE set rate and only judge off of CO2 even if riding the rate! If CO2 is still low despite low rate, you are still considered over ventilating the pt.

PS and VCAC

you can still add PS to help with asynchrony even if on VCAC

thoracentesis

1. do it in ICU even if emergent-like

2. position leaning forward

3. labs

   1. redo ABG

   2. do NOT redo ECG, XR, lytes, CBC if stable + recovered

4. if atx is present (most often), start hyperinflation therapy

cancer pt

1. labs

   1. CT

   2. PET

   3. PA (get post XR afterwards)

   4. PFT

   5. ECG

   6. flex. bronch (for tissue sampling)

2. “pneumonectomy” = removal of lung, DECREASE VT

chest tubes leak

NEVER CLAMP! NEVER INCREASE VT!

call surgeon ASAP!!

TB

1. check Mantoux always for infection + AFB

2. can transport but pt must wear mask

3. all pt use standard!

neb deposition

SVN < ultrasonic, as US has deeper deposition

“thoracic” palpation

feels for crackles, choose it!

infection + meds

1. dornase = P. aeroiginosa

2. nebepent = PCP

3. relenza = flu

4. diflucan = fungal infection

high frequency chest compressions

aka HFCWO! Good for CF but expensive

pharm review

• babies:

  • PDA → indomethacin

  • Delay labor → terbutaline

  • Induce labor → pitocin

• infection

  • dornase = P. aeroiginosa

  • nebepent = PCP

  • relenza = flu

  • diflucan = fungal infection

• adults:

  • incruse ellipta ULAMA = COPD

  • procainamide = PVCs

  • IV heparin = PEs (TPA and STK AFTER heparin initiated)

indwelling cath

choose 7FR Cath to measure PAP, PCWP, CO

silica dust

1. treat w/ systemic steroids

2. don’t treat w/ -BAs, IS, PEP due to fibrotic lungs

CHF/edema medications

1. choose lasix despite low CO

2. choose digoxin despite increased pressures and low CO

transillumination

halo = good

lit up = bad

diaphragm hernia

treat w/ surgery

initiation of CPR and intubating in adults

even if you dont know if you have a pulse or not, still choose CPR if everything else is desaturating (BP, HR, RR, SpO2) as CPR will help everything.

don’t intubate even if unresponsive, if ventilating fine, just give O2.

If unstable even if PaO2 is 68-72, give 100% FiO2 due to instability.

serosanguinous fluid

serum + blood (>100mL/h = bad!)

choose shunt and coag study, NOT echo!

monitoring vitals

can choose vitals Q15min, timing/rate doesn’t matter, only matters you’re planning to check vitals.

IG choosing initial for adults

1. urinary output ALWAYS

initial vent settings for adults, indications for need of vent

1. indications for vent

   1. PaCO2 >50, pH <7.30

   2. decreased LoC, bradycardia, apnea

   3. cyanosis

   4. PF <25% + unresponsive to therapy (if asthma)

   5. pulses paradoxus >75

   6. sudden onset pain

   7. stridor

   8. silent BS

   9. cap refill >4s

1. initial vent settings

   1. VT <10mL/kg

bronchiectasis non CF discharge

1. choose ICS, -BAs, -MAs, antibiotics, mucolytics

2. O2

3. BHP/hyperinflation

4. increase PO fluids (oral fluids to improve hydration + thin secretions)

mucus plug

1. even if BS absent in a place, doesn’t mean pneumo! can be absent in a -LL, diminished in a -ML and normal/consolidation in UL. this means a plug is blocking off flow in LL! not a pneumo!

2. IPPB + postural drainage not indicated once plug is released

3. GIVE ICS

MRSA

1. contact precaution

2. vancomycin

choosing PF

ALWAYS choose for ANY COPDer even if its not asthma and even when they’re actively dying (high RR, etc.)

GB treatments

plasmapheresis AND STEROIDS!

If its progressed enough to where they cannot move their lower extremities, give heparin + elastic stockings etc

shunt vs mismatch

shunt = improves with pressure but not pure FiO2 change, as alveoli are perfused but are collapsed and thus not oxygenated

mismatch = should improve with FiO2 change

BPD treatnebt

steroids!