Guide to the nbrc hospital



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Billy Bob's Protocol Guide to the NBRC Hospital

Revised: Oct. 13, 2008



Adult CMV Rules

Intubate and Ventilate if:

PaCO2 with pH < 7.30 (Hypercarbia with Respiratory Acidemia)


Initial Ventilator Settings; use (adult)

A/C or SIMV (add PS +512 cwp to WOB through ETT)

f = 812 breaths per min.

Vt = 1012 ml/Kg (or 89 ml/Kg if 1012 not a choice)

Use only 10 ml/Kg Vt for child

For exacerbation of Severe COPD try-

1st: V/M @ 28% or 2 L/m N/C if V/M not an option; but avoid N/C b/c

delivery is estm.

2nd: BiPAP - if pH is < 7.30 (see: N COPD ABG)

where IPAP adjusts ventilation (1015 cwp)~ Vt with pH

and EPAP adjusts oxygenation (4 cwp) ~ PaO2

3rd: CMV with smaller Vt & FIO2 initial parameters or

If fails, switch to SIMV with PS



f = 812 breaths per min.

Vt = 6 10 ml/Kg (b/c hypercompliant)(also adjust with IPAP)

FIO2 = 30% 40%

PEEP = 2 5 cwp will help prevent air-trapping causing

intrinsic PEEP or auto-PEEP


For ARDS with PIP; can use Permissive Hypercapnea with

Vt = 57 ml/Kg allowing PaCO2 & keep pH > 7.25 (see below)
Initiate Pressure Control Ventilation (PCV) when Pplat > 3540 cwp or PIP > 50 cwp

b/c of chemical mediator release lung damage (ALI= acute lung injury)

Initial PCV settings;

PIPPCV estm. = at 50% of PIPA/C (on A/C) or = Pplat, then

target Vt by adj. PIPPCV where 5  7 ml/Kg IBW

(See Permissive Hypercapnea above) and add



PEEPPCV = 50% of PEEPA/C

FIO2 = 100% or 1.0

I:E = 1:2 or inverse ratio with pt. sedation; caution

2:1 ratios or > b/c Auto- PEEP can occur

Monitor Vt Exh. b/c PIP limit determines Vt: CL or Raw changes affect Vt Exh

PCV also indicated in pleural air leak where

set PIPPCV = PPlateau adjusting f to control PaCO2
For NMD with fatigued muscles and stable Cst - use Bilevel ventilation


Ventilation - Always treat FIRST; a combination of PaCO2 and pH;  ventilation when

respiratory acidosis < 7.30 pH; remember respiratory alkalosis is not a ventilation problem

Exceptions:



Severe COPD:- try BiPAP 1st b/c hard to wean from CMV

initiate IPAP~15 cwp with an EPAP~ 4 cwp (See: COPD normal ABG's)


NMD:- Respiratory Insufficiency (i.e.: RR >35 b/min., HR>100 b/min.

& even though N acid/base balance = intubate & CMV b/c impending AVF


Cerebral Trauma:- (i.e.: MVA, Sub-Arachnoid Hemorrhage) keep

PaCO2 = 25-30 Torr so pH is alkalotic to ICP (via vessel constriction) &

keep PaO2 ~ 100 Torr (i.e.:  FIO2 as needed)


OxygenationAlways treat 2nd; after evaluating ABG for

Respiratory Alkalosis (Acute or Uncompensated) with Mod. Hypoxemia

FIO2 to 60% max., then start CPAP b/c refractory hypoxemia

Wean from FIO2 and CPAP (or PEEP) by FIO2 1st till reach 60 %, then

PEEP until = 5 cwp, and then FIO2 again in 10% increments to ~ 40-30%

b/c O2 toxicity is 1st concern and barotraumas is 2nd


Can MV if FIO2 and PEEP is not an option (i.e.: f, Vt, add PS) to PaO2
Tissue Hypoxia exists if PvO2 < 30 Torr & or SvO2 < 56 %
DC all O2 therapy if PaO2 = > 5 X FIO2 %
Supplemental O2 Adult ~ should be in range of 30% to 60% FIO2
NRB (100%) ~ indicated ONLY in emergency or trauma conditions
CMV - Weaning Parameters: weanable if-

VC 1015 ml/kg IBW; measures for effective cough (monitor daily)

MIP ≤ -20 cwp; measures strength for effective cough (monitor daily); N= -50®100cwp

Vt spont 3 ml/lb. or 6.6 ml/Kg of IBW indicates "continue weaning"

RSBI = RRspont./Vt spont.(L) ; # < 100 = weanable; # > 100 = needs CMV

(A-a)G on 100% < 350 Torr before weaning attempted; where N = 60®100 Torr; b/c

>350 Torr  V/Q mismatch or diffusion deficit [i.e.: (A-a)G should be ]



VD/Vt < 0.60 = pt ready to wean; where 25%35% (i.e.:0.25  0.35)= N

Where: VD/Vt = PaCO2 - PECO2 and therefore

PaCO2

VD = PaCO2 - PECO2 X Vt

PaCO2



PEP > 40 cwp = weanable b/c effective cough (also: MEP, MEF)
Always choose MIP, VC, RRspon, Vt spon., when considering weaning, even if on A/C= 12

ETT Sizes - Adults:

Teenager (16 YO) = 7.0 mm;

Female (average size) = 7.5 – 8.0 mm;

Male = 8.0 – 8.5 mm

Large Adult = 9.0 – 10.0 mm
CMV - Weaning Strategy

Switch from A/C to SIMV where



f =10, 8, 6, 4 or 2 flow-by; after ABG results reveal respiratory alkalosis

without hypoxemia;

always adjust f (not Vt) to change Valveolar with SIMV or Control modes and

always adjust Vt (not f) to change Valveolar in A/C mode

consider PS of 512 cwp to  WOB through ETT (or 510 cwp)

FIO2 to 60 %, then PEEP/CPAP to 5 cwp, then FIO2 until 4030 %

Make changes b/c of :

ABG results reveal respiratory alkalosis without hypoxemia

or b/c pt. is resting comfortably with good spontaneous ventilation

measurements



or b/c MIP & VC (done daily) are acceptable

Note: Small ventilator changes are better than big changes

Remember: Adjust f to alter PaCO2 in SIMV or Control modes AND

Adjust Vt to alter PaCO2 in A/C (where VE is best changed)

Auto-PEEP (intrinsic PEEP) - Monitor expiratory flow curves returning to zero;

causes risks of barotrauma & CO


ABG for Severe COPD; Normal values

PaO2 = 50  65 Torr

PaCO2 = 50  60 Torr or 

pH = 7.30  7.35

HCO3-  32 mEq/L

Note - COPD chemoreceptors not depressed until PaO2 ~ >70 Torr


IBW Calculation (NBRC)

female = 105 lb for 60" plus 5 lb/in. over 60"

male = 106 lb for 60" plus 6 lb/in. over 60"
Estimate VE, PaCO2, Vt or f, where:

f(Desired) X PaCO2 (Desired) = f(Actual) X PaCO2 (Actual)

and therefore the following can be formulated:

fdesired = (f current) (PaCO2 current)/ PaCO2 desired ; where (↑)(↓) = (↓)(↑) or (↓)(↑)=(↑)(↓)

. .

VE desired = (VE current)(PaCO2 current) , Also

PaCO2 desired

Vt desired = (VE current)(PaCO2 current)

PaCO2 desired
Neonatal Rules

(3,000 g or 3 Kg is normal birth wt. ~ 6.6 lbs.; anything less is probably a premie)



Initial Ventilator Settings for babies; Switch baby to PCV from CPAP after:

CPAP = 8 10 on 80% with PaO2 < 50 Torr and PaCO2 > 60 Torr (see neonate N ABG below)

Pressure Control for neonates with

f = 40 breaths per min.(or in range 3050 b/min.)

where normal RR = 4060 b/m



PIP = 25 cwp (or in range 1525 cwp)

FIO2 = 0.60 (b/c baby was on CPAP at 0.60)

PEEP = 2  4 cwp (only after initial therapeutic setting of 45cwp)

*Note - when PEEP, Vt will  b/c of PC mode (i.e.: Vt=PIP-PEEP)

HFV = 3 types


  1. HFPPV: where f = 60100/min., Vt = 35 ml/Kg, I:E = 1:3 or <

  2. HFJV: where f = 100600/min., PIP ~ 810 cwp, I:E = 1:11:4

Alarms: PLow

  1. HFO: where f = 603,600/min., Vt < VD anatomic

Also:

ECMO is indicated for those infants not responding to PC ventilation

Surfactant replacement is indicated for infants with RDS to open

up atelectatic alveoli; given within 1224 hours of 1st symptoms



Ventilator Changes for Neonates

Ventilation - Always treat first; a combination of PaCO2 and pH

Oxygenation – Always treat 2nd a combination of FIO2 and PEEP

PEEP by only 24 cwp at a time

Caution with PPHN (Persistent Pul. Hypertension Neonate) b/c compressed

alveolar capillaries  patent ductus arteriosis & or Foramen Ovale
FIO2 = 0.10 max. at a time, unless option exists to:

Titrate FIO2 to maintain SpO2  93%


Extubate when CPAP is @ 2 cwp (b/c normal FRC is maintained with CPAP = 2 cwp)
Apgar Scores: 5 parameters @ 0, 1 & 2 pts with 10 pts max.

710 = N = observe, sx upper awy w bulb syr., place in warmer

4 6 = moderate asphyxia = BVM stimulate & place on O2

0 3 = severe asphyxia = immediate resuscitation, ventilation with FIO2


ABG for Neonates:

PaO2 = 50 70 mmHg (Sills PaO2 neonate = 60 – 70 Torr)

PaCO2 = 35 45 mmHg

pH = (7.25) 7.35  7.45

HCO3- = 2026

where, ROP (retinopathy of prematurity) ~ PaO2 > 80 Torr

also, Umbilical ABG = Radial ABG

Capillary Gases for Neonates:

PcO2 = 4050 Torr

PcCO2 = 4050 Torr
N Vital Signs for Neonates:

HR = 130-150 b/min., BP = 75/45 (9060/6030); RR = 4060 b/min.
acrocyanosis (peripheral cyanosis) is N after birth;

however, central cyanosis is NOT Normal and O2 trx must be initiated



Serum Glucose Levels should be measured in INFANTS

CBC should be assessed for O2 carrying capacity of the blood & infection

Ductus Arteriosus – detected via two PTCO2 electrodes i) R upper chest (preductal) &

ii) L chest, abdn, or thigh (post ductal)



CPAP for Neonates:

Start CPAP ONLY when pt demonstrates hypoxemia on 60 % FIO2 (indicates atelectasis)

Remove ETT when CPAP = 2 cwp b/c < will ↓ FRC below N

CPAPmax. Neonates = 12 cwp (Sills p. 402)


ETT Sizes (neonates): 3,000 g or 3.0 Kg is normal birth wt.; anything less is probably a premie)

Pre-Term 2.5 Kg = 2.5 mm;

Full Term (3840 wks gestational) = 3.0 mm;

1 year old = 4.0 mm
CSE- DO NOT ORDER ON INFANTS - PEFR, MIP, VC as inappropriate

EKG

Recommend 12-lead ECG = to dx. signs/symptoms of acute serious cardiac arrhythmia



Atrial Fibrillation = Cardioversion is indicated; energy level = 25100 joules

Ventricular Fibrillation (also: Pulseless Ventricular Tachycardia) = Defibrillation is indicated;

200 J initially, then  energy to 360 Joules if 2nd or 3rd is not successful.

All other cardiac arrhythmias are trxed w medication

Medication vs. Cardiac conditions:



Lidocaine - trx. Ventricular Fibrillation, Ventricular Tachycardia & PVCs

Epinephrine - trx. Ventricular Fibrillation, Sinus Arrest & Asystole

Atropine - trx. Sinus Bradycardia & Asystole

HR measured via EKG grid lines as: 300 (60/0.2), 150, 100, 75, 60, 50 (6th box or 60/1.2)


Equipment Rules

Flow Conversion to L/sec: 60 L/min = 1.0 L/sec

50 L/min = 0.83 L/sec

45 L/min = 0.75 L/sec

40 L/min = 0.67 L/sec

30 L/min = 0.50 L/sec

5 L/min = 0.0833 L/s; i.e.: 20 L/m = 4(0.08333) = 0.33 L/s
Air:Oxygen Ratios: 60% = 1:1

50% = 5:3

45% = 2:1

40% = 3:1

35% = 5:1

30% = 8:1

28%= 10:1

26%= 15:1

24% = 25:1

Heliox:

ONLY delivered via NRM



80/20 mixture = 1.8 X O2 flow = actual flowHeliox

shortcuts = multiply O2 flowmeter rate by 2 & round  to estm. He/O2 flow

= divide He/O2 Rx by 2 & round ­ for O2 flowmeter flow to use

70/30 mixture = 1.6 X O2 flow = actual flowHeliox

shortcuts = multiply O2 flowmeter by 1.5 & round ­ estm. He/O2 flow

= divide He/O2 Rx by 1.5 & rd ­ for O2 flowmeter flow to use

70/30 is lowest He concentration delivered b/c O2 is heavy


LOX:

1 lb LOX = 344 L gaseous O2

1 L LOX = 2.5 lb LOX = 860 L gaseous O2
Cylinder to Empty

Textbook calculation # min = (# psig)X[(0.28~E; 3.14~H )]

# L/min

# min = # hours

60 min/hr.

Billy Bob's Shortcut:

* for E cylinder ~ substitute 0.28 to 0.3

* drop one zero from the # psig and multiply by 3

* divide by # L/m, which ~ # min

* drop the last digit and divide by 6, ~ # hours

* choose the # min or hours that is slightly lower than calculated

* for H cylinder: substitute 3 for 3.14 and round up
Capnography - N exhaled air contains CO2 = 4.55.5% or 3545 Torr

If ETT is in the esophagus, then this value will be near zero % (i.e.: 0.5%)

Note: PaCO2 > PETCO2 and

P(a-ET)CO2 + PETCO2 estimates PaCO2 also

P(a-ET)CO2 = 15 Torr

P(a-ET)CO2> N or is ­­ indicates Pulmonary Emboli, LHF or COPD

Also: exhaling to END Max Exhalation can differentiate PE above: i.e.

P(a-RV)CO2> N = PE where P(a-RV)CO2= N indicates LHF or COPD


Transcutaneous O2 Analyzers – PTCCO2 zeroed on RA: think Perfusion & Diffusion
IS - min VC => 10 ml/kg otherwise chg to IPPB
UAC ~ distal tip @ T6  T10; b/c lower causes cyanosis of lower extremities
CPT with head  ~ if not tolerated add 10% FIO2 or change to PEP Device
NO (nitric oxide) is adm @ 10 ppm initially & ­to 20 ppm, where PVR>240 dynes.sec.cm-5

Reminder: PVR = N = 1.5 3.0 Torr or 80 - 240 dynes∙sec∙cm-5

SPAG - set the nebulizer as high as it will go, then add enough drying flow to =

15 L/min total; also, drying chamber should have < 10 L/min. or no aerosol

Oropharyngeal Awy - used ONLY for unconscious pt. to maintain patent upper airway.

Combitube (ETC: Esophageal Tracheal Combitube) - an emergency awy device

inserted with minimal skill; not used with pediatric nor short adult pt.s;

use a colorimeter or capnography to determine where the tube is placed

Chest Tubes:

placed in 2nd  4th anterior intercostal space to evacuate air

placed in 6th  8th intercostal space to evacuate fluid

vacuum set at -20 cwp for Pleur-Evac System, or at

-15 cwp for direct line suction (b/c of < sx control)

Galvanic Fuel Cell – “recalibrate” before replacing fuel cell, if FIO2 measurement a problem

LMA – Laryngeal Mask Airway:

- inserted by minimally skill or perhaps an anesthesiologist during surgery (vs. ETT)

- lubricate posterior mask; insert with the index finger  over epiglottis f/b

mask inflated ­ 60 cwp

- can NOT be used on conscious nor semiconscious pts (b/c of gag reflex)

(must be unconscious)

- gastric distention = bagging or CMV where PIP > 20 cwp b/c LMA will leak

- aspiration can still occur
Pulse Oximeters –

think Perfusion & shine a Light through the blood


Hemodynamics ­ ¯ ® ¬ ³ ± »

CVP = N = 6 1 Torr; reflects RH pressure (also reflects RV preload)
PAP = N = 25/10 Torr (3020 Torr/155 Torr), reflects RH pressure

PAP when PVR or PCWP; then CVP also 

also PAP b/c of PaCO2, pH, or PaO2, hypervolemia (start Lasix)

PAP b/c hypovolemia (add fluids), pul. vasodilation, or PaO2


PCWP; N = 124 Torr; measures L Atrial press. & LV end-diastolic press.; where

PCWP = left heart abn.s (i.e.: CHF, Mitral & Aortic Valve Stenosis)

PCWP > 18 Torr b/c of "Cardiogenic PE" from CHF (LHF)

Also, increased b/c aortic stenosis, mitral valve regurgitation)

PCWP < 4 Torr = hypovolemia;

NOTE: PE with N PCWP indicates "Noncardiogenic PE" (i.e.: ARDS);

Balloon tip inflation hold for < 1520 sec. to prevent infarction

PVR = N = 1.5 3.0 Torr or 80 - 240 dynes∙sec∙cm-5

if PVR = pulmonary hypertension (b/c of acidemia, hypercapnia, hypoxia, then PAP)

then CVP & PAP are also 
SVR (Systemic Vascular Resistance) = N = 900 - 1400 dynes∙sec∙cm-5;

SVR < 900 ~ hypovolemia;

SVR > 1400 ~ hypervolemia
Tissue Hypoxia = SvO2 < 56% & or = P vO2 < 30 Torr: where N. P vO2 = 40 Torr (3743)
CI =Cardiac Index =QT/BSA  N QT = 2.54.0 L/min/sm2of body surface area

= a reflection of QT (cardiac output)

CI < 2.5 ~ hypovolemia;

CI > 4.0 ~ hypervolemia


QT = VO2 __________ = Cardiac Output (or total perfusion),

[C(a-v)O2] X 10 where VO2 = O2 consumption


C(a-v)O2 = Arteriovenous O2 Content = (1.34)(Hb)[S(a-v)O2] + (0.003)[P(a-v)O2]

N = 4 6 vol% or where > 6 ~ CO (maybe trx w fluid intake)

and < 4 ~ CO (septic shock or anemia may be indicated)
If PvO2 after PEEP, then QT demonstrated; therefore PEEP to previous level
RQ = V/Q = 4.2/5.0 = 0.8 = N
Lab Data       

Air bubble - should be suspected in an ABG when PO2 + PCO2 > 140 Torr on RA

Sputum:


Green ~ pseudomonas (foul smelling)

Yellow ~  WBC's or staph

Color vs. disease:

CB = viscous yellow or green

CF = viscous yellow or green

PE = Pink & frothy

Asthma without infection = Clear, white

Electrolytes:

Na+ = 135  145 mEq/L; ~ 140; Na+ = muscle weakness & difficult vent weaning

K+ = 3.5  5.0 mEq/L; ~ 4; K+ = muscle weakness & AVF; cardiac arrhythmias &

flatted "T" wave; difficult vent. Weaning



Cl- = 95  105 mEq/L; ~ 100; Cl- = K+ also ; Cl- = weakness

Ca+ = 4.25  5.25 mEq/L; ~ 5; Ca+ = muscle weakness & difficult vent weaning
Others:

WBC > 11k = infection; > 17k = severe infection

Sweat Chloride Test - for CF; positive > 60 mEq/L

HTLV-III ~ test for HIV infection

L/S Ratio = N = 2:1; 1.5:1 = 50% chance RDS; 1:1 = 90% chance RDS (start surfactant)

Umbilical ABG = Radial ABG

Cardiac Enzymes - Lab blood test run to determine if MI occurred

BUN ~ blood/urea/nitrogen =  in renal failure

HbCO measurement is an effective test for smoking cessation program noncompliance



Pathology:       

Tension Pneumothorax - suspect when PEEP, with suddenly restless, agitation,

 BS on a lateral side, asymmetrical chest movement, tracheal movement away from mid-

line; Trx - insert Lg bore needle/rubber catheter into 2nd (between 2&3) intercostal space.
Severe COPD - typical ABG's

PaO2 = 50 - 65 Torr (chemoreceptors are activated in this range)

PaCO2 = 50 to 60 Torr (respiratory acidosis)

pH = 7.30 - 7.35; (partly compensated respiratory acidosis)

HCO3- = 34 - 37 mEq/L (metabolic alkalosis compensation)

Note - chemoreceptors not depressed until PaO2 ~ >70 Torr


Try NIPPV (BiPAP) first before intubating b/c hard to wean COPDers from CMV

I-Hold or Ipause = helps to distribute Vt more evenly to all lung areas; Gas diffusion,

intrathoracic pressure, atelectasis, P(A-a)G & oxygenation



Percussion ~ tapping over pt.s chest & listening to the sound

Flat sound - over areas of sternum, muscles, atelectasis (tissue or bone)

Dull sound - over areas that are fluid filled (heart, liver, pleural effusion, pneumonia)

Resonant – normal

Hyperresonant – over hyperinflated areas i.e. COPD, Status Asthmaticus
Palpation ~ to touch for, or listen to:

Abnormalities of anatomy or areas of tenderness: ie.: tracheal shift, fractured ribs

Tactile fremitus – “99” is spoken with changes in vibrations felt

Vocal fremitus – 99’ is spoken with normal air muffling heard via stethoscope


IPPB indicated post-op for a sedated pt. requiring prevention of atelectasis trx

when IS not tolerated


PFT Rules:       

Interpretation of Results

# > 15% = significant response (improvement) to bronchodilator

mild, moderate and severe


Inspiratory flow = N = 2530 L/m
When interpreting PFT results, look at the choices~ 3 incorrect choices will type a

wrong pathology (i.e.: restrictive vs. obstructive). Choose the other single type.


MVV - performed for 5 -12 sec only (Sills); 10, 12, 15 sec's (Persing); @70-120 bpm
Geisler Tube Ionizer- a nitrogen analyzer used to measure ing exhaled N2 during

inspiration of 100% O2 for the determination of RV, FRC and TLC\

However, use helium washout with COPD pts b/c 100% O2 not used
Physiology Calculations:       

Alveolar-Air Equation

PAO2 = (PB - PH2O)FIO2 - PaCO2(1.25); simplify where



shortcut

PAO2 = (7)O2% - PaCO2 + 10



i.e.: PB = 747, FIO2 = 50 and PaCO2 = 35

= (7 X 50) - (35+10) = 350 - 45 = 305 Torr



Desired FIO2 ; where  FIO2 = PaO2 therefore divide; i.e.: where FIO2/PaO2 = 1; or

Desired FIO2 = Actual FIO2

Desired PaO2 Actual PaO2 simplified


Desired FIO2 = (Desired PaO2) X (Actual FIO2)

Actual PaO2

Also via math: where (↑)(↓) = (↓)(↑) or (↓)(↑)= (↑)(↓)

Bubble in ABG if:-

PaO2 + PaCO2 > 140 Torr on RA; {should be < or = with (A-a)G}

Dead Space:

Anatomic normal: VD anatomic = 1 ml/lb. IBW = 2.2 ml/kg IBW

Intubated Pt.: VD Intubation = 0.5 ml/lb. IBW = 1 ml/kg IBW
↑VD = ↑ PaCO2 (i.e.: pulmonary emboli)
Capillary Refill = N = or < 3 sec.; If

> 3 sec. = indicates ↓perfusion, hypotension or a cold extremity


Cyanosis ~ 5 g/dL Hb is unsat.: or Hb > 5 g/dL

Oxygen Content = CaO2 = (1.34)(Hb)[SaO2] + (0.003)[PaO2]

Where N = 15  20 vol % (NO REFERENCE)


IBW Ht. M(lb./Kg) F(lb./Kg)

5'0" 106/48 105/48

5'2" 118/54 115/52

5'4" 130/59 125/57

5'6" 142/65 135/61

5'8" 154/70 145/66

5'10" 166/76 155/71

6' 178/81 165/75


Peak Flow Conversions:

50 L/min = 0.83 L/sec

40 L/min = 0.67 L/sec

30 L/min = 0.5 L/s


Cstatic (adult) = Nadult = 100 ml/cwp

Nventilator = 6070 ml/cwp


Cst (neonate) = Nneonate = 5 ml/cwp (3 Kg)
Cst = N = Vt exh________

Pplat - PEEP


Cdyn = N = Vt exh________

PIP - PEEP


Raw = PIP - Pplat / # L/sec ;

Nnonintubated = 0.6 2.4 cwp/L/s;

Nintubated = 5 cwp/L/s

NBTsat = 47 mmHg (PH2O) = 44 mg H2O/Lgas


Pharmacology

Mucomyst - ONLY adm for thick & tenacious secretions i.e.: Bronchiectasis &

CF; also: can  bronchospasms



Lidocaine(Xylocaine) - instilled directly into ET tube - will cease coughing due to

bronchospasm (see cardiac conditions below) and

- also adm for ventricular arrhythmias via IV or ETT if IV not available

Sedate & Paralyze is most efficient method of treating combative pt on CMV

Valium (diazepam) - a sedative commonly administered during a bronchoscopy\

(a short acting antianxiety med.)



Versed (midazolam) - a sedative commonly administered during a bronchoscopy

(a short acting barbiturate)



succinylcholine (Anectine) - muscle relaxant facilitates intubation;

paralysis X 5', 2 mg (should add sedative)

pancuronium (Pavulon)- paralysis while on CMV; reversed with Tensilon (neostigmine)

nitroprusside sodium (Nipride)- a potent fast-acting peripheral vasodilator to BP(hypertension)

Inderal - adm to BP (hypertension)

Servanta (artificial surfactant) - indicated for RDS with CXR revealing ground-glass appearance

or L:S < 2:1; adm. 12-24 hrs after symp. appear; PaO2 will as atelectasis reverses



Narcan - reverse effects of narcotics

Hypertonic Saline - 1.8% (2 X 0.9) to induce cough

Theophylline - AOP (apnea of prematurity); an oral Bd in COPD; 10 ® 20 mg/L

Added to regime only after albuterol, Atrovent & IV steroids fail to reverse B.spasm



Tobramycin (Tobi)- antibiotic(pseudomonas); 300 mg X 2/day aerosolized

digoxin (Lanoxin) - adm to SV and CO b/cpumping action of heart i.e. CHF

dornase alpha (Dnase)- trx copious secretions of CF; adm. 1 X /day aerosolized

Atropine - adm to HR (rev. bradycardia): can  occurrence of PVC's if present

dopamine (Inotropin) - adm to BP; also HR after atropine failed

nitric oxide - inhaled to trx PVR; a pulm. vasodilator; 10 ppm initial, where >20 ppm is toxic

Bretylium - for pulseless V-tach and V-fib

epinephrine - for pulseless V-tach and V-fib; also a standard for CPR to BP and HR;

NOT if PVC's present as can  their occurrence



Mestinon (pyridostigmine Br.) - for trx of MG (cholinesterase inhibitor); a neostigmine

prototype



Mannitol (osmitrol) - adm to ICP (# >25 cwp), a neurologic diuretic

Luminal (phenobarbital) - sedative - hypnotic (barbiturate) - for fighting CMV

Dilantin - Trx seizure activity

Medication vs. Cardiac conditions:



Lidocaine - trx. Ventricular Fibrillation, Ventricular Tachycardia & PVCs

Epinephrine - trx. Ventricular Fibrillation, Sinus Arrest & Asystole

Atropine - trx. Sinus Bradycardia & Asystole

Other:


- Stop bronchodilator if HR > 20 b/m or >20%

-  med. dose will  adverse reaction


CSE - Assessment for Level of Respiratory Distress

CMV

Ventilator function - quick check of vent for appropriate settings/function

Ability to pass suction catheter - ensures tube patency from secretions/kink

BS - to check for bilateral inflation or adventitious (bad) sounds

Chest percussion - assessing percussion note can help diagnose pul. problem

Manually ventilate - to assess compliance and Raw

Chest excursion - unequal or asymmetrical chest movement

Heart rate - to assess level of distress

Tracheal shift - palpate suprasternal notch for midline or shifted (pneumothorax)

Quick Assessment ~ Choose ONLY those assessments that can be performed visually &

at bedside (stage 1 & 2; No ABG, CXR, CBC, etc.)


CSE - POSSIBLY SELECT ON THIS EXAM

Muscle tone - pt with NM disease or premature infant

Clubbing - consider age of pt. (except CF adolescents)

Deep tendon reflex - differentiates GB vs. MG b/c weakness () with GB diseased

pt vs. normal in MG (MG/Myasthenia Gravis; GB/Guillain-Barre’)

QT - for pt with cardiac disease only

PAP - only for cardiac pt or where a Swan-Ganz catheter is already inserted

PvO2 only where a Swan-Ganz catheter is already inserted

Allen's test - only before performing an arterial stick at the wrist

Ability to swallow - only in NM disease pt (swallowing difficuly may require intubation)

Swallow ability- for toddler R/O epiglottitis or upper awy obstruction

CVP - only a cardiac pt. or where a central line has been inserted

ABG's - evaluates ventilatory & oxygenation status; however, this painful test

may NOT be necessary if pt is resting comfortably or SpO2 = N

ICP - only in head trauma pt's; zero on RA and ONLY before attachment

Tracheal position - ONLY when pneumothorax is suspected

Serum glucose level - only for diabetes or neonatal pt's

Breathe mints - are helpful after pentamidine trx b/c of bad taste

Pulmonary angiogram - procedure to detect pulmonary embolus

Response to painful stimuli - select only when pt is unconscious

Babinski reflex - bottom foot rubbed with dull object, toes inward = N,

toes outward = neurologic defect ONLY i.e. brain damage, - GB; +MG

Gag reflex - tested with NMD determines level of paralysis; also unconscious or

semiconscious - determines depth of depression; caution b/c can cause

vomiting and aspiration; assess level of hazard chocking with MG & GB but

not performed if pt. eating/drinking properly

Electromyography – EMG tests muscle weakness & endurance of NMD i.e. MG

Sx - ONLY PRN; Never q10 or q20, etc.

ABG - ONLY PRN; Never q day

Urine Output - measured (40 ml/hr) to assess cardiac (perfusion) or kidney failure

Bilateral grip test - in NMD tests muscle endurance via hand muscles

CBC (infant) - 30k at birth, 18k at 1 wk, 11k at 2 wk (Wilkens; Assess, p223)

Post Extubation - if offered, choose SVN with Epinephrine X 2 over 2 hour & or

Beclovent MDI X 2 over 2 hour (remember: only if offered)

IPPB with FIO2 1.0 ~ Choose when ABG demonstrates 1) poor ventilation &

2) poor oxygenation and more assessment information is needed

Carotid Artery Message or Valsalva Maneuver ~ common nonelectrical trx for SVT

(Supraventricular Tachycardia) via vagal stimulation.

Lukens Trap- used for collection of sputum during sxing

Expiratory Retard- use to help splint obstructive awys (ie.: wheezes) to remain open

Heimlich Maneuver- performed 1st during choking (do not clap on pts. back)

Urine output and color – if a trauma patient b/c can demonstrate internal bleeding

Peripheral Pulses – Only if cardiac pt. & to evaluate foot perfusion (dorsalis pedis)

CSE - ALWAYS SELECT

VS - should always be a part of pt evaluation; Also

BP - to assess CV status

Pulse & respiratory rate - assess CP status

Body Temperature - assess presence of infection

LOC - important to evaluate in any pt.

BS - essential to evaluate adventitious air movement through areas of the lungs

MIP - evaluates respiratory muscle strength

cough effort & production - can pt protect airway & presence of Pul infection

Vt spon. - evaluates respiratory muscles for effective alveolar ventilation

VC - evaluates effectiveness of cough to protect airways (should be >1,000 ml)

Sputum production - can be diagnostic for infection or other conditions

CBC - to determ O2 capacity (Hb) and presence of infection (WBC>11K)

CSE - DO NOT SELECT ON THIS EXAM

Hering-Breuer reflex - stretch receptors cannot be evaluated

bowel sounds - provides little relative information about respiratory status

VD/Vt ratio - time consuming and difficult to assess

O2 Consumption - hard to tolerate by pt; is also expensive and time consuming

MVV - performed in the PFT lab, it is stressful and offers little information

Moro reflex - performed on infants (startled, they raise their arms up & out)

EEG – can be mistaken for ECG or EKG

PA CXR – must be an AP view ONLY (pt.s are very sick & can not stand)

100 ml VD is NEVER added to spontaneous breathing pt b/c will PaCO2

Silverman Score - newborn assessment

Dubowitz Score - estm. gestational age of newborn



DO NOT ORDER ON INFANTS

PEFR, MIP, VC



CSE - ALMOST ALWAYS SELECT

SpO2 - Except for suspected HbCO poisoning

MIP, VC, RRspon, Vt spon., RSBI, BS, VS, T, CBC, LOC, CXR, Pulse, when

considering weaning, even if on A/C= 12 but without major acute health issues



Also called bedside spirometry; weaning parameters


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