CCRN Review Part 1 (of 2)
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““Never let what you cannot do Never let what you cannot do
interfere with what you can do”interfere with what you can do”- - John WoodenJohn Wooden - -
CCRN REVIEW PART 1CCRN REVIEW PART 1
Sherry L. Knowles, RN, CCRN, CRNISherry L. Knowles, RN, CCRN, CRNI
TOPICSTOPICS Acute Coronary SyndromesAcute Coronary Syndromes Acute Myocardial InfarctionAcute Myocardial Infarction Heart BlocksHeart Blocks Heart FailureHeart Failure Cardiac AlterationsCardiac Alterations Aortic Aneurysms Aortic Aneurysms CardiomyopathyCardiomyopathy Shock States Shock States Peripheral Vascular DiseasePeripheral Vascular Disease HemodynamicsHemodynamics
ARDSARDS Chronic Lung DiseaseChronic Lung Disease DrowningDrowning PneumoniaPneumonia PneumothoraxPneumothorax Pulmonary EmbolismPulmonary Embolism Respiratory FailureRespiratory Failure Gastrointestinal AlterationsGastrointestinal Alterations GI BleedingGI Bleeding PancreatitisPancreatitis
CCRN REVIEW PART 1CCRN REVIEW PART 1
OBJECTIVESOBJECTIVES1.1. Understand the different types of acute coronary syndromes.Understand the different types of acute coronary syndromes.
2.2. Identify basic coronary circulation and how it relates to different Identify basic coronary circulation and how it relates to different types of myocardial infarctions.types of myocardial infarctions.
3.3. Anticipate potential complications associated with an AMI.Anticipate potential complications associated with an AMI.
4.4. Identify the standard treatment of an AMI.Identify the standard treatment of an AMI.
5.5. Distinguish between various AV blocks.Distinguish between various AV blocks.
6.6. Recognize the signs & symptoms of heart failure.Recognize the signs & symptoms of heart failure.
7.7. Identify the treatment of heart failure.Identify the treatment of heart failure.
8.8. Recognize the general definition and classifications of aortic Recognize the general definition and classifications of aortic aneurysms.aneurysms.
9.9. Understand the different types of aortic dissections.Understand the different types of aortic dissections.
10.10. Recognize the signs & symptoms of cardiomyopathy.Recognize the signs & symptoms of cardiomyopathy.
11.11. Differentiate between the different types of cardiomyopathy.Differentiate between the different types of cardiomyopathy.
12.12. Identify the treatment for the different types of cardiomyopathy.Identify the treatment for the different types of cardiomyopathy.
CCRN REVIEW PART 1CCRN REVIEW PART 1
OBJECTIVESOBJECTIVES13.13. Understand the different stages of shock.Understand the different stages of shock.
14.14. Differentiate between different types of shock.Differentiate between different types of shock.
15.15. Distinguish between arterial and venous peripheral vascular disease.Distinguish between arterial and venous peripheral vascular disease.
16.16. Identify the various treatments for peripheral vascular disease.Identify the various treatments for peripheral vascular disease.
17.17. Define respiratory failure.Define respiratory failure.
18.18. Identify the various treatments for acute respiratory failure.Identify the various treatments for acute respiratory failure.
19.19. Recognize the signs & symptoms and causes of various respiratory Recognize the signs & symptoms and causes of various respiratory alterations.alterations.
20.20. Identify the standard treatment for various respiratory alterations.Identify the standard treatment for various respiratory alterations.
21.21. Explain the common causes of gastrointestinal bleeding. Explain the common causes of gastrointestinal bleeding.
22.22. Describe the most commonly seen treatments for GI bleeding.Describe the most commonly seen treatments for GI bleeding.
23.23. Describe the signs & symptoms of acute pancreatitis and available Describe the signs & symptoms of acute pancreatitis and available treatments.treatments.
CCRN REVIEW PART 1CCRN REVIEW PART 1
Acute Coronary Acute Coronary SyndromesSyndromes
Acute MIAcute MI
Aortic AneurysmsAortic Aneurysms
Cardiac AlterationsCardiac Alterations
Cardiovascular ConditionsCardiovascular Conditions
CardiomyopathyCardiomyopathy
Heart BlocksHeart Blocks
Heart Failure Heart Failure
Shock StatesShock States
DEFINITIONSDEFINITIONS
– Term used to cover a group of symptoms Term used to cover a group of symptoms compatible with acute myocardial ischemiacompatible with acute myocardial ischemia
– Acute myocardial ischemia is insufficient blood Acute myocardial ischemia is insufficient blood supply to the heart muscle usually resulting from supply to the heart muscle usually resulting from coronary artery disease coronary artery disease
Acute Coronary SyndromeAcute Coronary Syndrome
DEFINITIONDEFINITION
– Infarction occurs due to mechanical obstruction Infarction occurs due to mechanical obstruction
of a coronary artery (or branch) caused by a of a coronary artery (or branch) caused by a
thrombus, plaque rupture, coronary spasm thrombus, plaque rupture, coronary spasm
and/or dissection.and/or dissection.
– STEMI vs. NSTEMI (non-STEMI)STEMI vs. NSTEMI (non-STEMI)
Acute Myocardial InfarctionAcute Myocardial Infarction
SIGNS & SYMPTOMSSIGNS & SYMPTOMS
– Complains Vary Complains Vary
May include crushing chest pain (which may or may May include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric not radiate), back, neck, jaw, teeth and/or epigastric pain, SOB, nausea/vomiting and dizzinesspain, SOB, nausea/vomiting and dizziness
– ST elevations on ECGST elevations on ECG
– Elevated cardiac enzymesElevated cardiac enzymes
Acute Myocardial InfarctionAcute Myocardial Infarction
SIGNS & SYMPTOMSSIGNS & SYMPTOMS
PAWP, PAWP, CO, CO, SVR, dysrhythmias, SSVR, dysrhythmias, S44, ,
cardiac failure, cardiogenic shockcardiac failure, cardiogenic shock
– Diaphoresis, pallor, referred painsDiaphoresis, pallor, referred pains
– Diabetics and women often present abnormal Diabetics and women often present abnormal
symptomssymptoms
Acute Myocardial InfarctionAcute Myocardial Infarction
Coronary CirculationCoronary Circulation
I I AVRAVR V1 V1 V4V4
II II AVL V2 V5 AVL V2 V5
III III AVF V3 V6 AVF V3 V6
II II
VV
12 Lead ECG12 Lead ECG
ST ELEVATIONSST ELEVATIONS– Anterior Wall MIAnterior Wall MI
Leads VLeads V11-V-V44
Reciprocal changes in leads II, III, and aVFReciprocal changes in leads II, III, and aVF Area supplied by the LADArea supplied by the LAD
– Inferior Wall MIInferior Wall MI Leads II, III and aVF Leads II, III and aVF Reciprocal changes in leads I, and aVLReciprocal changes in leads I, and aVL Area usually supplied by the RCAArea usually supplied by the RCA
Acute Myocardial InfarctionAcute Myocardial Infarction
ST ELEVATIONSST ELEVATIONS– Lateral Wall MILateral Wall MI
I, aVL, VI, aVL, V55 and V and V66
Area supplied by the Circumflex arteryArea supplied by the Circumflex artery
– Posterior Wall MIPosterior Wall MI Reflected on the opposite wallsReflected on the opposite walls Opposite deflectionsOpposite deflections
Acute Myocardial InfarctionAcute Myocardial Infarction
Coronary ArteriesCoronary Arteries
Anterior Wall MIAnterior Wall MI
Inferior Wall MIInferior Wall MI
COMPLICATIONSCOMPLICATIONS
– Dysrhythmias, heart failure, pericarditis, Dysrhythmias, heart failure, pericarditis,
ventricular aneurysms, ventricular thrombus, ventricular aneurysms, ventricular thrombus,
VSD, mitral regurgitation, papillary muscle (or VSD, mitral regurgitation, papillary muscle (or
chordae tendineae) rupture, pericardial chordae tendineae) rupture, pericardial
effusions, pericarditiseffusions, pericarditis
Acute Myocardial InfarctionAcute Myocardial Infarction
NURSING INTERVENTIONSNURSING INTERVENTIONS– OO22
– BedrestBedrest
– Serial ECG’sSerial ECG’s
– Serial cardiac enzymesSerial cardiac enzymes
– Keep pain free (NTG. MSOKeep pain free (NTG. MSO44))
– MONA MONA (Morphine, O2, Nitroglycerin, Aspirin),(Morphine, O2, Nitroglycerin, Aspirin), Heparin, beta-blockers, and ace inhibitors. May also Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2b3a inhibitorsinclude thrombolytics or Gp2b3a inhibitors
– PCI, PTCA, IABP, CABG PCI, PTCA, IABP, CABG
Acute Myocardial InfarctionAcute Myocardial Infarction
TREATMENTTREATMENT
– Time Is Heart MuscleTime Is Heart Muscle
– Prompt ECGPrompt ECG
– Goals: Relieve pain, limit the size of the Goals: Relieve pain, limit the size of the infarction and to prevent complications infarction and to prevent complications (primarily lethal dysrhythmias) (primarily lethal dysrhythmias)
Acute Myocardial InfarctionAcute Myocardial Infarction
TREATMENTTREATMENT
– MONA MONA (Morphine, O2, Nitroglycerin, Aspirin)(Morphine, O2, Nitroglycerin, Aspirin), , Heparin, beta-blockers, and ace inhibitors. Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2b3a May also include thrombolytics or Gp2b3a inhibitorsinhibitors
– Cardiac Catheterization (with angioplasty, Cardiac Catheterization (with angioplasty, atherectomy and/or stent)atherectomy and/or stent)
– IABP, CABG, educationIABP, CABG, education
Acute Myocardial InfarctionAcute Myocardial Infarction
Balloon AngioplastyBalloon Angioplasty
Vascular Stent DeploymentVascular Stent Deployment
AtherectomyAtherectomy
SPECIFIC TREATMENTSSPECIFIC TREATMENTS– Inferior Wall (IWMI)Inferior Wall (IWMI)
FluidsFluids (with RV infarct) (with RV infarct) InotropicsInotropics Afterload reducing medicationsAfterload reducing medications
– Anterior Wall (AWMI)Anterior Wall (AWMI) DiureticsDiuretics InotropicsInotropics Afterload reducing medicationsAfterload reducing medications
Acute Myocardial InfarctionAcute Myocardial Infarction
Aortic AneurysmsAortic Aneurysms
DEFINITIONDEFINITION– A bulge or ballooning of the aorta A bulge or ballooning of the aorta
When the walls of the aneurysm include all three When the walls of the aneurysm include all three layers of the artery, they are called true aneurysmslayers of the artery, they are called true aneurysms
When the wall of the aneurysm include only the When the wall of the aneurysm include only the outer layer, it is called a pseudo-aneurysmouter layer, it is called a pseudo-aneurysm
– May be thoracic or abdominalMay be thoracic or abdominal
Aortic AneurysmsAortic Aneurysms
CAUSESCAUSES Atherosclerosis Atherosclerosis
Marfan syndrome Marfan syndrome
Hypertension Hypertension
Crack cocaine usage Crack cocaine usage
Smoking Smoking
Trauma Trauma
Aortic Aneurysms RuptureAortic Aneurysms Rupture
An aortic aneurysm, depending on its size, may An aortic aneurysm, depending on its size, may rupture, causing life-threatening internal bleedingrupture, causing life-threatening internal bleeding
The risk of an aneurysm rupturing increases as the The risk of an aneurysm rupturing increases as the aneurysm gets largeraneurysm gets larger
The risk of rupture also depends on the location of The risk of rupture also depends on the location of the aneurysmthe aneurysm
Each year, approximately 15,000 Americans die of a Each year, approximately 15,000 Americans die of a ruptured aortic aneurysm. ruptured aortic aneurysm.
Aortic AneurysmsAortic Aneurysms
CLASSIFICATIONSCLASSIFICATIONS
– Classified by shape, location along the aorta, Classified by shape, location along the aorta, and how they are formedand how they are formed
– May be symmetrical in shape (fusiform) or a May be symmetrical in shape (fusiform) or a localized weakness of the arterial wall (saccular)localized weakness of the arterial wall (saccular)
Aortic AneurysmsAortic Aneurysms
Aortic AneurysmsAortic Aneurysms
SIGNS & SYMPTOMSSIGNS & SYMPTOMS
– Often produces no symptoms Often produces no symptoms
– If an aortic aneurysm suddenly ruptures it presents If an aortic aneurysm suddenly ruptures it presents with extreme abdominal or back pain, a pulsating with extreme abdominal or back pain, a pulsating mass in the abdomen, and a drastic drop in blood mass in the abdomen, and a drastic drop in blood pressure pressure
– An increase in the size of an aneurysm means an An increase in the size of an aneurysm means an increased in the risk of rupture increased in the risk of rupture
Aortic AneurysmsAortic Aneurysms
THORACIC SIGNS & SYMPTOMSTHORACIC SIGNS & SYMPTOMS– Back, shoulder or neck pain Back, shoulder or neck pain
– Cough, due to pressure placed on the tracheaCough, due to pressure placed on the trachea
– Hoarseness Hoarseness
– Strider, dyspneaStrider, dyspnea
– Difficulty swallowing Difficulty swallowing
– Swelling in the neck or armsSwelling in the neck or arms
Aortic DissectionsAortic Dissections
DEFINITIONDEFINITION
– Tearing of the inner layer of the aortic wall, which Tearing of the inner layer of the aortic wall, which allows blood to leak into the wall itself and causes allows blood to leak into the wall itself and causes the separation of the inner and outer layersthe separation of the inner and outer layers
– Usually associated with severe chest pain radiating Usually associated with severe chest pain radiating to the backto the back
Aortic DissectionsAortic Dissections
A.A. Dissection Dissection beginning in the beginning in the ascending aorta ascending aorta
B.B. Whenever the Whenever the ascending aorta ascending aorta is not involved is not involved
Aortic DissectionsAortic Dissections
A.A. Dissection Dissection beginning in the beginning in the ascending aorta ascending aorta
B.B. Whenever the Whenever the ascending aorta ascending aorta is not involved is not involved
Aortic DissectionsAortic Dissections
Aortic DissectionsAortic Dissections
Aortic AneurysmsAortic Aneurysms
COMPLICATIONSCOMPLICATIONS
RuptureRupture
Peripheral Peripheral embolization embolization
InfectionInfection
Spontaneous Spontaneous occlusionocclusion of aorta of aorta
Aortic AneurysmsAortic Aneurysms
TREATMENTTREATMENT
Medical managementMedical management
– Controlled BP (within specific range)Controlled BP (within specific range)
Surgical repairSurgical repair
> 4.5 cm in Marfan patients or > 5 cm in non-> 4.5 cm in Marfan patients or > 5 cm in non-Marfan patients will require surgical Marfan patients will require surgical correction or endovascular stent placementcorrection or endovascular stent placement
CardiomyopathyCardiomyopathy
DEFINITIONDEFINITION
– Diseases of the heart muscle that Diseases of the heart muscle that cause deterioration of the function of cause deterioration of the function of the myocardiumthe myocardium
CardiomyopathyCardiomyopathy
CLASSIFICATIONSCLASSIFICATIONS– Primary / Idiopathic (intrinsicPrimary / Idiopathic (intrinsic))
Heart disease of unknown cause, although viral Heart disease of unknown cause, although viral infection and autoimmunity are suspected causesinfection and autoimmunity are suspected causes
– Secondary (extrinsicSecondary (extrinsic)) Heart disease as a result of other systemic diseases, Heart disease as a result of other systemic diseases,
such as autoimmune diseases, CAD, valvular such as autoimmune diseases, CAD, valvular
disease, severe hypertension, or alcohol abusedisease, severe hypertension, or alcohol abuse
CardiomyopathyCardiomyopathy
Hypertropic CardiomyopathyHypertropic Cardiomyopathy
Restrictive CardiomyopathyRestrictive Cardiomyopathy
Dilated CardiomyopathyDilated Cardiomyopathy
Hypertropic CardiomyopathyHypertropic Cardiomyopathy
Bizarre hypertrophy of the septumBizarre hypertrophy of the septum– Previously called IHSS Previously called IHSS
Idiopathic Hypertropic Subaortic StenosisIdiopathic Hypertropic Subaortic Stenosis
– Known as HOCM Known as HOCM Hypertropic Obstructive CardiomyopathyHypertropic Obstructive Cardiomyopathy
Positive inotropic drugs Should Positive inotropic drugs Should NotNot Be Used Be Used Contractility will Contractility will outflow tract obstruction outflow tract obstruction
Nitroglycerin Should Nitroglycerin Should NotNot Be Used Be Used– Dilation Will Worsen The Problem Dilation Will Worsen The Problem
HarleyHarley
Hypertropic CardiomyopathyHypertropic Cardiomyopathy
TREATMENTTREATMENT– Relax the ventriclesRelax the ventricles
Beta BlockersBeta Blockers Calcium Channel Blockers Calcium Channel Blockers
– Slow the Heart RateSlow the Heart Rate Increase filling timeIncrease filling time
– Use Negative InotropesUse Negative Inotropes Optimize diastolic fillingOptimize diastolic filling
– Do Not use NTGDo Not use NTG Dilation will worsen the problemDilation will worsen the problem
Restrictive CardiomyopathyRestrictive Cardiomyopathy
Rigid Ventricular WallRigid Ventricular Wall
– Due to endomyocardial fibrosis Due to endomyocardial fibrosis
– Obstructs ventricular fillingObstructs ventricular filling
Least common formLeast common form
Restrictive CardiomyopathyRestrictive Cardiomyopathy
TREATMENTTREATMENT
– Positive InotropicsPositive Inotropics
– Diuretics Diuretics
– Low Sodium DietLow Sodium Diet
Dilated CardiomyopathyDilated Cardiomyopathy
Grossly dilated ventricles without hypertrophyGrossly dilated ventricles without hypertrophy
– Global left ventricular dysfunction Global left ventricular dysfunction
– Leads to pooling of blood and embolic episodesLeads to pooling of blood and embolic episodes
– Leads to refractory heart failure Leads to refractory heart failure
– Leads to papillary muscle dysfunction secondary to Leads to papillary muscle dysfunction secondary to LV dilation LV dilation
Dilated CardiomyopathyDilated Cardiomyopathy
TREATMENTTREATMENT
– Positive InotropesPositive Inotropes
– Afterload ReducersAfterload Reducers
– Anticoagulants with Atrial FibAnticoagulants with Atrial Fib
CardiomyopathiesCardiomyopathies
CardiomyopathyCardiomyopathy
GENERALIZED TREATMENTGENERALIZED TREATMENT– Positive InotropesPositive Inotropes
Except with Hypertropic CardiomyopathyExcept with Hypertropic Cardiomyopathy
– Vasodilators Vasodilators Except with Hypertropic CardiomyopathyExcept with Hypertropic Cardiomyopathy
– Reduce Preload & AfterloadReduce Preload & Afterload– DiureticsDiuretics– Beta BlockersBeta Blockers– Calcium Channel BlockersCalcium Channel Blockers– IABPIABP– Vasodilators (as indicated)Vasodilators (as indicated)– Fluid RestrictionFluid Restriction
– Daily weights, prn O2, planned activities, Daily weights, prn O2, planned activities, education, and emotional supporteducation, and emotional support
– Consider Heart TransplantConsider Heart Transplant
BREAK!BREAK!
CCRN REVIEW PART 1CCRN REVIEW PART 1
Conduction DefectsConduction Defects
STABLE VS UNSTABLESTABLE VS UNSTABLE
– StableStable
Start with medicationsStart with medications
– UnstableUnstable
Shock (cardioversion or defibrillation)Shock (cardioversion or defibrillation)
Normal Sinus RhythmNormal Sinus Rhythm
Heart RateHeart Rate 60 - 100 bpm60 - 100 bpm
RhythmRhythm RegularRegular
P WaveP Wave Before each QRS & identicalBefore each QRS & identical
PR Interval (in seconds)PR Interval (in seconds) 0.12 to 0.200.12 to 0.20
QRS (in seconds)QRS (in seconds) < 0.12< 0.12
Atrial FibrillationAtrial Fibrillation
AFibAFib– Multifocal atrial impulses at rate 300-600/min Multifocal atrial impulses at rate 300-600/min
– Irregular conduction to ventriclesIrregular conduction to ventricles
Atrial FlutterAtrial Flutter
AFLAFL– Atrial impulses at rate of 250-350/min Atrial impulses at rate of 250-350/min
– Regularly blocked impulses at the AV nodeRegularly blocked impulses at the AV node
– Saw tooth flutter wavesSaw tooth flutter waves
Wandering Atrial PacemakerWandering Atrial Pacemaker
WAPWAP– Multiple ectopic foci in the atriaMultiple ectopic foci in the atria
– Three or more p wave morphologiesThree or more p wave morphologies
– Rate < 100Rate < 100
Supraventricular TachycardiaSupraventricular Tachycardia
SVTSVT– Supraventricular rhythm at rate 150-250 Supraventricular rhythm at rate 150-250
– P waves cannot be positively identifiedP waves cannot be positively identified
Atrial Tach = supraventricular rhythm with p wave morphology Atrial Tach = supraventricular rhythm with p wave morphology that is noticeably different from the that is noticeably different from the
sinus p wavesinus p wave
Ventricular TachycardiaVentricular Tachycardia
VTVT– Ventricular rate of 100-250/minVentricular rate of 100-250/min
– Wide QRSWide QRS
Torsades de PointesTorsades de Pointes
Polymorphic VTPolymorphic VT– VT with alternating ventricular focus VT with alternating ventricular focus
– Often associated with prolonged QT Rate < 100Often associated with prolonged QT Rate < 100
Heart Blocks (AV Blocks)Heart Blocks (AV Blocks)
Sinus Rhythm with First Degree AV BlockSinus Rhythm with First Degree AV Block
Sinus Rhythm with Second Degree AV Block, Type 2Sinus Rhythm with Second Degree AV Block, Type 2
Sinus Rhythm with Second Degree AV Block, Type 1Sinus Rhythm with Second Degree AV Block, Type 1
Third Degree AV BlockThird Degree AV Block
DEFINITIONDEFINITION
– A condition in which the heart cannot pump A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of sufficient blood to meet the metabolic needs of the bodythe body
– Pulmonary (LVF) and/or systemic (RVF) Pulmonary (LVF) and/or systemic (RVF) congestion is present.congestion is present.
Heart FailureHeart Failure
DEFINITIONDEFINITION– Pulmonary EdemaPulmonary Edema
Fluid in the alveolus that impairs gas exchange byFluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus andaltering the diffusion between alveolus and capillarycapillary
Acute left ventricular failure causes cardiogenic Acute left ventricular failure causes cardiogenic pulmonary edemapulmonary edema
Non-cardiogenic pulmonary edema is a synonym for Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS)Adult Respiratory Distress Syndrome (ARDS)
Heart FailureHeart Failure
COMPENSATORY MECHANISMSCOMPENSATORY MECHANISMS– Sympaththetic nervous system stimulationSympaththetic nervous system stimulation
TachycardiaTachycardia Vasoconstriction and increased SVRVasoconstriction and increased SVR
– Renin-angiotensin-aldosterone system Renin-angiotensin-aldosterone system activationactivation
Hypo perfusion to the kidneys (renin)Hypo perfusion to the kidneys (renin) Vasoconstriction (angiotension)Vasoconstriction (angiotension) Sodium and water retention (kidneys)Sodium and water retention (kidneys) Ventricular dilationVentricular dilation
Heart FailureHeart Failure
FUNCTIONAL CLASSIFICATIONSFUNCTIONAL CLASSIFICATIONS
– Class I Class I
– Class IIClass II
– Class IIIClass III
– Class IVClass IV
Heart FailureHeart Failure
(without noticeable limitations)(without noticeable limitations)
(symptoms upon activity)(symptoms upon activity)
(severe symptoms upon activity)(severe symptoms upon activity)
(symptoms at rest)(symptoms at rest)
COMPLICATIONSCOMPLICATIONS– HypotensionHypotension
– DysrhythmiasDysrhythmias
– Respiratory FailureRespiratory Failure
– Progressive DeteriorationProgressive Deterioration
– Acute Renal FailureAcute Renal Failure
– Fluid & Electrolyte ImbalancesFluid & Electrolyte Imbalances
Heart FailureHeart Failure
TREATMENTTREATMENT– Improve OxygenationImprove Oxygenation
– Decrease Myocardial Oxygen DemandDecrease Myocardial Oxygen Demand
– Decrease PreloadDecrease Preload
– Decrease AfterloadDecrease Afterload
– Increase ContractilityIncrease Contractility
– Manage DysrhythmiasManage Dysrhythmias
– Educate!Educate!
Heart FailureHeart Failure
Vascular DiseaseVascular Disease
Aorto/Iliac Disease: Pre & Post PTA/StentAorto/Iliac Disease: Pre & Post PTA/Stent
Peripheral Vascular DiseasePeripheral Vascular DiseaseSYMPTOMSSYMPTOMS
PAINPAIN
PAIN RELIEFPAIN RELIEF
EDEMAEDEMA
PULSESPULSES
INTEGUMENT INTEGUMENT CHANGESCHANGES
ULCERSULCERS
SKIN TEMPERATURESKIN TEMPERATURE
SEXUAL ISSUESSEXUAL ISSUES
ARTERIALARTERIAL
Upon walkingUpon walking
On resting, standing or On resting, standing or dependent position of lower limbs dependent position of lower limbs
NoneNone
Decreased or absentDecreased or absent
Hair lossHair lossSkin shinySkin shinyNail thickeningNail thickeningPallor when elevatedPallor when elevatedRed when dependentRed when dependent
Ulcers located on toes, lateral Ulcers located on toes, lateral areas or site of traumaareas or site of traumaGangrene possibleGangrene possible
CoolCool
ImpotencyImpotencySexual dysfunctionSexual dysfunction
VENOUSVENOUS
While standingWhile standing
Elevation of extremitiesElevation of extremities
Present, edematousPresent, edematous
May be difficult to palpateMay be difficult to palpate
Brownish pigmentationBrownish pigmentationMay be cyanotic when May be cyanotic when extremities are dependentextremities are dependent
Ulcers located on ankles, Ulcers located on ankles, medial or pre-tibial areasmedial or pre-tibial areas
Normal or warmNormal or warm
Not presentNot present
Peripheral Vascular DiseasePeripheral Vascular Disease
TREATMENTSTREATMENTS– MedicalMedical
Are they taking ASA, Coumadin, Ticlid, Plavix, Are they taking ASA, Coumadin, Ticlid, Plavix, Oral Contraceptives, Hormones?Oral Contraceptives, Hormones?
– InvasiveInvasive PTA, atherectomy, stentsPTA, atherectomy, stents
– SurgicalSurgical GraftsGrafts
Peripheral Vascular DiseasePeripheral Vascular Disease
Bypass GraftsBypass Grafts
DEFINITIONDEFINITION
– Inadequate perfusion to the body tissuesInadequate perfusion to the body tissues
– Low blood pressure with impaired perfusion Low blood pressure with impaired perfusion to the end organsto the end organs
– May result in multiple organ dysfunctionMay result in multiple organ dysfunction
ShockShock
TYPES OF SHOCKTYPES OF SHOCK
– Hypovolemic ShockHypovolemic Shock
– Cardiogenic ShockCardiogenic Shock
– Distributive Shock Distributive Shock
– Obstructive ShockObstructive Shock
ShockShock
ShockShock
COMPENSATORY MECHANISMSCOMPENSATORY MECHANISMS –TachycardiaTachycardia
Attempts to deliver more blood to the tissuesAttempts to deliver more blood to the tissues
–VasoconstrictionVasoconstriction Attempts to maintain adequate BP in order to Attempts to maintain adequate BP in order to
adequately perfuse the body tissuesadequately perfuse the body tissues
–Increased ADH SecretionIncreased ADH Secretion ADH makes the body hold onto water in an effort to ADH makes the body hold onto water in an effort to
maintain volume and thus enough blood pressure to maintain volume and thus enough blood pressure to perfuse the body tissuesperfuse the body tissues
Types of ShockTypes of Shock
Hypovolemic ShockHypovolemic Shock– Inadequate perfusion to the tissues due to insufficient intravascular Inadequate perfusion to the tissues due to insufficient intravascular
volumevolume
Cardiogenic ShockCardiogenic Shock– Inadequate perfusion to the tissues due to heart failureInadequate perfusion to the tissues due to heart failure
Distributive ShockDistributive Shock– Inadequate perfusion to the tissues due to blood flow out of the Inadequate perfusion to the tissues due to blood flow out of the
intravascular space causing insufficient intravascular volumeintravascular space causing insufficient intravascular volume
– Anaphylactic, Septic, and Spinal ShockAnaphylactic, Septic, and Spinal Shock Obstructive ShockObstructive Shock
– Inadequate perfusion to the tissues due to obstruction of blood flowInadequate perfusion to the tissues due to obstruction of blood flow
Hypovolemic ShockHypovolemic Shock
SIGNS & SYMPTOMSSIGNS & SYMPTOMSLow BPLow BP TachycardiaTachycardia
Orthostatic Hypotension Orthostatic Hypotension RestlessnessRestlessness
Confusion Confusion Agitation (or Agitation (or listless)listless)
Thirst Thirst PallorPallor
Cool, Clammy SkinCool, Clammy Skin Resp. Rate Resp. Rate
UOPUOP CO CO
PAWPPAWP CVP CVP
SVR SVR Lactate Levels Lactate Levels
Hypovolemic ShockHypovolemic Shock
TREATMENTTREATMENT
–Volume (IVF, Blood)Volume (IVF, Blood)
Cardiogenic ShockCardiogenic Shock
SIGNS & SYMPTOMSSIGNS & SYMPTOMSLow BPLow BP RestlessnessRestlessness
Agitation (or listless)Agitation (or listless) ConfusionConfusion
TachycardiaTachycardia PallorPallor
UOPUOP CO CO
PAWP (low with RVF) PAWP (low with RVF) CVPCVP
SVR SVR Lactate Levels Lactate Levels
JVDJVD Peripheral EdemaPeripheral Edema
Ventricular Gallop (S3)Ventricular Gallop (S3) DyspneaDyspnea
Pulmonary CracklesPulmonary Crackles
TREATMENTTREATMENTBedrestBedrest O2O2
COCO Positive InotropesPositive Inotropes
Preload & AfterloadPreload & Afterload DiureticsDiuretics
VasodilatorsVasodilators PositioningPositioning
Myocardial DemandMyocardial Demand IABPIABP
Cardiogenic ShockCardiogenic Shock
Anaphylactic ShockAnaphylactic Shock
SIGNS & SYMPTOMSSIGNS & SYMPTOMSLow BPLow BP TachycardiaTachycardiaRestlessnessRestlessness Confusion Confusion Agitation (or listless)Agitation (or listless) Thirst Thirst PallorPallor Warm FeelingWarm FeelingPruritusPruritus HivesHivesAngioedemaAngioedema BronchoconstrictionBronchoconstrictionWheezingWheezing Laryngeal EdemaLaryngeal EdemaDyspneaDyspnea Cool, Clammy SkinCool, Clammy Skin UOPUOP CO CO PAWPPAWP CVP CVP
SVR SVR Lactate Levels Lactate Levels
TREATMENTTREATMENT– Epinephrine Epinephrine
– IVFIVF
– VasoconstrictorsVasoconstrictors
– Support/Maintain AirwaySupport/Maintain Airway
Anaphylactic ShockAnaphylactic Shock
Obstructive ShockObstructive Shock
SIGNS & SYMPTOMSSIGNS & SYMPTOMSLow BPLow BP
TachycardiaTachycardiaRestlessnessRestlessness Confusion Confusion
Agitation (or listless)Agitation (or listless) Pallor Pallor Cool, Clammy SkinCool, Clammy Skin CO , CO ,
UOPUOP
Symptoms related to causeSymptoms related to cause
Obstructive ShockObstructive Shock
CAUSESCAUSESPulmonary EmbolusPulmonary Embolus TamponadeTamponade
Tension PneumothoraxTension Pneumothorax Aortic AneurysmAortic Aneurysm
TREATMENTTREATMENTTreat the CauseTreat the Cause
SIRS Sepsis Severe Septic MODS DeathSIRS Sepsis Severe Septic MODS DeathInfection Infection Sepsis Shock Sepsis Shock
Sepsis SyndromeSepsis Syndrome
Sepsis– SIRS’ response with presumed/confirmed infectionSIRS’ response with presumed/confirmed infection
Severe Sepsis– Sepsis associated with organ dysfunction, hypoperfusion Sepsis associated with organ dysfunction, hypoperfusion
(lactic acidosis, oliguria, altered mental status etc.), or (lactic acidosis, oliguria, altered mental status etc.), or hypotension (SBP < 90 mmHg or ↓ SBP > 40 mmHg)hypotension (SBP < 90 mmHg or ↓ SBP > 40 mmHg)
Septic Shock– Sepsis with perfusion abnormalities and hypotension Sepsis with perfusion abnormalities and hypotension
despite adequate fluid resuscitationdespite adequate fluid resuscitation
Sepsis SyndromeSepsis Syndrome
EARLY STAGE (Hyperdynamic)EARLY STAGE (Hyperdynamic)Normal BPNormal BP TachycardiaTachycardiaConfusion Confusion Agitation (or listless)Agitation (or listless) Respiratory RateRespiratory Rate TemperatureTemperatureNormal ColorNormal Color Normal or Normal or UOP UOPNormal PAWPNormal PAWP CO CO SVR SVR
LATE STAGE (Hypodynamic)LATE STAGE (Hypodynamic)Low BPLow BP TachycardiaTachycardiaOrthostatic Hypotension Orthostatic Hypotension RestlessnessRestlessnessConfusion Confusion Agitation (or listless)Agitation (or listless)Thirst Thirst PallorPallorCool, Clammy SkinCool, Clammy Skin UOP UOP COCO PAWP PAWP CVPCVP SVR SVR Lactate LevelsLactate Levels
Septic ShockSeptic Shock
Homeostasis Gets LostHomeostasis Gets Lost
3.3. Improve PerfusionImprove Perfusion– Prevent organ dysfunctionPrevent organ dysfunction– Treat temp as neededTreat temp as needed
2.2. Treat The CauseTreat The Cause – Pan culture, antibiotics Pan culture, antibiotics
– Seek primary site of infectionSeek primary site of infection
– Direct therapy to primary causeDirect therapy to primary cause
1.1. Stabilize The PatientStabilize The Patient– Fluids (lots of fluids) 150ml/hr or moreFluids (lots of fluids) 150ml/hr or more
– VasoconstrictorsVasoconstrictors
Treatment for SepsisTreatment for Sepsis
HEMODYNAMICSHEMODYNAMICS
Invasive PA Catheter Invasive PA Catheter ContraindicationsContraindications
Mechanical Tricuspid or Pulmonary Valve Mechanical Tricuspid or Pulmonary Valve
Right Heart Mass (thrombus and/or tumor)Right Heart Mass (thrombus and/or tumor)
Tricuspid or Pulmonary Valve EndocarditisTricuspid or Pulmonary Valve Endocarditis
BasicBasic ConceptsConcepts
CO = HR X SVCO = HR X SV
BP = CO x SVRBP = CO x SVR
CO and SVR are inversely relatedCO and SVR are inversely related
CO and SVR will change before BP changesCO and SVR will change before BP changes
StrokeStroke VolumeVolume
Components Stroke VolumeComponents Stroke Volume
– PreloadPreload:: the volume of blood in the the volume of blood in the ventricles at end diastole and the stretch ventricles at end diastole and the stretch placed on the muscle fibersplaced on the muscle fibers
– AfterloadAfterload:: the resistance the ventricles the resistance the ventricles must overcome to eject it’s volume of must overcome to eject it’s volume of bloodblood
– Contractility: the force with which the the force with which the heart muscle contracts (myocardial heart muscle contracts (myocardial compliance)compliance)
PAC Insertion SequencePAC Insertion Sequence
Phlebostatic AxisPhlebostatic Axis
4th ICS Mid-chest, regardless of head elevation4th ICS Mid-chest, regardless of head elevation
RAP (CVP)RAP (CVP)
RVPRVP
PAPPAP
PAOPPAOP
0-8 mmHg0-8 mmHg
15-30/0-8 mmHg15-30/0-8 mmHg
15-30/6-12 mmHg15-30/6-12 mmHg
8 - 12 mmHg8 - 12 mmHg
Normal Hemodynamic ValuesNormal Hemodynamic Values
Normal Hemodynamic Normal Hemodynamic ValuesValues Values normalized for body size (BSA)Values normalized for body size (BSA)
CI:CI: 2.5 – 4.5 L/min/m2.5 – 4.5 L/min/m22
SVRI:SVRI: 1970 – 2390 dynes/sec/cm-1970 – 2390 dynes/sec/cm-
5/m25/m2
SVI or SI:SVI or SI: 35 – 60 mL/beat/m235 – 60 mL/beat/m2
EDVI:EDVI: 60 – 100 mL/m260 – 100 mL/m2
Mixed Venous Oxygen Mixed Venous Oxygen SaturationSaturationSvO2SvO2
End result of O2 delivery and End result of O2 delivery and consumptionconsumption
Measured in the pulmonary arteryMeasured in the pulmonary artery An average estimate of venous saturation for An average estimate of venous saturation for
the whole body.the whole body.
Does not reflect separate tissue perfusion or Does not reflect separate tissue perfusion or oxygenationoxygenation
Measuring PA PressuresMeasuring PA Pressures
Measure All Hemodynamic Values Measure All Hemodynamic Values at End-Expirationat End-Expiration
– ““Patient PeakPatient Peak””
– ““Vent ValleyVent Valley””
Measure all pressures atMeasure all pressures at end-expirationend-expiration AtAt bottom curvebottom curve with mechanical ventilatorwith mechanical ventilator
– ““Vent-ValleyVent-Valley”” Intrathoracic pressureIntrathoracic pressure increasesincreases during during
positive pressure ventilations (inspiration)positive pressure ventilations (inspiration)
– Positive deflection on waveformsPositive deflection on waveforms Intrathoracic pressureIntrathoracic pressure decreases decreases during during
positive pressure expirationpositive pressure expiration
– Negative deflection on waveformsNegative deflection on waveforms
Measuring PA PressuresMeasuring PA Pressures
Spontaneous RespirationsSpontaneous Respirations
a-wavea-wave– Atrial contractionAtrial contraction
– Correct location for measurement of PAOPCorrect location for measurement of PAOP Average the peak & trough of the a-waveAverage the peak & trough of the a-wave
– Begins near the end of QRS or at the QT Begins near the end of QRS or at the QT segmentsegment
Delayed ECG correlation from CVP since PA Delayed ECG correlation from CVP since PA catheter is further away from left atriumcatheter is further away from left atrium
PAOP WaveformPAOP Waveform
c-wavec-wave– Rarely presentRarely present
– Represents mitral valve closureRepresents mitral valve closure
v-wavev-wave– Represents left atrial fillingRepresents left atrial filling
– Begins at about the end of the T waveBegins at about the end of the T wave
PAOP WaveformPAOP Waveform
Cardiogenic Shock is the only shock with Cardiogenic Shock is the only shock with PAWP PAWP
Early (Hyperdynamic) Shock is the only shock with Early (Hyperdynamic) Shock is the only shock with CO and CO and SVRSVR
Neurogenic Shock is the only shock with Neurogenic Shock is the only shock with bradycardiabradycardia
Anaphylactic Shock has the definitive characteristic of wheezing due Anaphylactic Shock has the definitive characteristic of wheezing due to bronchospasmto bronchospasm
Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic
CVP/RAP
PAWP or Norm
CO
BP
SVR
HR Normal
Shock ProfilesShock Profiles
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ARDSARDS
Drowning Drowning
PneumothoraxPneumothorax
Respiratory Respiratory
FailureFailure
Respiratory AlterationsRespiratory Alterations
ChronicChronic LungLung DiseaseDisease
PneumoniaPneumonia
PulmonaryPulmonary
EmbolismEmbolism
ARDSARDS
DEFINITIONSDEFINITIONS
– Severe respiratory failure associated with pulmonary Severe respiratory failure associated with pulmonary infiltrates (similar to infant hyaline membrane disease)infiltrates (similar to infant hyaline membrane disease)
– Pulmonary edema in the absence of fluid overload or Pulmonary edema in the absence of fluid overload or depressed LV function (Non-cardiogenic pulmonary edema)depressed LV function (Non-cardiogenic pulmonary edema)
– Originates from a number of insults involving damage to the Originates from a number of insults involving damage to the alveolar-capillary membranealveolar-capillary membrane
Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome
ARDSARDS
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
– Inflammatory mediators are released causing extensive Inflammatory mediators are released causing extensive
structural damagestructural damage
– Increased permeability of pulmonary microvasculature Increased permeability of pulmonary microvasculature
causes leakage of proteinaceous fluid across the alveolar–causes leakage of proteinaceous fluid across the alveolar–
capillary membrane capillary membrane
– Also causes damage to the surfactant-producing type II cellsAlso causes damage to the surfactant-producing type II cells
ARDSARDS
CXR CHARACTERISTICSCXR CHARACTERISTICS– Normal size heart Normal size heart
– No pleural effusion No pleural effusion
– Ground GlassGround Glass appearance appearance
– Often normal early in the disease but may rapidly Often normal early in the disease but may rapidly
progress to complete whiteoutprogress to complete whiteout
ARDSARDS
ARDSARDS
SIGNS & SYMPTOMSSIGNS & SYMPTOMS– Symptoms develop 24 to 48 hours of injurySymptoms develop 24 to 48 hours of injury
Sudden progressive disorderSudden progressive disorder Pulmonary edemaPulmonary edema Severe dyspneaSevere dyspnea Hypoxemia Hypoxemia REFRACTORYREFRACTORY to O2 to O2 Decreased lung compliance Decreased lung compliance Diffuse pulmonary infiltratesDiffuse pulmonary infiltrates
– Symptoms may be minimal compared to CXRSymptoms may be minimal compared to CXR – Rales may be heardRales may be heard
ARDSARDS
Common Risk Common Risk FactorsFactors Other Risk FactorsOther Risk Factors
Sepsis Sepsis Massive Massive Trauma Trauma Shock Shock MultipleMultiple
Transfusions Transfusions Pneumonia Pneumonia
Aspiration Aspiration InfectionInfection
Smoke inhalation Smoke inhalation Inhaled toxinsInhaled toxins
Burns Burns Near Drowning Near Drowning
DKA DKA Pregnancy Pregnancy Eclampsia Eclampsia
Amniotic Fluid EmbolusAmniotic Fluid EmbolusDrugsDrugs
Acute Pancreatitis Acute Pancreatitis DIC DIC
Head Injury Head Injury ICP ICP
Fat Emboli Fat Emboli Blood Products Blood Products
Heart/Lung BypassHeart/Lung Bypass Tumor Lysis Tumor Lysis
Pulmonary ContusionPulmonary ContusionNarcoticsNarcotics
RISK FACTORSRISK FACTORS
ARDSARDS
TREATMENTTREATMENT
– Respiratory SupportRespiratory Support
– PEEP, CPAPPEEP, CPAP
Chronic Lung DiseaseChronic Lung Disease
COPDCOPD– Presents with hyper-inflated lung fields Presents with hyper-inflated lung fields
Due to chronic air trappingDue to chronic air trapping
May be barrel chestedMay be barrel chested
– May lead to cor pulmonale May lead to cor pulmonale (right-sided heart failure)(right-sided heart failure)
Due to chronic high pulmonary pressuresDue to chronic high pulmonary pressures
– Often hypercarbic (high pCO2)Often hypercarbic (high pCO2) Often dependent upon hypoxic driveOften dependent upon hypoxic drive
Chronic Lung DiseaseChronic Lung Disease
COPD TREATMENTCOPD TREATMENT– Avoid overuse of oxygenAvoid overuse of oxygen (except in emergencies) (except in emergencies)
– BronchodilatorsBronchodilators
– SteroidsSteroids
– HydrationHydration
– EducationEducation
Pursed Lip BreathingPursed Lip Breathing
Leaning UprightLeaning Upright
Near DrowningNear Drowning Salt WaterSalt Water
– Causes body fluids to shift into lungsCauses body fluids to shift into lungs Osmosis: From low to high concentrationOsmosis: From low to high concentration Results in hemoconcentration & hypovolemiaResults in hemoconcentration & hypovolemia
– Results in acute pulmonary edemaResults in acute pulmonary edema Fresh WaterFresh Water
– Fluids shift into body tissuesFluids shift into body tissues Results in hemodilution & hypervolemiaResults in hemodilution & hypervolemia Can result in gross edemaCan result in gross edema
– Damaged alveoli fill with proteinaceous fluidDamaged alveoli fill with proteinaceous fluid May lead to pulmonary edemaMay lead to pulmonary edema
PneumoniaPneumonia
Lung infection (bacterial, viral, or fungal)Lung infection (bacterial, viral, or fungal)
– Most commonly caused by SMost commonly caused by Streptococcus treptococcus pneumoniaepneumoniae
Symptoms include fever, pleuretic chest Symptoms include fever, pleuretic chest pain, productive cough, and tachypneapain, productive cough, and tachypnea
– Often presents bronchial breath sounds over the Often presents bronchial breath sounds over the lung area lung area
Treatment involves giving the right antibioticTreatment involves giving the right antibiotic
PneumothoraxPneumothorax DEFINITIONSDEFINITIONS
– Simple pneumothoraxSimple pneumothorax Results from buildup of air or pressure in the pleural spaceResults from buildup of air or pressure in the pleural space
– Spontaneous pneumothoraxSpontaneous pneumothorax May be due to blebs that ruptureMay be due to blebs that rupture The 2 key risk factors are increased chest length and The 2 key risk factors are increased chest length and
cigarette smokingcigarette smoking
– Tension pneumothoraxTension pneumothorax Involves a buildup of air in the pleural space due to Involves a buildup of air in the pleural space due to
one-way movement of airone-way movement of air Progressively worsensProgressively worsens Requires immediate interventionRequires immediate intervention
PneumothoraxPneumothorax
Tension PneumothoraxTension Pneumothorax
PneumothoraxPneumothorax
CAUSESCAUSES
– BarotraumaBarotrauma
– InjuryInjury
– BlebsBlebs
PneumothoraxPneumothorax
SIGNS & SYMPTOMSSIGNS & SYMPTOMS– Standard PneumothoraxStandard Pneumothorax
Sharp "pleuritic" chest pain, worse on breathingSharp "pleuritic" chest pain, worse on breathing Sudden shortness of breathSudden shortness of breath Dry, hacking cough (may occur due to irritation Dry, hacking cough (may occur due to irritation
of the diaphragm)of the diaphragm) May cause mediastinal shift May cause mediastinal shift
– Tension pneumothoraxTension pneumothorax Signs of standard pneumothorax with signs of Signs of standard pneumothorax with signs of
cardiovascular collapse cardiovascular collapse Immediately life threateningImmediately life threatening May cause mediastinal shiftMay cause mediastinal shift
PneumothoraxPneumothorax TREATMENTTREATMENT Spontaneous pneumothoraxSpontaneous pneumothorax
– Depends on symptoms & size of pneumothorax Depends on symptoms & size of pneumothorax
– Provide respiratory supportProvide respiratory support
– May need chest tube or needle decompression May need chest tube or needle decompression Some resolve without interventionSome resolve without intervention
Tension pneumothoraxTension pneumothorax– RequiresRequires immediate immediate intervention intervention
– May cause cardiovascular collapseMay cause cardiovascular collapse
– May need chest tube or needle decompression May need chest tube or needle decompression 22ndnd intercostal space intercostal space
TREATMENTTREATMENT
– PleurodesisPleurodesis
PneumothoraxPneumothorax
Chemical or surgical adhesion of the lung Chemical or surgical adhesion of the lung to the chest wallto the chest wall
Used for multiple collapsed lungs or Used for multiple collapsed lungs or persistent collapsepersistent collapse
Flail ChestFlail Chest
DefinitionDefinition
Signs & SymptomsSigns & Symptoms
Pulmonary EmbolismPulmonary Embolism
– Arterial embolus that obstructs blood flow to the lung Arterial embolus that obstructs blood flow to the lung
– Symptoms include sudden dyspnea, cough, chest Symptoms include sudden dyspnea, cough, chest pain, hemoptysis and sinus tachycardiapain, hemoptysis and sinus tachycardia
– Blood gas shows low pO2 & low pCO2Blood gas shows low pO2 & low pCO2
– May present positive Homan’s SignMay present positive Homan’s Sign
– May present loud S2May present loud S2
Diagnostic TestsDiagnostic Tests
– CXRCXR– VQ ScanVQ Scan– Spiral CTSpiral CT
– Pulmonary arteriogramPulmonary arteriogram – Venous ultrasound of the lower extremitiesVenous ultrasound of the lower extremities– ABG with low pO2 & low pCO2ABG with low pO2 & low pCO2– D-Dimer D-Dimer
Pulmonary EmbolismPulmonary Embolism
TreatmentTreatment– Requires immediate intervention Requires immediate intervention
– Provide respiratory supportProvide respiratory support
– Treat pain & comfortTreat pain & comfort
– Usually includes intravenous heparinUsually includes intravenous heparin Heparin reduces risk of secondary Heparin reduces risk of secondary
thrombus formation while clot is reabsorbedthrombus formation while clot is reabsorbed
– May require embolectomyMay require embolectomy
– May require thrombolysisMay require thrombolysis
– May need umbrella filter May need umbrella filter
– May need long term anticoagulantsMay need long term anticoagulants
Pulmonary EmbolismPulmonary Embolism
Respiratory FailureRespiratory Failure
DEFINITIONSDEFINITIONS
– Failure to maintain adequate gas exchange Failure to maintain adequate gas exchange
– Inadequate blood oxygenation or CO2 removalInadequate blood oxygenation or CO2 removal
– PaO2 < 50 mmHg PaO2 < 50 mmHg and/or PaCO2 > 50 mmHg and/or PaCO2 > 50 mmHg and/or pH < and/or pH < 7.35 7.35 on Room Air on Room Air
Respiratory FailureRespiratory Failure
TYPE ITYPE I Hypoxemia Hypoxemia withoutwithout hypercapnia hypercapnia
TYPE II TYPE II Hypoxemia Hypoxemia withwith hypercapnia hypercapnia
Respiratory FailureRespiratory Failure
CAUSESCAUSES
– V/Q MismatchingV/Q Mismatching
– Intrapulmonary ShuntingIntrapulmonary Shunting
– Alveolar HypoventilationAlveolar Hypoventilation
Respiratory FailureRespiratory Failure
V/Q MISMATCHING V/Q MISMATCHING
– COPDCOPD
– Interstitial Lung DiseaseInterstitial Lung Disease
– Pulmonary EmbolismPulmonary Embolism
Respiratory FailureRespiratory Failure
PULMONARY SHUNTINGPULMONARY SHUNTING
– AV fistulas/malformationsAV fistulas/malformations
– Alveolar collapse (atelectasis)Alveolar collapse (atelectasis)
– Alveolar consolidation (pneumonia)Alveolar consolidation (pneumonia)
– Excessive mucus accumulation Excessive mucus accumulation
Respiratory FailureRespiratory Failure
SIGNS & SYMPTOMSSIGNS & SYMPTOMS
– Restlessness / AgitationRestlessness / Agitation
– Confusion / Confusion / LOC LOC
– Tachycardia / DysrhythmiasTachycardia / Dysrhythmias
– Tachypnea / Dyspnea Tachypnea / Dyspnea
– Cool, clammy, pale skin Cool, clammy, pale skin
Respiratory FailureRespiratory Failure
ARTERIAL BLOOD GASESARTERIAL BLOOD GASES
– pH 7.30 / pO2 45 / pCO2 80pH 7.30 / pO2 45 / pCO2 80
– pH 7.30 / pO2 55 / pCO2 65pH 7.30 / pO2 55 / pCO2 65
– pH 7.32 / pO2 50 / pCO2 50pH 7.32 / pO2 50 / pCO2 50
– pH 7.55 / pO2 65 / pCO2 22 pH 7.55 / pO2 65 / pCO2 22
Respiratory FailureRespiratory Failure
TREATMENT TREATMENT – Ensure Adequate VentilationEnsure Adequate Ventilation FiO2FiO2
Ineffective with shuntingIneffective with shunting Prolonged O2 > 40% causes O2 toxicityProlonged O2 > 40% causes O2 toxicity Must use caution with CO2 retainersMust use caution with CO2 retainers
– Chronic hypercapnia causes CO2 retainers Chronic hypercapnia causes CO2 retainers to use hypoxic driveto use hypoxic drive
– Too much O2 can depress respirationsToo much O2 can depress respirations
BREAK!BREAK!
CCRN REVIEW PART 1CCRN REVIEW PART 1
GI BleedGI Bleed
PancreatitisPancreatitis
Gastrointestinal AlterationsGastrointestinal Alterations
CAUSESCAUSES– UGI BleedingUGI Bleeding
Includes the esophagus, stomach, duodenumIncludes the esophagus, stomach, duodenum
– Peptic Ulcer Disease (PUD), or Esophageal VaricesPeptic Ulcer Disease (PUD), or Esophageal Varices
– ASA, NSAID’s, Anticoagulants, AlcoholASA, NSAID’s, Anticoagulants, Alcohol
– H. PyloriH. Pylori
– LGI BleedingLGI Bleeding Includes the jejunum, ileum, colon, rectum Includes the jejunum, ileum, colon, rectum
– Colorectal cancer, Polyps, Hemorrhoids, IBD Colorectal cancer, Polyps, Hemorrhoids, IBD
Gastrointestinal BleedingGastrointestinal Bleeding
Gastrointestinal BleedingGastrointestinal Bleeding
Gastrointestinal BleedingGastrointestinal Bleeding HematemesisHematemesis – vomiting of blood (or coffee ground – vomiting of blood (or coffee ground
material) (indicates bleeding above the duodenum )material) (indicates bleeding above the duodenum )
MelenaMelena – passage of black tarry stools > 50ml (indicates – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel)degradation of blood in the bowel)
HematocheziaHematochezia – passage of red blood (rectal bleeding)– passage of red blood (rectal bleeding)
Occult BleedingOccult Bleeding – bleeding that is not apparent to the – bleeding that is not apparent to the patient and results from small amounts of bloodpatient and results from small amounts of blood
Obscure BleedingObscure Bleeding – occult or obvious but source not – occult or obvious but source not identifiedidentified
Gastrointestinal BleedingGastrointestinal Bleeding
HematemesisHematemesis – – always UGI sourcealways UGI source
MelanaMelana – – indicates blood has been in GI tract indicates blood has been in GI tract for extended periods for extended periods – Mostly UGIMostly UGI– Small bowelSmall bowel– Rt colon (if bleeding relatively slow)Rt colon (if bleeding relatively slow)
HematocheziaHematochezia – Mostly colonMostly colon– Massive UGI bleeding (not enough time for degradation)Massive UGI bleeding (not enough time for degradation)
TREATMENTTREATMENT– Find the underlying causeFind the underlying cause
– Fluid volume replacementFluid volume replacement
– Endoscopy or colonoscopyEndoscopy or colonoscopy
– Medical and /or surgical therapy Medical and /or surgical therapy SomatostatinSomatostatin IV or intra-arterial vasopressinIV or intra-arterial vasopressin SclerotherpaySclerotherpay Angiography with embolizationAngiography with embolization ElectrocoagulationElectrocoagulation Band ligationBand ligation Balloon tamponade (Sengstaken-Blackmore tube)Balloon tamponade (Sengstaken-Blackmore tube)
Gastrointestinal BleedingGastrointestinal Bleeding
The PancreasThe Pancreas
The Pancreas secretes digestive enzymes, The Pancreas secretes digestive enzymes, bicarbonate, water, and some electrolytes into bicarbonate, water, and some electrolytes into the duodenum via the pancreatic ductthe duodenum via the pancreatic duct
– Lipase, Amylase, TrypsinLipase, Amylase, Trypsin
The Pancreas also produces The Pancreas also produces and secretes insulin and secretes insulin
PancreatitisPancreatitis
DEFINITIONDEFINITION– An autodigestive process resulting An autodigestive process resulting
from premature activation of from premature activation of pancreatic enzymespancreatic enzymes
PancreatitisPancreatitis
PATHOSHYSIOLOGYPATHOSHYSIOLOGY
• Inactive pancreatic enzymes are activated outside Inactive pancreatic enzymes are activated outside of the duodenumof the duodenum
• The swelling pancreas causes fluids to shift into The swelling pancreas causes fluids to shift into the retro peritoneum and bowel the retro peritoneum and bowel
• Fluid shifts can cause severe hypovolemia and Fluid shifts can cause severe hypovolemia and hypotensionhypotension
• Inflammation cause commotion around pancreasInflammation cause commotion around pancreas
PancreatitisPancreatitis
MANY CAUSESMANY CAUSES– AlcoholismAlcoholism
– Biliary DiseaseBiliary Disease
– GallstonesGallstones
– InfectionsInfections
– HyperparathyroidismHyperparathyroidism
– HypertriglyceridemiaHypertriglyceridemia
– HypercalcemiaHypercalcemia
– Peptic Ulcer DiseasePeptic Ulcer Disease
– Cystic FibrosisCystic Fibrosis
– Vascular DiseaseVascular Disease
– Multiple DrugsMultiple Drugs
– Much Much MoreMuch Much More
PancreatitisPancreatitis
SIGNS & SYMPTOMSSIGNS & SYMPTOMS– Abdominal PainAbdominal Pain
– Nausea & VomitingNausea & Vomiting
– Abdominal DistentionAbdominal Distention
– JaundiceJaundice
– MalnutritionMalnutrition
– HematemesisHematemesis
– Grey Turner’s SignGrey Turner’s Sign
– Cullen’s SignCullen’s Sign
– Elevated Amylase, Elevated Amylase,
Lipase, LDH, AST, WBC’s Lipase, LDH, AST, WBC’s
BUN, and GlucoseBUN, and Glucose
PancreatitisPancreatitis
COMPLICATIONSCOMPLICATIONS– HypocalcemiaHypocalcemia– HypotensionHypotension– Acute Tubular NecrosisAcute Tubular Necrosis– DICDIC– Obstructive JaundiceObstructive Jaundice– Erosive GastritisErosive Gastritis– Paralytic IleusParalytic Ileus– Pseudocyst or AbscessPseudocyst or Abscess– Bowel InfarctionBowel Infarction– Internal BleedingInternal Bleeding– Fat NecrosisFat Necrosis
– Pleural Effusion (left)Pleural Effusion (left)– Pulmonary InfiltratesPulmonary Infiltrates– Hypoxemia Hypoxemia – AtelectasisAtelectasis– ARDSARDS– Pericardial EffusionPericardial Effusion– Mediastinal AbscessMediastinal Abscess– HyperglycemiaHyperglycemia– HypertriglyceridemiaHypertriglyceridemia– EncephalopathyEncephalopathy
PancreatitisPancreatitis
TREATMENTTREATMENT– StabilizationStabilization
Correct Fluid AndCorrect Fluid And Electrolyte StatusElectrolyte Status
– Respiratory SupportRespiratory Support – Control PainControl Pain
DemerolDemerol
– NG TubeNG Tube NPONPO
– TPNTPN Restricted DietRestricted Diet
– Monitor For ComplicationsMonitor For Complications
– Monitor Blood SugarMonitor Blood Sugar
– Drug TherapiesDrug Therapies Somatostatin, Somatostatin,
AnticholinergicsAnticholinergics
– Watch For Signs Of Watch For Signs Of InfectionInfection
– PrayPray
PancreatitisPancreatitis
FULMINATING PANCREATITISFULMINATING PANCREATITIS• Overwhelming form Overwhelming form
• Necrotizing formNecrotizing form
• Extreme symptomsExtreme symptoms
• Seen with ESRF patientsSeen with ESRF patients
• May lead to ARDS & DICMay lead to ARDS & DIC
PancreatitisPancreatitis
FULMINATING PANCREATITISFULMINATING PANCREATITIS• Signs & SymptomsSigns & Symptoms
Tachycardia & low BP (may be the only sign) Tachycardia & low BP (may be the only sign)
Pulmonary & cerebral insufficiency Pulmonary & cerebral insufficiency
Acute diabetic ketosis or oliguriaAcute diabetic ketosis or oliguria
Hemorrhagic pancreatitis may appear Hemorrhagic pancreatitis may appear
THE ENDTHE ENDPART 1PART 1
CCRN REVIEWCCRN REVIEW
THANK YOUTHANK YOU
CCRN REVIEW PART 1CCRN REVIEW PART 1
ReferencesReferences American Heart Association. (2005). Guidelines 2005 for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Available at: www.americanheart.org.
Bridges EJ.(2006) Pulmonary artery pressure monitoring: when, how, and what else to use. AACN Adv Crit Care. 2006;17(3):286–303.
Chulay, M., Burns S. M. (2006). AACN Essentials of Critical Care Nursing. McGraw-Hill Companies, Inc., Chapter 23.
Finkelmeier, B., Marolda, D. (2004) Aortic Dissection, Journal of Cardiovascular Nursing: 15(4):15–24.
Hughes E. (2004). Understanding the care of patients with acute pancreatitis. Nurs Standard: (18) pgs 45-54.
Sole, M. L., Klein, D. G. & Moseley, M. (2008). Introduction to Critical Care Nursing. 5th ed. Philadelphia, Pa: Saunders.
Thelan, L. A., Urden, L. D., Lough, M. E. (2006). Critical care: Diagnosis and Treatment for repair of abdominal aortic aneurysm. St. Louis, Mo.: Mosby/Elsevier. pg 145-188.
References ContinuedReferences Continued Urden, L., Lough, M. E. & Stacy, K. L. (2009). Thelan's Critical Care Nursing:
Diagnosis and Management (6th ed). St. Louis, Mo.: Mosby/Elsevier.
Woods, S., Sivarajan Froelicher, E. S., & Motzer, S. U. (2004). Cardiac Nursing. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins.
Wynne J, Braunwald E. (2004). The Cardiomyopathies in Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine (7th Edition). Philadelphia: W.B. Saunders, vol. 2, pps. 1659–1696, 1751–1803.
Zimmerman & Sole. (2001). Critical Care Nursing (3rd Edition). WB Saunders., pgs. 41-80, 176-180, 242-266.
Anderson, L. (July 2001). Abdominal Aortic Aneurysm, Journal of Cardiovascular Nursing:15(4):1–14, July 2001.
Irwin, R. S.; Rippe, J. M. (January 2003). Intensive Care Medicine. Lippincott Williams & Wilkins, Philadelphia: pgs. 35-548.
Wung, S., Aouizerat, B. E. (Nov/Dec 2004). Aortic Aneurysms. Journal of Cardiovascular Nursing. Lippincott Williams & Wilkins, Inc.:19(6):409-416, 34(2).