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CCRN
SIADH ANS: increased ADH level, holding on to too much water, dilutional hyponatremia. Decreased osmolarity=hypoosmolar. Decreased urinary output. QUIZ: CSF normal protein, glucose, WBCs, specific gravity, ANS: Protein <100, Glucose: 70 WBCs: 4 cells/mm2 Specific gravity 1. QUIZ: Poikothermia ANS: fluctuation of core body temperature of more than 2° C due to changes in ambient room temperature QUIZ: pathophysiology of a seizure ANS: neurons in the cerebral cortex fire at the same time in a paroxysmal burst. QUIZ: System driven outcome ANS: include length of stay, readmission rate, and resource utilization. QUIZ: Arterial supply to the brain: vertebrobasilar, common carotid, meningeal arteries ANS: The vertebrobasilar arteries supply the posterior portion of the brain. The common carotid arteries supply the anterior area of the brain. The meningeal arteries supply the superior portion of the brain. QUIZ: Pheochromocytoma ANS: a benign tumor of the adrenal medulla, causing hyper-secretion of epi/norepi. s/s: hypertension, sweating, headache, palpitations, apprehension, nausea/vomiting, tremor, pallor, abdominal pain, chest pain, and hyperglycemia. QUIZ: Acute radiation syndrome ANS: what occurs in humans after whole body reception of large doses of ionizing radiation delivered over a short period of time. Circulatory collapse, increased intracranial pressure, vasculitis, and meningitis causing death within 3 days QUIZ: Complications of SIADH ANS: seizure activity QUIZ: Treatment of SIADH (avoid what solutions?) ANS: Fluid restriction 3% nacl (1500 osmolarity over 25cc/hr or less) Dont do hypotonic solutions! Asses for fluid overload QUIZ: hypertonic solutions ANS: D5LR; D5 1/2 NS; D5NS QUIZ: hypotonic solutions ANS: 0.5% NS (HNS or 0.45% NS); 2.5% dextrose in 0.45% NS (D2.5 45% NS) QUIZ: Osmolality and Sodium ANS: 275-295= normal osmolality. Sodium=135-145. Usually two times the sodium
QUIZ: Causes of SIADH ANS: Viral PNA Oat cell carcinoma Head problems Increased serum osmolality Anesthesia and analgesics Stress QUIZ: Diabetes insipidus (urine specific gravity?) ANS: No ADH, can't keep water, increased UOP. Hypernatremic, hyperosmolar, increased urinary output (6-24L a day of clear urine) urine specific gravity 1.001-1. Severe hypovolemia QUIZ: Causes of diabetes insipidus (what medication?) ANS: Head problem Dilantin (DI) QUIZ: Treatment of diabetes insipidus (medication, fluid, monitoring x2) ANS: Pitressin/vasopressin (same as ADH) Give fluids (increase intravascular volume) Monitor urine specific gravity EKG monitor for ischemia QUIZ: Hypoglycemia s/s ANS: Low blood sugar- adrenaline released- liver converts glycogen into glucose, so: Tachycardia, palpitations, diaphoresis, irritable, restlessness Confusion, lethargy, slurred speech, seizure, coma, death. IF YOU ARE IN A BETA ADRENERGIC BLOCKER, you only see the CNS symptoms QUIZ: DKA (BS, breathing, acid vs K) ANS: Blood Sugar 400 to 900, Dehydration, No insulin, Ketones, Kussmaul breathing (deep labored breathing). Whenever you see a high acid level you therefore see a high potassium level. For every drop of 0.1 in pH you see an increase by 0.6 of potassium QUIZ: HHNK (who gets, BS, breaths) ANS: Hyperglycemic hyperosmolar non-ketotic coma. Common with old age, diet controlled diabetics, TPN patients, who get a lot of inteavascular sugar, and pancreatitis as pancreas is eating itself, does not work properly. Blood sugar 1000-2000, severe dehydration, about 6 to 10 Liters behind. Patient still makes insulin, so it can occur over months, preventing the breakdown of fats which causes no acidosis, little tiny baby breaths. QUIZ: Treatment DKA ANS: insulin (a lot) A fair amount fluids first saline and then D5 1/2 NS QUIZ: Treatment HHNK ANS: Only a little insulin
improves neurological outcomes. Patients most often treated with medical management of increased ICP. QUIZ: Intraventricular hemorrhage (causes, treatment x3, monitoring) ANS: Bleeding within ventricle of brain, Caused by trauma, neoplasm, AVM, HTN, aneurysm. Treatment: Correct coagulopathy, treat SBP> 180 mm Hg or DBP> 105 mm Hg Target SBP ≤ 150 mm Hg. Administer anti seizure medication. Monitor hematoma expansion with daily CT. If hydrocephalus suspected, placement of ventriculostomy drain and monitoring of ICP may be necessary. ICP= 70- QUIZ: subarachnoid hemorrhage (s/s, causes, diagnosis, treatment, complications) ANS: Bleeding where the cerebrospinal fluid circulates. Caused by cerebral aneurisms, AV malformations, hemorrhage from brain tumor. s/s severe occipital headache "thunderclap HA" "Worst HA of my life", brief loss or altered LOC, n/v, photophobia, focal neurologic deficits, and a stiff neck. Graded I to V, from less to most severe. Diagnosed with CT san, lumbar puncture (Bloody CSF when done within 24 hrs of event). After diagnosis is made, a cerebral angiogram is done to show size, shape and location. Treatment:Surgical or endovascular treatment. Airway management, BP control (nitroprusside or labetolol, but don't drop too quickly as that can cause cerebral ischemia), seizure control (fosphenytoin), ECG monitoring for changes. Complications: Rebleeding (2-10 days), hydrocephalus (requires ventriculostomy drain and keep ICP at less than 20 mmHg), vasospasm (s/s excessive drowsiness, focal neurological deficits, or coma. treated by use of nimodipine and triple H therapy: hypervolemia, hypertension, hemodylution. QUIZ: space occupying lesions of the brain (how diagnosed) ANS: Brain + blood + CSF= constant. Anything else you add is a space occupying lesion (tumors, extra CSF, blood). Examples are glioma, meningioma, pituitary adenoma, acoustic neuroma or metastatic tumor. Can compress healthy brain tissue and cause herniation (movement of brain tissue across compartments). Increase intracranial pressure. s/s if invasive are focal deficits like paralysis, paresthesia, visual deficits. If intracranial hypertension can cause papilledema, vomiting, seizures, headache, change in LOC and behavior. Tumors are diagnosed with EEG and biopsy. QUIZ: Ischemic stroke (Diagnosis, treatment, nursing interventions) ANS: Caused by blood clot. 85% of all strokes. Diagnosis: treatment must be done within 3 hours, neural examination, a non-contrast CT scan ASAP. CBC, electrolytes, renal panel, coag panel, liver function and others depending on symptoms. Treatment: rTPA within 3 hours. 2 peripheral IV caths inserted, Then administer bolus 10% of total dose, 0.9 mg/kg (max 90 mg) over 1 minute, and give the rest over 1 hour. After treatment, increased risk of converting ischemic to hemorrhagic stroke. VS and neuro checks every 15-30 min for 6-12 hrs. if changes, report immediately and perform stat CT scan to r/o hemorrhage. QUIZ: Concussion ANS: a violent shaking up or jarring of the brain that may result in a temporary loss of awareness and function. May or may not have LOC, temporary loss of
vision, pallor, listlessness, memory loss & vomiting. Rest in acute stage, later surgical treatment if necessary QUIZ: Subdural hematoma (onset) ANS: An accumulation of blood beneath the dura mater but outside the brain. Tends to have slower onset, HA. Prompt craniotomy or surgical intervention needed. QUIZ: Epidural hematoma ANS: An accumulation of blood between the skull and the dura matter. Lucid interval following head trauma, followed by a period of awareness that may last several hours before brain function deteriorates, sometimes leaving the patient in a coma. Treated with prompt surgical evacuation QUIZ: Pupillary reflexes (parasympathetic response, sympathetic response, innervation) ANS: Parasympathetic: pinpoint Sympathetic: dilate Eye movement innervated by 3rd cranial nerve QUIZ: Tentorial notch ANS: Located at base of skull, above midbrain QUIZ: Foramen magnum ANS: Located at the base of the skull, bellow the midbrain and Tentorial notch. QUIZ: Uncal herniation (s/s) ANS: Lateral shift of the brain. 1st symptoms dilation of pupils on the same side of injury. Later change of level of consciousness QUIZ: Supratentorial herniation (s/s x 3) ANS: Brain gets pushed downward into the Tentorial notch. The 1st symptom is change in level of consciousness. Later dilated pupils, last hyperventilation. If no treatment Cushing occurs QUIZ: Cushing (s/s) ANS: The brain herniated into the Foramen magnum. Symptoms include decrease HR, RR, and widening pulse pressure. The only thing that may help is mannitol QUIZ: Interventions for increased intracranial pressure ANS: Keep patient alkalotic Do not give hypotonic solutions (Fluid goes in the cell, D5W) Do not flex or hyperextend the neck Feed patient, prevent protein loss Don't use restraints QUIZ: Guillain-Barre ANS: Antibodies attack the myelin sheaths of peripheral nerves (loss of conduction) beginning in the distal nerves and ascends symmetrically. The body regenerates myelin sheaths within 3 weeks to 3 months, improving symptoms. CSF has high protein levels. Causes: Respiratory infection, Epstein Barr virus, vaccination, Hepatitis, HIV. S/S: weakness, ascending paralysis, descending improvement.
QUIZ: Pancreatitis causes, diagnosis, consequences x5 s/s x2 ANS: Autodigestion of pancreas. Causes: ETOH, obstruction (infection or gall stones), Drug toxicity (cyclosporins, steroids, thiazides, tetracyclines), trauma. Diagnostic changes: elevated amylase, lipase. Consequences: Hypocalcemia (body needs calcium to digest fatty pancreas), HHNK (pancreas is being destroyed, patient can develop high BS, left sided pleural effusion and atelectasis as well as bilateral rales, ARDS (phospholipase A released during autodigestion goes to lungs and kills type 2 alveolar cells, decreasing surfactant production), Cullen's sign (bruised umbilicus) and Grey-Turner's sign (bruising in the flank and groin). QUIZ: Small bowel obstruction ANS: Small distention, because patient has vomiting and diarrhea. QUIZ: Large bowel obstruction ANS: Large amounts of distention, Patient does not have any vomiting or stooling. QUIZ: Function of the Liver ANS: Kupper cells detoxify the blood that comes from every organ in the body. Hepatocytes make bile, Makes aminoacids and proteins, including albumin, prothrombin and fibrinogen, converts glucose into glycogen for storage, and glycogen into glucose when extra energy is needed, Liver also converts ammonia into urea to be excreted in the gut and urine. QUIZ: What to avoid in liver disease ANS: Potassium: If K level drops, the kidney retains and with it, an ammonia ion, increasing encephalopathy risk. Replace Potassium. If diuresed give potassium sparing diuretic. BUN: The breakdown of blood urea nitrogen produces ammonia, do not allow your patient to become dehydrated. Protein: If a patient has GI bleed, or if eating proteins, the breakdown creates ammonia, worsening encephalopathy. pH: Acidity worsens liver disease, do not give lactated ringers as the lactate will not be converted into ammonia by the liver and the patient will become acidotic. All of these cause increased ammonia level and encephalopathy. *Do give neomycin to patient to avoid ammonia production by bacterial flora in the gut. QUIZ: Very high levels of indirect or unconjugated bilirubin ANS: Caused by disease of the liver, hepatic failure or liver disease. QUIZ: Very high levels of direct or conjugated bilirubin ANS: Caused by disease of the gall bladder, or biliary tract disease. QUIZ: sign of ruptured spleen or encapsulated bleeding spleen ANS: 55% will have Kehr's sign, which is left shoulder pain. QUIZ: Acute renal failure ANS: Can be pre-renal (due to decreased blood supply to kidneys caused by CHF or low BP, hemorhage, burns, sepsis, transfusion reactions) or
renal (due to damage to tissues or nephrons caused by ATN, heavy metals, medications, street drugs, rhabdomyolysis, radiocontrast dye) QUIZ: Stages of acute tubular necrosis ANS: Oliguric stage (lasts 10-17 days, increased BUN, creatinine, potassium, fluid overload, CHF), Polyuric stage (lasts 2 weeks-3 months, proximal tubule damaged, increased urine output, low potassium, fluid depletion, still high BUN and creatinine), lastly the recovery stage (lasts 3 months to 1 year. QUIZ: Pre-renal renal failure lab values ANS: Urinary sodium ~20 (showing the kidneys are working and retain sodium to retain fluid for low perfusion) BUN: Creatinine ratio of 20: Lasix/Fluid challenge: The patient makes more urine than they had made the hour before QUIZ: Acute renal failure urinary sodium, BUN:Creatinine lab values. ANS: Urinary sodium 40- BUN:Creatinine ratio of 10: Lasix/Fluid challenge: The UOP does not significantly increase. QUIZ: Chronic renal failure stages ANS: Diminished Renal reserve: 50% nephrons are lost Renal insufficiency: 75% Nephron loss ESRD: 90% nephron loss Uremic Syndrome: Complete nephron loss An inverse relationship exists between serum creatinine levels and GFR; and the stage of Chronic renal failure QUIZ: CRRT ANS: Removes fluid and solutes slowly, for medically unstable patients. Used to maintain fluid balance and pH. Used in: fluid overload, acute renal failure, chronic renal failure, electrolyte imbalances, drug overdose. Can be artetiovenous or venovenous CRRT. 4 modes: SCUF: Slow continuous ultrafiltration: only removes fluid. CVVH: A little water a little solutes CVVHD: Takes fair amount of fluid and solutes CVVHDF: Maximum fluid and solute removal. QUIZ: Hyperkalemia (s/s, treatment order) ANS: Initially, a peaked t wave, at around 6.3 causes prolonged PR interval, at 7, no p wave at 7.5 widening QRS, higher levels show the "sine" wave, causes severe muscle weakness. 1st: For elevated potassium causing severe EKG changes the treatment is Calcium Chloride. Doesn't lower levels, just protects the heart. 2nd: Give insulin and glucose IV. 3rd: Give sodium bicarb to push the K in the cell 4th Give kayexelate to excrete the potassium.
QUIZ: Stages of shock. ANS: Ebb/compensatory phase: immediately after event, SNS stimulation, releasing epinephrine, norepinephrine. This increases HR, BP, RR. Adrenal gland releases cortisol and Antidiuretic hormone. Renin and angiotensin released causing vasoconstriction and fluid retention. If prolonged, severe vasoconstriction causes metabolic acidosis, and decreased oxygenation of tissues. When metabolic acidosis develops, you have systemic vasodilation, drop in BP and CO. s/s: anxious, irritable, tachycardia, cool and pale, decreased UOP. fear, withdrawal, anger, hostility, anxiety, depression and hyper-arousal common. Metabolic derangements/Progressive phase: Vasodilation, Edema due to lactic acidosis, increased cardiac output, and hyperdynamic circulation; impaired oxygen transport due to vasoconstriction, altered glucose metabolism due to cortisol release, and altered protein and fat metabolism. s/s obtunded, stuporous, hypotension, decreased cvp, PCWP, CO, Increased SVR. QUIZ: what questions do you ask when caring for trauma patient? ANS: AMPLE Allergies Medications Past illnesses Last meal Events preceding injury QUIZ: Acetaminophen poisoning ANS: treatment: Mucomyst 140 mg/kg loading dose, then 70 mg/kg every 4 hours for 17 doses. Activated charcoal if recently ingested. Causes liver damage. Stages of said damage: I Nausea and vomiting II RUQ pain III Liver function abnormalities. QUIZ: Salicylate poisoning ANS: Aspirin overdose. Antidote: Lavage, activated charcoal and administer large doses of bicarb (excretes aspirin faster, treats renal tubular acidosis) QUIZ: Lead 1, aVL ANS: Looks at the lateral wall of the heart Lead 1: Right arm to left arm aVL: Imaginary point of heart to left arm QUIZ: lead 2, 3 and aVF ANS: Looks at the inferior wall of the heart Lead 2: Right arm to left leg Lead 3: Left arm to left leg aVF: Imaginary point in heart to left leg QUIZ: Right axis deviation ANS: QRS is predominantly negative in lead I and aVL and positive in lead aVF. Caused by right ventricular hypertrophy. QUIZ: Left axis deviation ANS: QRS is predominantly negative in leads 2, 3, and aVF. Caused by hypertrophy of the ventricular wall.
QUIZ: Heart failure ANS: Impaired cardiac function where either one or both ventricles are unable to maintain an adequate cardiac output. Classes are I-IV, class IV is the most symptomatic even at rest. Measured by ejection fraction QUIZ: Hypertensive Crisis types (x3), s/s, consequences x2 ANS: Altered LOC, seizure vomiting, severe HA, epistaxis, visual disturbances. Essential, accelerated (DBP
120 mmHg) and malignant hypertension (DBP >140 mmHg). Associated with retinal hemorrhages and papilledema (Swelling around the optic nerve). Treatment is vasodilators and sympathetic blocking agents. QUIZ: Left sided heart failure-systolic ANS: Begins with a reduction in left ventricular contractility reducing the EF to less than 50% Examples of etiologies include idiopathic dilated cardiomyopathy and myocardial infarction. The ventricle tries to compensate by dilating and increasing HR. Initially this helps maintain cardiac output, but eventually if dilation a persist contractility will decrease. As HR is high, myocardial oxygen demand increase. s/s: fatigue, weakness, lethargy, orthopnea, tachycardia on exertion, basilar rales rhonchi and wheezes, elevated PCWP, PADP, murmur of mitral insufficiency, skin cool, moist, cyanotic, hypoxia, respiratory acidosis. QUIZ: Left sided diastolic heart failure ANS: symptoms: exercise intolerance, orthopnea, tachycardia on exertion, basilar rales, rhonchi, wheezes, elevated PCWP and PADP, holosystolic murmur if evidence of tricuspid or mitral regurgitation, hypoxia and respiratory acidosis. QUIZ: Right sided heart failure ANS: s/s easily fatigued, dependent/pitting edema, anorexia, weight gain, oliguria, venous distention, extra heart sounds, elevated CVP, right atrial and right ventricular pressures. QUIZ: Hypertensive crisis consequences ANS: Hypertensive encephalopathy, irreversible end-organ damage to brain, kidneys, heart; finally death. Increased ICP, CVA, MI. QUIZ: Hypertensive crisis causes ANS: Untreated HTN, renal dysfunction, endocrine disorders. QUIZ: Hypertensive crisis risk factors ANS: Diabetes, smoking, obesity, contraceptives, HLD, pregnancy induced HTN. QUIZ: Hypertensive crisis goals in order x4 ANS: 1) Determine cause 2) Detect and prevent sequelae 3) Decrease BP no more than 25% in first 1-2 hrs 4)Provide Pt teaching. QUIZ: Hypertensive crisis common treatments ANS: Potent vasodilators (Nitroprusside or Fenoldopam), Nitroglycerin, nicardipine (cardene), a Calcium channel
QUIZ: Carotid artery stenosis ANS: Carotid arteries develop atherosclerosis. Symptoms are neurological. With significant blockage symptoms include TIAs or stroke. Diagnosis made with carotid Doppler studies. Treated with carotid stent QUIZ: PTCA Complications ANS: Hematoma, AV fistula, pseudo aneurism, retro peritoneal bleed, acute loss of distal circulation. Assess for bruit at insertion site as a sign of pseudo aneurism QUIZ: valvular defects ANS: Not all require surgical intervention. the most commonly replaced are aortic and mitral. Nursing interventions: assessment of hemodynamic stability and adequacy of tissue perfusion, evaluation of dysrhythmia, assuring diagnostic studies. QUIZ: Aortic Stenosis ANS: Overtime the valve becomes stiff and non-compliant. Occurs when valve is open, during systole.the only effective surgical intervention for aortic valve disease is aortic valve replacement (AVR). Systolic murmur, hollow sound QUIZ: Aortic Valve replacement (Types, risks, follow up meds) ANS: Done with either a metal alloy or a bio-prothetic valve (porcine or bovine). In addition to the risks associated with other cardiac surgery, risks include emboli originating from a calcified valve, cannulation of the aorta, hypo-perfusion or prosthetic valve thrombus. Patient will need anticoagulation such as intravenous heparin or enoxaparin. Warfarin may be used when the patient is stabilized and being prepared for discharge. The expected therapeutic range for valve replacement is 3.0 to 4.0. Medications that can alter bleeding times should be avoided such as aspirin, ibuprofen, birth control pills and certain antibiotics. QUIZ: Mitral stenosis (pathophysioloby, causes x2, treatments x2, type of murmur) ANS: Progressive narrowing of the mitral valve opening to less than 1.5 cm. Can occur due to aging or inflammatory changes. Occurs when the valve is open, during diastole. Treatment is commissurotomy and valve replacement. Sound is rough, rrrrrr QUIZ: Aortic regurgitation/ insufficiency ANS: Blood flows backward during diastole as a result of the lack of complete closure of the valve. Medical therapy to control blood pressure, improve oxygenation, and improve stroke volume (inotropic drugs) should be instituted to preserve ventricular function until the patient is significantly decompensated and valve replacement becomes necessary. Open aortic valve replacement as well as percutaneous AVR are surgical interventions. Heard during diastole. QUIZ: Mitral valve regurgitation ANS: caused by infectious or autoimmune, congenital malformations, dilation of the left ventricle, Marfan's syndrome. Acute disease can be caused by rupture of the chordae tendinae from endocarditis or rheumatic heart disease, traumatic injury or papillary muscle dysfunction. Blood flows back in to the left atrium (regurgitation) as a result of the incompetent valve. Left atrial diastolic pressures increase quickly, and the left atrium cannot compensate. Cardiac output falls dramatically, causing pulmonary edema and cardiogenic shock. Patients often requiring
intra-aortic balloon pump (IABP) and vasopressors for support until the patient is stabilized for surgical intervention. QUIZ: Atrial Septal defect ANS: A defect at the level of the atrium. Three types. sinus venosus (where the right atrium and the superior vena cava join), ostium secundum (around the foramen ovale), ostium primum (at the lower end of the septum). The blood us usually moving from high to low pressures. Fluid overload occurs due to increased flow to the right side of the heart. A systolic murmur is audible as blood flow increases across the pulmonic valve. Surgical intervention is recommended to avoid long-term pulmonary hypertension. There is a chance that the patient may develop conduction blocks due to injury to the bundle of his. Patient may require a temporary pacemaker. QUIZ: Ventricular septal defect ANS: The most common type of defect in children. Can be membranous and muscular and subdivided to supra-crystal, AV canal type and crista supraventricularis. Surgical intervention is recommended to avoid long-term pulmonary hypertension. There is a chance that the patient may develop conduction blocks due to injury to the bundle of his. Patient may require a temporary pacemaker. When the left to right shunting becomes irreversible, the pressures become so high, the shunting goes from right to left side. This is called Eisenmenger's syndrome. QUIZ: Coarctation of the aorta: causes, consequences, how is it diagnosed (signs), how is it treated ANS: Narrowing or infolding of the lumen of the aorta. Most often occurs just past the branching of the third large vessel from the arch of the aorta. the ventricle enlarges as a result of the increased pressure gradient and can fail due to the increased after-load. Prolonged hypertension can lead to other conditions that result from cardiovascular disease such as strokes, CAD, heart failure, and possibly aortic dissection or rupture. Collateral circulation develops and helps to feed the lower body and extremities with oxygenated blood. the 3 sign occurs: dilated ascending aorta, constriction of the aorta, and a poststenotic dilation. Cardiac cath required to assess the depth of the pressure gradient. Surgical correction is required via a thoracotomy incision. complications include hemothorax, chylothorax, paradoxical hypertension and transient abdominal pain. Spontaneous aortic rupture can occur in an older patient prior to surgical intervention and most often leads to death. QUIZ: cardiac myxoma ANS: a benign neoplasm of the heart. Located in the atrium along the septum. Triad symptoms: heart failure, evidence of embolism and systemic illness (malaise, fever, weight loss and fatigue). Tumor resection is only treatment. QUIZ: MAZE procedure ANS: Used for treatment of atrial dysrhythmias/ Radio- frequency ablation for intractable supraventricular or ventricular dysrhythmias. A series of cuts are made into the atrial tissues. The goal is to disrupt the reentry pathways and direct the impulse of the sinus node to the AV mode. It requires open heart surgery and has the same risks as a CABG, including bleeding, infection and cardiac dysrhythmias. QUIZ: Dilated cardiomyopathy ANS: Characterized by dilated ventricles, although it may only be left sided dilation, without the muscle hypertrophy. Results in more global
QUIZ: Pulmonary artery wedge pressure (PAWP/PCWP/PCOP) ANS: reflects the left atrial pressure. Normal value is 4-12 mmHg. You must correlate the wave form with the EKG wave form. Put air into balloon, you get an a wave after the QRS complex, c wave immediately after and then v wave. There is a little delay of mechanical waves turning into electrical waves. V wave goes after the t wave in the EKG. elevated in mitral stenosis cardiac tamponade, volume overload, constrictive pericarditis. Wedge is low in shock. Pulmonary artery wedge pressure is always 1-4 mmHg lower than pulmonary artery diastolic pressure. If this is the case, catheter is in wrong zone (must be in zone III) or patient has PEEP >10 (Change the peep from cm H2O, into mmHg, divide by 1.36 and then divide by 2. Subtract that pressure from the recorded wedge, and you will get your actual wedge). QUIZ: Heart murmur causes ANS: -Forward flow of blood through stenotic valves (valve is open) -Backward flow of blood through incompetently closed valves, insufficiency (valve is closed) QUIZ: How do you know if Swan-Ganz catheter is in ZoneI or II? ANS: Damped wedge tracing, PAWP is higher than the PAD, absence of A and V waves, Marked respiratory variations. The way to confirm this is by Xray confirmation. QUIZ: symptomatic bradycardia (symptoms and treatment) ANS: Symptoms: cool moist skin, chest pain, hypotension, syncope, fatigue, weakness, decreased level of consciousness, dyspnea. Caused by a dysfunction of the pacemakers. caused by coronary ischemia, MI, age, metabolic disorders, drugs such as beta blockers, calcium channel blockers, and cardiac glycocides. Treatment: atropine 0.5 mg IV, repeat in 5 minute intervals by up to 3 mg; transcutaneous pacemaker. Patient with second degree heart block type II and complete heart block will require a permanent pacemaker. Vasopressors are usually required as well. QUIZ: Symptomatic tachycardia ANS: Usually it is the body's attempt to compensate for a change in cardiac output. QUIZ: Atrial fibrillation with RVR (medications x3) ANS: Treatment: -diltiazem (Cardizem) first bolus of 0.25 mg/kg given over 2 minutes and followed with second dose as needed. Then a continuous infusion started at 10 mg/hr. ). -betablockers (labetalol, metoprolol, esmolol). -adenosine, a 6 mg rapid bolus, then a 12 mg dose after one or two minutes. The drug causes a brief asystolic period as the SA or AV node is reset from reentry and followed by a return to sinus rhythm. QUIZ: Ventricular tachycardia ANS: Treatment: -amiodarone bolus of 150 mg over 10 minutes followed by initiation of a continuous infusion at 1 mg/min. -synchronised cardioversion if the patient remains hemodynamically stable. If the patient becomes unstable, immediate defibrillation is required.
QUIZ: Torsade de pointes ANS: a type of ventricular tachycardia that shows a classic polymorphous origination. treatment is 1-2 grams of magnesium sulfate over 30- seconds, can be repeated 5-15 minutes. a continuous infusion can be started at 3- mg/min. QUIZ: Right bundle branch block ANS: Rabbit ears in V1 and MCL1 and widening of QRS as well as ST depression and T wave inversion. QUIZ: Left bundle branch block ANS: Wide QRS complexes, deep S waves in V through V3 and tall R waves in V4 through V6, S T depression in V5, V6, 1, and AVL QUIZ: PVC in left ventricle ANS: An irritable cardiac cell firing an inappropriate electrical impulse. That signal does not follow the tracts of the nodes, therefore takes a lot longer and goes in the opposite direction than the rest of the impulses, creating a large upright complex. The electrical impulse briefly bounces back in the other direction, that moves away from the positive charge. "Big mountain: big problem" QUIZ: PVC in right ventricle ANS: R wave is wide. QUIZ: Asystole drugs of choice ANS: epinephrine 1 mg IV Q 5 min, or vasopressin 40 units Q 5 min in replacement of the first or second dose of the other. QUIZ: Automatic implantable cardioverter/Defibrillator AICD ANS: Can be performed through transvenous means through the subclavian vein. Device detects life threathening dysrhythmias like Vtach Vfib, provides defibrillation. Can be "interrogated" to ascertain the frequency of delivered shocks, rhythm at the time of shock and battery life. There is a 75% likelihood of spontaneous discharges in the first year. QUIZ: Pacemaker ANS: device that can sense either or both chambers, and they can defibrillate and deliver shock when appropriate. The primary purpose is to treat bradycardia. Three conditions are important to observe for: failure to pace, failure to capture and failure to sense. QUIZ: Therapeutic hypothermia ANS: Most effective when it occurs within 6 hours of ROSC, The criteria to start includes: -Out of hospital VF or non-perfusing VT with ROSC but no neurological verbal or physical response. -18-80 years of age (research in the pregnant women has not been conclusive) -Absence of cardiogenic shock -Some facilities also use APACHE scores for inclusion. Patients myst be cooled to a core temp of 32-34, must have this core temp sustained 12-24 hours. Patient requires sedation and paralytic agents in most cases. Rewarming must be done slowly, 1 degree every hour until return of normothermic state.
Diltiazem, verapamil: calcium channel blockers Adenosine and Magnesium: unclassified. QUIZ: Acute pulmonary embolus (causes, risk factors, diagnosis, treatment) ANS: Can be from detached thrombus, vegetation, foreign body or fat. Fat embolus: about 3-4 days after trauma to long bones. Thrombus: originates from extremities where DVTs form, generally the legs, where a portion detaches and travels to lungs. Increase vascular resistance->extra strain on right heart->new BBB or new afib-
decreased ventilation of blood/tissues. Risk factors: immobilization of >3 hrs, oral contraceptives, anticoagulant deficiencies, lupus anticoagulant, malignancy (breast, colon, lung), vasculitis or other endothelial damage/inflammation. Diagnostics: CT of the chest with IV contrast, or VQ scan for kidney patients who cannot get contrast. D-dimer test (only useful in healthy patient's with no other co- morbidity). Treatment: If hemodynamically stable: Heparin drip, LMWH (enoxaparin), or antithrombin II binder (fondaparinux). If recurrent, an IVC filter. QUIZ: ARDS ANS: Respiratory failure, lowered pO2 not responsive to high oxygen needing intubation and mechanical ventilation with PEEP. Causes: Sepsis, pneumonia, trauma, and aspiration of gastric contents account for 85% of cases. Treatment: 1. supportive (tracheobronchial toilet), maintain oxygenation, maintain PO 60 with conservative use of PEEP and FiO2. QUIZ: Acute lung injury ANS: an umbrella term for hypoxemic respiratory failure; acute respiratory distress syndrome is a severe form of acute lung injury. *acute onset of impaired gas exchange (PaO2/FIO2 <30) and the presence of bilateral alveolar or interstitial infiltrates in absense of CHF *(check JVP and BNP) QUIZ: respiratory distress syndrome ANS: lack of surfactant production -> airway collapse -> hyaline membrane disease due to necrotic epithelial cells and plasma proteins in lining of airways QUIZ: Community acquired PNA ANS: Most common in age >65, asthma, diabetes, renal failure patients, HIV or immunodeficiency, antibiotic resistance. Patients often treated with beta lactim ABX combo like cefotaxime, or ceftriaxone and either a macrolide or a fluoroquinolone (levaquin). QUIZ: Aspiration PNA ANS: most common in elderly with mild dysphagia, musculoskeletal system disease or medications that cause drowsiness. Physicians often add to combo of abx a clindamycin or metronidazole to cover anaerobes. QUIZ: Hospital acquired PNA ANS: an infection that develops at least 72 hours after being admitted. ABX include vancomycin, cephalosporisn, carbapenems,
fluoroquinolones, aminoglycosides like gentamycin. double or triple therapy recommended. QUIZ: COPD ANS: Airway obstruction associated with emphysema and chronic bronchitis. Caused by tobacco use, smoke exposure, occupational exposure, air pollution. Genetic factors include alpha-1-antitrypsin deficiency (enzyme protects the lung from digestive enzyme). s/s worsening dyspnea, sputum production, cyanosis. end stage cardiovascular circulation compromise, right sided heart failure in the absence of left sided heart failure (cor pulmonale), wheezing, tachypnea, chest protrusion, accessory muscle use, pursed lip breathing and rales on examination. COPD exacerbations are almost always due to bacterial infection, therefore, antibiotics are added to the course of beta agonists, anticholinergics and intravenous corticosteroids. QUIZ: pulmonary fibrosis ANS: formation of scar tissue in the lung caused by long standing inflammation of the alveoli, and limited ability to fully expire air. Common with chronic bronchitis. QUIZ: Pulmonary hypertension ANS: Elevated pulmonary pressure (>25mmHg in the lung, normal is 15 mmHg) -> increase in pulmonary vascular resistance to blood flow through small arteries and arterioles. s/s: dyspnea on exertion, fatigue, lethargy, syncope with exertion, chest pain, and symptoms of right-sided CHF (edema, abdominal distention, JVD). Dependent on cause, treatment can include diuretics, beta-blockers, blood thinners, surgical procedures, mitral or aortic valve repair, and lifestyle changes. QUIZ: Pneumothorax ANS: Air enters the pleural space. Underlying lung may collapse from the pressure. Patient presents with dyspnea. if the rim of air is greater than 2 cm, a needle thoracostomy and chest tube insertion is performed. QUIZ: Pneumopericardium ANS: air in the pleural space of the heart. if there is a large amount of air, filling of heart is compromised, and cardiac tamponade occurs. Treatment is a needle decompression or pericardiocentesis. QUIZ: Pneumomediastinum ANS: the medial borders of the lung laterally, the sternum anteriorly and the spine posteriorly have air, which should not be there. Generally not an emergency, however if it is large, pneumothorax and/or pneumopericardium can occur. should monitor for tachypnea, tachycardia, hypoxia, and hypertension, which are signs of impending compromise. QUIZ: Perivascular interstitial emphysema ANS: Normally there is no air in the wall of the alveoli and surrounding vasculature. when air leaks or an alveoli bursts, it goes in the perivascular space, and has the potential to dissect through tissues if there is large alveolar pressure, and could cause a pneumothorax and/or pneumopericardium.
