Test 2 MS2

Acute Respiratory Distress Syndrome (ARDS)

• Requires mechanical ventilation

• Results from another condition (i.e. trauma)

• Life-threatening condition

What differs ARDS from respiratory failure?

• ARDS has an acute onset

• ARDS shows severe hypoxemia — despite O2

  • Refractory hypoxemia

• in ARDS there are Bilateral infiltrates on chest x-ray

ARDS common causes

• Sepsis

• Pneumonia

• Aspiration

ARDS risk factors

• 60 y/o or older

• Trauma

• Traumatic brain injury

• Drowning

• Drug overdose

• Recent cardiac-related surgery

• Smoking

• Excessive alcohol use

ARDS- clinical cues

• Tachypnea

• Respiratory distress

• Tachycardia

• Crackles in lungs

ARDS potential complications

• Infection

• Respiratory complications

• GI complications

• Cardiac complications

• Renal failure

• MODS

ARDS testing

• Arterial blood gas

• Chest x-ray

• Complete blood count (CBC)

• Find the cause

Principles of ARDS management

ABCDEF Bundle - ARDS

• A- Assess, prevent, and manage pain

• B- Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)

• C- choice of analgesia and sedation

• D- Delirium: assess, prevent, and manage

• E- Early mobility and exercise

• F- Family engagement and empowerment

ARDS- Prone positioning

• Improves oxygenation

  • Reduces hypoxemia

  • Enhances ventilation-perfusion matching

• Promotes more uniform distribution of air in lungs

• Decreases atelectasis

  • Reopens collapsed alveoli

• Improves lung compliance

  • Reduces ventilator-induced lung injury

• Facilitates drainage of respiratory secretions

  • Aids in clearing airways

• Reduces risk of ventilator-associated pneumonia

Respiratory Failure

• A general term for when the respiratory system fails

• There is an altered gas exchange

• There are 2 main concerns:

  • Oxygenation

  • Carbon dioxide elimination

Causes for Respiratory Failure- Pulmonary causes

• Tumor

• Pneumonia

• COPD

• Asthma

• Cystic fibrosis

Causes for Respiratory Failure- Non-pulmonary causes

• Muscle weakness

• Neuromuscular disease

• Medications

• Narcotic/sedative overdose

• Chest wall trauma

Respiratory failure risk factors

• Pollution, air irritants

• Smoke and second-hand smoke

• 65 y/o or older

• Alcohol and drug use (overdose)

• Opioid use

• Sedative use

• Noncompliance with respiratory medications

Pulmonary embolism (PE)

• A blockage that causes the pulmonary artery blood flow to be altered

• Emboli can be made of:

  • Blood

  • Air

  • Fat

  • Cancer

  • Tumors

  • Foreign body  

 

PE- Virchow’s Triad

Virchow's triad is a medical model that outlines the three primary categories of factors that lead to blood clot formation (thrombosis) inside a blood vessel

• Increased coagulability

• Venous stasis

• Endothelial tissue injury

PE Risk factors

• T- Trauma, travel

• H- Hypercoagulable state, hormone replacement therapy

• R- Recreational drugs (IV)

• O- Older age (>40)

• M- Malignancy

• B- Birth control pills or patches

• O- Obesity, obstetrical (pregnancy, 1st 6 weeks postpartum)

• S- Surgery

• I- Immobilization

• S- Serious illness

Use THROMBOSIS to remember

PE clinical cues

• Common:

  • Dyspnea

  • Chest pain

  • Cough

• More severe

  • Arrhythmias

  • Shock

  • Syncope

PE complications

• Dec. cardiac output

• Dec. perfusion/oxygenation

• Lung damage

• Heart strain/damage

• Pleural effusion

Testing for PE

• Chest X-ray

• EKG (nonspecific ST/R wave abnormalities)

• VQ Scan

• CT angiography (standard)

• D-dimer (elevated)

• ABG (hypoxemia/hypocapnia)

PE Treatment

• Anticoagulation

  • Immediate

  • Long term

• Thrombolytic therapy

  • TPA (Tissue plasminogen activator)

    • Hypotension, no bleeding risk

    • For massive PE

• Surgical

  • Embolectomy

    • Rare

    • Other options failed or are not possible

    • Hemodynamically unstable

Bleeding precautions

R- razor (electric only)

A- aspirin (NO!)

N- Needles (small gauge)

D- Decreased needle sticks

I- Injury (protect from)

Intracranial Pressure (ICP)

• Normal pressure ranges between 5-15 mmHG

• Increased ICP decreases cerebral perfusion and causes ischemia, cell death, and further edema (herniation)

• The earliest sign of increasing ICP is change in LOC 

Signs of Increased ICP (IICP)

• Headache

• Increased BP

• Confusion

• Shallow breathing

• Nausea

Causes of IICP

• Head injury (most common)

• Brain tumor

• Subarachnoid hemorrhage

• Toxic/viral encephalopathy

• Cerebral edema

ICP Fluctuations

• Persons body temperature

• Oxygenation status, especially CO2 and O2 levels

• Body position

• Arterial and venous pressure

• Anything that increase intra-abdominal or thoracic pressure (vomiting, coughing, bearing down, etc.)

Cerebral Perfusion Pressure (CPP) Formula

CPP = MAP - ICP

Adequate CPP is 60-100 mmHG

CPP <50 mmHG results in permanent neurologic damage

A CPP <30 mmHG results in ischemia and is incompatible with life

Maintaining CPP

• CPP > 70 is the goal

• Monitor respiratory status; even slight hypoxia or hypercapnia can impact cerebral perfusion

• Assess VS and neurologic status every 15 minutes to every hour

• Strategies to reduce cerebral edema

  • Cerebral edema peaks 24-36 hours

• Strategies to control factors that increase ICP

• Avoid extreme head rotation

CPP complications

• Cerebral edema and herniation

• Decreased cerebral perfusion pressure

• Seizure

• Fluid and electrolyte abnormalities

  • SIADH

  • DI

• Hyperthermia

• Nutrition problems

• Brain death

Cerebral edema

• Fluid buildup around the brain

• Can be fatal if untreated

Cerebral edema common causes

• Blood-brain barrier interruptions

• Brain injury

• Excess sodium then water

• Meningitis

Subarachnoid Hemorrhage

• Blood between arachnoid and pia mater

Subarachnoid Hemorrhage Risk factors

• Older then 50

• Brain injury

• Hypertension

• Smoking

Subarachnoid Hemorrhage Clinical Cues

• Early signs

  • Sudden “thunderclap” headache

  • “Worst headache of my life”

  • Double vision

  • Altered LOC

  • Nausea/vomiting

  • Neck pain

  • Stiffness

• Late signs:

  • Vasospasm

  • Cerebral ischemia

  • Coma

  • Seizures

  • Rebleeding

  • Hydrocephalus

Head Injury: Primary injury

Due to the initial damage

• Contusions

• Lacerations

• Damage to blood vessels

• Acceleration/deceleration injury

• Due to foreign object penetration

Head injury: Secondary injury

Damage evolves after the initial insult

• Cerebral edema

• Ischemia

• Chemical changes associated with the trauma

Head injury manifestations

• Depends on the severity and location of the injury

  • Scalp wounds

  • Tend to bleed heavily, portals for infection

• Skull fractures

  • Usually have localized, persistent pain

• Fractures of the base of the skill

  • Raccoon’s eyes

• Battle’s signs

  • ecchymosis behind the ears

• CSF leak

  • Halo sign

  • Ring of fluid around the blood stain from drainage

Glasgow coma scale

Decorticate vs decerebrate posturing

Head injury safety

• Fall risk

• Seizure precautions

• Up with assist

• Increased rounding

• Education

  • wear a seatbelt

  • wear helmets/protective gear for sports

  • adequate lighting

  • limit alcohol and illicit substances

  • don’t drive impaired

  • avoid driving if taking medications that cause drowsiness or dizziness

  • Get help if feeling angry/frustrated when caring for a child

Spinal cord functions

• Reflexes

• Motor control

• Sensory information

• Autonomic function

Spinal cord injury causes

• Motor vehicle accidents

• Falls

• Violence

• Sports

• Surgical injuries

• Birth defects

• Infections

• Cancer

• Arthritis

• Osteoporosis

Spinal cord injury risk factors

• Spinal fractures

• Ages 16-30 and older then 65

• Not wearing protective gear

• No seatbelt use

• Chemical impairment

• Areas of violence

• Medical conditions

Spinal cord injury clinical cues

• C1-4: Ventilator dependence

• C1-7: Limited proprioception

• T1-8 Affects trunk movement, lack of abdominal control

• T9-12 Limited abdominal control

• L1-S5: Loss of bowel and bladder functioning, affects sexual function

Spinal cord injury treatment

• Stabilization

• Fix cause if possible

• Limit complications

Spinal cord injury prevention and education

• wear seatbelt

• car with airbags

• don’t drive impaired

• Fall prevention

• Protective gear for sports

• Bike helmets

• Ground level trampolines, single use

• Responsible gun use

Autonomic Dysreflexia

• Massively uncompensated

• Cardiovascular reaction

• Sympathetic nervous system

  • Sudden high BP

  • Sudden low HR

• T6 or above

• Most common immediately after spinal cord injury

Spinal cord injury resilience

What is wound healing altered by

Poor perfusion

Poorly controlled diabetes

Vasoconstriction

Immunosuppression

Venous insufficiency

Types of tissue injuries

Moisture

Friction

Shearing

Pressure

Burns

Trauma

Infection STONEES assessment

S-Size becoming larger

T-Temperature increasing

O-Osseous, bone exposed

N-New breakdown

E-Erythema

E-Exudate

S-Smell

Healing factors for skin

Perfusion

Nutrition

Protein

Vitamins A, B, C, D, E

The fire triangle

Oxygen, heat, and fuel

Burn Prevention

• No smoking in bed

• No smoking with oxygen

• Keep matches/lighters away with children

• Avoid toxic gases

  • No methamphetamine cooking

  • Avoid cyanide

  • Avoid carbon monoxide

• Have a fire extinguisher and know how to use it

• Max water temperature setting 120F/48.9C

• Avoid electrical wires when digging outside

• No flammable liquids to start a fire

• Watch loose clothes while cooking

• Working smoke detectors and carbon monoxide detectors

First degree burn

Damage to the epidermis, such as sunburn

second degree burn

Damage to epidermis and dermis

third degree burn

Damage to epidermis and dermis that will require skin grafting

fourth degree burn

same as third degree but extending fat layer

fifth degree burn

same as 3rd degree burn but extending into muscle layer

sixth degree burn

same as 3rd degree but extending to the bone

Burn ABCDE Assesement

• A: Airway, assess for patency and inhalation injury​

• B: Breathing, assess quality and rate of respirations​

• C: Circulation, assess blood pressure, pulse, skin color​

• D: Disability, assess for neurologic impairment or other trauma​

• E: Exposure and environmental control, remove all clothing, jewelry, and contact lenses. Observe for any remaining burning substances on the skin and remove them. View entire body, including the client’s back. Assess temperature to avoid making client hypothermic

Burn Surface area

• Total body surface area

• Is an assessment of injury to the skin

• Rule of nines

  • most common, easy to use

• The lung and browder method

  • More precise, includes age of pt

• Palmer method

  • Small burns, for scattered burns

Rule of nines burns

• Head 9%

• Right arm 9%

• Left arm 9%

• Front 18%

• Back 18%

• Right leg 18%

• Left leg 18%

• Genital 1%

Parkland formula for burns

• 2-4ml x weight kg x TBSA = 24 hour replacement

  • unless stated, assume 4ml

• ½ in 8 hours

  • half of total volume divided by 8

• ½ in 16 hours

  • half of total volume divided by 16

Complications for burns

• Wound infection

• Pneumonia

• Bacteremia

• Dehydration

• Kidney injury

• Acute compartment syndrome (ACS)

• Sepsis

• Acute respiratory distress syndrome (ARDS)

Compartment syndrome

painful

Decreased blood flow

Acute or chronic

Burns Grafting

• Decrease infection risk

• Prevent further loss of:

  • Fluid

  • Protein

  • Electrolytes

  • Heat loss

• Autograft:

  • Patients own skin

• Allograft:

  • Biologic from donors

    • alive or decreased

• Xenograft:

  • From animals

    • usually pigs

Do for burns

Cool the burn with water

apply aloe vera

bandage the burn

take pain reliever

Don’t for burns

Don’t use oils

Don’t use egg

Don’t pop blisters

Don’t use ice

Med math

order/given * mL

Drip Rate (gtt/min)=Time (minutes) / Volume (mL)×Drop Factor (gtt/mL)​

lbs/2.2= kg

Safe dosage → parameter * weight = range

Cardiac Output Formula

CO = Heart rate× Stroke volume​

Mean Arterial Pressure (MAP) formula

• MAP= SSP+ 2(DBP) / 3

• The average pressure in the arteries during one cardiac cycle

• Better indicator of perfusion to vital organs than SBP

• 70-100 is normal

• 65-70 is adequate

• 64 and below is concern for poor perfusion

Ataxia

Inability to coordinate muscle movement

Rigidity

Characteristic features are stiffness, inflexibility, and the inability to bend, twist, or stretch

Halo sign

Contains blood and cerebrospinal fluid (CSF)

Delerium

Disorientation, can progress to irreversible brain damage

Flaccidity

Lack of muscle tone

Battle’s sign

Ecchymosis behind the ear

Spasticity

Is a type of hypertonia that causes continuous contraction, tightness, and stiffness in muscles

Monro Kellie hypothesis

• the skull is a fixed, rigid space containing three main components:

  1. Brain tissue

  2. Blood

  3. Cerebrospinal fluid (CSF)

• Because the skull cannot expand, the total volume of these three components must remain relatively constant.

• If one component increases in volume, the other components must decrease to compensate.

  • If compensation fails, intracranial pressure (ICP) increases