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Air Methods Critical Care Exam (200)
Answered Questions 2024/
What is the most reliable method of confirming and montioring correct placement of an ET tube? - ANSWER-Continuous waveform capnography The upper airway consists of... - ANSWER-Nose, Mouth, Jaw, Oral Cavity, Pharynx, and Larynx No gas exchange occurs here __________, it's called ____________. - ANSWER-Nose to terminal bronchioles, anatomical dead space. (2ml/kg of inspired tidal volume) They conduct airflow towards gas exchange units. Crycothyroid membrane - ANSWER-between thyroid and cricoid, avascular structure that connects the thyroid and cricoid cartilage. Site of CRiCOTHYROTOMY- an emergency opening of the airway. A PaCO2 greater than 45 mmHg indicates: A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. - ANSWER-C. Respiratory acidosis PaCO2 normal range - ANSWER- 35 - 45 mm Hg Less than 35 likely means hyperventilation Tracheal deviation AWAY from the affected side, decreased breath sounds, and hyperresonance... What's happening? - ANSWER-Tension pneumothorax In a tension pneumothorax tracheal deviation goes in what direction? - ANSWER- AWAY from affected side. Normal mean pulmonary artery pressure - ANSWER- 10 - 20 mmHg Pulmonary hypertension is a mean PA pressure greater than... - ANSWER-(PAm) greater than 20 Primary pulmonary hypertension - ANSWER-Idiopathic genetic disorder caused by abnormal structure of the pulmonary blood vessels Name three causes of secondary pulmonary hypertension.. - ANSWER-1. Passive PH- the result of back pressure. Mitral Stenosis, LV systolic failure.
- Active PH- Constriction of the pulmonary circuit Increased volume in pulmonary circuit (i.e. congenital heart disease)
- Obstruction as in Chronic recurrent PE TNP of the Pregnant patient - ANSWER-Resuscitation priorities are the same. The best way to take care of the baby is to take care of mama Mechanisms of injury and biomechanics the most common cause of maternal injury is...
- ANSWER-Blunt trauma caused by MVC. Second is BT caused by falls, 3rd is violence fetal distress is an early sign of maternal distress... Why? - ANSWER-Catecholamine mediated vasoconstriction resulting from blood loss shunts blood away from the fetus to the mom. Fetal hypo perfusion is evidenced by.... - ANSWER-Fetal tachycardia (140 to 160+) and fetal bradycardia The FRC in a pregnant patient is.... - ANSWER-Reduced by the gravid uterus lifting the diaphragm. chest tube placement in a pregnant patient is 1-2 spaces higher - ANSWER-Because of the lifted diaphragm What is the cause of physiological anemia in pregnant patients? - ANSWER- Hemodilitional anemia occurs. Plasma volume increases 30-50%. Preterm Labor (PTL) - ANSWER- abruptio placentae - ANSWER-premature separation of the placenta from the uterine wall On a pregnant patient... - ANSWER-Chest compressions must be higher on the sternum. Any preg patient 20 weeks pregnant or more with a uterus above the umbilicus should have the uterus left laterally displaced during compressions to avoid aortocaval compression. A 15 degree tilt of the long board or lateral displacement. What is the Maternal Fetal Triage Index? - ANSWER-A valid reliable 5 level triage tool that may assist in the triage of obstetric trauma patients. Displacing the uterus off the vena cava can improve CO by - ANSWER-approximately 30%! Continuous fetal monitoring is recommended... - ANSWER-for all pregnant patients 20 or more weeks gestation... or (uterus above belly button). Fundal height measurement - ANSWER-equals the approximate gestational age in weeks, until week 32.
STEMI diagnosis - ANSWER-Chest pain + positive cardiac enzyme (TROP. >0.4), and -
- ST segment ELEVATIONS greater than 1 mm in two or more contagious leads V1-V
- Reciprocal (depressions) changes in leads II, III, AVF STEMI EKG findings - ANSWER-STEMI STEMI EKG findings more - ANSWER--St elevations > 1mm in Limb leads: 1, II, III, avF, avL
- St elevations > 2mm in precordial leads (v1-v6) AND/OR
- NEW LBBB Contiguous leads with reciprocal changes in opposite leads First degree Heart Block EKG - ANSWER-AV block Prolonged PR Interval greater than 120-200 ms second degree heart block type 1 Wenkebach - ANSWER-AV block in which occasional electrical impulses from the SA node fail to be conducted to the ventricles. PR interval progressively lengthens greater than 120-200ms + dropped beats. Maternal cardiopulmonary arrest...If any moribund patient is 24 weeks or more perimortem c section must be considered. AHA recommends c section initiation within...
- ANSWER-4 minutes... delivery with in 5 minutes of any unsuccessful maternal resuscitative attempts. Second Degree Heart Block (Mobitz II) - ANSWER-= Damage AT av node - moderate
- PR-interval is normal; QRS complexes are dropped erratically
- ALL must have a pacemaker in the next 72 hrs. STEMI Nitro gtt - ANSWER- 5 - 10 mcg per minute Titrate by 10 mcg max dose 300 mcg per minute How do you mix epi? - ANSWER-Mix 1 mg in 1 L NS or D5W or LR for a concentration of 1 mcg/ ml What's the epi dose for hypotension s/p arrest? - ANSWER-0.1 - 0.5 mcg/kg/min What is the epi dose for anaphylaxis? - ANSWER- Pediatric Epinephrine dose - ANSWER- PALS 2020 update - ANSWER-AHA 2020 BASIC BP
Diastolic BP of at least 25mmhg in infants and at least 35 mmhm in children correlates with better outcomes. PALS Brady with a pulse - ANSWER-Assess airway, breathing, mental status Most common cause is hypoxia! could also be hypothermia and or medications. s/s of shock? AMS? hypotensive? Start CPR if any of these Always start CPR if HR < 60 bpm iv access Give Epi 0.01 mg/kg (0.1ml of 0.1mg/ml solution) Repeat Q 3-5 minutes Initial management of pediatric respiratory distress or Failure A - ANSWER-1. A-ABC. Support open airway: Comfort or Head tilt chin lift. Jaw thrust. Clear airway if indicated. (suction nose or mouth if indicated) Consider OPA or NPA. IDENTIFY type and Severity of respiratory problems Initial management of pediatric respiratory distress or Failure B - ANSWER-2. B-Monitor Spo2 withPulse ox. Provide high concentration O2, via non rebreather
- Administer inhaled meds: Albuterol or Epi. as needed
- Assist ventilation with child ambu + o2 if needed. Prepare for intubation if needed. Initial management of pediatric respiratory distress or Failure C - ANSWER-3.C-Monitor heart rate, rhythm and BP. Establish IV/IO access. and fluids/ meds as needed. Evaluate Identify Intervene What is an upper airway obstruction? - ANSWER-Interruption in airflow through nose, mouth, pharynx, or larynx. The large always outside the thorax. PALS What causes upper airway obstruction? - ANSWER-Airway Swelling (anaphylactoid rx) ,Infection r/t croup Aspirated foreign body enlarged tonsils or adenoids Decreased level of consciousness GCS of 8? Infants and small children are especially vulnerable to - ANSWER-Upper airway obstruction. Infants are obligate nose breathers. PALS Management of upper airway obstruction - ANSWER-position of comfort, or jaw thrust chin lift 100% FIO2 via non rebreather
- Carefully weigh decision to suction. Don't do it if it's croup of anaphylaxis.
- give nebulizer epinephrine particularly if swelling is beyond the tongue.
PALS Management of acute asthma Mild to Moderate - ANSWER--Administer humidified O2 in high concentration via nasal cannnula or O2 mask. K
- Keep SpO2 >= 94%
- Administer Albuterol via MDI or Nebulizer
- PO corticosteroids PALS Management of Moderate to Severe Asthma - ANSWER--Administer O2 for a SpO2 >= 94% NC or NRB
- Albuterol via MDI with Spacer or Nebulizer
- Continuous Albuterol may be needed
- Administer Ipatroprium in combo with the albuterol
- Corticosterorids IV
- Magnesium Sulfate 25-50mg/Kg via slow IV bolus over 15 to 30 minutes. MAX 2g
- Labs as indicated PALS Management of Severe Asthma - ANSWER-In Addition to all of the interventions for moderate to sever asthma...
- Consider Terbutaline 10mcg/Kg load over 5 minutes SQ or as a gtt 0.1 mcg/kg/min or IM epi as an alt.
- Bipap
- If refractory hypoxemia intubate. Epi Dose, Flight nurse trick - ANSWER-0.1ML/kg no matter what concentration according to Bill. PALS Defibrillation dose - ANSWER-2 J/kg PALS Cardioversion dose - ANSWER-0.5-1 J/KG PALS Calcium Dose & Indication - ANSWER-Only for known/suspected hypocalcemia 20 mg/kg Calcium Chloride SLOW IV push PALS Increased ICP Cushings Triad - ANSWER-Caused by increased ICP and impending herniation.
- Irregular Breathing
- Hypertension
- Tachycardia In adults it's bradycardia Hyperventilate the patient to prevent further increases in ICP
- hypertonic saline, Osmotic agents (dose?)
- Treat pain and agitation aggressively once airway is established.
- Avoid hyperthermia PALS management of respiratory distress due to poisoning - ANSWER--Support airway
- give antidote
- call poison control
Ventilation Management - ANSWER-a Tidal volume is 5-7mL/Kg aprox. 500ml for an adult
hemodynamic changes in Cardiogenic shock - ANSWER-SBP (Down) SVR (UP) CVP (UP) CO (Down) PAP (UP) Wedge (UP) PVR (UP) Coags (PT/INR/PTT) - ANSWER-PT 11-14s PTT (20-40 sec) heparin INR (0.9-1.2) Coumadin Platelets : 150-450k Blood Gas - ANSWER-pH: 7.35-7. PaCO2: 35- 45 PaO2: 80- 100 HCO3: 22- 26 chemistry panels (renal, hepatic, comprehensive, metabolic) - ANSWER-Na+ 135- 145 Cl- 95 - 105 K+ 3.5-4. Cr 0.6-1. Glucose 70- 100 Magnesium 1.7-2. Magnesium - ANSWER-1.7-2. K+ (potassium) - ANSWER-3.5-5.0 mEq/L Na+ - ANSWER- 135 - 145 mEq/L Glucose - ANSWER- 70 - 110 mg/dL Cr (Creatinine) - ANSWER-0.6-1.3 mg/dL Systemic Vascular Resistance (SVR) - ANSWER-the force opposing the movement of blood within the blood vessels [(MAP-CVP) / CO] x Normal: 750-1600 dynes/sec SVR Formula & Normal - ANSWER-(MAP - CVP / ) x 80
Spontaneous Intermittent Mandatory Ventilation SIMV - ANSWER--Has a preset rate /minute ventilation Allows patient to over breathe a set Spontaneous breaths are not supported, so tidal volume varies based on what the patient can pull Pressure Control Ventilation - ANSWER-Set pressure - Machine is set to deliver a certain pressure over a certain I-time. pressure remains constant Tidal Volume changes as lungs change Pressure Support Ventilation (PSV) - ANSWER--Used to lower the work of spontaneous breathing and augment a patients spontaneous tidal volume
- PSV is often used with SIMV and CPAP, or as a stand alone mode to facilitate weaning
- Psv should increase spontaneous Vt, decrease respiratory rate and decrease WOB
- PSV decreases work of breathing that is superimposed by the artificial airway Stroke Volume (SV) - ANSWER-The volume of blood pumped forward with each ventricular contraction. EDV-ESV= SV 50 - 100 cc per beat basically Males: 65- 110 Females: 66- 148 RSI drugs paralytics - ANSWER-Rocuronium 1mg/ Kg Onset 1 minute Duration 30 minutes RSI drugs paralytics Succs - ANSWER-Succs 1mg/kg Onset Duration Contraindications: hyperkalemia 10 days post burn crush Denervation injury MH predisposition RSI drugs induction k - ANSWER-Ketamine 1-2 mg/kg Bronchodilator RSI Drugs Induction E - ANSWER-Etomidate 0.3mg/kg RSI drugs pretreat lidocaine - ANSWER-Used to blunt sympathetic response to intubation. Ex TBI with increased ICP Lidocaine 1mg/kg Lead II looks at - ANSWER-The apex of the heart- should be a positive deflection. It's a positive lead that looks at the apex of the heart. P wave: atrial depolarization
Left bundle branch... - ANSWER-Is what actually depolarizes the intraventricular septum In lead II, depolarization of the septum ( LBB) is what part of the ekg? - ANSWER-The negative deflection known as the Q wave! The Q wave is indicative of intraventricular Septal depolarization The R the wave is indicative of - ANSWER-Ventricular depolarization SaO2 - ANSWER- 95 - 100% percent of hemoglobin that is saturated with oxygen. Adult Acls Dopamine infusion dose - ANSWER- 2 - 10 mcg/ kg / min Adult ACLS Epi infusion dose - ANSWER- 2 - 10 mcg/kg/min Adult ACLS Bradycardia Atropine dose - ANSWER-1st dose: 0.5 mg bolus Repeat q 3-5 minutes Max dose 3mg Adult ACLS Cardiac Arrest Amio dose: 1st: 300mg bolus 2nd: 150mg - ANSWER- Adult ACLS how many compressions? - ANSWER-At least 100 compressions a minute Vasopressin push dose & infusion dose - ANSWER-1 dose of 40 units 0.02-0.04 units per minute Thrombocytopenia - ANSWER-Platelet count of less than < 150,000 uL Trauma triad of death - ANSWER--Hypothermia: warm room, warm blanket, warmed fluid
- Coagulapathy
- Metabolic acidosis DIC Coag Lab values - ANSWER-D-Dimer 1-5 mcg/ml Fibrinogen < 100 mg/dL (Normal 200-400 mg/dL) Normal PR interval - ANSWER-0.12-0.20 seconds Normal QRS duration - ANSWER-0.04-0.12 seconds WBC - ANSWER-Normal is 5-10K mm
ACLS VF or PULSELESS VT Amiodarone dose - ANSWER-Shock, CPR Epi 1 mg q 3-5 minutes Amio 300 mg bolus first dose Amio 150 mg Second dose calculating CCF code - ANSWER-Actual Chest compression time / Total code time ACLS Magnesium Drug facts - ANSWER-Na/K pump agonist Suppression on L- and T-type calcium channels and suppression of ventricular after- depolarizations ACLS Torsades with long QT interval providers should... - ANSWER-Magnesium Sulfate 1-2 g IV diluted in 10 mL Bolus over 20 minutes ACLS Septic Shock Tx - ANSWER-ABX! Don't Delay 30 mL/Kg crystalloid LR septic shock and Central VENOUS ScVO2 oxygen extraction LOW < 65% is bad. - ANSWER-Drawn from a CVC. Surrogate to Svo2. Normal oxygen extraction is 25 - 30% corresponding to a ScvO2 >65% < 65% = Impaired tissue oxygenation
80% = High PaO2; or suspect: — Cytotoxic dysoxia (e.g. cyanide poisoning, mitochrondial disease, severe sepsis) — Microcirculatory shunting (e.g. severe sepsis, liver failure, hyperthyroidism) — Left to right shunts Adult Dopamine IV Infusion Dose - ANSWER--Correct hypovolemia first
- 5 - 20 mcg/ kg / min
- don't use for cardiogenic shock with CHF
- Don't mix with Bicarb Adult Norepinephrine (levophed) Infusion Dose - ANSWER-0.1- 2 mcg /kg/ min Adult Lidocaine - ANSWER-VF/VT 1.5mg/kg IVP Repeat 3-5 min Max 3mg/kg (2 doses) GTT: 20 to 50 mcg/kg/minute. 1 to 4 mg/minute Adult Vassopressin Gtt dose - ANSWER-from 0.01 to 0.05 units/min Most common cause of PEA- - ANSWER-hypovolemia and Hypoxia Arrest r/t Massive Saddle PE - ANSWER-Give Fibrinolytics
Arrest r/t Cardiac tamponade... - ANSWER-Give volume
- decompress tension pneumothorax - ANSWER-TX with needle decompression and chest tube insertion Fibrinolytics - ANSWER-Alteplase, reteplase and tenecteplase Administer to patients with STEMI > 2 mm in leads V2 and V CI (Absolute)
- Active bleeding or bleeding diathesis
- Any prior intracranial hemorrhage
- Recent intracranial or intraspina surgery or trauma (last 3 months)
- Intracranial neoplasm, arteriovenous malformation, or aneurysm
- Arotic dissection
- Sever uncontrolled hypertension
- Ischemic stroke within past 3 months, except acute ischemic stroke within 4.5 hrs. Relative
- Pregnancy
- Active peptic ulcer
- Current use of anticoagulant SE
- Bleeding, hypotension, intracranial hemorrhage, fever NOTE
- Door-to-needle time should be < 30 mins (for fibrinolytcis) ACS Heparin - ANSWER-4000 unit bolus (0.8 ml CI: GI bleeds, SAH, Already taking coumadin, plavix, other d ACS Metoprolol (Lopressor) - ANSWER-Indications: MI, Tachy, hypertensive Dose : 5mg slow IV push at 5 minute intervals for a max of 15 mg. long acting, CI: hypotensive, brady A lactate level of > ___ is a poor prognostic sign - ANSWER-Lactate > 4 Definition of sepsis, severe sepsis and septic shock - ANSWER-Sepsis: SIRS + Infection Septic Shock: Severe Sepsis + SBP <90, MAP < 65, or Lactate > 4 after Fluids. (30ml/kg) SIRS Criteria (systemic inflammatory response syndrome) - ANSWER->= 2 of the following:
38.3 (100.9F) or < 36 (96.8F) Heart Rate > 90 bpm
- RR > 20 or PaCO2 < 32 (hyperventilating) (normal 35-45)
- Fixed and dilated pupils
- Seizures Normal ICP ranges from: - ANSWER- 0 - 15 mm Hg Treatment is indicated if sustained >20-25 mm HG CPP= Map-ICP Goal is >60 (usually 70-90) How do you calculate Cerebral perfusion pressure? - ANSWER-CPP = MAP - ICP (or cvp, whichever is greater) Goal >60 (usually 70-90) What are the first tier interventions for elevated ICP? - ANSWER-1. patient positioning: HOB 30-45 degrees...manages venous drainage
- Prevent compression of juglar veins
- Keep head mid line 4 straight legs 5 decrease stimuli 6 treat pain 7 normo thermia - fever is associated with worse outcomes What are the second tier interventions for elevated ICP - ANSWER-- mannitol 20% osmotic diuretic
- 0.25 to 1 gram /kg IV bolus Use filter!
- monitor serum osmo (adult normal 285-295) peds (275-290)
- watch for hypo kale Mia Keep CPP > 60 What are the Stroke care 1 hour goals? - ANSWER-1. NIHSS
- Ct w/o contrast Door to needle time for ischemic embolic What three things cause cerebral vasoconstriction? - ANSWER-Hypertension Hypocarbia Alkalosis Which things cause cerebral vasodilation? - ANSWER-Hypotension Hypercarbia Acidosis What MAP range is necessary for cerebral auto regulation to be maintained? - ANSWER- 50 - 150 mm Hg What happens to cerebral blood flow when the patient is hypoxic? ( pao2 less than 50)?
- ANSWER-Cerebral vasodilation occurs.
One Evidence of loss of cerebral auto regulation is - ANSWER-Cushings's response: Widening pulse pressure Reflex bradycardia Decreased respiratory efforts maintain a CPP of ______ to - ______ to optimize cerebral blood flow - ANSWER-Greater than 65 Usually 70- 90 Normal 60- 100 Acceptable 50-70 mm Hg How do you calculate MAP? - ANSWER-Systolic BP + (2 x DBP) / 3 Which leads look at the inferior surface of the heart? ie RV infarction inferior MI? - ANSWER-II III & aVF What does an inferior MI look like on EKG? - ANSWER- What are some physical exams you can perform to assess systemic vascular resistance? - ANSWER-pulse pressure variation What are Kinematics and why do we care? - ANSWER-Kinematics and the physics of energy transfer What is dynamic compliance? - ANSWER-Dynamic compliance is static compliance plus airway resistance. bronchospasm would affect dynamic compliance because it increases airway resistance.Differentiate between the factors that affect airway resistance and factors that affect expansion of the alveoli, lung, or chest wall. Dynamic compliance is affected by airway resistance factors. Commotio cordis is a phenomenon in which: - ANSWER-ventricular fibrillation is induced following blunt trauma to the chest during the heart's repolarization period. Ashman phenomenon - ANSWER-Aberrant conduction of a supraventricular beat commonly seen in patients with atrial fibrillation; wide SV beat after a QRS complex that is preceded by a long pause. Which of the following may be useful in systolic dysfunction but may be detrimental in diastolic dysfunction? A. β-blockers B. Angiotensin-converting enzyme inhibitors C. Aldosterone antagonists D.
C.
Tricuspid valve D. Mitral valve In a pulmonary artery waveform the three components of the waveform are systole, dicrotic notch, and diastole. Systole is the pressure generated by the right ventricle so that the pulmonic valve will be pushed open, the dicrotic notch is caused by the closure of the pulmonic valve, and diastole is the pressure in the pulmonary artery during ventricular diastole. The diastolic pressure is a reflection of the vascular tone in the pulmonary vascular bed. If the vessels are constricted or if there is back pressure from the left side of the heart, the diastolic pressure will be high. A 36 yo patient presents in VTACH what is the most appropriate drug? A.Amiodarone (Cordarone) B.Verapamil (Calan) C.Adenosine (Adenocard) D.Ibutilide (Corvert) - ANSWER-The first drug for a wide QRS complex tachycardia is amiodarone. If the rhythm does not respond to amiodarone, synchronized cardioversion is indicated. Verapamil and adenosine typically are used for narrow QRS complex tachycardia. Eliminate options b and c. Ibutilide is used for acute-onset atrial fibrillation. This rhythm is regular, so eliminate option d and choose option a. An S4 is noted during cardiac auscultation. This sound indicates: - ANSWER-A. atrial contraction and propulsion of blood into a noncompliant ventricle. B. inflammation of the pericardium. C. opening of a defective semilunar valve. D. rapid ventricular filling into an already distended ventricle. An S4 occurs during the end of diastole when the atria contract but the ventricle is noncompliant. An S4 occurs in myocardial ischemia, infarction, and hypertrophy. Most patients with an acute myocardial infarction have an S4 for the first 48 hours. What are signs of hypoperfusion after a rhythym change? - ANSWER-Assess the patient for clinical indications of hypoperfusion (e.g., cool skin, decreased urine output, narrowed pulse pressure, and hypotension). A lateral Wall MI will be seen as St elevations in which leads, and stems from a blockage in which coronary arteries? - ANSWER-1. High Lateral: lead 1 and AVL V5 and V6 are low lateral wall... ischemia from the circumflex artery.
In Acute coronary Syndromes unstable angina is characterized by...... - ANSWER-- Ischemic Symptoms suggestive of ACS
- No Troponin elevation
- with or without ECG changes NSTEMI characteristics - ANSWER- universal recipient blood type is... - ANSWER-AB positive universal donor blood type - ANSWER-O negative Rh disease (erythroblastosis fetalis) - ANSWER- RhoGAM shot - ANSWER-given to mother soon after the first delivery, miscarriage, or abortion so that antibody binds to fetal RBC and removed it from the body before the mother makes Rh antibody What type of blood is given to women of childbearing age? - ANSWER- Platelets indications - ANSWER-volume in the bag is about 150 mls, to assist with coagulation of blood. idications: bleeding, hemophelia, thrombocytopenia, platelets dysfunction FFP (fresh frozen plasma) 150-160ml - ANSWER-indications: pts who need coagulation factors - liver failure, DIC, Burns, massive RBC transfusion Product of choice for pts with multiple deficiencies Cryoprecipitate 50ml - ANSWER-- Clients with hemophilia (deficiency of clotting factor), are given cryoprecipitate to replace the deficient factor as a prophylactic measure before any invasive procedure, surgery or when actively bleeding.
- Cryoprecipitate provides therapeutic amounts of Facto 8, Factor 13, von Willebrand factor and fibrinogen. These concentrates are made with recombinant DNA technology and are the treatment of choice with hemophilic A and von Willebrands disease. Indications for Fresh Frozen Plasma - ANSWER-Burns,
