Advanced critical Care Module 1 Exam Questions and Correct Answers.

Advanced critical Care Module 1 Exam Questions and Correct Answers What are some reasons for performing or monitoring a patient's neurological status? - Correct Answers: • Mental status • Cranial nerve function • Motor system- movement, ability to move • Coordination • Sensory system • Reflexes What are the parts of the brain? - Correct Answers: Brain consist of three parts: the cerebrum, which contains two hemispheres; the brainstem (midbrain, pons, and medulla,); and the cerebellum Functions: movement, LOC, ability to speak and write, emotions, memory - Correct Answers: Cerebrum consists of midbrain, pons, medulla oblongata. Most cranial nerves originate in brainstem. Regulation of heart rate, blood pressure, and breathing. - Correct Answers: Brainstem Posterior part of the brain. Responsible for equilibrium, muscle tone, and coordination. Cerebellar lesions cause: Loss of coordination (ataxia), Tremors, Disturbances in gait and balance. - Correct Answers: Cerebellum Functional divisions - Correct Answers: Sensory system (afferent) Motor system (efferent) Which part of the nervous system controls breathing? - Correct Answers: Brainstem What issues can a herniated vertebral disc cause? - Correct Answers: o Herniated vertebral disk is the most common spinal nerve root pathology o Involvement of multiple nerve roots = Guillain-Barré o Phrenic nerves arise from spinal roots C3 to C5 o Damage can result in diaphragmatic paralysis o (have pain, affects posture, gait, balance) What is LOC? - Correct Answers: Level of Consciousness and Content of Consciousness (COC): most important parts of the neurologic exam LOC- awake and alert COC- aware and thinking Alert and oriented X 3 (name, date, and location) Main goal is to determine consciousness. A change in either is first clue to CNS dysfunction. Compromise of LOC may be due to: -Generalized dysfunction (e.g., overdose) -Abnormality in specific area Why do we determine it? - Correct Answers: Determines consciousness What scale is used to quantify neurologic impairment? - Correct Answers: Glasgow Coma Scale (GCS) Score given for: ▪ Motor response ▪ Verbal response • Poorly suited for patients with impaired verbal response (e.g., aphasia, hearing loss, tracheal intubation) ▪ Eye opening What are the ranges on the GCS? - Correct Answers: • Scale goes from 3 (deep coma) to 15 (fully awake) • GCS- 12-15 non-ICU observation • GCS- 9-12 Significant insult • GCS- 9= severe coma = requires endotracheal intubation When do we intubate? - Correct Answers: GCS less than or equal to 8 intubate, if a patient is intubated when assessment is done the letter "T" is attached to the score GCS 5T What is the Babinski sign? - Correct Answers: o Plantar reflex o Tested when suspected L4-L5 or S1-S2 injury o The presence of dorsiflexion of the great toe with fanning of the remaining toes during testing of the plantar reflex o Normal in children 12-18 months abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. - Correct Answers: Cheyne-Stokes breathing abnormal pattern of breathing characterized by groups of regular deep inspirations followed by regular or irregular periods of apnea - Correct Answers: Biot's respirations characterized by a deep, rapid breathing pattern. It is typically an indication that the body or organs have become too acidic. In an attempt to expel carbon dioxide, which is an acidic compound in blood, the body starts to breathe faster and deeper. - Correct Answers: Kussmaul's respirations . What is the main goal of assessing mental status? - Correct Answers: Determine consciousness What is an apnea test? - Correct Answers: Declares brain death How is an apnea test performed? - Correct Answers: ▪ Normalize the blood gas ▪ Disconnect patient from ventilator ▪ Administer 100% O2 via the ETT ▪ Monitor for 8-10 minutes ▪ Absences of spontaneous breathing and PaCO2 of 60mmHg or 20mmHg above the baseline is indicative of a positive apnea test = brain dead What does PetCO2 stand for? - Correct Answers: o End-tidal PCO2 (PetCO2) is used to estimate dead space ventilation o Patient End-Tidal Carbon Dioxide o End-tidal PCO2 (PetCO2) At what point in the capnography curve is it measured? - Correct Answers: o Normal capnogram shows PCO2 of zero at start of expiratory breath (Phase I), exhalation of dead space gas o Soon afterward, the PCO2 level rises sharply (Phase II) and plateaus as alveolar gas is exhaled (Phase III) o End-tidal PCO2 (PetCO2) is used to estimate dead space ventilation Alveolar dead space + anatomic dead space = what? - Correct Answers: o Anatomic dead space (normally in conducting airways): 1 mL/kg IBW o Alveolar dead space (alveoli is ventilated, but not perfused) -PHYSIOLOGICAL DEAD SPACE What carries 99% of the oxygen in the blood? - Correct Answers: Red blood cells "hemoglobin" (12-16 normal range) . How does a V/Q mismatch affect oxygenation of pulmonary capillary blood? - Correct Answers: When a ventilation/perfusion mismatch is present, there will be less oxygen in the pulmonary capillary blood (no exchange matching the blood perfusion) What happens to cardiac output when there is left shift in the oxygen dissociation curve? - Correct Answers: o Left shift = Increased affinity (decreases C.O. to limit amount of blood and O2 delivered) o Right shift = Decreased affinity (increases C.O. to move more blood and O2) What is the normal range for PaO2? - Correct Answers: 80-100 mmHg What is PvO2? - Correct Answers: Partial pressure of O2 in mixed venous blood o Indication of O2 use by the entire body o Normal range 30- 40mmHg o Blood sample taken from pulmonary artery catheter (PvO2, SvO2, and CvO2) non-invasive, measurement of CO2 - Correct Answers: Capnometry graphic display of CO2 levels as they change during breathing - Correct Answers: Capnography device that measures CO2 levels - Correct Answers: Capnometer What is the most common technique used to measure CO2 in respiratory gases? - Correct Answers: ▪ Side stream ▪ Gas from the airway is extracted through a narrow plastic tube to the sample measuring chamber ▪ Mainstream ▪ The sampling chamber attaches directly to the ET and analysis is performed at the airway Capnometer functions on basis that CO2 absorbs infrared light, the greater the concentration of CO2 in the sample, the less is the infrared light that arrives at the detector Two techniques: o Mainstream technique places an analysis chamber in patient's breathing circuit o Side stream technique pumps small volume of gas from circuit into nearby analyzer . At the beginning of exhalation, the PETCO2 reads 0 mm Hg. Is that normal? - Correct Answers: Normal capnogram shows PCO2 of zero at start of expiratory breath (Phase I), exhalation of dead space gas What is the normal difference between PETCO2 and PaCO2? - Correct Answers: o ETCO2 usually reads about 3-5mmHg less that PaCO2 o At setup of capnometer, take note of ETCO2 reading o Then get a blood gas to get PaCO2 reading o If ETCO2 reading is 35 and PaCO2 is 40, you can always assume that the ETCO2 reading at the bedside is always about 5 below o If ETCO2 starts to increase, assume that the PaCO2 is increasing What does the sharp downstroke and return to baseline on a capnograph represent? - Correct Answers: It represents the end PCO2 that is used to estimate dead space ventilation What can cause a sudden rise in PETCO2 on the monitor? Sudden decrease? - Correct Answers: How much pleural fluid is in each hemithorax on a normal adult? - Correct Answers: About 8ml of fluid per hemithorax (its similar to interstitial fluid and decreases friction caused by expanding lungs in thorax during inspiration) When is intrapleural pressure most negative? - Correct Answers: o During inspiration- intrapleural pressure is -8 o During exhalation- intrapleural pressure is -4 o When air or fluid enters the pleural space (not normal), the pressure gradient changes and the lung collapses o The lungs have collapsed, so there is less volume of air, which causes the pressure in the lungs to increase What diseases are the most common causes of pleural effusions? - Correct Answers: o Congestive Heart Failure (CHF): high hydrostatic pressure increases pleural fluid production = most common cause of effusions o Nephrotic syndrome o Transudative: effusions forming while pleural space is undamaged CHF, Cirrhosis, nephrotic syndrome, hypoalbuminemia, lymphatic obstruction, peritoneal dialysis, atelectasis, central venous catheter in pleural space, urinothorax. o Exudative: occur due to inflammation of lung or pleura and have higher protein and inflammatory cell content (70% of all effusions) Malignancies, infectious disease, pulmonary embolism, GI disease, collagen vascular disease, drug-induced pleural disease, hemothorax, chylothorax. What is a meniscus sign and what does it represent? - Correct Answers: o Shows on CXR. Sign of pleural effusion (fluid in pleural space). o Chest radiography o Most common method of detecting effusions o Upright PA and lateral decubitus are useful o 1-cm meniscus lung to rib allows for thoracentesis If you are attempting to remove air from the pleural space, where would you insert the chest tube? - Correct Answers: To drain air: • Incision made over chest in 2nd or 3rd intercostal space at midclavicular line • Advance chest tube superiorly, toward apex of lung (top) • Air rises If you were removing fluid, where would it be placed? - Correct Answers: To drain fluid: • Incision made over 4th or lower intercostal space at midaxillary line • Advanced chest tube posteriorly, toward base of lung • Fluid settles low • Percutaneous needle aspiration of effusion sample • Drainage for lung re-expansion involves placement of chest tube • Risks include: ▪ Artery laceration ▪ Infection ▪ Pneumothorax - Correct Answers: Thoracentisis • insertion of a chest tube • Allows air and fluid to leave the chest • Drainage container is below the level of the chest tube, so gravity helps air and fluid to drain - Correct Answers: Chest Tubes- Thoracotomy Once the air leak has resolved, how soon should you remove the chest tube? - Correct Answers: 48hours after the air leak is no longer seen = nearly zero reoccurrence What are the complications if not removed at the recommended time? - Correct Answers: • As soon as air leak visually ceases = 25% rate of pneumo recurring What is the most common symptom associated with a pneumothorax? - Correct Answers: Chest pain What age group is most prone to having a spontaneous pneumothorax? - Correct Answers: Usually occurs in their late teenage years or early 20s (18-25) and are tall & thin What would you expect to see on a chest x-ray with a tension pneumothorax? - Correct Answers: • Mediastinal shift to the contralateral side, diaphragmatic depression, and expansion of the ribs o A tension pneumothorax is life-threatening!!! o Chest wall is intact o Air enters the pleural space from the lung o Positive pressure forces air into the pleural space o Pressure is transmitted to mediastinum (heart and blood vessels) o Pushes mediastinum and trachea to the unaffected (opposite) side o Compromised cardiac output o Needs immediate needle decompression Where would you insert a needle to relieve a tension pneumothorax? - Correct Answers: Large IV catheter/needle is inserted in the 2nd rib space in the midclavicular line. The needle is advanced until air can be heard exiting. The needle is withdrawn, and the catheter is left in place. Chest x-rays are the most common tool used to diagnose a pneumothorax, but if you needed a more accurate estimate of the size, what test would you order? - Correct Answers: Computed tomography (CT) What is the normal value for O2 consumption? - Correct Answers: o DO2- amount of O2 delivered to tissues, plus the rate at which it occurs o Normal- 1000ml of O2/minute o VO2- amount of O2 used by the tissues, plus the rate at which it occurs o Normal- 250ml of O2/minute What does PaCO2 tell you on an ABG? - Correct Answers: • How the patient is ventilating • PaCO2: standard for assessing ventilation: standard for assessing ventilation. Changes in metabolism, lung mechanics, Changes in metabolism, lung mechanics, ventilatory efficiency, equipment function may ventilatory efficiency, equipment function may precede changes in blood gas What does VD/Vt tell us? - Correct Answers: • Dead Space-Tidal Volume Ratio (VD/VT) • VD- inspired volume that does not come in contact with pulmonary capillary blood • VT- total tidal volume • Higher ratio indicates more wasted ventilation • ICU common to be 0.60 What is the normal range for VD/Vt? - Correct Answers: • VD/VT = PaCO2 - PECO2 /PaCO2 • Normal: 25% to 40% (0.25-0.40) critical: 0.60 • Patients on ventilator have higher VD/VT What can cause an increase PETCO2? - Correct Answers: Causes of increased end-tidal carbon dioxide values • Decreased effective ventilation • Increased CO2 production, agitation, stress, shivering, fighting the ventilator, pain, anxiety, recovery from sedation or paralysis What can cause an decrease PETCO2? - Correct Answers: Causes of decreased end-tidal carbon dioxide values • Increased effective ventilation • Marked decrease in effective ventilation • Decreased CO2 production • Decrease in lung perfusion Causes of absent end-tidal carbon dioxide values • Apnea • Cardiac arrest • Ventilator disconnect or malfunction • Airway obstruction What is the normal range for C.O.? - Correct Answers: • Cardiac Output = HR x Stroke Volume • 4 - 8 l/min (5-6 when resting is normal)