Complex Care Session 10: hemodynamic monitoring in shock

Session 10: hemodynamic monitoring in shock

 

MAP: mean arterial pressure (average of systolic and diastolic BP)

  • We want it above 65 mmHg 

Systolic BP: want this to be above 90 mmHg in most cases for adequate perfusion

 

Pulse pressure

  • SBP -DBP: greater than 40 is vasodilation. Less than 40 is vasoconstriction.
    • In septic shock there is vasodilation
    • In cardiogenic shock there will be vasoconstriction.

 

CVP – central venous pressure. Venous central line that measures end vena cava pressure.

ABP – Arterial blood pressure. Catheter inserted into the radial or femoral arteries usually. The tubing is pressurized to overcome the arterial blood pressure. To get an accurate reading the fixture that measures the pressure must be level with the patient.

 

Changes in venous O2 or Arterial O2 (SvO2 vs ScvO2)

  • Increased O2 delivery from: increased SaO2, Increased HGB, Increased cardiac output
  • Decreased O2 consumption: decreased need(hypothermia), access(vasoconstriction), and capability(tissue death)
  • Decreased O2 delivery: decreased O2 sat, decreased HGB, decreased CO
  • Increased

 

Shock:

Shock HR BP RR UO SVO2
Cardiogenic up down (Low PP)  Up w/ crackles down down
Hypovolemic up down (Low PP)  Up then D down down
Neurogenic down down (high PP) dysfunction dysfunction Normal to high
Anaphylactic up down (high PP) up incontinence Normal to high
Septic up down (high PP) up Down (none) Down, increased late
obstructive up down (Low PP) up down Normal to down

 

Cardiogenic shock: pump issue

  • Decreased stroke volume, decreased stroke volume
  • Causes MI, arrhythmias,
  • s/s: tachypnea, crackles, anxiety,

Hypovolemia: decreased fluid volume

  • absolute hypovolemia: hemorrhage, DI, Diuretics
  • Relative hypovolemia: fluid moving out of the vasculature into extra vasculature. Burns and liver failure.
  • Increased HR, CO, RR
  • Decreased: SV, CVP, PAP (pulmonary arterial pressure)
  • The body can compensate for about a 15% volume deficit

 

Distributive: poor distribution of circulating blood.

  • Neurogenic shock:
    • T6 or above trauma
    • Hypotension, bradycardia, vasodilation relative hypovolemia,
  • Anaphylactic reaction
    • Profound vasodilation, capillary permeability, edema, leading to bronchospasm
    • Angioedema(facial swelling), hives

obstructive:  physical blockage to flow.

  • Cardiac tamponade
  • Pulmonary embolism

 

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Complex Care Session 9: Burns

Session 9: Burn

 

Prevention of burn injuries is the top priority

Most common is to get burned by a flame, and next highest is scalding

 

  • Burns are often measured by percentage of total body size
  • Most common complications associated with burns are: in adults, Cellulitis uti and pneumonia, and in older patients tend to get wound infection and pneumonia.
  • Only give antibiotics if there is a high risk of infection, or signs of infection.
  • Depths of burns
    • Superficial, partial thickness, 1st degree: still have hair that is anchored,
      • Caused by, sun, and minor heats
      • Treat with: aloe vera, NSAIDS, no alcohol, benadryl.
    • Deep partial thickness, second degree: loose sweat glands, and hair follicles, has blisters
      • Takes 10-21 days to heal
      • May need skin grafts
      • Need to wait 24 hours to see how deep the burn really is
      • Deroof blisters that are greater than 2 cm
    • Full thickness 3rd and 4th degree: down to the fat layer.
  • Inhalation injury – priority is maintaining the airway.
  • Steven johnson’s – less than 10% of of total body
    • Not very bloody, sloughing off of skin
  • Tens – Affects greater than 30% of total body surface area.
    • Very bloody, Sloughing off of skin.
  • Amniotic graft tissue can be used for grafting over the eyes. This tissue is taken from donated placenta.
  • Electrical injuries – internal burning,visible burns on an entry point and exit point.
    • Deep muscle and nerve injury
    • Difficult to assess the extent of the injury
    • Patient can have rhabdomyolysis and compartment syndrome (five P’s are the s/s for compartment syndrome.)

 

  • Chemical burns
    • Irrigate the burn to get the chemical out
  • Tar burns
    • Cool the tar then we use oil to get the hard tar off.
  • Frostbite
    • Can regain vasculature to fingers and toes with tPA if treated under 24 hours from injury.
  • Phases of burns
    • Emergent first 48 hours
    • Acute – weeks to months
    • Rehabilitation phase – over two years
  • Fluid resuscitation in burns
    • 2ml of LR*TBSA*KG
    • Need 30-50ml/hr of urine output
  • Greater than 20% burn we will gown and glove to prevent infection of the patient.
  • Compartment syndrome – swelling of a compartment and the pressure will need a escharotomy or fasciotomy to relieve pressure.
    • 5 p’s for compartment syndrome: Pulseless, paresthesias, pallor, PAIN, paralysis.
  • Graft types
    • Autograft – patient own skin
    • Allograft – cadaver skin
    • Xenograft – pigskin
    • CEA – cultured epithelial cells
  • Sheet graft – one continuous piece of skin
  • Mesh graft – take the sheet and poke holes in the skin then stretch it out.
  • Meds used:
    • Increased need for pain meds due to the hypermetabolic state.
    • Antianxiety: benzodiazepines,
    • Beta blocker
    • Anabolic steroid – oxandrolone, growth hormone
      • Used for months to promote tissue growth.

Complex Care Session 8: Endocarditis, Pericarditis, and valvular diseases.

Session 8: Infective endocarditis, pericarditis, and valvular diseases.

 

Valvular diseases:

  • Mitral Valve stenosis: valve leaflets fuse together and cause a decrease in the blood flow across the valve. Most commonly caused by rheumatic heart disease.
    • Diastolic murmur, loud S1, exertional dyspnea, palpitations, and fatigue.   
  • Mitral Valve regurgitation: incomplete closure of the valve leaflets causing blood to flow backward from the left ventricle to the left atrium. caused by Rheumatic heart disease, endocarditis, cardiomyopathy, and issues with the chordae tendinea
    • s/s: systolic murmur, pulmonary edema, cardiogenic shock
  • Aortic Valve Stenosis: Stenotic valve between the aorta and the Left Ventricle.
    • Systolic murmur, Soft S1,S2, and impressive S4
    • s/s: Angina, Syncope, dyspnea on exertion.
    • The aortic valve has two “os” (openings to the coronary arteries) that feed the coronary arteries.
  • Aortic Valve Regurgitation: Floppy valve causing backflow from the Aorta to the LV.
    • Diastolic murmur
  • Treatment: Lower BP and increase CO
    • Meds: vasodilation(nitro), positive inotropes (digoxin), Diuretics, Anticoagulation, antiarrhythmics, beta blockers,

 

  • Endocarditis: Infection of the endocardium usually the heart valves.
    • Strep viridans and staph aureus are the most common types.
    • Effects Left heart 90% of the time, and usually the mitral valve.
    • s/s: new murmur or change in existing murmur, Fever,
    • Embolization of a portion of the vegetation: Thrombotic stroke from a vegetation embolus of the bacteria, micro emboli in Kidneys extremities and spleen if the infection is originating on the right side of the heart. If originating on the left side of the heart pulmonary issues are a risk factor.
    • Right valves are effected at the lower percentage and are correlated with IV drug use.
    • Subacute: Slow and long course, patient usually has a pre-existing heart valve issue.
    • Acute: faster progression of the illness, may not have a pre-existing heart valve issue,
    • Risk factors: Cardiac conditions, artificial heart valve, IV drug abuse, Bacteremia, Intravascular devices,

 

  • Pericarditis: inflammation of the pericardium, the sac surrounding the heart.
    • Normal fluid around heart is 15-30ml
    • Increased chest pain with inspiration
    • due to: infection, uremia, acute MI, Trauma, Dissecting AA, Auto immune, Rheumatic diseases, and some medications.
    • s/s:ST elevation on all leads, Echocardiogram to see thickness of pericardial tissue, chest x-ray will show large cardiac shadow, Pericardial tamponade,
    • Pulsus paradoxus – an exaggerated decrease in Blood pressure upon inspiration, greater than 10 mmhg. (you need an arterial line to monitor this.)  
      • This is caused by cardiac tamponade, the fluid that builds up in the pericardium causes pressure changes that decrease the stroke volume of the left ventricle. The right ventricle presses the septum towards the left ventricle causing decreased stroke volume.

 

Session 5: Endocrine

Session 5: Endocrine

 

Diabetic Ketoacidosis

  • More common in DM1 but possible in DM2
  • s/s dry mucous membranes, tachycardia, hypotension, Kussmaul respirations, glucose over 250, dehydrated Altered LOC.
  • HypoKAlemia, HypoNatremia,
  • The cells cannot take in glucose so they must metabolize fats, which causes a waste product of Ketone acid.
  • Give Insulin and monitor electrolytes and replace any that are out of normal, Give bicarb

 

HHNS – Hyperosmolar Hyperglycemic nonketotic Syndrome

    • Common in DM2
    • s/s: NO ketones production, GLU > 600,

 

  • FIRST THING TO GIVE: FLUIDS!!!!!, then insulin

 

  • Not giving BiCarb

 

SIADH – Retaining water, not urinating

  • Too much ADH
  • Low electrolytes
  • Do not replace Na too quick due to cerebral swelling.
  • 8-12 MeQ per day Na replacement.
  • These people may need to be on a fluid restriction, with no free water.
  • Demeclocycline – reduces the action of ADH

DI – always urinating

  • Not enough ADH
  • Dehydration
  • Tachycardia, hypotension, thirsty, dehydration…
  • DDAVP – reduces the urine output
    • This will not work with nephrogenic DI because the issue is with the nephron not ADH.

 

Cushing’s disease

  • Increased production of the “stress” hormone ACTH from the pituitary tumor
    • This is usually caused by a pituitary tumor
  • At risk for everything associated with glucocorticoids
  • Buffalo hump, mustache, hair loss, thin arms, large abdomen, Moon face, weight gain, insomnia, thin skin.
  • Alternate s/s: depression, changes in appetite, Fatigue, decreased concentration and libido.
  • These people will need to be on exogenous corticosteroids to counteract the glucocorticoid ACTH
    • Do not abruptly stop the medication.

Session 4: ECG

Session 4: ECG Electrocardiogram

 

Properties of cardiac tissue

  • Automaticity – tissue that can initiate an impulse without an outside force acting on it.
  • Contractility – the ability to respond to an impulse through a mechanical force
  • Conductivity – transmit an impulse
  • Excitability – the ability to be stimulated by the electric impulse.

 

  • Polarized is the resting state of the heart
    • Na out and K in the cell
  • Depolarized is the working of contraction phase of the heart
    • Na inside and K moves outside
    • If depolarization does not happen in a synchronized way then the chamber will not be able to contract effectively
  • Repolarization – the recovery phase moving from depolarization to polarized
  • Absolute refractory phase – the muscle cannot be depolarized under any physiologic stimuli. This occurs after the start of depolarization, during repolarization.
    • From the beginning of the QRS to the peak of the T
  • Relative refractory phase – after the absolute refractory phase where the muscle will respond to strong stimulus.
    • A vulnerable phase during the t wave, where we do not want to shock.
  • Nodes
    • SA node –  located in the right atrium and automatically fires 60-100 times per minute.
    • AV node – on the right side of the heart between the right atria and the right ventricle, this can fire at 40-60 beats per minute if needed,
    • Bundle of His – central heart in between all of the chambers.
    • Right and left bundle branches –  in between the ventricles
    • Purkinje fibers – in the bottom sides of the heart. This can fire at 15-40  

Getting an ECG

  • Electrodes are placed on the chest and the electrical activity reflects the activity in the heart.
  • The electrodes are placed at specific locations.
  • Common forms of ECGs are 3, 5, and 12 lead. The more leads the better “picture” of the heart we can get.

Interpreting the graph

  • Horizontal lines represent voltage (up and down)
  • Vertical lines represent time (left to right)
  • One small box represents 0.04 second from left to right, and 0.1mV up and down
  • One large box represents 0.2 seconds from left to right, and 0.5mV up and down
    • One large box is 5×5 small boxes.

Waveform

  • The waveform is made up of peaks and valleys that are designated as the letters P through U. Each letter corresponds to a specific part of the Waveform.
  • P wave – Atrial depolarization, rounded and shorter than the QRS complex
  • PR interval – Measurement from the beginning of the p wave to the beginning of the QRS
    • Normal is 0.12-0.2 seconds
    • This is the time is takes for the impulse to travel from the SA node through the AV node and into the ventricles.
  • QRS – ventricular depol, less than or equal to 0.12 seconds
  • ST segment – end of V Depol to the beginning of V Repol
    • Elevation correlates with myocardial infarction
    • Depression correlates with ischemia
  • T – ventricular repolarization
  • QT interval – total duration of depol and repol

ECG interpretation

  1. Determine regularity
    1. Regular? Regularly irregular? Irregularly irregular?
  2. Calculate the heart rate
    1. Count the R waves on a 6 second strip and multiply by ten
    2. Do the atrial and ventricular waves match?
  3. Assess the P waves
    1. Are they present?
    2. Are the a consistent shape
    3. Is the ratio of P:QRS 1:1?
  4. Measure the PR interval
    1. Is is consistent? Is it normal?
    2. Can it be measured?
  5. Measure the QRS
    1. Do the complexes look the same?
    2. Is the measurement normal?

Rhythms

  • sinus tach – BPM over 100
    • Beta blockers will reduce rate
    • Adenosine given in a FAST 4 second push will slow or stop the heart to restart in a better rhythm
  • Sinus Brady – normal rhythm less than 60 bps
    • All Trained Dogs Eat
    • Atropine
    • Transcutaneous pulsing
    • Dopamine
    • Epinephrine
  • Atrial dysrhythmias
      • Likely to form a clot in the atrial these people need to be on anticoagulants for life.
      • AV node controls the  number of impulses that pass and then depolarize the ventricles. Needs a good AV node to control rate.
      • Controlled is a HR less than 100 uncontrolled is over 100
      • Unstable will need Synchronized Electrocardioversion, beta blockers, Vagal maneuver
      • Decreased CO and increased chance for clots.
    • Atrial flutter – saw tooth
      • One ectopic foci that is discharging an impulse at 250-400 times per minute
      • F waves no P waves
    • Atrial Fibrillation
      • Multiple ectopic foci that are discharging at 250-40 times per minute
      • Most common clinically significant dysrhythmia
      • Most common cause of a ischemic stroke.
  • Synchronized cardioversion – synchronized shock on the R wave
    • Need an R wave
    • Can convert them out of A flutter or fib
    • May keep them in sinus for 3-6 months
    • Amiodarone Is used to prolong the time in sinus
    • May throw a clot that was in the atrium once the rhythm converts back to sinus.
    • Get a transesophageal echocardiogram to look for clots.
  • Heart blocks
    • 1st degree
      • Consistent Long PR interval over 0.20
      • Do not treat usually do to lack of signs and symptoms
    • Second degree type one, or wenckebach, or Mobitz 1
      • AV node conduction issue
      • Progressively increasing PR interval until a QRS is missed and the arrhythmia start over
      • Usually asymptomatic
    • Second degree type II, or Mobitz II
      • Normal PR interval with a dropped QRS every so often
      • Monitor for a third degree heart block
    • Third degree heart block
      • No communication between the atria and ventricles
      • Need a pacemaker, from the cathlab
  • Ventricular dysrhythmias
    • PVC – Premature ventricular contraction
      • Can be normal and untreated
      • Bigeminy – on pvc for one normal
      • Trigeminy – two PVC for every normal PQRST
      • Causes – hypoxia
      • Amiodarone is the drug of choice
    • V Tach –
      • Can cardiovert
      • Can easily turn into V fib
      • Pulseless we will defibrillate
      • Large sharp “QRS” complexes one immediately after another with no breaks
    • V Fib
      • Defibrillate to hope the SA node takes over
      • Smooth rapid continuous electrical activity with no breaks
      • Cannot cardiovert
      • AICD is an internal defibrillation device
  • PEA
    • Pulseless electrical activity
    • Give fluids and epi
  • Asystole
    • Straight line on the ECG

Session 3: Coagulation and GI Issues

Session 3 Coagulation and GI Issues 

 

Prothrombin time PT

    • Monitor Warfarin therapy

 

  • Normal: 11-13
  • INR: 1-3

 

    • INR is the ratio between PT and PTT
  • Extrinsic system
  • Warfarin’s antidote is vitamin K, so have the patient on a diet that has consistent Vit K levels.

Activated Partial Thromboplastin time

  • Monitor Heparin therapy
  • Intrinsic system
  • 21-38 seconds

Platelet count

  • 150,000 – 350,000
  • Thrombocytopenia
    • Low platelet count
    • Around 50,000 is where s/s tend to arise
    • s/s: LOC, SOB, fatigue, Bloody stools, skin color changes

 

Immune Thrombocytopenic Purpura

  • ITP
  • Autoimmune
  • Platelets are seen as foreign by the spleen and are destroyed. The spleen are recognizing the antibodies on the platelet.
  • Treatment: corticosteroids, splenectomy, transfuse platelets

 

TTP

  • Schistocytes – abnormal blood cell
  • Normal PT and aPTT
  • Treatment: immunosuppression, Splenectomy, DO NOT GIVE PLATELETS, plasmapheresis

 

HIT

    • Heparin induced Thrombocytopenia
    • No heparin once this develops
    • Use a Direct thrombin inhibitor instead of Heparin (argatroban)

 

  • Table 31-16 on page 654

 

 

Hemophilia – genetic X linked recessive disorder where the person makes low amounts of a clotting factor.  

  • Person cannot make enough clotting factor
  • Type A – low in factor VIII, most common
  • Type B – low in factor IX
  • Tend to bleed in joints.
    • Rest the joint once there is bleeding, RICE, Passive range of motion ONCE BLEEDING STOPS.
  • Administer clotting factor
  • Education of when to come in: joint swelling, bruise getting worse/bigger, after trauma, confusion,
  • No contact sports for these patients.
  • Wear a med bracelet

 

DIC

  • Disseminated intravascular Coagulation
  • Thrombotic phase – fibrin and platelets in the microvasculature
  • Anticoagulant phase – Bleeding
  • Replacement of blood products when bleeding
    • Treat symptoms and chase labs to get to a therapeutic level.

 

Acute Gastrointestinal Diseases

 

  • Upper GI bleed
    • Bright red vomit
    • Coffee stools
  • Lower GI bleed
    • Bright red stool or tarry
    • Vomit may have dark red/black blood
  • Acute bleed
    • H/H may drop with in 4 hours of bleed
    • Give fluids
  • Giving blood
    • Need a type and screen sample within 72 hours
    • Co Sign with another nurse
    • MRN, name, expiration date.
    • Chills (shivering), Back pain, fever, flushed skin, are a sign of a Hemolytic transfusion reaction
      • Temperature and Blood pressure changes.

 

  • Functions of the liver
    • Metabolize fats/ steroids, Make bile, Detoxification, storage of glycogen, and vitamins.
    • Cirrhosis
      • Caused by, Hep C, Alcohol intake, Right sided Heart failure, Non alcoholic fatty liver disease.
      • Diagnostic levels – increased ALT, AST, and ammonia, Decreased Proteins, Increased PT and PTT
      • Hepatic encephalopathy – ammonia levels increased and can cause changes in LOC
      • Decreased protein diet (this may change in the future)
      • These people should not have alcohol
      • These people tend to be hypokalemia, Potassium replacement is necessary to avoid Arrhythmias.

 

  • Acute liver failure
    • Usually due to overdose of tylenol
    • Severe liver impairment correlated with hepatic encephalopathy
    • Can last 8 – 26 weeks after s/s onset
    • 40% morbidity rate.

 

  • Pancrease
    • Secretes enzymes, 90% proteolytic, Amylolytic, or Lipolytic
    • Secretin –  stimulates bicarb and water to control pH in the intestines
    • Acute Pancreatitis – pancreatitis inflammation
      • Caused by – Gallbladder disease, trauma, biliary sludge, surgery
      • Results from premature enzyme activation causing digestion of the pancreas and surrounding organs.
      • s/s: Left upper quadrant pain that is piercing, continuous and gets worse with eating, reduced bowel sounds, Shock, hypovolemia
      • Diagnosis – increase amylase and lipase, liver enzymes, bilirubin, and decrease calcium
      • Treatment plan: relieve pain, prevent shock, reduce pancreatic secretions, correct fluid and electrolyte imbalances, antibiotic prophylaxis, remove the cause if possible.
      • Prevention – stop smoking, drinking, restrict fats, don’t binge, may have permanent damage.

Session 2: Neuro

 

Session 2: Neuro

 

Spinal cord injury

 

  • Spinal cord injury patients can have lower BP’s such as 80/52
  • The issue of BP changes is when there is a large change from baseline.
  • S2,3,4 can have issues with bowel and bladder sphincter contractility
    • These are reflexes controlled in the spinal cord.
  • Spinal shock is not neurogenic shock
    • Spinal shock = spinal loss of reflexes, motor, and sensory at and below the level of injury.
      • Spinal shock is inflammation from the injury or lesion and goes away
      • Exists in the acute phase
      • No peristalsis, no voiding, need foley catheter
  • T6 and above can have autonomic dysreflexia
  • Cervical spine and above are tetraplegic and below are paraplegic
  • Injury at T12 and below is flaccid bladder
  • Injury above T12 and above is spastic bladder
  • Autonomic dysreflexia – an over reaction to something below the level of injury such as bladder distension, or a stubbed toe.
    • Above LOI vasodilation, HA, Flushed skin,  
    • Below LOI vasoconstriction, cold clammy, goose bumps, pale.

 

Stroke

 

  • Ischemic stroke – caused by loss of blood flow due to clot
    • Give TPa if within 4.5 hours of symptom onset
    • Neet CT scan to confirm Ischemic stroke
    • Excluded from TPa administration if: Head trauma or stroke in the last three months, aneurysm, active bleed, platelet count under 100,000,  INR >1.7, PT > 15 seconds. Taking warfarin, taking heparin in the last 48 hours with a high aPTT vessel

 

Epidural hemorrhage – usually ARTERIAL, FAST

Subdural hemorrhage – usually VENUS, SLOW

 

Pituitary Tumors

  • s/s – vision changes, increased ICP, DI or SIADH may be present.
  • Avoid cough, sneeze, sucking.
  • Watch for CSF leak, test leak for glucose and Halo test.
  • Surgery for this to be removed is through the nose.
  • Monitor for headache after surgery. This points toward a CSF leak.

Rosenbaum Pocket eye exam

  • An eye test on a notecard that tests each eye at an arm’s length. Make sure that the room is lit well for this test, and they have their glasses if they need them.

 

  • ICPs
    • Normal 0-10 mmhg
    • Increased is at 15 mmhg
    • Look for changes in LOC, pupils, Cushing’s triad Widening pulse pressure, bradycardia that is irregular, and irregular respiratory rate.
    • Causes – hypercapnia, hypoxemia, vasodilation

 

  • Cerebral perfusion pressure
    • The pressure that we need to perfuse the brain by overcoming the ICP.
    • >60 is normal.
    • The higher the CPP the higher the perfusion to the brain. (to a point)

 

  • Hemicraniectomy – removing a portion of the skull to allow for ICP to go down.
    • This person NEEDS a helmet when out of bed.
  • Raccoon eyes – indicative of a csf leak. Dark to black or reddish swelling under the eyes.
    • Keep HOB raised to allow the swelling to go down.