Advanced Patho Exam 1-5 Final Exam Review

Describe the components of Virchow's triad.

Hypercoagulability of blood Cancer, thrombophilia, inflammatory disease.... Vessel wall injury Surgery, chemical irritation, inflammation.... Stasis of blood Immobility, varicose veins, venous obstruction....

Provide an interpretation of the patient's chest x-ray above.

Hyperinflation, flattened diaphragms, narrowing of the heart, air trapping

Discuss the potential complications associated with the use of succinylcholine.

Hyperkalemia Malignant hyperthermia Increased ICP Increased intraocular pressure Increased intragastric pressure

Recognize the clinical presentation of a diaphragmatic hernia.

Hypovolemic shock Severe respiratory distress Bowel sounds in the chest

Tridil®, Nitrostat®, Nitro-Bid®(Nitroglycerin)

IV infusion in ICU (also transdermal, sublingual) Venous and coronary dilation Indication Ischemic chest pain Mild-to-moderate hypertension CHF with ischemic heart disease Post-op hypertension Caution in hypovolemia and RV failure

Recognize the indications for RSI.

Impending respiratory failure secondary to cardiopulmonary disease states Acute injury that threatens airway patency Head injury Burns with inhalation injury The inability to maintain or protect the airway CVA Overdoses

What changes would you suggest?

Increase frequency, lower the Vt and increase PEEP

Osmotic Diuretics:

Increase osmotic pressure in the kidneys Water is not reabsorbed Used in management of TBI and cerebral edema Example: Mannitol

Be familiar with how a pulmonary embolus will affect measures of oxygenation and hemodynamics.

Increased Qs/Qt Increased O2ER Normal VO2 Normal C(a-v)O2 Decreased DO2 Decreased SvO2 Increased CVP Increased RAP Increased PA Increased PVR Decreased CO Decreased SV Decreased or normal PCWP Normal SVR

Diuretics

Indications: Hypertension CHF Examples: Loop Thiazide* (•Thiazides are most common type of diuretic used.) Potassium sparing Carbonic anhydrase inhibitors Osmotic

Outline the components of the physical examination used to assess chest trauma.

Inspection Palpation Percussion Auscultation

Cerebellar stroke

Ipsilateral ataxia Discoordination Truncal or gait ataxia imbalance

Explain why ADH is released in response to hypovolemic shock.

Is released in response to a decrease in BP and Na+ levels

Explain why the administration of magnesium sulfate may be beneficial in the management of severe asthma.

It is a smooth muscle relaxer.

Explain what the mnemonic "LEMON" represents and why it is used.

It is used for determining if the patient will be easy or difficult to intubate Look externally Examine Mallampati grade Obstruction Neck mobility

Name the sedative that is the induction agent of choice in patients with bronchospasm.

Ketamine

Explain the benefits of using ketamine or propofol to sedate a patient with severe asthma prior to intubation.

Ketamine - Relaxes smooth muscle - Increases circulating catecholamines - Inhibits vagal outflow - Does not cause histamine release Propofol - May cause bronchodilation

Discuss the indications and contraindications for the King tube and LMA.

King tube Indications Patient is unconscious and without purposeful movement Does not have a gag reflex Unable to perform endotracheal intubation Apneic or RR < 6 At least 4 feet tall Contraindications Positive gag reflex Known esophageal injury, surgery, or disease History of laryngectomy with stoma Any circumstance where airway edema is suspected or could develop Ingestion of a caustic substance Allergic or anaphylactic reaction LMA Indications Airway control when intubation is unsuccessful or not possible due to lack of equipment or trained personnel Comatose states Cardiac and/or respiratory arrest Contraindications Patients with a gag reflex Facial trauma Esophageal trauma Suspected foreign body airway obstruction Non fasting patient Poor lung compliance

Epidural hematoma

Lemon rapidly expanding with arterial blood Skull fracture Torn middle meningeal artery Dura pushed away by hematoma

Provide the names of common diuretics along with their classifications.

Loop - furosemide (Lasix), bumetanide, torsemide Thiazide - hydrochlorothiazide Potassium sparing - amiloride, spironolactone, and triamterene

Describe the effects of low-dose, moderate-dose, and high-dose dose dopamine.

Low-dose (< 5 mcg/kg/min) - "renal dose" - Renal and mesenteric dilation Moderate-dose (5 - 10 mcg/kg/min) - β stimulation - Positive inotrope High-dose (> 10 mcg/kg/min) - stimulation - Increase BP through vasoconstriction

Explain what lung settings are used for lung protective strategy.

Lower end-inspiratory (plateau) pressures Lower Vt Higher rates Higher PEEP

Discuss ventilator management strategies for a patient with burn injuries.

Lung protective strategies Permissive hypercapnia

Obstructive shock hemodyanmic values

MAP: decreased CO/SV: decreased DO2: decreased CVP: increased MPAP: increased PCWP: increased or no change SVR: increased or no change

Distributive shock hemodyanmic values

MAP: decreased CO/SV: increased DO2: increased CVP: decreased MPAP: decreased PCWP: decreased SVR: decreased

Hypovolemic shock hemodyanmic values

MAP: decreased or no change CO/SV: decreased DO2: decreased CVP: decreased MPAP: decreased PCWP: decreased SVR: increased

Cardiogenic shock hemodyanmic values

MAP: decreased or no change CO/SV: decreased DO2: decreased CVP: increased MPAP: increased PCWP: increased SVR: increased

Outline complications associated with burn injuries.

MODs Renal failure Respiratory failure Liver failure Heart failure GI organ failure DIC Fluid loss Hypothermia Wound infection Hypermetabolism Scarring Joint calcification Depression

Thiazide diuretics:

Mainstay of therapy for primary hypertension Inhibit NaCl reabsorption in distal convoluted tubules Increase HCO3-, Cl-, and K+ excretion Moderately potent Example: hydrochlorothiazide

Explain how cerebral perfusion pressure can be increased.

Maintain 60 mmHg - 80 mmHg Focus first on lowering ICP Then increase MAP

Discuss the treatment recommendations for a pulmonary embolus.

Maintain SpO2 greater than or equal to 90% Anticoagulation • High-molecular weight heparin (unfractionated) • Requires frequent lab testing • Low-molecular weight heparin • Safer and more effective than high-molecular weight heparin • Enoxaparin, dalteparin, and tinzaparin • Coumadin (Warfarin) Thrombolytic agent • Streptokinase (Streptase®) • Urokinase (Abbokinase®) • Alteplase (Activase®) • Reteplase (Retavase®) Preventive measure • IVC filter (Greenfield filter & TrapEase filter) • Pneumatic compression • Pulmonary embolectomy (last resort)

ACE Inhibitors

Mechanism of Action & Effect - Decreases level of Angiotensin II and aldosterone - Reduces peripheral arterial resistance - No affect on HR or contractility Indications Hypertension CHF Example: lisinopril

Calcium Channel Blockers

Mechanism of Action & Effect - Lowers peripheral vascular resistance - Suppresses depolarization - Reduces contraction strength, HR, conduction velocity, & decreases CO Indication Angina Hypertension Atrial dysrhythmias Examples: diltiazem and verapamil

Dopaminergics

Mechanism of Action & Effect Stimulates receptors in myocardium and renal, coronary, and intestinal blood vessels Low dose= dilates renal & mesenteric blood vessels Mod dose= + inotrope & chronotrope effects High dose= systemic vasoconstriction Indications Hypotension Low urine output Shock Example: Dopaminemine

Phosphodiesterase Inhibitors

Mechanism of Action & Effects - Improves cardiac contractility & relaxation - Vasodilation Indication Short-term management of CHF Example: milrinone

Nitrates

Mechanism of Action & Effects - Organic nitrates lead to the formation of nitric oxide - Increases cGMP - Decreases release of Ca++ - Smooth muscle relaxation Indications: Angina Acute MI Acute heart failure Example: nitroglycerin

Provide examples of the sedatives used for induction.

Midazolam Lorazepam Dexmedetomidine Propofol Etomidate Ketamine

List the names of common alpha-1 adrenergic drugs.

Midodrine Phenylephrine

Outline the recommendations for PEEP settings based on the severity of ARDS.

Mild = 5 to 10 cmH2O Moderate = 10 to 15 cmH2O Severe = 15 to 20 cmH2O

State the normal distance between the thyroid cartilage and mandible and explain whatit indicates.

Minimum of 2 fingers Is the airway tucked under the base of the tongue

State the normal hyomental distance and explain what it indicates.

Minimum of 3 fingers or > 6.5 cm Predicts the ability to lift the tongue into the mandible

Explain the physiological benefits of prone positioning.

More homogenous distribution of the mechanical stress and strain secondary to mechanical ventilation Improved V/Q ratio Lower mortality rates

State which opiates can cause the release of histamines.

Morphine Dilaudid

Identify complications associated with rib fractures.

Most common blunt trauma injury Pain with breathing, coughing, or pressing on the chest Crepitus common over fracture site Ribs 4 to 10 most fractured Fractures of ribs 8 to 12 look for Diaphragmatic tears Liver or spleen injury Great force required to break 1st and 2nd ribs Associated with myocardial contusion, bronchial tears, and vascular injury

Describe how a coup-contrecoup injury occurs.

Most coup-contrecoup injuries occur when the person's head slams against a stationary object.

Loop diuretics:

Most potent diuretics Inhibit Na+, K+, and Cl- reabsorption in Loop of Henle Increase excretion of H2O, Cl-, K+ and Na+ Examples: furosemide, bumetanide, torsemide

Echocardiogram

Most used test to diagnose heart failure Can assess for systolic and diastolic failure Assess ventricular wall function Determine valvular problems Classifications Heart failure with preserved EF (HFpEF)- EF > 50% Heart failure with mid-range EF (HFmrEF)- EF 40% - 50% Heart failure with reduced EF (HFrEF)- EF < 40%

List four potential mechanisms of injury for TBI.

Motor vehicles crashes Falls Firearms Work-related Alcohol is a major factor in many TBIs

Describe the signs and symptoms of cardiac tamponade. Becks Triad Tx: Pericardiocentsis

Muffled heart sounds Hypotension JVD

Flolan® (Epoprostinol)

Naturally occurring prostaglandin Potent vasodilator Administration Infusion Continuous inhalation Indication Primary pulmonary hypertension

Inderal® (Propranolol)

Non-selective β1-blocker Indication Hypertension Caution High incidence of CNS adverse effects May cause bronchoconstriction

Discuss the 2023 practice guidelines for ARDS.

Nonintubated patients with AHRF (acute hypoxemic respiratory failure), not related to cardiogenic pulmonary edema or chronic lung disease Use of HFNC vs. conventional O2 therapy to reduce intubation risk Intubated patients with ARDS Use low Vt ventilation Do not use prolonged high pressure recruitment maneuvers or brief high pressure maneuvers Intubated patients with moderate to severe ARDS Use prone positioning Do not routinely use continuous infusions of NMBA Refer to patient who meet the criteria for ECMO

Describe brain-type natriuretic peptide (BNP) and the level considered diagnostic for heart failure.

Normal < 100 pg/mL HF likely > 400 pg/mL Natriuretic peptides are protein molecules secreted by the ventricular musculature in response to volume or pressure overload Help the heart handle overload and ventricular stretching Causes natriuresis, vasodilation, and diuresis Synthesized and released in response to ventricular stress

Identify patient populations that are most affected by TBI.

Older adults Racial and ethnic minorities Military service member and Veterans People in correctional or detention facilities Homeless individuals Survivors of domestic violence

Outline the pharmacologic management for a patient presenting with a severe asthma exacerbation.

Oxygen - Should be administered to all pts. with hypoxemia SpO2 < 90% - Target > 92% in adults (> 95% in pregnant women) Inhaled β2-agonists - 2.5 - 5 mg nebulized every 20 minutes for three doses then every 1-4 hours - For severe exacerbations, 10-15 mg can be administered via continuous nebulization over 1 hour - May also give 4-8 puffs MDI every 20 minutes for three doses, then taper Combined β2-agonist/ipratropium - One vial (ipratropium 0.5 mg and albuterol 2.5 mg) every 20 minutes for three doses and then as needed for up to 3 hours Corticosteroids - Methylprednisolone 40 - 60 mg IV - Prednisone 60 mg PO Magnesium sulfate 2 grams IV over 20 minutes

List treatments utilized in the management of chest trauma.

Oxygen therapy Chest tube Thoracotomy Video-assisted thoracoscopy (VATS) Mechanical ventilation

Provide an interpretation of the ABG above including acid-base and oxygenation status. The ABG 30 minutes after intubation is: pH 7.22; PaCO2 72 mmHg; PaO2 50 mmHg; HCO3- 30 mEq/L; SaO2 79%

PC respiratory acidosis with moderate hypoxemia

Identify the acceptable values for PaO2, SpO2, and FiO2.

PaO2 = 55 to 80 mmHg SpO2 = 88 to 95% FiO2 < or = 60%

Right-side stroke

Paralyzed left side hemiplegia Spatial-perceptual deficits Tends to minimize problems Short attention span Visual field deficits Impaired judgment Impulsive Impaired time concept Right side brain damage = left side body weakness

Left-side stroke

Paralyzed right side hemiplegia Impaired speech and language Slow performance Visual field deficits Aware of deficits, depression, anxiety Impaired comprehension Left side brain damage = right side body weakness

Given a patient scenario, recognize the signs and symptoms of left-sided heart failure.

Paroxysmal nocturnal dyspnea Elevated pulmonary capillary wedge pressure Pulmonary congestion Caught Crackles Wheezes Blood tinged sputum Tachypnea Restlessness Confusion Orthopnea Tachycardia Exertional dyspnea Fatigue Cyanosis

Identify the criteria for admission to a burn center.

Partial thickness > 20% BSA (10-50 years old) Partial thickness > 10% BSA (<10 or > 50 years old) Full thickness > 5% BSA any age Burns involving face, eyes, ears, genitalia, joints, hands, feet Burns with inhalation injury High voltage electrical burns Chemical burns Burns complicated by fracture or other trauma Burns in high risk patients

List signs and symptoms indicating the potential need for endotracheal intubation.

Persistent cough, stridor, or wheezing Hoarseness Deep facial or circumferential neck burns Singed nasal hairs Carbonaceous sputum Blistering or edema in the nasopharynx Depressed mental status

Primacor® (Milrinone)

Phosphodiesterase inhibitor Positive inotrope and vasodilator 15-20 times more potent than amrinone Short-term treatment of myocardial dysfunction and high SVR

Describe the characteristic findings of heart failure on a chest x-ray.

Pleural effusion Cephalization of vessels Kerley B lines Increased cardiothoracic ratio Bat winging

Cordarone® (Amiodarone)

Potent antiarrhythmic Indications: Life-threatening ventricular arrhythmias SVT Unlabeled use: Afib Action: Prolong action potential Increase refractory period Inhibits alpha and beta-adrenergic CV effects

Nipride®, (Nitroprusside)

Potent direct-acting vasodilation Venous and arteries (systemic, coronary, pulm, & renal) Decreases preload, PVR, and SVR Increases SV Indications Acute hypertensive crisis Acute decompensated heart failure Toxicity Cyanide Thiocyanide Methemoglobin

Levophed® (Norepinephrine)

Predominant a1 and some β1 stimulation Systemic arteriole constriction except coronary and cerebral vessels Indication Cardiogenic shock Septic shock Caution Increases myocardial O2 consumption

Review the advantages and disadvantages of pressure-control and volume-controlventilation.

Pressure control Allows for better patient-ventilator synchrony Decelerating flow pattern allows better gas distribution Volume control Allows safe Vt delivered in a consistent pattern Avoids alveolar distention

Discuss the prehospital management of TBI.

Prevent Hypotension (systolic < 90 mmHg) Hypoxia (PaO2 < 60 mmHg) Intubation recommended: TBI with GCS < 9 Inability to protect airway SpO2 < 90% despite the administration of supplemental O2 Nonintubated patients provide O2 to maintain SpO2 between 90% to 93% Fluid resuscitation with normal saline Serial neuro assessments Immobilize neck and spine

Outline the treatment goals for ICU management of TBI.

Prevent or control secondary injury Manage ICP Maintain adequate cerebral perfusion pressure Optimize oxygenation and BP Manage temperature, glucose, and seizures Antiseizure medications to prevent and treat post-traumatic seizures Prevent fever Fever shown to ICP and worsen secondary brain injury in patients with severe TBI

Describe the mechanism of action for dobutamine.

Primarily β1 adrenergic - Increased CO, BP, HR - Decreased peripheral vascular resistance Short term management of severe CHF when the patient maintains near-normal to normal BP

Dobutrex® (Dobutamine)

Primarily β1 adrenergic Increased CO, BP, HR Decreased peripheral vascular resistance Short term management of severe CHF when the patient maintains near-normal to normal BP

Primary Brain Injury

Primary Brain Injury Direct impact Acceleration/deceleration Penetrating brain injury Blast waves

Discuss the complications associated with the inflammatory response resulting from an inhalational injury.

Progressive pulmonary dysfunction Pneumonia***** ARDS

Recall which two sedatives provide dose related sedation.

Propofol and precedex

Why does the use of Propofol carry a risk of an increased PaCO2?

Propofol is in a lipid base

Using the article Emergency Airway Management in Acute Severe Asthma, by Jagoda and Sullivan, identify the two medications that are considered appropriate to use for induction agents in patients with severe asthma. What benefits do these medications offer?

Propofol or ketamine; both have bronchodilator properties.

Name the sedatives that are recommended by the Society of Critical Care Medicinewhen targeting light levels of sedation in adults receiving mechanical ventilation andcontinuous sedation.

Propofol or precedex

Using the article, Management of Life-Threatening Asthma in Adults, by Mannam and Siegel, discuss the criteria for ICU admission.

Pt.s with FEV1 or PEFR < 40%, particularly those not responding despite 1 to 2 hours of therapy; those with risk factors for fatal asthma and/or signs of severe illness, or hypoxemia requiring supplemental oxygen.

State the most common chest injury in children.

Pulmonary contusion

State the most common cause of obstructive shock.

Pulmonary embolism

Identify major risk factors for fatal asthma.

Recent history of poorly controlled asthma Prior history of near-fatal asthma Poor perception of dyspnea

Explain why increased fluid entry into the alveoli and decreased clearance of fluid occursin ARDS.

Release of vasoactive substances Increased alveolar capillary membrane permeability Outward migration of blood cells & fluids from capillaries Pulmonary edema Impaired gas exchange

Describe how pulmonary hypertension occurs in ARDS.

Release of vasoactive substances Vascular narrowing and obstruction Pulmonary hypertension

State the goals of pharmacological treatment of heart failure.

Remove sodium and water with diuretics Increasing contraction of the heart with positive inotropic activity Decreasing vascular resistance with vasodilators

Provide potential causes for a hemothorax.

Rib fractures Lung parenchymal injuries Minor venous injuries

Identify chest injuries that are usually identified during the secondary survey.

Rib fractures and flail chest Pulmonary contusion Simple pneumothorax Simple hemothorax Blunt aortic injury Blunt myocardial injury

Identify which nondepolarizing drugs have a reversal agent and provide the name of thedrugs.

Rocuronium Vecuronium Sugammadex

Name two tools that can be used to calculate total body surface area (TBSA).

Rule of nines Lund and browder chart

Lopressor® (Metoprolol)

Selective β1-blocker Action: Decrease force of contraction Decrease HR Indications: Acute management of hypertension Ischemic heart disease MI

Recognize the most common causes of RDS.

Sepsis Aspiration of GI contents Trauma Blood transfusions Burns and inhalation injury Pancreatitis Thoracic surgery Drug overdose Pulmonary contusion Medications Aspirin Tricyclic antidepressants

Describe the underlying pathophysiology associated with a severe asthma exacerbation.

Severe airflow resistance due to bronchial mucosal inflammation and edema, constriction of bronchial smooth muscles, and mucus in the bronchial lumen. Increased intrathoracic pressure from air trapping; depletion of catecholamines during prolonged exacerbations; dehydration through insensible water loss.

Provide the definition of shock.

Shock is defined as a state of cellular and tissue hypoxia due to - reduced oxygen delivery and/or - increased oxygen consumption or - inadequate oxygen utilization

Identify potential complications associated with prone positioning.

Skin breakdown Line dislodgement Unplanned extubation Back pain

Explain the differences between slow onset fatal asthma and rapid onset fatal asthma.

Slow onset fatal asthma - ~80-85% of patients who die of asthma have a history of progressive symptoms for > 12 hours and often 1-3 weeks - Airways show extensive inflammation and obstruction of the airways due to tenacious mucus and shed epithelial cells - Patient-induced predisposition factors Rapid onset fatal asthma - Death occurs < 2-6 hours after symptom onset - Usually associated with massive exposure to external triggers

Be familiar with the ACC/AHA stages of heart failure.

Stage A At-Risk for Heart Failure: Patients at risk for HF but without current or previous symptoms/signs of HF and without structural/functional heart disease or abnormal biomarkers Patients with hypertension, CVD, diabetes, obesity, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or family history of cardiomyopathy Stage B Pre-Heart Failure: Patients without current or prevvious symptoms/signs of HF but evidence of 1 of the following: Structural heart disease Evidence of increased filling pressures Risk factors and increased natriuretic peptide levels or persistently elevated cardiac troponin in the absence of competing diagnoses Stage C Symptomatic Heart Failure: Patients with current or previous symptoms/signs of HF Stage D Advanced Heart Failure: Marked HF symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT

Identify the only depolarizing paralytic.

Succinylcholine First introduced in 1949 Quickest onset and shortest duration of all NMBAs Binds to Ach receptor sites Inactivated by enzymes pseudocholinesterase Causes depolarization of muscle membrane leading to fasciculations and muscle contractions

In the above article, which paralytics are recommended for use during the intubation process? Based on the patient's IBW provide the dose for both.

Succinylcholine 90 mg-122 mg (1.5-2mg/kg) or Rocuronium 61 mg (1 mg/kg)

Identify classification of burns based on burn depth.

Superficial First degree Partial thickness Second degree Full thickness Third and fourth degree

Describe the characteristics of first-, second-, third- and fourth-degree burns.

Superficial (first degree) Minor tissue damage to outer epidermal layer Intense and painful inflammatory response "Sunburn" Management Symptomatic treatment Partial thickness (second degree) Entire epidermis into variable depth of dermis Management Cool burn and cover with clean, dry dressing Often antibiotic creams Full thickness (third degree) Epidermis and dermis Scars contract, limit motion Deeper full thickness Leather like eschar Management Burn center Fourth degree Included in some burn classifications Penetrates Subcutaneous tissue Muscle Fascia Periosteum Bone

Xylocaine® (Lidocaine)

Suppresses Purkinje system automaticity and spontaneous depolarization of ventricles Indication Ventricular arrhythmias Caution Not recommended in patients with heart blocks

Identify two options available for performing a recruitment maneuver.

Sustained inflation breath 40 cmH2O for 40 seconds Stepwise RM Stepwise increase in PEEP

Recognize the Well's value that is consistent with a high risk for a pulmonary embolus.

Symptoms of DVT: 3 points Other diagnosis less likely than PE: 3 points HR > 100: 1.5 points Immbolization or surgery within 4 weeks: 1.5 points Previous DVT or PE: 1.5 points Hemoptysis: 1 point Malignancy: 1 point Hight: > 6 Moderate: 2-6 Low: < 2

Provide the most common presenting signs of a pulmonary embolism.

Tachypnea - Stimulation of the peripheral chemoreceptors - Reflexes from the aortic and carotid sinus baroreceptors Calf or thigh swelling, erythema, edema, and/or tenderness

Describe an AV malformation.

Tangle of abnormal blood vessels connecting arteries and veins in the brain Affects < 1% of the population

Identify the major pathological change associated with smoke inhalation.

The development of edema in the airways Tracheobronchial injury caused by steam and toxic chemicals causing bronchoconstriction

Discuss the renin-angiotensin system and how it is beneficial for patients in hypovolemic shock.

The kidneys sense a decrease in blood pressure and release renin from the juxtaglomerular apparatus (JGA) Renin converts angiotensinogen to angiotensin I In the lungs, angiotensin-converting enzyme (ACE) converts angiotensin I to angiotensin II Angiotensin II causes vasoconstriction, resulting in increased BP Angiotensin II also stimulates the adrenal glands to release aldosterone Within the kidneys, aldosterone promotes the reabsorption of sodium and water The circulating blood volume increases, further raising the BP

Describe the three physiological injuries associated with smoke inhalation.

Thermal injury to upper airway Chemical injury to upper and lower airway Systemic effects of toxic gasses

Summarize the physiologic changes that occur in ARDS.

Thickened diffusion membrane Inflamed exudate-filled alveoli Collapsed bronchioles Lost elasticity of parenchyma Massive shunt SEVERE HYPOXIA

Describe how the brain receives its blood supply.

Through four vessels Carotid arteries 80% of cerebral blood flow Vertebral arteries Forms basilar artery 20% of cerebral blood flow Interconnected at various levels Circle of Willis

Provide new changes in the New Global Definition of ARDS.

Time to installation Up to seven days - known risk factors Pulmonary edema Not explained by cardiogenic edema or intravascular volume overload Radiologic features Bilateral infiltrates on CXR or CT or on lung ultrasound (by trained professional) Not explained by nodules, pleural effusion, or atelectasis Hypoxemia Mild = 201 - 300 with NIV/CPAP PEEP >/= 5 or HFMP > 30L/min Moderate = 101 - 200 com, PEEP >/= 5 Severe = </= 100 com, PEEP >/= 5 Hypoxemia SpO2/FiO2</= 315 with SpO2 </= 97%

Be familiar with the Berlin definition of ARDS.

Timing Within 1 week of a known clinical insult or new/worsening respiratory symptoms Chest imaging Bilateral opacities not fully explained by effusions, lobar/lung collapse, or nodules Origin of edema Respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment (for example, ECHO) to exclude hydrostatic oedema if no risk factor is present Oxygenation Mild = 200 < PaO2/FiO2 < or = 300, with PEEP or CPAP > or = 5 cmH2O Moderate = 100 PaO2 < FiO2 < or = 200, with PEEP > or = to 5 cmH2O Severe = PaO2 / FiO2 < or = 100, with PEEP > or = 5 cmH2O

Recognize complications associated with recruitment maneuvers.

Transient hypotension and desaturation Pneumothorax Transient alveolar distention

Provide an interpretation of the ABG including acid-base and oxygenation status. ABG: pH 7.16; PaCO2 88 mmHg; PaO2 48 mmHg; HCO3- 27 mEq/L; SaO2 77%; NRBM at 15 LPM

Uncompensated respiratory acidosis with moderate hypoxemia

Identify the appropriate time frame for the use of succinylcholine to facilitate endotracheal intubation.

Used during the first 72 hours of a severe burn only Increased risk of severe hyperkalemia

Explain what the mnemonic "BOOTS" represents and why it is used.

Used for determining how difficult it will be to get a mask seal Beards Obesity Old Toothless Snoring

Discuss the benefits of neuromuscular blocking agents.

Used to improve patient-ventilator synchrony Facilitate lung protective ventilation Improve chest wall compliance Reduce oxygen consumption

Recognize potential complications associated with ARDS.

VAP UTI C diff MRSA VRE Pneumothorax Renal failure Ileus Stress ulcers Anemia DVT & PE

What ventilator settings would you recommend?

VC or PC; frequency 10-12; Vt 6-8 ml/kg IBW; MV < 115 ml/kg/min; PEEP 5 cmH2O; start FiO2 at 100% and titrate to maintain SpO2 > 90% or PaO2 > 60 mmHg Pplat <30 cmH20

Identify invasive therapies available for the management of heart failure.

Valve replacement Coronary artery stents Coronary bypass Cardiac resynchronization therapy Left ventricular assist device Heart transplant

You are working the night shift at a small community hospital ED when a patient arrives via EMS with difficulty breathing. Upon patient arrival you observe a 34-year-old woman sitting upright and leaning forward on the stretcher struggling to breathe with accessory muscle use. The paramedic reports they were called to the patient's residence by the husband who found her on the bedroom floor leaning against the bed trying to "catch her breath" at shortly after 1 am when he arrived home from a business trip. An empty albuterol inhaler was found next to her on the floor. According to the husband, she called him at 8am saying that her asthma was acting up after walking the dog. She received 2 nebulizers with 2.5 mg Albuterol enroute to the hospital. Vital signs are the answer.

Vital signs: HR 128; RR 26 and shallow; BP 82/54 mmHg; SpO2 74% on NRBM at 15 LPM. Patient appears fatigued and can only answer questions 1-2 words at a time. BBS: Faint inspiratory and expiratory wheezes throughout all lung fields. ABG: pH 7.16; PaCO2 88 mmHg; PaO2 48 mmHg; HCO3- 27 mEq/L; SaO2 77%; NRBM at 15 LPM PMH: 3 hospitalizations for asthma in the previous year. Two required ICU admission and intubation. Meds: Symbicort 80/4.5 mcg 2 inhalations BID; Montelukast 10 mg QD; Albuterol MDI 2 puffs every 4 hours PRN. Last filled 2 weeks ago.

Define the terms volutrauma, atelectrauma, and barotrauma.

Volutrauma Alveolar distention Atelectrauma Repetitive opening and closing of the alveoli Oxygen toxicity Biotrauma (pulmonary and systemic response to alveolar overdistension)

Describe the classes of the Mallampati score.

When patient opens their mouth, they are looking for anatomic landmarks The less anatomy that you can see, the more difficult an intubation will be

Based on the GINA guidelines, does this patient meet the criteria for a severe asthma attack? If so, what criteria is present?

Yes. Talks in words; leans forward, uses accessory muscles to breathe; HR > 120 bpm; room air SpO2 < 90% on room air.

Vasodilators

decrease SVR and afterload

Diuretics do what?

decrease fluid overload and preload

Nitroglycerin/Nesiritide

decrease preload

BNP (brain natriuretic peptide)

decreases preload and afterload

List the three layers of meninges.

dura mater arachnoid mater pia mater

Digoxin (Lanoxin)

increases preload

Pneumothorax

thoracotomy

Tenormin® (Atenolol)

Β1-selective blocker Action: Decreases force of contraction Decreases HR Indications: Acute management of hypertension Ischemic heart disease MI

Trandate® (Labetalol)

β1-blocker w/ a-1 blocking effects Action: Decreases force of contraction Decreases HR Direct vasodilation Indications: Hypertensive crisis

List three major risk factors that are indicative of poorly controlled asthma. Does the patient present with any of these factors? If so, which?

• Increases in dyspnea and wheezing* • Increases in the frequency of nocturnal awakenings • Increased use of SABA rescue medication* • Increased diurnal variability in PEFR • Hospitalization or ED visits in the past year* • Recent or current use of oral glucocorticoids

Provide the protocol for using inhaled β2-agonists during a severe asthma exacerbation.

■ Inhaled β2-agonists - 2.5 - 5 mg nebulized every 20 minutes for three doses then every 1-4 hours - For severe exacerbations, 10-15 mg can be administered via continuous nebulization over 1 hour - May also give 4-8 puffs MDI every 20 minutes for three doses, then taper

The patient continues to fatigue and has not demonstrated improvement of symptoms despite the administration of three albuterol/Atrovent nebulizers over the past hour. She is 5'6". IBW

(61 kg)

Provide common causes of anaphylactic shock.

- "A generalized, rapidly evolving, multisystemic allergic reaction" - Often fatal without treatment - Occurs usually within one hour of exposure - Foods - Medications - Hymenoptera stings - IV contrast materials

Irreversible shock (organ damage):

- "Multiorgan failure" (MOF) - Irreversible organ damage - Signs and symptoms include: - Anuria - Acute renal failure - Severe lactic acidemia - Severe hypotension - Obtunded and coma

Name the three types of shock that are classified as distributive.

- 66% distributive shock the most common (includes septic shock) - Septic - Neurogenic - Anaphylactic

Embolus

- A blood clot that becomes dislodged and travels to another part of the body - May originate from one large thrombus or occur as a shower of small emboli

Thrombus

- A blood clot that forms and remains in a vein

State the anatomical location for a saddle embolus.

- A large thrombus detaches, passes through the right heart and becomes lodged in the bifurcation of the pulmonary artery

Explain the mechanism of action for the following classes of drugs: Adrenergic blockers Phosphodiesterase inhibitors Cardiac glycosides Ace inhibitors Direct vasodilators Loop diuretics Angiotensin receptor neprilysin inhibitor Inotropes

- Adrenergic blockers Decreases cardiac workload by slowing the heart rate and decreasing the blood pressure Example: carvedilol - Phosphodiesterase inhibitors Increase cardiac output by increasing the force of myocardial contraction Example: milrinone - Cardiac glycosides Increase cardiac output by increasing the force of myocardial contraction Example: digoxin - Ace inhibitors Increase cardiac output by decreasing preload and afterload Example: lisinopril - Direct vasodilators Decrease the cardiac workload by dilating vessels and reducing preload Example: isosorbide dinitrate - Loop diuretics Increase cardiac output by reducing fluid volume and decreasing blood pressure Example: furosemide - Angiotensin receptor neprilysin inhibitor Works synergistically to control heart failure Inhibits the enzyme neprilysin, increasing levels of natriuretic peptide Results in enhanced secretion of sodium vasodilation Example: entresto (sacubitril and valsartan) - Inotropes Increase contractility Example: Dopamine

State the primary medication utilized in the treatment of anaphylactic shock.

- Airway! Airway! Airway! - IV fluids - Epinephrine - B2-adrenergics - Diphenhydramine & ranitidine - Prednisone

Explain what a D-dimer test assesses and state what value is "positive" for the potential presence of a pulmonary embolus.

- Also known as the fibrinogen test - Looks for an increased level of the protein fibrinogen (part of the clotting process) - Values > 500 ng/mL are considered positive - Use clinical correlation

Describe the signs and symptoms of cardiogenic shock.

- Ashen or cyanotic - Cool, clammy skin - Mottled extremities - Peripheral edema - JVD - Tachycardia - Weak pulses - AMS - Abnormal heart sounds - Crackles - Low urinary output

Identify the anatomic lung alterations associated with a pulmonary embolus.

- Blockage of the pulmonary system - Pulmonary infarction - Atelectasis - Alveolar consolidation - Bronchospasm

State five sources of emboli.

- Blood clots - Fat - Air - Amniotic fluid - Bone marrow - Tumor fragments

Compensated (Pre-shock):

- Body compensates for decreased perfusion - Minimal objective indicators - Treatable and reversible if recognized

Identify the patient population that would benefit from the administration of milrinone.

- CHF

State the preferred method for diagnosing a pulmonary embolus.

- CT angiogram

Decompensated (Shock):

- Compensatory mechanisms have become overwhelmed. - Obvious signs generally require a significant impact by the shock mechanism (ie CI less than 2.5 L/min/m2 or 25% loss of blood volume) - These signs and symptoms are not specific to any one form of shock but can help in the differential diagnosis

Explain what happens when patients experience neurogenic shock.

- Consequence of primary and secondary spinal cord injury - Sympathetic nervous system signals cannot make it past the level of injury - Parasympathetic signals are not opposed

Identify physiological causes of systolic heart failure.

- Coronary artery disease - Diabetes mellitus - Hypertension - Valvular heart disease - Dysrhythmias - Congenital heart disease - Peripartum cardiomyopathy - Drugs - Ischemic cardiomyopathy - Rare conditions

Identify physiological causes of diastolic heart failure.

- Coronary artery disease - Diabetes mellitus - Hypertension - Valvular heart disease (AS) - Hypertrophic cardiomyopathy - Restrictive cardiomyopathy o Heart muscle becomes stiff - Constrictive pericarditis o Pericardium becomes thickened or scarred

Rapid onset fatal asthma

- Death occurs < 2-6 hours after symptom onset - Usually associated with massive exposure to external triggers

Describe the cardiovascular effects of increased intrathoracic pressure from air trapping.

- Decreased preload - Increased afterload

Explain how ACE inhibitors work to lower systemic blood pressure.

- Decreases level of Angiotensin II and aldosterone - Reduces peripheral arterial resistance - No affect on HR or contractility Indications Hypertension CHF Example: lisinopril

Provide the definition of pulmonary hypertension.

- Defined as an increase in mean pulmonary artery pressure ≥ 25 mmHg at rest or > 30 mmHg during exercise - Normal range is 10 - 20 mmHg at rest - Frequently a complication of COPD and ILD - More common in women than men (3:1) - Patients may have mild to moderate PH for several years without remarkable signs and symptoms

Recognize potential complications that can result from cardiogenic shock.

- Dysrhythmias - Renal Failure - MODS - Stroke - Thrombus formation

Identify the key characteristic of obstructive shock.

- Extracardiac causes of cardiac pump failure

Outline the treatment for neurogenic shock.

- Fluids for blood pressure - Vasopressors if fluids are ineffective o Norepinephrine - Atropine for bradycardia

State the most common pathogens responsible for severe sepsis and septic shock.

- Gram-positive bacteria - (Pneumococcus, Enterococcus) most common pathogens responsible for severe sepsis & septic shock

Be familiar with treatment options for patients with Group 1 pulmonary hypertension.

- Group 1: o Oral calcium channel blockers (diltiazem) o Prostaglandins (Iloprost, epoprostenol, Treprostinil) o Endothelin receptor antagonist o Inhaled nitric oxide o Phosphodiesterase inhibitors o Heart or lung transplant

Treatment options for Group 2 through 5

- Group 2: • Treat the underlying condition - Group 3: • Oxygen therapy - Group 4: • Blood-thinning medications • Pulmonary thromboendarterectomy - Group 5: • Treat the cause

Provide indications for the administration of alpha-2 adrenergic drugs.

- Hypertension Example: Clonidine

Provide two indications for the administration of dobutamine.

- Hypertensions - Shock

Recognize the symptoms of neurogenic shock.

- Hypotension - Bradycardia - Flushed warm skin

Recognize the changes associated with a pulmonary embolism on an arterial blood gas.

- Hypoxemia - Widened A-a gradient - Respiratory alkalosis and hypocapnia

Outline the treatment for cardiogenic shock.

- Improve systolic BP & coronary perfusion o Dopamine (preferred in patients with ¯ BP) o Dobutamine o Milrinone o Vasodilators - Relax vascular smooth muscle and ¯ SVR - Improves forward flow and CO o Diuretics

Recognize clinical indications for intubation and mechanical ventilation in a patient presenting with severe asthma.

- Inability to maintain respiratory effort - Breaths are shallow and have small volumes are examples - Depressed mental status - Cyanosis

Explain how impaired hepatic and renal function can affect serum drug levels.

- Increased serum levels - Intensified drug effects - Prolonged action - Predisposition to drug toxicity

Provide three types of viruses that can cause septic shock.

- Influenza A & B - RSV - Coronavirus - Human metapneumovirus - Parainfluenza

Associate abnormal electrolyte levels with the use of diuretics.

- Inhibit Na+, K+, and Cl- reabsorption in Loop of Henle - Increase excretion of H2O, Cl-, K+ and Na+ - Hypokalemia - Hypochloremia - Hyponatremia

Discuss the mechanism of action of alpha-2 adrenergic drugs.

- Inhibit sympathetic vasomotor centers in CNS - Vasodilation and decreased HR - Inhibit renal release of renin

State two implantable devices that are utilized in the management of cardiogenic shock.

- Intra-aortic balloon pump - Left ventricular assist device

Define cardiogenic shock.

- Leading cause of death in AMI o Leading cause of cardiogenic shock is AMI - "Decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume".

State the time required for a mature blood clot to form.

- Mature clot takes 24 hours to form

Provide the treatment used in patients with hypovolemic shock.

- Maximize oxygen delivery - Control blood loss - Fluid resuscitation (1-2 L bolus)

Beta-1 Blockers

- Mechanism of Action & Effect - Block B1 receptor sites in myocardium Indications Hypertension Angina A-fib CHF Example: metoprolol

Beta-1 Agonists

- Mechanism of Action & Effect - Increase in force of contraction, HR, CO and BP Indications Hypotension Shock Example: Dobutamine

Cholinergic Antagonists

- Mechanism of Action & Effects - Blocks ACh receptor sites - Decreases vagal simulation Indication Symptomatic bradycardia Example: atropine

Recognize negative effects associated with the administration of nitrates.

- Methemoglobin

List the names of common beta-1 blockers.

- Metoprolol

Identify the leading cause of cardiogenic shock.

- Myocardial infarction

Name the vasopressor of choice for patients in septic shock.

- Norepinephine

Recommend initial ventilator settings for a patient with severe asthma.

- Optimal mode not known; volume limited is recommended - Caution with pressure modes- varying Vt - Rate 10-12 - Vt 6-8 mL/kg IBW - MV < 115 mL/kg/min - PEEP 5 cmH2O... check for intrinsic PEEP - FiO2 start at 100% and titrate to maintain SpO2 > 90% or PaO2 > 60 mmHg

Identify patient populations that have an increased risk for the development of a pulmonary embolus.

- Overall incidence higher in males - Incidence rises with increasing age- especially among women - Patients with malignancy - Pregnant women - Acute stroke - Hospitalized patients - Acute spinal cord injury - Joint replacement - Inherited clotting disorders

Identify potential causes for pulmonary hypertension Group 3.

- PH due to lung disease and/or chronic hypoxemia - Causes: o COPD o ILD o Sleep-related disorders o Chronic exposure to high altitude o Common

Identify the defining characteristics of septic shock.

- Patients meet the criteria for sepsis, but require the use of vasopressors to maintain a MAP ≥ 65 mmHg despite adequate fluid resuscitation - Fatal abnormalities of blood circulation and cellular metabolism - Adequate fluid resuscitation is 60 mL/kg to 80 mL/kg - Lactate level > 2 mmol/L - Mortality rate of 40% - 50%

Provide indications for the administration of alpha-1 adrenergic drugs.

- Postural hypotension · Midodrine - Shock · Phenylephrine

Describe the effects of alpha-1 adrenergic drugs on the vascular system.

- Potent arterial and venule vasoconstriction of vascular beds except cerebral and coronary vessels

State the three stages of shock.

- Pre-shock - Shock - End-organ dysfunction

Discuss the three factors influencing stroke volume.

- Preload - Contractility - Afterload

Describe the difference between up-regulation and down-regulation.

- Prolonged use of agonist drugs or exposure to endogenous catecholamines may blunt response (down regulation) - Prolonged use of antagonists may cause increased sensitivity to agonists once discontinued (up regulation)

Identify common causes of hypovolemic shock.

- Rapid fluid loss results in multiple organ failure o Inadequate circulating volume o Inadequate perfusion o Hemorrhagic* o Internal or external trauma o Abdominal aortic aneurysm o GI bleeding o Non-hemorrhagic o Dehydration

Identify the key characteristic of hypovolemic shock.

- Reduced intravascular volume causes a decrease in CO

Name the diagnostic test considered to be the gold standard for diagnosing pulmonary hypertension.

- Right heart catheterization is the gold standard for diagnosing PH o Only test that directly measures pulmonary artery pressures

Identify the most common form of shock in patients admitted to the ICU.

- Septic shock - Sepsis is the most common form of shock in patients admitted to the ICU - Followed by cardiogenic and hypovolemic - Obstructive shock is rare

Recognize the key characteristic of distributive shock.

- Severe peripheral vasodilation

Identify Hampton's hump on a chest x-ray and explain its significance.

- Shallow, hump-shaped opacity in the periphery of the lung, with its base against the pleural surface and hump towards the hilum

Provide three additional causes of cardiogenic shock.

- Systolic dysfunction - Massive PE - Aortic dissection - Coronary artery disease - Cardiac dysrhythmias - Valvular dysfunction - Diastolic dysfunction

Describe the difference between systolic heart failure and diastolic heart failure.

- Systolic dysfunction is primarily decreased contractility - Heart failure with reduced ejection fraction (HFrEF) - Diastolic prevents ventricles from filling completely due to stiffness - Heart failure with preserved ejection fraction (HFpEF)

signs and symptoms of shock

- Tachycardia - Dyspnea - Restlessness - AMS - Diaphoresis - Metabolic acidosis - Hypotension - Oliguria - Cool, clammy skin

Describe the cardiovascular response to hypovolemic shock.

- Tachycardia - Increased myocardial contractility - Peripheral vasoconstriction - Redistribution of blood to vital organs - Results from an increased release of norepi and decreased vagal tone

Recognize signs and symptoms of hypovolemic shock.

- Tachycardia - Increased myocardial contractility - Peripheral vasoconstriction - Redistribution of blood to vital organs - Results from an increased release of norepi and decreased vagal tone - Hypotension - Cold, clammy skin - Dry mucous membranes - ¯ urine output

Using the GINA guidelines, describe the clinical presentation of a patient with a severe asthma exacerbation.

- Talks in words - Leans forward - Is agitated - Uses accessory muscles to breathe - RR > 30 breaths/min - HR > 120 beats/min - Room air SpO2 < 90% - PEF 33-50% of their best or predicted value

Discuss the role of NIPPV for the management of severe asthma.

- The optimal role for NIV has not been established - Alternative for patients who are not at risk of respiratory failure - May reduce the need for intubation - May be tried in patients with a severe, persistent exacerbation despite maximal bronchodilator therapy if intubation is not immediately required

Discuss the clinical presentation of a patient with a pulmonary embolism.

- Wide variety of signs and symptoms - Most common is sudden onset of chest pain and shortness of breath - Cough - Shock - Dysrhythmia - Syncope, lightheadedness, and confusion

Outline what interventions should be done in the first three hours of diagnosing septic shock.

- Within the first 3 hours: - Obtain lactate level - Obtain blood cultures prior to antibiotics - Broad-spectrum antibiotics - Administer 30 mL/kg of crystalloid solution for hypotension or lactate levels ≥ 4 mmol/L - Patients with septic shock often require 4-6 L or more of crystalloid solution

Slow onset fatal asthma

- ~80-85% of patients who die of asthma have a history of progressive symptoms for > 12 hours and often 1-3 weeks - Airways show extensive inflammation and obstruction of the airways due to tenacious mucus and shed epithelial cells - Patient-induced predisposition factors

Beta blockers

-olol decreases afterload and increases preload

ACE inhibitors

-pril decreases preload and SVR

Angiotensin II Receptor Blockers (ARBs)

-sartan decreases afterload and SVR

The decision is made to intubate the patient.

...

The patient is placed on the following ventilator settings per the physician: AC/VC Rate 20 Vt 420 mL PEEP +8 cmH2O FiO2 80% Ti 0.8 sec Patient is sedated and paralyzed.

...

Given a patient scenario, recognize signs and symptoms of CO poisoning.

10% No symptoms Heavy smokers can have as much as 10% to 15% COHb 15% Mild headache 25% Nausea and a serious headache Fairly quick recovery after treatment with O2 and or fresh air 30% Symptoms intensify Potential for long term effects especially in the case of infants, children, victims of heart disease, and pregnant women 40 to 60% Mental confusion, weakness, loss of coordination, and unconsciousness

Provide the recommended treatment for CO poisoning and hydrogen cyanide poisoning

100% oxygen Hyperbaric oxygen

State the normal interincisor gap and explain what it indicates.

2 to 3 fingers or 40 mm

What is the target SpO2 for an adult patient presenting with a severe asthma exacerbation?

> 92% in adults (> 95% in pregnant women)

Explain how diffuse axonal injury occurs.

A diffuse axonal injury (DAI) is a type of brain injury that causes tears in the brain's long connecting nerve fibers, called axons. This injury occurs due to a blunt injury that causes the brain to rotate and shift rapidly inside the skull

According to the article Status Asthmaticus, by Chakraborty and Basnet, why is the use of a nebulizer preferred over an MDI in an emergency setting?

A nebulizer is still preferred in an emergency setting because of less need for supervision, coordination, and continued instructions.

Discuss the management of an ischemic stroke.

ABCs Establish time of onset Rule out mimics Noncontrast CT/MRI Glucose Manage BP IV tPA if initiated within 4.5 hours of symptom onset Intra-arterial fibrinolytic therapy within 3-6 hours of symptom onset Mechanical thrombectomy within 24 hours of symptom onset Antithrombotic therapy DVT and PE prophylaxis Statins

Vasotec® (Enalapril)

ACE Inhibitor (parenteral administration) Arterial and venous dilator Indication Hypertension

Identify which external features can help you predict a difficult airway.

Absence of a facial and pharyngeal structures Crouzon syndrome Pierre robin Progeria Severe retrognathia Incisors, canines, and molars "Bull neck" diphtheria Obesity

List the absolute and relative contraindication for prone positioning.

Absolute Unstable spinal fracture Relative Recent sternotomy High BSA of anterior burns Unstable pelvic or long bone fractures Elevated ICP Massive hemoptysis

Classiication of PE

Acute- develops signs and symptoms immediately after obstruction of the vessels Subacute- presents within days or weeks following the initial event Chronic- slowly develops signs of pulmonary hypertension over years

Discuss the required preparatory steps prior to RSI.

Administer 100% FiO2 Have BVM available Assess for difficult airway Position patient Continue monitoring HR, ECG, SpO2, and EtCO2 Atropine Nondepolarizing agent Vascular access Have equipment prepared Prepare medications

Provide examples of the classes of drugs in the previous objective. Adrenergic blockers Phosphodiesterase inhibitors Cardiac glycosides Ace inhibitors Direct vasodilators Loop diuretics Angiotensin receptor neprilysin inhibitor Inotropes

Adrenergic blockers Example: carvedilol - Phosphodiesterase inhibitors Example: milrinone - Cardiac glycosides Example: digoxin - Ace inhibitors Example: lisinopril - Direct vasodilators Example: isosorbide dinitrate - Loop diuretics Example: furosemide - Angiotensin receptor neprilysin inhibitor Example: entresto (sacubitril and valsartan) - Inotropes Increase contractility Example: digoxin, milrinone, dobutamine,

List five risk factors for developing ARDS.

Advanced age Female gender Smoking Alcohol use Aortic vascular surgery CV surgery Traumatic brain injury Pancreatitis Pulmonary contusion Infectious pneumonia

Describe the signs and symptoms associated with a tension pneumothorax.

Air trapped in the pleural space Anxiety Cyanosis Increased dyspnea Tracheal deviation Hypotension Tachycardia JVD Unequal chest rise Subcutaneous emphysema

Outline the components of the primary survey.

Airway maintenance with cervical spine protection Breathing and ventilation Circulation and hemorrhage control Disability and neurologic status Exposure and environmental control

Describe how Precedex works.

Alpha 2 adrenergic agonist (inhibits the release of NE) Not used as an induction agent Dose is adjusted to achieve desired sedation Can decrease HR and BP Time to extubation is shorter when compared to propofol

Discuss the management of a hemorrhagic stroke.

Anticonvulsants Antihypertensives Beta-blockers ACE inhibitors Nicardipine Hydralazine Nitroprusside (can increase ICP) Osmotic diuretics

Pitressin® (Vasopressin)

Antidiuretic hormone Vasoconstriction increases SVR Indication Advanced septic shock w/ other meds Acute massive GI hemorrhage

Recognize differential diagnoses of ARDS.

Asthma COPD CHF Pneumonia** Pneumothorax Sepsis**

Identify which cardiac dysrhythmia is a risk factor for an ischemic stroke.

Atrial fibrillation

Subdural hematoma

Banana slowly expanding with venous blood Superior sagittal sinus Torn bridging vein Dura is attached to the skull, so cannot cross falx, tentorium

Outline the recommendations for mechanically ventilating a patient with a TBI.

Be cautious with ETCO2 Acute hypercarbia may increase ICP (vasodilation) Acute hypocarbia may cause cerebral ischemia (vasoconstriction) Recommendation: Keep > 30 mmHg Target PaO2 > 60 mmHg PEEP 15 - 20 cmH2O or APRV is safe (neither impacts ICP)

Discuss the characteristics of the chest x-ray seen in a patient with ARDS.

Bilateral opacities - not fully explained by effusions, lobar/lung collapse, or nodules Baby lung Bat wing "Ground glass"

Discuss the mechanism of action of beta-1 blockers.

Block B1 receptor sites in myocardium Indications Hypertension Angina A-fib CHF

Describe Cushing's triad and what it is associated with. Caused by increased ICP's

Bradycardia Hypertension Irregular RR

Define what a stroke is.

Brain attack Sudden interruption of blood flow to the brain Results in neurological deficit

Identify the various divisions of the adult brain and the functions associated with each.

Brain stem Medulla Pons Midbrain Cerebellum Diencephalon Hypothalamus Thalamus Cerebrum Midbrain Helps regulate LOC Helps regulate the sleep/wake cycle (reticular activating system) Pons Rate and depth of respiration Medulla oblongata BP, HR, and RR

Identify physiological causes of increased airway resistance.

Bronchial mucosal inflammation and edema Constriction of bronchial smooth muscle Mucus in the bronchial lumen

Explain the signs and symptoms associated with a flail chest.

Bruising Seatbelt sign Crepitus

Describe the use of diuretics in the management of hypertension and congestive heart failure.

CHF - treat fluid overload (reduce fluid buildup in the body) Hypertension - diuretics help the kidneys remove salt and water through the urine. This lowers the amount of fluid flowing through the veins and arteries. As a result, blood pressure goes down.

Provide how beta-1 blockers are beneficial in the management of hypertension and congestive heart failure.

CHF = lowers the HR, BP, and allows the heart to work smarter not harder The heart has to work harder if the BP is too high HTN makes the heart work harder, so it allows for the heart to stop working as hard

Identify three differential diagnoses of severe asthma.

CHF; MI; PE; upper airway obstruction; foreign body aspiration; tracheobronchomalacia; endobronchial lesion; COPD; bronchiolitis; vocal cord dysfunction; hyperventilation syndrome; acute bronchitis/pneumonia

Calculate cardiac output given heart rate and stroke volume.

CO = HR x SV

Calculate cerebral perfusion pressure.

CPP = MAP-ICP Maintain 60 mmHg - 80 mmHg Focus first on lowering ICP Then increase MAP

Name the gold standard for evaluating ARDS.

CT is the gold standard

Provide examples of diagnostic tests used to assess chest trauma.

CT scan FAST (focused abdominal sonography for trauma) Labs ABG's CBC

List diagnostic tests that can be used to identify a hemothorax.

CXR Takes 400 to 500 mLs to obliterate the costophrenic angle CT Focused assessment with sonography for trauma (FAST)

Calan®; Isoptin® (Verapamil)

Ca++ channel blocker Indications: Narrow QRS tachyarryhythmias SVT AFib A-Flutter

Procardia® (Nifedipine)

Ca++ channel blocker Selective vasodilating effects (little myocardium) Indication Hypertension Not angina due to reflex tachycardia

Cardene® (Nicardipine)

Ca++ channel blocker Vasodilator Indication Short term treatment of hypertension Alternative to other treatment

Cardizem® (Diltiazem)

Ca++ channel blocker Cardiac depressant and vasodilator Indication Supraventricular arrhythmias A fib Caution May decrease CO in pts with CHF

Adenocard® (Adenosine)

Ca++ channel blocker Naturally occurring in the body Action: Depresses sinus automaticity Alters repolarization of atrial tissue Slows conduction through AV node Indication: SVT

Explain how echocardiography can assist with the diagnosis of heart failure.

Can assess for systolic and diastolic failure Assess ventricular wall function Determine valvular problems

Provide four examples of toxic compounds that are found in smoke.

Carbon monoxide Hydrogen cyanide Phosgene Ammonia Sulfur dioxide Formaldehyde Hydrogen sulfide Acrylonitriles

Explain the mechanism by which angiotensin 2 helps regulate systemic blood pressure.

Causes vasoconstriction, resulting in increased blood pressure

Be familiar with the NYHA classifications of heart failure.

Class 1: No limitation of physical activity, ordinary physical activity does not cause symptoms Class 2: Slight limitation of physical activity; comfortable at rest; ordinary physical activity causes symptoms Class 3: Marked limitation of physical activity; comfortable at rest, but less than ordinary activity causes symptoms Class 4: Severe limitations and discomfort with any physical activity; symptoms present even at rest

Identify the classification that is labelled as PAH.

Classification Group 1 Pulmonary arterial hypertension (PAH) o Caused when the arteries of the lungs become narrowed, thickened, or stiff o Increases the workload of the right side of the heart Causes: o Idiopathic PAH o Heritable PAH o Induced by drugs or toxins o Connective tissue disease Rare

List the names of common alpha-2 adrenergic drugs.

Clonidine Guanfacine

What would you suggest to the physician as the next pharmacological therapy?

Continuous bronchodilator treatment, corticosteroids or magnesium sulfate.

Recognize the difference between decorticate and decerebrate posturing.

Decorticate (Flexor) Arms are like C's Moves in toward the cord Problems with cervical spinal tract or cerebral hemisphere Decerebrate (Extensor) Arms are like e's Problems within midbrain or pons Decerebrate posturing is usually indicative of more severe damage lower in the brainstem.

Carbonic anhydrase inhibitors:

Decrease HCO3- reabsorption Weak diuretic properties May cause metabolic acidosis Example: Diamox

Brainstem stroke

Decreased LOC Nausea and vomiting Eye movement abnormality Double vision Dysconjugate gaze Decreased mobility on one of both sides Dysarthria Dysphagia Abnormal respirations Vertigo, dizziness Hearing loss Locked in syndrome

Explain the difference in the mechanism of action between depolarizing andnondepolarizing paralytics.

Depolarizing Mimics acetylcholine but remains on receptor sites longer Prolongs depolarization Paralysis results because muscles cannot repolarize Nondepolarizing Block ACh receptor sites ACh cannot transmit the impulse Muscles cannot contract Paralysis begins

Describe the signs and symptoms associated with a pulmonary contusion.

Develops over 24 hours Hypoxia Decreased compliance Increased PVR

Lanoxin® (Digoxin)

Digitalis preparation Action: Weak positive inotrope Prolongs refractory period and slows ventricular response Indications: Chronic heart failure A flutter and A fib Caution: narrow therapeutic-to-toxic index

Epinephrine

Direct-acting catecholamine a and β effects Low doses= primary β High doses= primary a Indication Cardiac arrest Hypotension Caution Avoid in patients with myocardial ischemia

Discuss the benefits of performing a recruitment maneuver.

Dynamic, transient increase in transpulmonary pressure Attempts to open previously atelectatic alveoli This increases the size of the baby lung Allows for better gas exchange Less overall overdistention of alveoli

Describe common signs and symptoms seen in a patient with pulmonary hypertension.

Dyspnea Fatigue Hoarseness Lightheadedness Hemoptysis Syncope Chest pain Peripheral edema Ascites Tachycardia Cyanosis Raynaud's disease

Identify potential complications of RSI.

Esophageal Bradycardia Increased ICP Trauma Pneumothorax Right mainstem Aspiration Laryngospasm Hypotension

Identify sedative is an ultra-short-acting barbiturate and blocks the stress induced rise incortisol production for 4-6 hours.

Etomidate

Potassium-sparing diuretics:

Examples: amiloride, spironolactone, and triamterene

Describe the long-term effects of ARDS.

Exercise limitations Abnormal lung function Cognitive impairment Memory loss Depression

Identify the three phases of ARDS.

Exudative Proliferative Fibrotic

Using the article Management of Life-Threatening Asthma in Adults, by Mannam and Siegel, identify the signs and symptoms above that indicate the presence of a life-threatening asthma attack.

FEV1 < 30% of best or predicted; SpO2 < 90%; PaO2 < 60 mmHg; PaCO2 > 45 mmHg; silent chest; cyanosis; exhaustion; confusion or coma; hypotension or bradycardia

Explain the components of the Cincinnati Prehospital Stroke Scale.

Facial droop Arm drift Abnormal speech If any one of these three signs is present as a new event, the probability of stroke is 72%

Given a patient scenario, recognize the signs and symptoms of right-sided heart failure. Cor pulmonale

Fatigue Increased PVR Ascites Enlarged liver and spleen May be secondary to chronic pulmonary problems Distended jugular veins Anorexia and complaints of GI distress Weight gain Dependent edema

Describe "baby lungs".

First introduced in the middle 1980s Well aerated areas of the lung amid the less compliant, atelectatic areas Located primarily in the non-dependent lung regions

Explain what the Parkland Formula is used for.

Fluid resuscitation 4 mL x BSA (%) x weight (kg)

Recognize when an escharotomy is indicated.

For severe swelling

Secondary Brain Injury

Free radical injury Electrolyte imbalance Inflammation Vascular injury Cerebral vasospasm

Discuss ED management of TBI.

Frequent VS Neuro exam including GCS and pupillary movement Serial neuro exams to monitor for clinical deterioration Evaluation and management of increased ICP Cerebral herniation Labs (CBC, lytes, BGL, coag, BAC, urine toxicology)

Outline the components of the Glasgow Coma Scale and identify the score that is associated with severe TBI.

GCS less than 8 intubate GCS <9 is severe injury GCS between 9 and 13 is moderate injury GCS 14 - 15 mild injury

Provide examples of unconventional therapies that can be tried when standard treatment fails to reverse a severe asthma attack.

General anesthesia Can reduce bronchospasm and airway resistance Heliox Rarely necessary Can cause ventilator malfunction ECMO May be beneficial in patients with severe asthma exacerbation and refractory respiratory acidosis

List the five classifications of pulmonary hypertension.

Group 1: Pulmonary arterial HTN (NO, EPO, Flolan) Straight up PAH Group 2: Left-side heart disease (Heart issue) Group 3: Lung disease and/or chronic hypoxemia (COPD) Group 4: Chronic thromboembolic pulmonary hypertension Group 5: Unclear mechanism

Identify the most prevalent classification of pulmonary hypertension and potential causes.

Group 2: - PH due to left heart disease - Most common form of PH - Causes: o Systolic dysfunction o Diastolic dysfunction o Valvular disease o Most common

List measures that can be taken to reduce ICP.

HOB at 30° to permit adequate venous drainage External ventricular drain (EVD) Keep ICP < 22 mmHg Sedation (Propofol) Decompressive craniectomy

Identify two additional treatments that may be of benefit to your patient.

Heliox, ECMO

State the two types of strokes and identify which type is most prevalent.

Hemorrhagic Ischemic Most prevalent

Name the components of the burn cocktail and explain why each is administered.

Heparin Prevents the formation of fibrin casts NAC Remove bronchopulmonary casts Albuterol Promotes bronchodilation

While performing the ventilator check, you observe the above waveforms. What problems do you note and how would you adjust the settings?

High PIP. Air trapping and absence of no-flow zone. Place patient in PC; lower the Ti if possible; Vt 4-6 ml/kg which will allow for a higher frequency.

Provide an argument for not using corticosteroids in the treatment of ARDS.

High dose steroids used in the early stages of ARDS have no benefit and may increase the rate of infection Low dose steroids in ARDS showed improvements in gas exchange without improvement is clinically significant endpoints Risk factor for muscle weakness and poor muscle recovery