Critical Care FINAL

Critical Care FINAL unstable angina - severe increasing chest pain that may occur at rest and requires nitrate therapy to resolve; high risk of MI within 18 months manifestations - severe retrosternal, left pectoral or epigastric pain radiating to jaw/LUE, pressure/burning/squeezing pain unrelieved by rest dx - H&P, cardiac enzymes, cholesterol levels, EKG, cardia cath tx - nitrates, Bblockers, CCBs, percutaneous intervention, bypass sx, pain management decreased preload, contractility, perfusion; increased afterload MI - death of myocardial cells as a result of unrelieved myocardial ischemia from occlusion NSTEMI - usu from partial occlusion of a vessel, but can be seen in pts with hypoxemic resp failure or shock STEMI - usu occurs because of plaque rupture manifestations - precordial (left), substernal or back pain that is crushing/tight/squeezing with min responsiveness to nitro, sense of impending doom, EKG changes and cardiac enzyme elevation tx for NSTEMI without cardiac cause - O2/support tx for STEMI or NSTEMI with cardiac cause - MONA, clopidrogel/heparin, PCI in cath lab, TPA for STEMI, antidysrythmics, BBlockers, ACE inhibitors septic shock def - A subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65mmHg or greater AND serum lactate level greater than 2mmol/L (>18mg/dL)in the absence of hypovolemia sepsis tx tx - blood cultures, broad spectrum abx, lactate level, pressure bag fluids for hypotension, vasopressors if fluid resuscitation does not work -- norepi, then vasopressin, then epi BiPAP v. CPAP v. vents - BiPAP - used to relieve work of breathing in reversible resp distress; also used as transition for pts with high risk of reintubation CPAP - used in obstructive sleep apnea at night *cannot restrain people with these - risk for aspiration if pt throws up and cannot remove mask* vents - supportive care that provides forced air during inspiration, pt is not breathing on their own Afib - irregular rhythm in which the atria are quivering instead of contracting main features - irregular RR, no P waves tx- anticoags to prevent clots; watchman procedure- rate control with bblockers, CCBs, digoxin - chronic AFib tx with conversion (amioderone or cardioversion) /ablation Aflutter - irregular rhythm in which the atria are fluttering instead of contracting; more organized and less chaotic than AFib main features - fast, regular rate, F waves tx- anticoags considered- with Aflutter hx, rate control- acute Aflutter, convert with amioderone/cardioversion SVT - rapid atrial tachy that develops from repetitive firing from a focus, short diastole, and new action potentials key features - regular rhythm, HR above 150, narrow QRS, no P wave tx- consider vagal maneuvers, adenosine, Bblockers, CCBs, antidysrhythmics and cardioversion if SVT does not resolve on its own 1st degree HB - electrical impulse moves more slowly thru the AV node key features - PR interval greater than 0.20 sec problem - usually no concerns/asymtomatic tx-monitor for rhythm changes 2nd degree HB type 1 (Wenkebach) - each impulse from the SA node is delayed slightly longer until the heart skips a beat key features - PRs increasingly longer and then no QRS problem - usu no concerns, slight CO drop tx-monitor for hypo perfusion or worsening block 2nd degree HB type 2 - electrical signals sometimes fail to reach ventricles causing an irregular and slow HR key features - P wave with dropped QRS, bradycardia tx-immediate transcutaneous pacing needed until a permanent pacemaker can be placed (this will often progress to 3rd degree HB) 3rd degree HB - electrical signal from atria to ventricles is blocked key features - no relation between the P wave and QRS, bradycardia tx- immediate transvenous pacing until permanent pacemaker can be placed VFib - life threatening chaotic wavy rhythm due to quivering of the ventricles; total loss of CO and pulse key features - chaotic irregular waves, rate up to 600 bmp tx-defibrillation VTach - life threatening wave characterized by 3 or more PVCs in a row with rapid HR; pt may or may not have a pulse key features - broad QRS, HR greater than 160defibrillate for pulseless vtach AC:S PEA/Asystole - call for help begin CPR/venting attach defib and leads to confirm rhythm give epi ASAP then q 3-5 mins treat underlying cause pulse check q 2 mins shock if rhythm becomes VFib/tach ACLS VFib/pulseless VTach - call for help begin CPR/venting defib ASAP - 1 shock 120-200J pulse check after 2 mins -if no pulse and same rhythm, shock and epi q3-5 mins -if no pulse and asystole, change to that algorithm repeat pulse check/next steps q 2 mins packed red blood cells - used in acute hemorrhage, symptomatic anemia... to restore O2 carrying capacity and intravascular vol; transfused over 1 -4 hrs threshold - hemoglobin of 7 for hemodynamically stable pts, 8 for actively bleeding, ortho/cardiac sx, or preexisting CV disease labs - H&H, ionized calcium platelets - used in acute hemorrhage, thrombocytopenia, platelet dysfunction to accumulate at a bleeding site for hemostasis; rapidly infused over 1 hr threshold - less than 50,000 in non-actively bleeding, less than 100,000 with mult traumas/CNS involvement, less than 20,000 for oncology pts labs - PLT fresh frozen plasma (FFP) - used for quick INR reversal in pts with supratherapeutic INR; provides some vol resuscitation threshold - INR greater than 1.5 labs - INR cryoprecipitate - most commonly used to induce hemosasis in pts iwht fibrinogen deficiency; also used to treat bleeding in pts with hemophilia A/von willebrands threshold - fibrinogen below 100 labs - fibrinogen whole blood - used in trauma, severe hemorrhagic shock to increase O2 carrying capacity, expand vol, and help with hemostasis threshold - hemorrhage greater than 25% total blood vol or greater than 10 units of blood in 24 hrs meds for hemostasis - vitamin K - for slow INR reversal protamine sulfate - for heparin overdose PCC (Kcentra) - for rapid INR reversal DDAVP - to stop bleeding in pts with von willebrands or mild hemophilia A FEIBA - to treat bleeding in pts with hemophila A or B Thromboelastogram (TEG) components - R value - time to initiate clot; need FFP if greater than 8 mins K - time to achieve clot strength; need cryo if greater than 4 mins alpha angle - rate of clot formation; need cryo if less than 47deg MA - strength/stability of clot; need platelets if less than 55mm A30/LY30 - amp 30 mins past MA; need TXA if greater than 8% T&S/crossmatch - type - A, B, AB, O screen - atypical antibody screening that may have formed during pregnancy/previous transfusion crossmatch - blood from pt and donor are mixed to assess for clumping *type/screen is good for 72 hrs* blood product preparations - leukocyte reduced - used for pts receiving a lot of blood products/anyone who has reacted to leukocytes in the past irradiated - used for donor units from a blood relative, HLA-matched donor units, immunosuppressed pts, premature newborns washed - removes plasma proteins for pts who have IgE anti IgA, with neonatal alloimmune thrombocytopenic purpura, pts with hx of severe allergic rxns to transfusions HLA matching - used to match similar antigen profiles volume reduced - removes excess plasma for pts at risk of fluid overload pooled - platelets are pooled from several donors to reach a therapeutic dose blood admin considerations - consent large bore IV filtered system, on a pump use 0.9 NSS to prime and flush system 2 RN ID of donor and recipient VS stay with pt for first 15 mins no more than 4 hr infusion monitor hypocalcemia if more than 4 units given use fluid warmer for mult units acute transfusion rxns - adverse S/S seen within the first 24 hrs of transfusion; most are seen within the first 15 mins of transfusion if rxn occurs... -stop blood -flush IV -VS -call provider •Febrile, nonhemolytic transfusion reaction (most common) •Allergic reaction •Acute hemolytic transfusion reaction •Hypotensive transfusion reaction •Transfusion-associated circulatory overload (TACO) •Transfusion-related acute lung injury (TRALI) •Transfusion-associated dyspnea •Transfusion-transmitted infection lethal triad - hypothermia- leads to decreased coagulation coagulopathy - leads to increased lactic acid acidosis - leads to decreased heart performance --> hypothermia GI bleed - S/S - tachy, hypotension, dropped H&H, hematemesis (bright & coffee ground are upper), black tarry stool - upper, bright red blood per rectum - lower, pallor, confusion, LOC, nausea tx - anticoag reversal, protonix, blood products, endoscopy interventions/sx retroperitoneal bleeding - S/S - tachy, hypotension, flank ecchymosis, abd distension, abd pain tx - anticoag reversal, blood products, endoscopy interventions/sx pulmonary hemorrhage - S/S - bright red blood from mouth or thru ETT, SOB, incessant cough, hypoxia need to intubate wet snake bite - 80% of bites, envenomation has occurred can be mild, moderate of severe but all bites should go to the ED dry snake bite - 20% of bites, no envenomation pts can still have an allergic rxn or develop an infection snake bite manifestations - bleeding, blurred vision, burning skin, diaphoresis, dizzy, fainting, fever, loss of coordination, N/V, parastheis, polydipsia, rhabdo, severe pain, tachy, edema, necrosis, weakness rattlesnakes - rapid onset coagulopathy, hypotenison, SOB, ptosis, paralysis cottonmouths/copperheads - rapid onset coagulopathy, hypotenison, SOB coral snakes - delayed onset NEUROTOXIC effects, hypotension, SOB, convulsions, secretions, paralysis, dysphagia, airway edema, abd pain snake bite tx - ABCs, fluids for hemodynamic instability, albumin if unresponsive to fluids, vasopressors if not responding to fluids/albumin IV antivenom, epi for anaphylaxis, anticholinesterase for neurotoxic effects, blood products for coagulopathy, pain meds circle bite/measure/ID time of bite, wash with soap and water, cover with sterile dressing, restrict movement of affected extremity to keep below the heart, remove jewelry, monitor VS, monitor coags, monitor urine output for rhabdo, NPO for possible intubation pre-hospital trauma management - ABCs, treat life threatening injuries establish airway, access, vent, pressure to hemorrhage sites, TXA if needed, spine immobilization, fracture stabilization, thoracotomy for tension pneumo transport pt to right level of care TXA - antifibrinolytic agent that reduced blood loss after sx and traumatic injury must be given within 3 hrs of injury primary survey - rapid 1-2 min systematic eval designed to ID life threatening injuries, establish priorities and provide interventions Airway/c spine Breathing and vent Circulation/hemorrhage control Disability/neuro status Exposure and environmental control Full set of VS/family Get resuscitation adjuncts secondary survey - initiated after all actual or potential life threatening injuries have been ID and addressed, and resuscitative efforts have been initiated - hx and inspection logroll for spine tenderness/deformities DRE pelvic stability ROM in joints doc lacs, abrasions, contusions examine ortho injuries resuscitation complications - hyperchloremic metabolic acidosis inflammatory organ injury (ARDS) disruption of early clots hypocalcemia from PRBCs hypernatremia from saline compartment syndrome from overload REBOA - [resuscitative endovascular balloon occlusion of the aorta] insertion and inflation of an endovascular balloon into the proximal aorta via the common femoral artery in patients with an exsanguinating torso hemorrhage balloon can be inflated in 3 zones depending on site of bleeding -Zone 1 - hemorrhage from aorta between L subclavian and celiac artery -Zone 2 - from diaphragm to lowest renal artery (generally avoided due to presence of visceral arteries) -Zone 3 - hemorrhage below renal arteries damage control surgery - rapid surgical control of active hemorrhage extensive or complex surgeries during initial phase of injury can trigger lethal triad several smaller surgeries are needed to fix extensive injuries but are usually deferred until 1-2 days after initial phase indications for trauma ICU admit - -hemodynamic instability from trauma -grade IV organ injury -spinal cord injury with neuro deficit -TBI -blunt myocardial injury -airway compromise -GCS < 9 -penetrating trauma to head, neck, chest, abd, pelvis, extremity proximal to knee/elbow -traumatic paraplegia/quadriplegia -post op management -discretion of ED attending blunt trauma injury - most common; MVCs, assaults, auto v ped; common injuries - splenic rupture, liver lac, pancreatic lac, diaphragm rupture, hemorrhage, kidney/bladder/bowel damage, pelvic fx, compartment syndrome, skull/extremity fractures manifestations - internal bleeding, abd distention/guarding/rigidity, hemodynamic instability, flank discoloration, ecchymoses, referred pain, extremity deformities penetrating trauma injury - usu easier to dx that blunt trauma; GSW, KSW, other penetrating weapons/ shrapnel common injuries - liver/spleen lac, bowel perf, peritonitis, diaphragm injuries, pneumo manifestations - internal/external bleeding, hemodynamic instability, anxiety, flank discoloration, abd rigidity/distention, abd compartment syndrome blast trauma injuries - form of blunt and penetrating trauma; bombs, grenades, landmines, mortar shells, dynamite, chemical fires common injuries - TBI, pneumo,, air embolism, auditory system injuries, burns, MI, strokes, blindness, spinal cord injuries, organ ruptures maniffestations - internal/external hemorrhage, hemodynamic instability, clogged ears, tinnitus, vertigo, balance disturbances, raccoon eyes, burns, SOB, decreased breath sounds, distended/firm abd FAST exam - focused assessment with sonography in trauma rapid bedside US exam to screen for blood around the heart (pericardial effusion) or abd organs (hemoperitoneum) head trauma - primary injuries - injury from direct contact to the head and brain - focal injuries include contusion, lac, intracrania hematomas -diffuse injuries include concussion, diminished/altered state of consciousness secondary injuries - injury that occurs after the initial head injury -intracranial hemorrhage, cerebral edema, increased ICP, hypoxia, infection, hypotension, resp complications, electrolyte imbal spinal trauma considerations - assess for stability/injury place C collar assess for neurogenic shock - hypotension, poor temp control assess for spinal shock - flaccidity, loss of reflexes, loss of voluntary movement -- *cannot dx spinal injury as complete or incomplete until spinal shock has resolved* MAP 85-90 for perfusion XR and CT can detect fractures or subluxation MRI can detect soft tissue injury unstable spine complications - subluxation - trauma exceeds spine's load bearing capacity and leads to structural failure and neural compression myelopathy - demyelination due to cord compression; leads to hyperreflexia, spasticity and weakness radiculopathy - compression of nerve roots; leads to hyporeflexia, atrophy, weakness, parasthesias, burning sensation, shooting pain musculoskeletal injuries - pelvic fractures, traumatic amps, limb fx, soft tissue injuries, crush injries, contusion sx emergencies include: open fx, compartment syndrome, septic arthritis, acute dislocations, femoral neck fx complications - compartment syndrome, rhabdo, hyperkalemia, VTE, fat embolism, DIC ICU post op management - will receive report from trauma bay nurse and surgical report from anesthesia assessment/VS labs drip management close glucose monitoring vent management monitoring incision/drainage strict I/O hypothermia management pain management wound care nutritional support thermal burns - 90-93% of all burns; usu caused by fire, scalding liquids, contact, steam severity of injury depends of duration of contact, temp of agent, amount of time exposed chemical burns - caused by bases, acids, organic compounds complications - CNS depression, hypothermia, hypotension, pulmonary edema, hemolysis, chemical pneumonitis/bronchitis, hepatic/renal failure electrical burns - greatest damage is at point of contact (entry and exit) severity depends of type and path of current, duration of contact, environmental conditions, tissue resistance, cross sectional area can cause irregular heartbeat, airway obstruction, bone fractures, cataract formation, paralysis, convulsions, muscle twitching, hypoxia, tissue necrosis, compartment syndrome, renal failure systemic inhalation injury - can occur from CO or cyanide CO - from wood or coal burning, frequent cause of on scene death. death occurs when 60%+ hgb is bound to CO cyanide - from smoke byproducts of carpet, plastics, vinyl flooring, upholstery, window coverings; leads to tissue ischemia and necrosis supraglottic inhalation injury - damage to pharynx and larynx causing edema and possible airway obstruction manifestations - hoarseness, dry cough, increased WOB, dysphagia, wheezing, stridor, hypercapnia, hypoxia subglottic inhalation injury - extensive damage to trachea/bronchi and alveoli that impairs pulmonary functioning, high odds of developing ARDS *hallmark sign is carbonaceous sputum* burn classification - superficial (1st degree) - epidermis only, heals in 3-5 days; S/S: erythema, dry skin, pain partial thickness (2nd degree) - epidermis and dermis -mild heals in 10-21 days; S/S: 1st degree plus blisters -deep heals in 2-4 weeks; S/S pallor, mottling, moist/dry skin, less painful than mild, blanching decreased full thickness (3rd degree) - destruction of epidermis, dermis, and underlying SQ tissue; does not heal and requires skin grafting; S/S: skin is thick/dry/leathery, white/cherry red/ or brown/black, no sensation, no blanching, thrombosed vessels full thickness (4th degree) - destruction of all layers to bone, needs amputation rule of nines - age 9 and above: -head, L arm and R arm - 9% each -chest/abd, back, L leg and R leg - 18% each -groin = 1% infant to 8 years old: -L arm and R arm - 9% each -head, chest/abd, back - 18% each -L leg and R leg - 14% each *subtract 1% from head for each year over age 1 palm method for small irregular burns (1 palm = 1%) LR for burns - more similar to body fluids than saline; does not contain dextrose which can lead to increased urine output contains lactate to buffer acidosis fluid guidelines for burns - 2-4 ml/kg per %burn give half of total fluids during first 8hrs from injury, then give the next half over the next 16 hrs do not give albumin until 8-12 hrs after injury nutrition for burn victiims - extremely important for recovery due to hypermetabolic state from burns - rapid breakdown of muscle and energy stores high calorie, high protein diet by mouth if unable to tolerate, enteral feedings renal failure ICU care - daily wt strict I/O monitor labs - BMP, CBC, ABGs, UA q 24 hrs classes of nephrotoxic meds - aminoglycosides (-cin) ACE inhibitors (-pril) cef- -floxacin NSAIDs penicillin rifampin tacrolimus vanc pre-renal failure - AKI from interference of blood delivery due to... hemorrhage, GI losses, diuretics, DI, burns, distributive shock, afterload reduction, anesthesia, HF, PE, pericardial tamponade, ACE inhibitors tx with isotonic fluids or blood, stop meds causing intravascular depletion/vasodilation intra-renal failure - AKI caused by interference with secretion/reabsorption; caused by nephrotoxicity most common condition is acute tubular necrosis manifestations - oliguria, inc BUN/Cr, dec Cr clearance, hyperK, proteinuria tx - stop nephrotoxic agent, fluid challenge, emergent dialysis if failure worsens post-renal failure - AKI from obstruction of urine due to BPH, renal calculi, tumors, edema, foley obstruction tx the cause indication for dialysis - when pts renal failure can no longer be treated with conservative medical management used to correct fluid and electrolyte imbalance, and to remove waste products hemodialysis - access - fistula, graft, dialysis catheter performed by dialysis nurse idications -emergent fluid/electrolyte/contrast removal, uremic encephalopathy, acute/chronic RF risks - hypotension, infection, bleeding, clotting of access freq - 1-4hrs daily or 3 days/week for chronic peritoneal dialysis - access - peritoneal dialysis catheter performed by dialysis nurse, bedside nurse or pt indications - chronic RF risks - infection, bleeding, clotting of access, hyperglycemia, peritonitis freq - 30mins - 8hrs daily CRRT - access - dialysis catheter performed by ICU nurse indications - hemodynamically unstable with acute or chronic RF risks - infection, bleeding, clotting of access freq - 24 hrs continuous CRRT concepts - ultrafiltration - move fluids from high pressure to low pressure convection - move dissolved solutes from high pressure to low pressure diffusion - move solutes from high conc to low conc anticoagulation during dialysis - used with CRRT to break up clots formed in the membranes from platelets, RBC, WBC, proteins... use heparin, or citrate and calcium placed in blood flow line right before membrane filter