Final exam

• Living will


  Patient's wants (do they want intubated?)
• Power of attorney (POA)

  Appointed person to make medical decisions if patient is unable
• End of life care

  Transition to make medical decisions if patient is unable
• Palliative care


  Can be a full code, symptom management
• Hospice


  No curative efforts, just pain management
• Pain scales


  • Numeric: rate pain from scale 0-10
  • Wong-baker faces scale: types of patients that would need this pain scale
  • Non-verbal pain cues CPOT- mainly used in ICU
• ABCs


  • Airway: obstructions
  • Breathing: tracheal deviation?
  • Circulation: do they have a tourniquet on?
• Forms of shock


  • Obstructive shock (Compression/obstruction)
  • Hypovolemic shock (Reservoir depletion)
  • Cardiogenic shock (Pump failure)
  • Distributive shock (Vasodilation)
• Obstructive shock


  • PE (treat with clot lysis)
  • Cardiac tamponade (pericardiocentesis)
  • Tension pneumothorax (needle decompression)
• Hypovolemic shock


  • Inadequate CO due to inadequate circulating volume, can be due to actual loss or loss outside vascular space (think ascites, burns)
  • Loss of 25% or more = manifestations
  • Examples: trauma, high-acuity surgical patients, hemorrhage, hypovolemia
  • Manifestations- hypotension, low CVP, elevated HR, low urine output, cool, clammy skin
  • Management- time is critical, secure airway, control fluid loss, fluid resuscitation (blood products)
• Cardiogenic shock


  • Myocardial tissue that no longer functions impairs contractility and CO, leads to pulmonary congestion, can then lead to systemic inflammatory response (vasodilation), lactic acidosis
  • Examples: Blunt cardiac injury, Dysrhythmia, Myocardial infarction
  • Manifestations- sustained hypotension, PAWP greater than 15 mm/Hg, CI less than 2.2, CP, pulmonary congestion, general shock signs!
  • Diagnose with EKG, echocardiogram, troponin, CXR, ABGs, electrolytes
  • Management- reduce pulmonary edema (IV diuretics), increase BP and CO with vasopressors and inotropes
• Distributive shock


  • Medical emergency!!!
  • Oxygenation impaired due to altered blood flow distribution; massive vasodilation occurs- resulting in hypovolemia
  • Examples: Anaphylaxis, sepsis, spinal cord injury (neurogenic shock)
  • Septic: Temp greater than 38˚ C or less than 36˚ C, HR greater than 90, RR greater than 20, WBC greater than 12,000 or less than 4,000, High lactate!
  • Neurogenic: associated with acute spinal cord injury, Spinal shock- temporary loss of spinal reflex activity developing below level of injury, sensorimotor function loss and HTN develop, flaccid paralysis that includes bladder and bowel, can last hours or weeks, FLUIDS will not help these people, they need pressors
  • Neurogenic manifestations: Hypotension, Bradycardia, Hypothermia
  • Neurogenic treatment: Stability of spine, Optimize oxygen delivery, Restore intravascular volume
  • Anaphylactic: severe systemic allergic reaction, type I hypersensitivity, leads to systemic vasodilation and increased capillary permeability, leading to life threatening edema, presents as allergic reaction, EPI first line, steroids, Benadryl, albuterol
• General management of shock


  • Optimizing oxygen delivery
  • Fluid resuscitations to restore preload and CO
  • Vasoactive drugs (Vasopressors, Inotropes, Vasodilators)
  • Decrease oxygen consumption (Neuromuscular blocking agents, sedation)
  • Maintain normothermia (antipyretics, fan, cooling blanket)
  • Maintain glucose level (goal 150)
• Crystalloid fluids


  • LR
  • Plasmolyte (less sodium than LR, maintains homeostasis)
  • NS
• Erythropoietin


  Hormone naturally produced by the kidney that helps stimulate RBC production
• Erythropoietin in renal failure


  Kidneys don't secrete the hormone, so patients get a monthly hormone injection to correct anemia and slow progression of renal failure
• CRRT


  • #1 reason why patients are on CRRT in the ICU: to cleanse the blood to help correct electrolytes, filter blood, or remove fluid, patient should be less fluid overloaded at the end of dialysis (oxygen needs will go down, BP will improve)
  • Filters waste from blood
  • Done for those who have sepsis/MODS or cannot tolerate hemodialysis
• CRRT monitoring


  • Electrolytes
  • ABGs
  • Weight
  • Signs of bleeding
• Common vasopressors


  • Vasopressin (mimics antidiuretic hormone)
  • Phenylephrine (alpha adrenergic drug)
  • Epinephrine (beta-adrenergic drug)
  • Norepinephrine (Levophed) (beta and alpha adrenergic drug)
• SIRS, Sepsis, MODS


  • SIRS: systemic inflammatory response syndrome, can be caused by infection, trauma and pancreatitis
  • SIRS -> Sepsis: positive lactate> 2 , hypotension, hypothermia (older adults), tachycardia, confusion
  • Sepsis management: Blood cultures prior to abx, Abx delivery within an hour, 30 ml/kg IV in the first 3 hours if hypotensive, High flow oxygen for initial hypoxia, Vasopressor initiation for MAP >65 and SBP> 90, Stress dose steroids, Stress ulcer prophylaxis, VTE prophylaxis, Renal replacement therapies
  • Untreated sepsis -> MODS: organ damage caused by sepsis from hypotension or bloodstream infection
• Troubleshooting a transducer


  1. Zero at the phlebostatic axis: if you get a number that's whack, you need to check where placement is and rezero it

  2. This is on the arterial line & should be in line with the heart
• Swan numbers and what they indicate


  • RAP (right atrial pressure): normal 2-6, increased = fluid volume excess, decreased = fluid volume deficit
  • RVP (right ventricular pressure): systolic 20-30 mm Hg, diastolic 2-8 mm Hg
  • PAP (pulmonary artery pressure): normal systolic 20-30 mm Hg, diastolic 8-15 mm Hg, increased = PH, MI, fluid overload, decreased = fluid volume deficit
  • PAWP (pulmonary artery wedge pressure): normal 4-12 mmHg, increased = Tachy, dyspnea, orthopnea, PND, crackles, extra heart sounds, decreased = fluid volume deficit
• What it will look like if Swan is wedged
• Vent parameters


  • Tidal volume (Vt): set on ideal body weight, 6 mL. per kilogram (controls CO2)
  • FiO2: how much oxygen you're getting, most you can have is 100% (controls oxygenation)
  • Rate: how many demand breaths they get in a minute (controls CO2)
  • PEEP: Atmospheric pressure, usually set at 5-8, at least 5 (our resting rate) (controls oxygenation)
• High PEEP can cause barotrauma and pneumothorax
• Types of burns


  • Thermal: Flames, hot objects
  • Chemical: Acid, alkali, organic substances
  • Electrical: Electrical current
  • Radiation & extreme cold: Radiant injury, frostbite
• Burn depth


  • Superficial partial thickness- epidermis and superficial layer
  • Deep partial thickness- epidermis and deep layer of dermis
  • Full thickness- epidermis, dermis, subcutaneous layers of skin and tissue
  • Deep full thickness- extends to muscle, tendons, or bone
• Rule of nines


  • Anterior and posterior head and neck= 9%
  • Anterior and posterior upper limbs =18%
  • Anterior and posterior trunk =36%
  • Perineum =1%
  • Anterior and posterior lower limbs =36%
• Parkland formula


  4 mL x TBSA x patient weight in kg, used to determine fluid resuscitation
• TRAUMA NAKED


  • Cover with clean sheet, remove clothes, 2 large bore IV, airway
• Burn complications


  • Third spacing
  • Compartment syndrome (decreased pulses, pale, swollen, tight skin, decreased urine output)
  • Rhabdomyolysis: breakdown of muscle, directly impacts kidneys
• Any signs of soot or inhalation: need to be intubated even if they seem fine & talking
• Pancreatitis risk factors


  • Chronic alcohol abuse
  • Lodged gallstone
• Pancreatitis presentation


  • Board like abdomen, rigid abdomen, ripping tearing pain, rule out heart attack and AAA
• Pancreatitis causes the pancreas to secrete digestion enzymes and impacts blood sugar since the pancreas secretes insulin
• Pancreatitis labs


  • Lipase
  • Amylase
• Pancreatitis management


  • Strict NPO
  • Fluids
  • No oral pain meds
• Pancreatitis can cause electrolyte imbalances
• Fluid resuscitation for burns

  4 mL x TBSA x pt. weight in kg
• TRAUMA NAKED


  • Cover with clean sheet, remove clothes, 2 large bore IV, airway