question

What to do first if patient has chest pain.

answer

Rest!

question

ECG changes in an acute MI

answer

ST elevation in 2 or more contiguous leads. Ischemia d/t full thickness loss of muscle. EMERGENCY.

question

Inferior leads

answer

II, III, aVF. RCA occlusion.

question

Septal leads

answer

V1 & V2.

question

Anterior leads

answer

V1 - V4. LAD lesion.

question

Lateral leads

answer

V5, V6, I, and aVL. Circumflex lesion.

question

Cardiac enzymes

answer

Troponins, CK-MB, and CK

question

Changes in CK

answer

Rise: 3-6 hours Peak: 24 hours Normal: 3-4 days

question

Changes in CK-MB

answer

Released after myocardial necrosis. Specific for myocardial damage. Rise: 3-12 hours Peak: 24 hours Normal: 2-3 days

question

Troponin I

answer

Protein found in cardiac muscle. High sensitivity. Rise: 3-12 hours Peak: 24 hours Normal: 5-10 days

question

Troponin T

answer

Protein found in cardiac muscle. High sensitivity. Rise: 3-12 hours Peak: 12-48 hours Normal: 5-14 days

question

Common conditions that cause a murmur

answer

Aortic dissection, aortic regurgitation (both acute & chronic), mitral valve regurgitation (both acute & chronic), mitral valve stenosis

question

Drugs to decrease afterload/SVR/PVR

answer

(Arterial Dilators) Nitroprusside, nitroglycerin, amrinone, alpha (Regitine) & Ca channel blockers

question

Drugs to increased afterload/SVR/PVR

answer

(Vasopressors) Epinepherine, norepinepherine, dopamine, neosynephrine

question

Drugs to decrease contractility/SVI

answer

Beta blockers (atenolol, metoprolol, propranolol, labetolol, esmolol) and Ca channel blockers

question

Drugs to increase contractility/SVI

answer

Positive inotropes, dobutamine, dopamine, milrinone, and digoxin

question

Drugs to decrease preload/CVP/PAWP

answer

Venous Dilators - Nitroglycerin, nitroprusside, amrinone, alpha & Ca channel blockers Diuretics - Furosemide, bumex, mannitol

question

Drugs to increase preload/CVP/PAWP

answer

Volume - Colloid, crystalloids, blood, hetastarch Dysrhythmia control - antirhythmics, pacemaker, AICD

question

Complications when using thrombolytics

answer

Allergic reaction, bleeding/hemorrhage, stroke

question

Failure to capture

answer

Pacer delivers a stimulus at the appropriate time but no depolarization occurs. No P or QRS wave after pacer spike.

question

Failure to fire/pace

answer

No pacer spikes seen

question

Failure to sense

answer

Pacemaker does not detects heart's intrinsic activity or interprets noncardiac activity as intrinsic activity. Spikes in inappropriate times.

question

Normal PR

answer

0.12 - 0.20

question

Normal QRS

answer

0.04-0.10

question

Normal QT

answer

Less than 0.48. Varies by age, HR, and gender.

question

Vasopressors

answer

Epinepherine, norepinepherine, dopamine, phenylephrine/neosynephrine, vasopressin/pitressin, milrinone/Primacor, dobutamine/Dobutrex

question

Indication for dopamine/Intropin

answer

Acts on SNS to increased HR and BP. Indicated for hypotension, low CO, decreased renal blood flow. Use if patient is bradycardic.

question

Doses of dopamine

answer

Low: 0.5-2 mcg/kg/min (dopaminergic) Intermediate: 2-10 mcg/kg/min (beta receptors, increases CO) High: over 10 mcg/kg/min (alpha receptors, vasoconstrict)

question

SE of dopamine

answer

Watch volume and starting BP. Use central line. Inactivated by sodium bicarb. Can cause acidosis. SE: ectopic beats, tachycardia, tissue necrosis d/t extravasation

question

Treatment of dopamine extravasation

answer

Phentaolmine 5-10 mg and possibly nitropaste to vasodilate

question

Indication for norepinepherine/Levophed

answer

Indicated for diastolic hypotension (specifically decreased SVR) and septic shock. Stimulates alpha ; beta receptors. Increased contractility, HR, and vasoconstriction.

question

Doses of norepinepherine

answer

2-12 mcg/min. Immediate onset.

question

SE of norepinepherine

answer

Replace volume first because it can cause GI and renal hypoperfusion. Have a central line. SE: dizziness, HA, hyperglycemia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation.

question

Treatment of norepinepherine, epinepherinem, dobutamine, and Neosynephrine extravasation

answer

Phentaolmine 5-10 mg.

question

Indications for epinepherine/Adrenalin

answer

Simulates alpha and beta receptors. Used post cardiac surgery for "stunned" myocardium. ACLS protocol. Bronchial relaxation at low doses, increased contractility at high doses.

question

Dosages of epinepherine

answer

2-20 mcg/min. Immediate onset. Irritating to heart, so only good for emergency use.

question

SE of epinepherine

answer

SE: myocardial/mesenteric/renal ischemia, tachycardia, hyperglycemia, HA, tissues necrosis with extravasation

question

SE of phenylephrine/Neosynephrine

answer

Pure alpha stimulator. Used during C/P bypass, anesthesia induced hypotension, vascular failure in shock. Vasoconstricts arterioles without cardiac effect.

question

Dosages of Neosynephrine

answer

10-100 mcg/min. Immediate onset.

question

SE of Neosynepherine

answer

Use central line. Wean this first! SE: Reflex bradycardia, myocardial/mesenteric/renal ischemia, tissue necrosis with extravasation.

question

Indications for vasopressin/Pitressin

answer

Antidiuretic hormone used to vasocontric. Endogenous hormone. Vasoconstricts peripheral arterioles ; vasodilates coronary, pulmonary, and CNS circulation. Effective for hypotension, shock, decreases needs of other pressors, and Cardiac surgery.

question

Dosages of vasopressin

answer

1-10 units/hr. Long half-life. Not titrated.

question

SE of vasopressin

answer

SE: Skin/mesenteric ischemia, bradycardia, decrease UOP ; result in hyponatremia, use with caution in neurosurgery patients

question

Indications for dobutamine/Dobutrex

answer

Beta I stimulator. Used to increase CO for systolic heart failure, cardiogenic shock, MV regurgitation, post MI, post cardiac surgery, C/P bypass for "stunned" myocardium.

question

Dosages for dobutamine

answer

2-15 mcg/kg/min.

question

SE of dobutamine

answer

Less effect on HR than dopamine. Use central line. Check compatibilities. Can be used peripherally during an emergency. SE: ectopic beats, tachycardia, arrhythmias, tissue necrosis with extravasation.

question

Indications for nitroprusside/Nipride

answer

Causes peripheral vasodilation by acting on venous and arterial smooth muscle. Decreases BP, SVR, preload, and afterload therefore increasing CO. Used for HTN, CHF, and hypertensive emergency.

question

Dosage of nitroprusside

answer

0.5-0.10 mcg/kg/min. Light sensitive. Start with low dose.

question

SE of nitroprusside

answer

Make sure there is adequate volume and the BP is above 90. May incompatibilities (can use with nitro ; heparin). Can cause thiocyanate toxicity with higher doses. Monitor for metabolic acidosis. SE: hypotension, HA, nausea, and vomiting.

question

Indications for milrinone/Primacor

answer

Positive inotrope with vasoactive activity. Increases CO and decreases SVR. Used in CHF and to increase CO.

question

Dosage of milrinone

answer

Bolus (50 mcg/kg over 10 minutes) and then gtt (0.375-0.75 mcg/kg/min). Precipitates with lasix. Longer half-life. Not titrated.

question

SE of milrinone

answer

Renal excretion. SE: arrythmias, decreased BP, HA, hypokalemia

question

Indications for nitroglycerin/Nitrostat

answer

Direct relaxation of vascular smooth muscle and vasodilation. Used for HTN, angina, CHF, and MI to decrease O2 demands.

question

Dosage of nitroglycerin

answer

5-200 mcg/min. Start low. Immediate response.

question

SE of nitroglycerin

answer

Use with caution for patient dependent on preload for CO (inferior wall MI or right sided MI). May see tolerance after 24 hours. SE: Hypotension, reflux tachycardia, HA, flushing, nausea.

question

IV antidysrhythmics

answer

Atropine = bradycardia Lidocaine = VT, ventricular irritability Amiodarone = afib, VTACH, Vfib Pronestyl = VTACH, Vfib (can cause torsades) Verapamil = CA channel block, IV push Diltiazem = Ca channel blocker, afib, make sure BP good Adenosine = SLAM IT, SVT, short half-life

question

Indications for a pacemaker

answer

Treat sudden cardiac death, EF ; 35%, sustained VT, refractory HF despite optimal medical management

question

Problems with pacemakers

answer

Failure to capture, over sensing, and under sensing

question

Signs and symptoms of cardiac tamponade

answer

Rise in filling pressure with decreased CO ; hypotension. CVP=PAOP=PAD. Sudden drop in bleeding. Narrowing pulse pressure. Tachycardia, dysrhythmias, decreased ECG voltage. Decreased UOP. Anxiety and restlessness. Low blood pressure and weakness. Chest pain radiating to neck, shoulders, or back. Trouble breathing or taking deep breaths. Rapid breathing. Discomfort that is relieved by sitting or leaning forward.

question

Postoperative care of chest tubes

answer

Assess q15 for first few hours to monitor drainage changes. Output to average ~100 cc/hr and should gradually decrease. Average is a total of 1L output. Chest tubes are removed when total drainage is 100 ml/hr then order PT, PTT, and platelets.

question

Purpose of Swan (PA) catheter

answer

Measure vascular capacity, blood volume, pump effectiveness, and tissue perfusion.

question

Normal CVP/RAP

answer

1-8 mm Hg

question

Normal PAWP/LVEDP (left ventricular end diastolic pressure)

answer

4-12 mm Hg

question

Normal PAP

answer

Systolic: 15-25 mm Hg Diastolic: 6-12 mm Hg

question

If PAWP is low?

answer

Hypovolemia

question

If PAWP is elevated?

answer

Hypervolemia and indicative of left ventricular failure.

question

Normal CO

answer

4-8 L/min

question

Normal SVO2

answer

60-80% O2 into lungs

question

Describe CVP waveform

answer

Three peaks (a, c, v waves) ; Two descents (x and y)

question

Describe "a" wave with CVP

answer

Represents atrial contraction. Correlates to PR interval.

question

Describe "c" wave with CVP

answer

Represents closure of tricuspid valve. Correlates to QRS complex.

question

Describe "v" wave with CVP

answer

Represents atrial filling. Correlates to TP interval.

question

How to measure CVP

answer

1) Phlebostatic axis (4th intercostal space ; midthoracic line) 2) Print strip. Measure at end expiration. VENTILATED = valley. Regular breathing = peak. 3) Find zpoint at end of QRS.

question

Describe x descent of CVP

answer

Atrial relaxation. Ventricular systole.

question

Describe y descent of CVP

answer

Tricuspid valve reopening

question

Causes of elevated CVP

answer

RV failure, tricuspid stenosis or regurg, pericardial effusion, constrictive pericarditis, superior vena cava obstruction, fluid overload, hyperdynamic circulation, high PEEP setting

question

Optimally dampened arterial waveform

answer

Done via fast flush.

question

Troubleshooting over damped arterial line waveforms

answer

No dicrotic notch, waveform is smooth and curved (abnormal). Check patient first. Check for blood clots, hypotension, correct leveling, insertion sight, straighten insertion site, air bubbles, pressure bag.

question

Troubleshooting under damped arterial waveforms.

answer

Hyperdynamic. Check position, insertion site, tubing length, loose connections, air bubbles.

question

Normal MAP

answer

65-105 mm Hg

question

Normal RV

answer

Systolic: 15-28 mm Hg Diastolic: 0-8 mm Hg

question

What does CVP measure? Why is it important?

answer

Direct measurement of the blood pressure in the right atrium and vena cava. It reflects ventricular preload and predicts fluid responsiveness, right ventricular infarction, right heart failure and cor pulmonale, tamponade, tricuspid regurgitation or stenosis, complete heart block, and constrictive pericarditis. PEEP ; 10 increases CVP due to positive inspiratory pressure exerted.

question

What does PAWP measure? Why is it important?

answer

Occurs when balloon is wedged and reflects left ventricular pressure. Directly measure pulmonary artery pressure. If there are left ventricular dysfunctions, such as with a myocardial infarct or cardiomyopathy, a low cardiac output may exist.

question

Situations when PAWP ; LVEDP

answer

Mitral stenosis, atrial myxoma, pulmonary venous obstruction (e.g. fibrosis, vasculitis), L to R shunt, COPD

question

Situations when PAWP ; LVEDP

answer

Left ventricular failure, raised intra-thoracic pressure (high PEEP), non-compliant left ventricle (e.g. hypertensive cardiomyopathy), aortic regurgitation

question

CLABSI prevention

answer

Hand hygiene, chlorhexidine skin prep, full-barrier precautions (mask, patient head turned away), avoid femoral vein, take out catheters as soon as possible, daily assessment of catheters

question

Normal ABGs

answer

pH: 7.35 - 7.45 PaCO2: 35 - 45 HCO3: 22 - 26 SaO2: 95 - 100 PaCO2: 80 - 100

question

Normal vacuum pressure for suctioning

answer

-20 mm Hg, low intermittent suctioning best, 120-140

question

Biphasic settings for defibrillation

answer

150 J

question

Goals when responding to ventilator alarm

answer

Always check patient first.

question

Possible causes of high pressure ventilator alarms

answer

Water in vent circuit, Coughing, Kinking or biting of endotube, Secretions in the airway, Bronchospasm, Tension pneumothorax

question

Possible causes of low pressure ventilator alarms

answer

Indicate that either the ventilator did not reach the pressure it expected or that some of the air it delivered was not exhaled back into the tubing for measurement. Look for disconnected tubing or an air leak. The most common places for leaks are around the ET tube cuff, poorly secured connections, and drainage and access ports on the tubing.

question

Verify ET tube placement?

answer

At the lip. Needs to be verified with a CXR.

question

ET tube problems

answer

Check cuff pressure (20-30 cm H20) - higher can cause necrosis. RT to evaluate cuff leak. Reposition to minimize skin breakdown. Change tubing every 24 hours. DO NOT exceed 120-140 when suctioning.

question

VAP prevention

answer

HOB ; 30, sedation reduction, weaning, DVT prophyalxis, oral cares, hand hygiene

question

Complications of chest trauma to lungs

answer

Pneumothorax, PE, pleural effusion, ARDS

question

Complications of high cervical injury/spinal cord

answer

Respiratory dysfunction: loss of function, loss of drive.

question

Protective measures to take for a high cervical injury

answer

Protect neck/spine, C4 innervates diaphragm - worry about breathing (probable intubation)

question

Components of neuro exam

answer

LOC, mental status, cognitive function, cranial nerves, motor, sensory, coordination, and reflexes

question

S/S of increased ICP

answer

Early: Change in LOC, agitation, headache, and vomiting. Late: Pupillary dilation from CN III compression and loss of reflexes.

question

Drugs to treat increased ICP

answer

Osmotic diuresis (mannitol, 3%, 23%). Sedation/analgesia. Reduce fever. Antihypertensives. Vasodilators. (Strict management of SBP.)

question

Normal ICP

answer

0-15

question

What does Babinski reflex indicate?

answer

Up going toe indicates pyramidal tract or upper motor neuron problem.

question

Stroke patient care

answer

Ischemic: IV thrombolytic if within 3 hours, frequent neuro checks, manage HTN, ASA, avoid hypotonic solution, manage BG, no steroids or anticonvulsants Hemorrhagic: Cause/location of bleed, keep euvolemic, avoid hyperthermia, anticonvulsants, quiet/dim room, HOB 30-45%, treat pain, avoid valsalva, prevent vasospams, HHH therapy, Mg replace, statins

question

Describe use of Dilantin

answer

IV form causes bradycardia. Will precipitate with ANYTHING other than NaCl.

question

Describe Diabetes Insipidus (DI)

answer

Due to ADH deficiency resulting in massive urine output, excessive thirst, and hyperosmolality

question

Describe SIADH

answer

Excess ADH results in highly concentrated urine with minimal output, appetite loss, nausea, vomiting, irritability, confusion, seizures.

question

Clinical presentation of DI

answer

Polyuria, polydipsia, altered normal bowel habits, signs of dehydration

question

Treatment of DI

answer

Fluid replacement and prevention of future episodes. Hypotonic fluids, oral fluids, vasopressin or nasal spray, I;O, weight, skin assessment, electrolytes, education

question

Lab values of SIADH

answer

Serum Na ; 120, serum osmolality 1.030, low Hgb ; Hct d/t hemodilution

question

Management of SIADH

answer

Treat underlying cause, reduce fluid intake, replace Na, possible hypertonic IV fluid administration, diuretic if needed, strict I;O, education

question

S/S of DKA

answer

Thirst or a very dry mouth, Frequent urination, High blood glucose (blood sugar) levels, High levels of ketones in the urine, Constantly feeling tired, Dry or flushed skin, Nausea, vomiting, or abdominal pain, Fruity odor on breath, A hard time paying attention, or confusion

question

Labs of DKA

answer

Glucose ; 350, hyperkalemia, hyponatremia, elevated BUN ; Cr, acidosis (pH ; 7.30), HCO3 ; 15

question

Treatment of DKA

answer

Insulin bolus ; gtt, IV fluids, monitor electrolytes, strict I;O, monitor neurological status

question

S/S of hypoglycemia

answer

Neurogenic - nervousness, sweating, intense hunger, trembling, weakness, palpitations, trouble speaking Neuroglycopenic - confusion, drowsiness, change in behavior, coma, seizure, death (BG ; 45)

question

Treatment of hypoglycemia

answer

Glucose (10-15gr x 3), Glucagon (IM), D50 (IV, potential for rebound hypoglycemia)

question

S/S of hyperglycemia

answer

Frequent urination, Increased thirst, Blurred vision, Fatigue, Headache

question

General info on diabetes

answer

Can be type I or type II. Type I pancreas stops producing insulin. Type II insulin resistance.

question

Treatment of diabetes type II

answer

Diet ; exercise are first treatment. Drugs: 1) Sulfonylurea - stimulate beta cells to release insulin 2) Biguanides (metformin) - improve sensitivity to insulin ; decrease glucose produced by the liver 3) Thiazolidinediones - Increased cell receptors, improves muscle effectiveness, decrease glucose produced in the liver 4) Alpha glucosidase - decreases ability of intestinal tract enzymes to metabolize carbs 5) Meglintinides - stimulate beta cells to release insulin 6) Insulin

question

What drugs cause adrenal crisis?

answer

Steroids

question

Lab indicators of renal function

answer

BUN and Cr

question

Describe drug adjustments to be made for patients in renal failure

answer

Decrease the dose or increase the during between doses (not cleared as well through the kidneys)

question

Renal diet restrictions

answer

Restrict Na, K, and protein.

question

Normal UOP

answer

30 ml/hr

question

Complications with acute renal failure

answer

Increased K, increased fluid, HTN

question

CAUTI prevention

answer

Hand washing, aseptic insertion technique, frequent pericare, no dependent loops, no kinked tubing

question

How to verify NG tube placement

answer

CXR

question

Assess for GI bleed

answer

Coffee ground emesis or drainage

question

Aspiration precautions

answer

HOB ; 30, frequent handwashing, assess feeding tube, assess for residuals, swallow study, ETT cuff at appropriate levels

question

GI suction

answer

Low intermittent. 120-140 mm Hg.

question

Describe digoxin toxicity

answer

Confusion, Irregular pulse, Loss of appetite, Nausea, vomiting, diarrhea, Palpitations, Vision changes (blind spots, blurred vision, changes in how colors look, or seeing spots), Decreased consciousness, Decreased urine output, Difficulty breathing when lying down, Excessive nighttime urination

question

Heparin reversal agent

answer

Protamine

question

When to use Amiodarone and dosage

answer

For VT with pulse (150 mg) or pulseless Vfib (300 mg)

question

Drug to use for asystole

answer

Epinepherine

question

Drug for bradycardia

answer

Atropine

question

What to do if a transfusion reaction starts?

answer

STOP the blood

question

What to do if a patient develops hypovolemic shock?

answer

FLUIDS first (crystalloid/collliod). Keep MAP ; 60 mmHg. Then support oxygenation. Vasopressors are fluid replacement is optimal.

question

Treatment of cardiogenic shock

answer

Vasodilators ; inotrops (nitro, dobutamine, milrinone) to optimize hemodynamics. Cardizem to stop afib. Remove obstruction. Surgery/stent/bypass.

question

Treatment of septic shock

answer

Fluids (crystalloid), antibiotics, follow lactate, get blood cultures before starting abx. Keep MAP ; 65 ; CVP 8-12 - can use pressors,

question

Best vasopressors for septic shock

answer

Neorepinephrine, Epinepherine, Vasopressin

question

What do we see in a patient with shock (or with activation of SNS)?

answer

1) Vasoconsriction, increased HR/SBP, increased RR, dilated coronary arteries d/t Epi ; Norepi 2) Increased ACTH, cortisol, and blood glucose d/t adrenals 3) Na ; H2O retention with decreased urinary output d/t RAAS activation

question

What to see with lidocaine toxicity in the heart?

answer

Ventricular irritability

question

Complications of long bone fractures

answer

Fat emboli, air emboli (PE)

question

Chest trauma complications

answer

Pneumothorax

question

Initial treatment for burn patients

answer

Follow ABCs - secure an airway, intubate early if there are signs of obstruction, watch for smoke inhalation, then LOTS of fluids

question

Nursing concerns with rewarming

answer

Watch for hyperkalemia (causing arrhythmias), hypoglycemia, and hypotension (secondary to vasodilation). Go slow! Do not allow shivering. Monitor electrolytes ; glucose frequently.

question

Normal cardiac index (CI)

answer

2.5-4.0

question

Normal stroke volume (SV)

answer

60-100

question

Normal stroke volume index (SVI)

answer

33-47

question

Normal systemic vascular resistance

answer

800-1200

question

Stress Induced Hyperglycemia in Critically Ill Patients

answer

• ;200 •Endogenous process resulting from inflammatory response •Exogenous sources: corticosteroids, immunosupps, sympathomimetics, D5 infusions, parenteral and enteral nutrition. •Volume depletion

question

Critical Illness and Insulin Resistance

answer

•Insulin resistance sustained by inflammatory mediators •Endocrine exhaustion leads to relative deficiency of insulin production

question

Novolog (Rapid Acting Insulin)

answer

Onset: 15 min Peaks: 1 hr Duration: 2-4 hrs

question

Humulin R/Novolin R (Regular/Short Acting Insulin)

answer

Onset: 30 min Peak: 2-3 hrs Duration: 3-6

question

NPH (Intermediate Insulin)

answer

Onset: 2-4 hrs Peaks: 4-12 hrs Duration: 12-20 hrs

question

Lantus/Levemir (Long-Acting Insulin)

answer

Onset: 1-2 hrs Peaks: (minimal peak) Duration: 18-26 hrs

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