F. A. Davis Company • Philadelphia
Purchase additional copies of this bookat your health science bookstore ordirectly from F. A. Davis by shoppingonline at www.fadavis.com or by calling800-323-3555 (US) or 800-665-1148 (CAN)
A Davis’s Notes Book
Gary C. White, MEd, RRT, RPFT
RespiratoryNotes
RespiratoryNotes
Respiratory Therapist’s Pocket GuideRespiratory Therapist’s Pocket Guide
00White (F)-FM 4/6/07 11:14 AM Page 3
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00White (F)-FM 4/6/07 11:14 AM Page 4
Waterproof and Reusable
Wipe-Free Pages
Write directly onto any page of Respiratory
Notes with a ballpoint pen. Wipe old entries off
with an alcohol pad and reuse.
TOOLSNEOPEDS PHARMCRIT
CAREPROCADVASSESS
BEDASSESSBASIC
Place 2 7/8�2 7/8 Sticky Notes here
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00White (F)-FM 4/10/07 6:55 PM Page 5
Look for our other Davis’s Notes titlesRNotes® Nurse’s Clinical Pocket Guide, 2nd edition
ISBN-10: 0-8036-1335-0 / ISBN-13: 978-0-8036-1335-5
Coding Notes Medical Insurance Pocket GuideISBN-10: 0-8036-1536-1 / ISBN-13: 978-0-8036-1536-6
Derm Notes Dermatology Clinical Pocket GuideISBN-10: 0-8036-1495-0 / ISBN-13: 978-0-8036-1495-6
ECG Notes Interpretation and Management GuideISBN-10: 0-8036-1347-4 / ISBN-13: 978-0-8036-1347-8
IV Therapy Notes Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1288-5 / ISBN-13: 978-0-8036-1288-4
LabNotes Guide to Lab and Diagnostic TestsISBN-10: 0-8036-1265-6 / ISBN-13: 978-0-8036-1265-5
LPN Notes Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1132-3 / ISBN-13: 978-0-8036-1132-0
MedSurg Notes Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1115-3 / ISBN-13: 978-0-8036-1115-3
NutriNotes Nutrition & Diet Therapy Pocket GuideISBN-10: 0-8036-1114-5 / ISBN-13: 978-0-8036-1114-6
MA Notes Medical Assistant’s Pocket GuideISBN-10: 0-8036-1281-8 / ISBN-13: 978-0-8036-1281-5
OB Peds Women’s Health Notes Nurse’s Clinical Pocket GuideISBN-10: 0-8036-1466-7 / ISBN-13: 978-0-8036-1466-6
Ortho Notes Clinical Examination Pocket GuideISBN-10: 0-8036-1350-4 / ISBN-13: 978-0-8036-1350-8
PsychNotes Clinical Pocket GuideISBN-10: 0-8036-1286-9 / ISBN-13: 978-0-8036-1286-0
Screening Notes Rehabilitation Specialists Pocket GuideISBN-10: 0-8036-1573-6 /ISBN-13: 978-0-8036-1573-1
Rehab Notes Evaluation and Intervention Pocket GuideISBN-10: 0-8036-1398-9 /ISBN-13: 978-0-8036-1398-0
IV Med Notes IV Administration Pocket GuideISBN-10: 0-8036-1446-2 / ISBN-13: 978-0-8036-1466-8
MedNotes: Nurse’s Pharmacology Pocket Guide, 2nd EditionISBN-10: 0-8036-1531-0 / ISBN-13: 978-0-8036-1531-1
For a complete list of Davis’s Notes and other titlesfor health care providers, visit www.fadavis.com.
00White (F)-FM 4/6/07 11:14 AM Page 6
1
BASIC
S
Isolation Categories
Isolation Respiratory Patient
Category Patient Placement Gloves and Gown Protection Transport
Droplet
Airborne
Contact
Private room.Cohorting is OK if
the secondpatient has thesame organism.
Private room(negativepressure with6–12 air changesper hour).Cohorting is OKif the secondpatient has thesame organism.
Private room.Cohorting is OKif the secondpatient has thesame organism.
Always wear gloves andgown.
Always wear gloves andgown.
Wear gloves for anypatient contact. Weargown if you anticipatecontact with patient,soiled equipment, orsoiled environmentalsurfaces.
Surgical mask
HEPA mask
No mask isrequired.
Patient should weara mask duringtransport.
During transport thepatient shouldwear a HEPAmask.
During transportensure thatany contacttransmission bythe patient isminimized.
01White (F)-01 4/6/07 11:22 AM Page 1
2
BASIC
SAge-Specific Considerations
Age Fears/ Verbal Motor Cognitive Special
Group Anxieties Strategies Senses Skills Ability Considerations
Infants
Toddlers
Anxietytowardstrangers.Fear ofseparationfromparent(s).
Separationfromparent(s).
Speak in alow, soft,calm voice.
Use concreteverbal com-municationstrategies.
Loudnoisesmaystartle aninfant.
Senses areacute.
Gross motorskills.
Begin todevelopfine motorskills.
Minimal.
Can under-standmore thanthey canverbalize.
Never leaveunattended;always useside rails oncribs.Support headand neck,protectingthe airway.
Requires closesupervision.Don’t leavesmall objectsthat maybecome achokinghazard.
(Text continued on following page)
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3
BASIC
S
Age-Specific Considerations (Continued)
Age Fears/ Verbal Motor Cognitive Special
Group Anxieties Strategies Senses Skills Ability Considerations
Child
Adoles-cent
Separation,death,disability,injury,pain.
Embarrass-ment, loss ofcontrol, lossof conscious-ness, changesin appear-ance/function,separationfrom peergroup.
Use con-creteverbalstrategies.
Be morethoroughin expla-nations.
Sensesareacute.
Sensesareacute.
Goodmotorskills.
Goodmotorskills.
Can under-stand more,explain whya child willbenefit fromtreatment ora procedure.
May becapable ofabstractthought.
Don’t leavesharps orother poten-tially hazar-dous items atthe bedside.Privacy be-comes moreimportant.
Privacy is veryimportant.Encourageverbalizationand partic-ipation inhealth-caredecisions.
(Text continued on following page)
01White (F)-01 4/6/07 11:22 AM Page 3
4
BASIC
SAge-Specific Considerations (Continued)
Age Fears/ Verbal Motor Cognitive Special
Group Anxieties Strategies Senses Skills Ability Considerations
Adult
Geriatric
Loss ofcontrol,changes inappearance/function,separationfromspouse,death.
Loss of control,changes inappearance/function,separationfrom spouse(significantother), death.
Be morethoroughin expla-nations.Involvethe patientin health-care deci-sions.
Be morethoroughin expla-nations.Involvethe patientin health-care deci-sions.
Hearing,taste, andsight maydecline.
Hearing,taste,sight(cataracts,maculardegenera-tion, etc.)maydecline.
Reflexesmay beslower,balanceand coor-dinationmay bedimin-ished.
Joints arestiffer andlessmobile.Balancemay bemoredimin-ished.
Possessesabstractthought.
Possessesabstractthought.Dementiaor othermentaldiminish-ment maybe present.
Be aware ofvalues effecton patient’scare. Endu-rance may bediminished.Independenceand fosteringself-careshould beencouraged.
Patient’s skin ismore fragile.Patient mayhavedysphasia.Patient shouldbe involved indecision-making.
01White (F)-01 4/6/07 11:22 AM Page 4
5
BASIC
S
Cultural Diversity
Characteristics African Americans Arab Americans
Eye contact
Touching
Gender role
differences
Religion and
spirituality
Blood/organ
donation
Diet and
nutrition
Death/dying
& birth
Misc.
Establish trust and demonstraterespect.
Generally accept therapeutictouch. Establish trust first.
Responsibility for decision-makingvaries by educational level andsocioeconomic status.
Belong to Baptist and otherProtestant sects; Muslim.
Will refuse blood if a Jehovah’sWitness. Are reluctant to donateblood or organs.
General, no prohibitions unlessprohibited by religious beliefs(pork not eaten by Muslims).
Reluctant to donate organs. Deathis a universal experiencetranscending racial, religious,and socioeconomic barriers.
Silence may indicate lack of trusttoward the caregiver.
Females may avoid eye contact with males andstrangers.
Is generally acceptable within the same gender,but is not acceptable between genders.
Most decisions are made by men. Care for dailyneeds is delegated to women.
Muslim (generally Sunni branch), also Protestant,Greek Orthodox, or other Christian faiths.
Mutilation of the body (autopsy) or organdonation may be refused. Some may donateorgans because it will benefit the community.
Most Muslims do not eat pork. Avoid icy drinkswhen sick or hot/cold drinks together.
Colostrum is believed to be harmful to infants.
Supportive family members may need to beencouraged to take breaks from caregiving.
(Text continued on following page)
01White (F)-01 4/6/07 11:22 AM Page 5
6
BASIC
SCultural Diversity (Continued)
Characteristics Bosnian Americans Native Americans
Eye contact
Touching
Gender role
differences
Religion and
spirituality
Blood/organ
donation
Diet and
nutrition
Death/dying
& birth
Misc.
Looking straight into someone’s eyes during aconversation shows honesty and frankness.
Shaking hands is OK. Strict Muslims do notallow male nurses to examine women.
Traditionally, a patriarchal family structure.
Majority are Muslim or Christian, a few maybe Jewish.
Organ donation and receiving blood productsare acceptable.
Pork is prohibited by Muslims. Medicationsshould not contain alcohol (also prohibitedby Muslims).
Many visitors can be expected. No cremationis allowed. May only want females presentduring delivery of a child.
Permanent life support is unacceptable. Mostconsider it shameful to accept Medicaid.
It is important to maintain sustainedeye contact during conversations.
Light touch handshake is OK.Maintain a respectful distancewhile interacting with the patient.
Varies from nation to nation.
May be traditional Native Americanbelief or Christian.
Blood and organ donation isgenerally not desired, but maybe open to discussion.
Restrictions will vary withreligious/spiritual beliefs.
Full family involvement occursthroughout all stages of life.Circumcision may be refused.
Older adults may prefer the use of“American Indian” over NativeAmerican.
(Text continued on following page)
01White (F)-01 4/6/07 11:22 AM Page 6
7
BASIC
S
Cultural Diversity (Continued)
Characteristics Mexican Americans Russian Americans
Eye contact
Touching
Gender role
differences
Religion and
spirituality
Blood/organ
donation
Diet and
nutrition
Death/dying
& birth
Misc.
May avoid direct eye contact withauthority figures (health-careproviders included).
Except for handshaking, touchingmay be considered disrespectful.
Entire family shares equally indecision-making.
Primary religion is Roman Catholic.
Will vary; may be against organdonation.
Catholics may refrain from eatingmeat on Fridays and during Lent.
Strong family support during labor.Most are very expressive duringbereavement.
Silence may sometimes indicate adisagreement with the plan ofcare.
Direct eye contact is OK. Nodding signi-fies approval.
Touching is OK once familiarity or friend-ship has been established.
Typically, both men and women share indecision-making.
Primary religions are Jewish, EasternOrthodox, and Christian. Many may notpractice a faith due to past oppression.
May refuse organ donation based onbelief that the body is sacred.
Drinks with ice should not be served.
Father may not attend birth, but theclosest female family member usuallydoes.
Interpreters should be used wheneverpossible.
01White (F)-01 4/6/07 11:22 AM Page 7
8
Weight,Temperature, and Length Conversions
Weight Temperature Length
Lb Kg �F �C Cm Inches Feet and Inches
300 136.4 212 100 142 56 4′8′′275 125.0 108 42.2 145 57 4′9′′250 113.6 107 41.6 147 58 4′10′′225 102.3 106 41.1 150 59 4′11′′210 98.5 105 40.6 152 60 5′0′′200 90.9 104 40.0 155 61 5′1′′190 86.4 103 39.4 157 62 5′2′′180 81.8 102 38.9 160 63 5′3′′170 77.3 101 38.3 163 64 5′4′′160 72.7 100 37.8 165 65 5′5′′150 68.2 99 37.2 168 66 5′6′′140 63.6 98.6 37.0 170 67 5′7′′130 59.1 98 36.7 173 68 5′8′′120 54.5 97 36.7 175 69 5′9′′110 50.0 96 35.6 178 70 5′10′′100 45.5 95 35.0 180 71 5′11′′90 40.9 94 34.4 183 72 6′0′′80 36.4 93 34.0 185 73 6′1′′70 31.8 92 33.3 188 74 6′2′′60 27.3 91 32.8 191 75 6′3′′50 22.7 90 32.1 193 76 6′4′′40 18.2 89 31.7 196 77 6′5′′30 12.6 88 31.1 198 78 6′6′′20 9.1 87 30.6 201 79 6′7′′10 4.5 86 30.0 203 80 6′8′′
BASICS
(Text continued on following page)
01White (F)-01 4/6/07 11:22 AM Page 8
9
BASICS
Weight,Temperature, and
Length Conversions (Continued)
Weight Temperature Length
Lb Kg �F �C Cm Inches Feet and Inches
5 2.3 85 29.4 206 81 6′9′′2.2 1 75 23.9 208 82 6′10′′2 0.9 74 23.31 0.45 73 22.8
72 22.271 21.770 21.169 20.668 19.932 0.0
Lb � Kg � 2.2 Lb/Kg Kg � Lb � 0.45 Kg/Lb
�F � ��C � �95
�� � 32 �C � (�F � 32)�59
�
inches � cm � 0.394 inches/cm cm � inches � 2.54 cm/inch
Pressure Conversions (60�F)
cmH2O mmHg KPa
5 3.68 0.49
10 7.35 0.98
15 11.03 1.47
20 14.71 1.96
25 18.38 2.4530 22.06 2.9435 25.74 3.43
(Text continued on following page)
01White (F)-01 4/6/07 11:22 AM Page 9
10
Pressure Conversions (60�F) (Continued)
cmH2O mmHg KPa
40 29.41 3.9245 33.09 4.4150 36.76 4.9055 40.44 5.3960 44.11 5.8865 47.79 6.3770 51.47 6.8675 55.15 7.3580 58.82 7.8485 62.5 8.3390 66.17 8.8295 69.85 9.31
100 73.53 9.80
1 cmH2O � 0.098 KPa 1 KPa � 10.21 cmH2O
1 mmHg � 1.36 cmH2O 1 cmH2O � 0.737 mmHg
ATPS � BTPS ATPS � STPD
BTPS � ATPS � � � � �STPD � ATPS � � � � �PB � Barometric pressurePH2O � Partial pressure of H2O at spirometer temperature
47 � Partial pressure of H2O at body temperature andpressure saturated
310 � Body temperature in KelvinT � Spirometer temperature (�C)
273�273 �T
PB � PH2O��760
310�273 � T
�P
PB
B
�
�
P
4H
72o
�
BASICS
01White (F)-01 4/6/07 11:22 AM Page 10
11
BEDASSESS
Patient Interview
Purpose
The patient interview facilitates the collection of subjectiveinformation regarding the patient’s present illness whileestablishing a professional rapport and trust with thepatient.
Structure of the Interview
■ Project a genuine interest in the patient■ Be sensitive to the patient’s concerns■ Give undivided attention to the patient and his or her
responses■ Use eye contact effectively
■ Introduction■ Be professional (dress, mannerisms, respect, etc.)■ Introduce yourself to the patient using last names
(Mr. Smith, I am Mrs. Lanker from respiratory care.)■ Use eye contact
■ Professionalism■ Conduct the interview seated beside the patient facing him
or her■ The patient should be seated upright with his or her eyes at
an elevation higher than yours■ Maintain privacy
■ Respect the patient’s beliefs and attitudes■ Use open-ended questions (Tell me, how is your breathing
this morning?)■ Use reflection in your responses (So your chest feels
tight.)■ Be empathetic
02White (F)-02 4/6/07 5:05 PM Page 11
12
History Taking
■ Biographical■ Age, gender, occupation, race/culture
■ Chief complaint■ What resulted in the patient seeking medical attention?■ What are the symptoms that caused the patient to seek
medical attention?■ Are there any associated symptoms (sweats/chills, fever,
cough, etc.)?■ Onset, duration, severity?
■ History of present illness■ Detailed description of each symptom described in the chief
complaint■ P, Q, R, S, T
◆ P (Provokes/Point): What causes it, what makes it better,where is it?
◆ Q (Quality): Dull, achy, how much is involved, how doesit look, how does it feel?
◆ R (Region/Radiation): Where does it radiate or spread?What makes it better? What makes it worse?
◆ S (Severity): Lichert scale 1 (no pain) to 10 (worst pain).◆ T (Timing): When did it start? Is it constant? Is it sudden
or gradual?■ Past medical history
■ Childhood illnesses■ Hospitalizations (injuries, accidents, emergent conditions,
etc.)■ Surgeries (elective, emergency, etc.)■ Allergies, immunizations■ Current medications (prescribed and over-the-counter)■ Social history
◆ Smoking: How long? What (cigarettes, cigars, pipe, etc.)?Have you quit? How long?
◆ Alcohol: How long? What (liquor, wine, beer)? Howoften? How much? How long?
◆ Drug use: What? How often? How long?
BEDASSESS
02White (F)-02 4/6/07 5:05 PM Page 12
13
BEDASSESS
■ Family history◆ Family history for chronic lung disease (asthma,
emphysema, bronchitis, cystic fibrosis)?◆ Family history for heart disease?◆ Family history for hypertension?◆ Family history for renal disease?◆ Family history for cancer?
■ Occupational/environmental history◆ Work: Shipyard, mining, farming, foundry work, mill
work, insulation installation, welding, chemical exposure,textile work, etc.
◆ Home: Air conditioning, evaporative cooling, humid-ifier, molds, insulation, plants, smoking, wood stoveuse
◆ Geographical: Histoplasmosis, coccidioidomycosis,blastomycosis
Vital Signs
Vital Signs
Assess vital signs upon admission as ordered; on change instatus, with chest pain or any abnormal sensation; before andafter administration of blood products or medications that cancause cardiovascular or respiratory changes; before and afterany intervention that can affect the cardiovascular or respira-tory system.
Vital signs should include temperature (T), heart rate (HR),respiratory rate (RR), blood pressure (BP), SpO2, and painassessment.
02White (F)-02 4/6/07 5:05 PM Page 13
14
BED
ASSE
SSNormal Ranges
Age Preemie Term 6 mo 1 yr 3 yr 6 yr 9 yr 12 yr 15 yr Adult Elderly
T 36.8 36.8 37.7 37.7 37.7 37 37 37 37 37 36
HR 140 80–180 80–140 80–140 80–140 75–120 50–90 50–90 50–90 60–100 60–100
RR 40–60 30–80 30–60 20–40 20–40 15–25 15–25 15–24 15–20 12–20 15–20
BP 73/55 73/55 73/55 90/55 90/55 95/57 95/57 120/80 120/80 120/80 120/80
SpO2 �95% �95% �95% �95% �95% �95% �95 % �95% �95% �95% �95%
02White (F)-02 4/6/07 5:05 PM Page 14
15
BEDASSESS
Head and Neck Assessment
■ Head—Facial expressions, cyanosis, pursed lip breathing,nasal flaring, eyes (pupil size and reaction)?
■ Neck—Jugular venous distension, use of accessory muscles,tracheal position, lymph node palpation?
Physical Examination of the Chest
Inspection
■ Respiratory rate: Normal, tachypnea, bradypnea?■ Rhythm: Regular, irregular?■ Pattern: Eupnea, hyperpnea, hypopnea, Kussmaul’s, Cheyne-
Stokes, Biot’s■ Chest conformation: A-P diameter, kyphosis, scoliosis,
lordosis, kyphoscoliosis, pectus?■ Digital clubbing?
02White (F)-02 4/6/07 5:05 PM Page 15
16
Ventilatory Patterns
Palpation
■ Tracheal position: Midline, deviated right or left?■ Areas of tenderness?■ Symmetry: Do the hands move uniformly?■ Tactile fremitus: Present or absent?■ Subcutaneous emphysema present?
BEDASSESS
Normal (Eupnea)
Cheyne-Stokes
Biot’s
Kussmaul’s
02White (F)-02 4/6/07 5:05 PM Page 16
17
BEDASSESS
Assessment of Chest Symmetry
Anterior
Posterior
02White (F)-02 4/6/07 5:05 PM Page 17
18
BEDASSESS
Percussion
■ Hyperresonance: Air trapping? Pneumothorax?■ Resonance: Normal air/tissue density?■ Dullness: Consolidation? Atelectasis? Pleural fluid?■ Flatness: Pleural effusion? Pneumonectomy?
Auscultation
■ Vesicular: Low pitched and soft with inspiration longer thanexpiration. Normal over most of the lung fields.
■ Bronchial: Harsh, loud and higher pitched with expirationlonger than inspiration. Normal over the manubrium.
■ Bronchovesicular: Moderate intensity and pitch with equalinspiratory and expiratory phases. Over sternum and lungapices.
■ Crackles: Discontinuous (starts and stops) fine, medium, orcoarse (inspiratory or expiratory). Can be caused by alveoliopening (fine), fluid in bronchioles (medium), and fluid inlarge airways (coarse).
■ Wheezes: Continuous “musical” sound (inspiratory orexpiratory). Caused by air flowing through narrowed airwaylumen. A wheeze will have a higher pitch if the narrowedlumen is very small. Wheezing should be described asinspiratory, expiratory, monophonic (single pitch), orpolyphonic (multiple pitches). Polyphonic wheezing occursduring the expiratory phase.
■ Rhonchi: Coarse, wet, low-pitched continuous soundsproduced by large amounts of secretions in the airways.Rhonchi may clear if the patient is asked to cough.
■ Rub: Grating or creaking sound (like leather rubbing). Causedby inflamed pleural layers or pleural irritation.
02White (F)-02 4/6/07 5:05 PM Page 18
19
BEDASSESS
Positions Used in Chest Auscultation
1
2
9
7
2
4
6 6
54
33
5 5
2
4
2
4
1
5
3
7
98
3
8
1 1
Posterior
Anterior
02White (F)-02 4/6/07 5:05 PM Page 19
20
Sputum/Cough
■ Cough—Duration (acute �3 weeks, chronic �3 weeks orrecurrent), productive, nonproductive, time of occurrence?
■ Sputum—Amount (�30 mL/day, �30 mL/day), color,consistency, odor, hemoptysis?
Ventilation Assessment
■ VE, VT, and Frequency■ Minute Volume (VE)—The volume exhaled or inhaled in
1 minute◆ Normal: 5–7 L/min (adult)
■ Tidal Volume (VT)—The resting volume inhaled or exhaledduring each breath◆ Normal: 4–7 mL/kg
■ Frequency (rate)—The number of breaths per minute.Normals:◆ Term infant: 30–80◆ 6-month-old: 30–60◆ Pediatric: 20–40◆ Adolescent: 15–25◆ Adult: 12–20
■ Rapid Shallow Breathing Index (frequency/tidal volume [L])■ Normal: �100
■ PaCO2■ Normal: 35–45 mmHg
■ PEtCO2■ Normal: 35–43 mmHg
■ Deadspace (VD ana, VD/VT)■ Anatomic: Normal 1 mL/Lb body weight
VD � 1 mL � Body Weight (Lb)
■ VD/VT: Normal 0.25–0.35
VD / VT �
■ Alveolar VentilationVA � (VD/ VT � VT)f
BEDASSESS
PaCO2 � PECO2
PaCO2
02White (F)-02 4/6/07 5:05 PM Page 20
21
BEDASSESS
Oxygenation Assessment
Alveolar air
Oxygen content
Oxygen delivery
Venous oxygencontent
Arterial-venousoxygen contentdifference
Oxygenconsumption
Oxygen extractionratio
End capillaryoxygen content
Pulmonary shunt
PAO2 � FIO2(PB � 47mmHg) �
Note: Only calculate at FIO2 of 0.21 or 1.0
CaO2 � SaO2(Hb � 1.34) � (PaO2 � 0.003)Normal: 15–24 mL/dLPaO2: 80–100 mmHgSpO2: �90%
DO2 � QT � (CaO2 � 10)Normal: 1000 mL/minSvO2(Hb � 1.34) � (PvO2 � 0.003)Normal: 12–15 mL/dLCaO2 – CvO2
Normal: 4–6 mL/dLPaO2/FIO2 Normal: �200
PaO2/PAO2 Normal: 0.8–0.9
VO2 � QT (Ca-vO2 � 10)Normal: 250 mL/min
O2 ER �
Normal: 0.25
CcO2 � (Hb � 1.34) � (PAO2 � 0.003)
Qs/QT �
Normal: �0.20
PaCO2
0.8
CaO2 � CvO2
CaO2
CcO2 � CaO2
CcO2 � CvO2
02White (F)-02 4/6/07 5:05 PM Page 21
22
BED
ASSE
SSDisease State Summary
Oxygenation
Physical Findings Ventilation Indices
Inspection Palpation Percussion Auscultation VT f PaCO2 SpO2 CaO2 QS/QT
Bronchi-
tis
Asthma
Emphy-
sema
Use of ac-cessorymuscles
Pursed lipbreathing
↑ A-P Dia
Use of ac-cessorymuscles
Pursed lipbreathing
↑ A-P Dia
Use of ac-cessorymuscles
↑ A-P Dia
↓ Normal orfremitus
↓ Normal orfremitus
↓ Normal orfremitus
Normal ordull
Normal orhyperre-sonant
Hyperreso-nant
↓Breathsounds,crackles,rhonchi &wheezing
Wheezing,crackles
Crackles &wheezing
↑ ↑ ↑ (chronic)
↑ ↑ ↓ (early)
↑ (severeor late)
↑ ↑ ↑
↓ ↓ ↑
↓ ↓ ↑
↓ ↓ ↑
02White (F)-02 4/6/07 5:05 PM Page 22
23
BED
ASSE
SS
Disease State Summary
Oxygenation
Physical Findings Ventilation Indices
Inspection Palpation Percussion Auscultation VT f PaCO2 SpO2 CaO2 QS/QT
CysticFibrosis
Pneumonia
PulmonaryEdema
PulmonaryEmbolus
Atelectasis
Use of ac-cessorymuscles
↑ A-P DiaDyspnea
Dyspnea
Dyspnea
Dyspnea
↑Fremitus
↑Fremitus
↑Fremitus
Normal
↑Fremitus
Hyper-resonant
Dullness
Dullness
Normal
Dullness
↓Breathsounds, crackles, & rhonchi
↓Breathsounds,crackles, &rhonchi
↓Breathsounds,crackles,rhonchi &wheezing
Wheezing,crackles,pleuralfriction rub
↓Breathsounds,crackles
↑ ↑ ↑
↓ ↑ ↓
↓ ↑ ↓
↓ ↑ ↓
↓ ↑ ↑ (severe)
↓ ↓ ↑
↓ ↓ ↑
↓ ↓ ↑
↓ ↓ ↑
↓ ↓ ↑
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Cardiac Assessment
Capillary Refill
■ Normal: �3 seconds■ Increased: �3 seconds (low cardiac output or decreased
peripheral perfusion)
Heart Rate
■ Normals■ Newborn 80–180/min■ 1 year 80–140/min■ 2 years 80–140/min■ 6 years 75–120/min■ 10 years 50–90/min■ 16 years 50–90/min■ Adult 60–100/min■ Geriatric 60–100/min
■ Points of palpation: radial, brachial, femoral, carotid, popliteal,posterior tibial, dorsal pedal
Blood Pressure
■ Normals■ Newborn 73/55 mmHg■ 1 year 90/55 mmHg■ 2 years 90/55 mmHg■ 6 years 95/57 mmHg■ 10 years 95/57 mmHg■ 16 years 120/80 mmHg■ Adult 120/80 mmHg■ Geriatric 120/80 mmHg
BEDASSESS
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BEDASSESS
Cardiac Palpation
■ Point of Maximal Impulse (PMI) – 5th intercostal spacemidclavicular line (left ventricular contraction)■ Left shift—cardiomegaly■ Left sternal border—right ventricular hypertrophy (COPD)■ Reduced—emphysema, hyperinflation■ Lobar collapse—shifts toward collapse■ Pneumothorax—shifts away from pneumothorax
■ Pulmonic palpation—2nd intercostal space at the sternalborder■ Increased—pulmonary hypertension
Cardiac Auscultation
■ Normal heart sounds:■ S1—Tricuspid and mitral valve closure during ventricular
contraction. Auscultated at lower left sternal border.■ S2—Pulmonic and aortic valve closure during diastole.
Auscultated at 2nd intercostal space at the sternal border.■ S3—Produced by rapid ventricular filling following systole.
Auscultated at the apex of the heart (5th intercostal spacemidclavicular line).
■ S4—Presystolic gallop. Auscultated late in diastole at theapex (5th intercostal space midclavicular line). Low-frequency sound and often transient, caused by decreasedventricular compliance or in increased diastolic volume.
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Positions used in heart auscultation
■ Abnormal auscultatory heart sounds:■ Split S1—Delayed closure between the tricuspid and mitral
valves (abnormally long S1 interval) can be caused by rightbundle branch block, preventricular contractions (PVCs), orventricular tachycardia.
■ Split S2—Delayed closure between the pulmonic and aorticvalves (abnormally long S2 interval) can be caused by atrialseptal defect, ventricular septal defect, pulmonic stenosis,pulmonary embolism, and a right bundle branch block.
■ Click—Early systolic high-frequency sound caused by rapidopening of the aortic valve. Late systolic (after S1) causedby mitral valve prolapse.
■ Snap—High-frequency sound occurring after S2 frequentlycaused by mitral stenosis.
BEDASSESS
Aortic
Tricuspid Mitral
Pulmonary
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BEDASSESS
■ Murmurs—Sustained heart sounds caused by turbulentblood flow through the heart.◆ Presystolic murmur: Heard at the start of S1 with its peak
occurring in the first third of systole. Caused by mitralstenosis or increased flow through the pulmonic valve.
◆ Midsystolic murmur: Heard just after S1 peaking at mid-systole. Caused by narrowed aortic or pulmonic valve.
◆ Late systolic murmur: Heard during late systole. Causedby mitral valve prolapse or tricuspid valve defects.
■ Early diastolic murmur: Heard at the start of S2 peaking inthe first part of diastole. Caused by aortic regurgitation.
■ Mid-diastolic murmur: Heart after S2 peaking at middiastole. This is a low-frequency sound, caused by mitralstenosis and best heard at the apex.
■ Late diastolic murmur: Heard late in diastole, oftenextending into S1, can be caused by mitral and tricuspidstenosis.
■ Bruits: Auscultatory heart sounds heard over the neck(carotid arteries). The sound is caused by turbulence(obstruction to blood flow) and is of mixed frequency.
Cardiac Enzymes
Enzyme Normal
Troponin (TnI) 0.0–0.1 ng/mLTroponin (TnT) �0.18 ng/mLCreatine phosphokinase (CPK) �150 U/LCPK-MB �3 ng/mL
Neurological Assessment
■ Mental status: Alert, confused, lethargic, comatose■ Motor ability:
■ Grip Strength: Ask patient to grip your hands. Is the gripequal? Ask the patient to push/pull your hands. Is it equal?
■ Feet: Ask the patient to push/pull your hands. Is it equal?
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■ Tremors, tics, mannerisms, gestures, gait hyperactivity,restlessness, agitation echopraxia, rigidity, aggressiveness
■ Posture: decorticate (arms rigidly flexed, legs extended),decerebrate (arms extended [pronated] and legs extended)
■ Pupil size: (See Vital Signs)■ Glasgow Coma Score (see Tab 5, Critical Care)
Nutritional Assessment
Body Mass Index
BMI � � 703
Body Mass Index Weight Status
�18.5 Underweight18.5–24.9 Normal25.0–29.9 Overweight�30 Obese
Body Fat
Skinfold ThicknessUse calipers to measure skinfold thickness at the biceps, triceps,subscapular, and suprailiac regions. Tables are used to translatethe data into relative percentage of body fat. Skinfold thicknessmeasurements are one way to estimate total body fat.
Maximum Percentage of Body Fat
�20 years of age 17 %20–22 years of age 18 %23–25 years of age 19 %25–29 years of age 20 %�30 years of age 22 %
weight in lbs.���(height in inches)2
BEDASSESS
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BEDASSESS
Lab Tests
Serum AlbuminMeasure of the protein fraction in the blood that corresponds toprotein reserves in the muscles. The test can be used to screenprotein depletion. However, 1/2 life is long (20 days) so valuescan be slow to change with changes in nutritional intake.
Serum Albumin Level Assessment
3.5–5.0 gm/dL Normal�2.5 gm/dL Deficient
Thyroxin-binding Prealbumin
This value quickly reflects changes in nutrition (1/2 life 2 days).
Thyroxin-binding
Prealbumin (TBP) Level Assessment
10–20 mg/dL Normal� 10 mg/dL Deficient
Retinol-binding ProteinA measure of a transport protein of retinol in the plasma (alpha1-globulin). This has a short 1/2 life (12 hours), and quicklyreflects changes in nutritional status.
Retinol-binding Protein (RBP) Assessment
3–6 micro gm/dL Normal�3 micro gm/dL Deficient
Urea NitrogenMeasurement of nitrogen content of the urine. An increase inurea nitrogen reflects in increase in protein catabolism.
Urea Nitrogen Assessment
8–25 mg/dL Normal�25 mg/dL Increased catabolism of proteins
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BED
ASSE
SSBasic Assessment
Name Weight Physician
Room Height Date
Age Race/Culture Time
Gender Admission DX RCP
HISTORY
Chief Complaint
HX of Present Illness
Current Medications:
Past Medical HX
Social History
Smoker: Yes ■ No ■
Cigarettes? Yes ■ packs/day ____ How many years? ____
Cigars? Yes ■ How many/day? _____ How many years? _____
Other? ________________
Alcohol use? Yes ■ No ■ What and how much/day? ____________
Nonprescription drug use? Yes ■ No ■
What and how often? ________________
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BED
ASSE
SS
Basic Assessment
VITAL SIGNS
Temp
Heart Rate
BP
Resp Rate
SpO2
PHYSICAL EXAMINATION INSPECTION
Rate: normal tachypnea bradypnea
Rhythm: normal irregular
Pattern: ______________________________
Increased A-P Dia? Yes ■ No ■
Kyphosis? ■ Lordosis? ■ Scoliosis? ■
Cyanosis? Yes ■ No ■
Pursed lip breathing? Yes ■ No ■
PALPATION
Tracheal Pos: midline L R
Areas of Tenderness? ______
Symmetry? ___________
Fremitus? Yes ■ No ■
Sub-Q Air? Yes ■ No ■
PERCUSSION Location
Hyperresonant ________
Resonant _____________
Dullness ______________
Flatness ______________
MENTAL STATUS
Alert: Yes ■ No ■
Confused: Yes ■ No ■
Lethargic: Yes ■ No ■
Comatose: Yes ■ No ■
HEAD/NECK
Head
Neck: JVP? Yes ■ No ■Lymph enlargement?
Yes ■ No ■Pupils
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BED
ASSE
SSBasic Assessment
SPUTUM/COUGH
Cough? Yes No
How long?
Productive? Yes No
How much?
Color/Odor?
Hemoptysis? Yes No
CARDIAC ASSESSMENT
Capillary Refill:
Normal Prolonged
Heart Rate
BP
PMI: Normal L R
Auscultation:
Bruits: Yes No
VENTILATION
VE
VT
f
RSBI
PaCO2
VD/VT
NEUROLOGICALASSESSMENT
Grip Strength: Normal Weak
Push Pull: Normal Weak
Tremors, tics, etc
Posture:
GCW:
OXYGENATION
CaO2
SpO2
PaO2
PaO2/ FIO2
Ca-vO2
QS/QT
NUTRITIONALASSESSMENT
BMI:
% Body Fat:
Serum Albumin
TBP:_______
RBP: ________
Urea Nitrogen: ___________
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BED
ASSE
SS
Basic Assessment
ARTERIAL BLOOD GASES
pH
PaCO2
HCO3
PaO2
BE
SaO2
Hb
COHb
MetHb
Current O2
CHEST X-RAY PULMONARY FUNCTION
FVC
FEV1
FEV1/FVC
PEF
DLCO
FRC
RV
TLC
RV/TLC
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ADV
ASSE
SSHematology
Complete Blood Count Men Women Differential %
Red blood cells (RBC)
Hemoglobin (Hb)
Hematocrit (Hct)
Mean cell volume (MCV)
Mean cell hemoglobin(MCH)
Mean cell hemoglobinconcentration
Platelets
4.6–6.2 million/dL
13.5–16.5 gm/dL
40–54%
80–90 �3
21–31 pgm
32–36%
150,000–400,000/mm3
4.6–6.2million/dL
12.0–15.0gm/dL
38–47%
80–90 �3
21–31 pgm
32–36%
150,000–400,000/mm3
Neutrophils
Bands
Eosinophils
Basophils
Lymphocytes
Monocytes
40–75%
0–5%
0–6%
0–1%
20–45%
2–10%
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ADVASSESS
Chemistry
Sodium (Na�)Potassium (K�)Chloride (Cl–)Carbon dioxide (CO2)Blood urea nitrogen (BUN)CreatineTotal proteinAlbuminCholesterolLow-density lipoproteins (LDL)High-density lipoproteins (HDL)Glucose
Collection and Evaluation of
Pulmonary Secretions
1. Have the patient rinse his or her mouth or preferably brushteeth.
2. Have the patient strongly cough to attempt to expectorate adeep pulmonary sample.
3. If the patient is unable to bring up a sample, administer anSVN or large volume nebulizer treatment with 10% saline(hypertonic saline), and repeat step 2.
4. If the patient is unable to cooperate or is unable to expec-torate an adequate sample, a sample can be obtained bynasotracheal suctioning or bronchoscopy.
5. Have the laboratory perform a Gram stain and look forsquamous epithelial cells (saliva). If there is a heavy concen-tration of squamous epithelial cells, re-obtain the sample.
137–147 mEq/L3.5–4.8 mEq/L98–105 mEq/L25–33 mEq/L7–20 mEq/L0.7–1.3 mg/dL6.3–7.9 gm/dL3.5–5.0 gm/dL150–220 mg/dL�130 mg/dL30–75 mg/dL70–105 mg/dL
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Microbiology
Microbiological assessment (bacteriology) is performed on bodyfluid/substance samples to determine the cause of infection(culture) and what antibiotics are effective (sensitivity). Besidesbacteria, samples can be tested for fungi, protozoa, and viruses.
Gram-Positive
Bacteria
StreptococcusStaphylococcusMycobacterium
tuberculosis
Gram-Negative
Bacteria
KlebsiellaHaemophilus
influenzaeLegionella
pneumophila
Common
Protozoa
Pneumocystiscarinii
Histology/Cytology
Histology is the study of the microscopic structure of tissue,whereas cytology is the study of cellular structure.
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ADVASSESS
Common Viruses
Influenza virusAdenovirusRespiratory syncytial
virusParainfluenza virusCytomegalovirus
Common Yeast
Candida
Common Fungi
AspergillusMicrosporumHistoplasmaBlastomycesCoccidioides
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ADVASSESS
Sample Preparation
Testing Preparation
Microbiology
Cytology
Histology
Skin Testing
■ Skin testing is the diagnosis of disease by subcutaneousinjection of small amounts of protein essence of the organism.Tuberculosis (TB), coccidioidomycosis, histoplasmosis,sarcoidosis, and allergies may be diagnosed using thistechnique.
■ TB Testing—Skin testing for TB is performed by injecting0.1 mL of purified protein derivative (PPD) subcutaneously.The test is read between 48 and 72 hours following injection.The injection site is evaluated for a wheal and redness,indicating a positive test.
Arterial Blood Gas Interpretation
Drawing Arterial Blood Gases
1. Correctly identify the patient.2. Verify correct oxygen/ventilator settings and record patient’s
temperature.3. Gather required equipment:
■ Blood gas collection kit (syringe, needle, antiseptic wipes[alcohol and iodine-based], stopper, container for ice)
■ Exam gloves■ Eye protection (goggles)■ Ice■ Required paper work
0.9% salineRinger’s lactate95% alcoholSaccomanno’s solutionFormalin
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ADVASSESS
4. Perform modified Allen test for collateral circulation (radialpuncture).
5. Don protective equipment (gloves and goggles).6. Prep puncture site (antiseptic wipe).7. Palpate pulse.8. Puncture site between a 30� and 45� angle.9. Draw sample.
10. Hold pressure on puncture site for 5 minutes followingcollection.
11. Expel all air from the sample.12. Cap and ice sample.
Arterial Blood Gas Normal Values
Value Range
pHPaCO2
HCO3�
BEPaO2
To accurately interpret arterial blood gas results, one must firstmemorize the normal values. Only after the normal values arecommitted to memory can blood gases be interpreted.
Steps to Interpret an Arterial Blood Gas
Respiratory Disturbances1. Evaluate the pH. Alkalosis? Acidosis?2. Evaluate the PaCO2. Is the PaCO2 moving opposite the pH? If
yes, it’s a respiratory acid/base disturbance.3. If it is a respiratory acidosis, determine if it’s acute or chronic:
■ Acute: If the PaCO2 increases by 10 mmHg the pH shoulddecrease by 0.08
■ Chronic: If the PaCO2 increases by 10 mmHg the pH shoulddecrease by 0.03
4. If it is a respiratory alkalosis, determine if it’s acute or chronic:
7.35–7.4535–45 mmHg22–26 mEq/L�280–100 mmHg
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ADVASSESS
■ Acute: For each 10 mmHg decrease in PaCO2 the pH shouldincrease by 0.08
■ Chronic: For each 10 mmHg decrease in PaCO2 the pHshould increase by 0.03
Metabolic Disturbances1. Evaluate the pH. Alkalosis? Acidosis?2. Evaluate the PaCO2. Is the PaCO2 moving the same direction
as the pH? If yes, it’s a metabolic acid/base disturbance.
Metabolic AcidosisIf it’s a metabolic acidosis:1. Determine if it’s an anion gap (AG) acidosis:
■ AG � Na� �(CI� � HCO�3)
■ Note: The HCO�3 must be from an electrolyte panel not the
blood gas data.■ Normal AG � 8 – 12 (�2)■ If the AG is 12 then it’s an anion gap acidosis.
2. Determine the respiratory compensation using Winter’sFormula.■ PaCO2 � 1.5 (HCO�
3)� 8 (�2)■ Note: The HCO�
3 must be from an electrolyte panel not theblood gas data.
■ If the PaCO2 is less than expected (Winter’s Formula), thereis a primary respiratory alkalosis.
■ If the PaCO2 is greater than expected (Winter’s Formula),there is a primary respiratory acidosis.
3. Determine the Delta gap:■ Corrected HCO�
3 � (HCO�3 � [AG � 12])
■ If the Delta gap is �24 it’s a nonanion gap (AG) acidosis.■ If the Delta gap is 24 there is a metabolic acidosis.
Metabolic Alkalosis■ Compensation for metabolic alkalosis is not as linear as in
metabolic acidosis (Note: Don’t use Winter’s Formula!).■ Compensation will tend to depress the respiratory drive,
increasing the PaCO2.■ Calculate the expected PaCO2.
■ PaCO2 � 0.9 (HCO�3) � 9
■ Note: The HCO�3 must be from an electrolyte panel not the
blood gas data.
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■ If the PaCO2 is � than expected, there is an underlyingrespiratory alkalosis.
■ If the PaCO2 is than expected, there is an underlyingrespiratory acidosis.
Cautions/Pitfalls1. Use the HCO�
3 from the electrolyte panel, not the calculatedvalue from a blood gas.
2. Draw the ABG at the same time as the electrolyte panel.3. Apply the formulas listed.
Respiratory Disturbance Etiologies
Respiratory Acidosis Respiratory Alkalosis
Lung disease (COPD, pneu-monia, etc.)
Pleural disease (effusion,hemothorax, pneumo-thorax, etc.)
Neuromuscular disorders(myopathies, neuropathies)
CNS depression (sedatives,anesthesia, respiratorycenter lesions)
Acute obstruction
Metabolic Acidosis Etiologies
Anion Gap Acidosis Nonanion Gap Acidosis
MethanolUremia (renal failure)DKA (diabetic ketoacidosis)ParaldehydeInborn errors of metabolism
(idiopathic)Lactic acidosisEthylene glycol intoxicationSalicylates
40
ADVASSESS
CNS disorders (CVA, tumor,infection)
Hormones/Drugs (progesterone,salicylates, etc.)
Fever (gram-negative sepsis)HyperthyroidismAnxietyPregnancy
HyperalimentationAcetazolamideRTA (renal tubular acidosis)DiarrheaUrectosigmoidostomyPancreatic fistula
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ADVASSESS
Metabolic Alkalosis Etiologies■ Extracellular fluid volume depletion (vomiting, diuretic
therapy, laxative abuse)■ Severe potassium depletion■ Mineralocorticoid excess syndrome (Cushing’s syndrome,
ectopic adrenocorticotropic hormone)■ Bartter’s syndrome
Evaluate the PaO2
■ PaO2 80–100 mmHg Normal■ 60 mmHg � PaO2 � 80 mmHg Mild hypoxemia■ 40 mmHg � PaO2 � 60 mmHg Moderate hypoxemia■ PaO2 �40 mmHg Severe hypoxemia
Chest X-Ray Interpretation
Chest x-rays are produced by passing a form of ionizing radi-ation through the chest, exposing a film plate. The image formedis the result of the differing radio densities of the anatomy as theenergy passes through the body.
Radiodensities of Common Materials
Air
Water
Fat
Bone
Plastic
Metal
Least dense
More dense than air
More dense than water
More dense than fat
Similar density to fat
Most radiodense
Appears black on a chestx-ray
Appears gray on a chestx-ray
Appears lighter gray thanwater on a chest x-ray
Appears white on a chestx-ray
Appears lighter gray on achest x-ray
Appears bright white on achest x-ray
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Common Radiographic Views
Posterior–Anterior (PA)
Preferred view because the cardiac silhouette is not magnified.
Anterior–Posterior (AP)
Common view of a portable chest x-ray; the cardiac silhouette ismagnified.
42
ADVASSESS
X-ray tube Filmplate
72 inches
X-ray tube Filmplate
72 inches
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ADVASSESS
Lateral
Evaluating a Chest X-Ray
Determine Technical Quality■ Rotation—Is the spine centered between the necks of the
clavicles on the PA or AP view? If not, is the rotation to theright or left?
■ Penetration—Can the vertebral columns be faintly seenthrough the center of the chest? If they are very distinct, it’soverpenetrated. If you can’t see them at all, it’sunderpenetrated.
X-ray tube Filmplate
72 inches
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ADVASSESS
Chest X-Ray Evaluation (Outside-In Approach)
Extrathoracicstructures
Bones
Pleura
Diaphragms
Lung parenchyma
Hilum
Heart
Trachea
Right and leftmainstem bronchi
Evaluate white tissue density againstthe black air space surrounding thebody. Look for subcutaneous airapically (air migrates superiorly).
Trace each rib, the clavicles, andsternum looking for fractures,costochondral separation. Lookfor spinal fractures, scoliosis, orkyphoscoliosis.
Evaluate the pleura for thickening orplaques (increased density). Look forpleural air (black w/o lung markings)or fluid (white water/fluid density).
Should be “dome” shaped with rightslightly higher than the left. Check thecostophrenic angle for blunting(pleural fluid).
If eight ribs overlie the lung fields it’s agood inspiration. More than 10 ribs ishyperinflation. Look for areas ofincreased density.
Increased density due to vascularvolume. Is it engorged (possibleCHF)?
Cardiac silhouette should be less than1/2 the diameter of the chest. Has aheart border been obscured (possiblepneumonia)?
Should be mid-line to about the fourthrib. Is it shifted (possible pneumo-thorax or atelectasis)?
Carina should be evident with rightmainstem bronchi branching at alesser angle than the left.
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ADVASSESS
Common Abnormalities
Volume changesVolume increase
Volume decrease
Fluid changes
Foreign objects
Hyperinflation (COPD): Flatteneddiaphragms, increased rib spacing,and darker appearance. Increased APdiameter and retrosternal airspace(lateral).
Atelectasis: Elevated diaphragm onaffected side. Shift of mediastinum toaffected side. Increased radiodensity.
Pneumothorax: Reduction in volume onaffected side. Loss of lung markings inregion of free air.
Consolidation: Increased radiodensity(lighter than normal), often more lobar(compare PA with lateral).
Pleural effusion: Blunting of costophrenicangles (PA) and posterior (lateral). Alateral decubitus projection can helpto quantify.
Congestive heart failure (CHF): Enlargedleft ventricle (early). Increased hilarcongestion. Increased fluid densitywith Kerley B lines along the rightbase. Increased size of heartsilhouette.
Pulmonary edema: Diffuse patchyinfiltrate pattern.
Chest tubes, nasogastric tubes,endotracheal tubes, feeding tubes,ECG leads, pacemakers, sternal clips,bullets, shotgun pellets.
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ADVASSESS
Electrocardiogram (ECG)
Lead Placement
■ Limb leads—(right arm, left leg, left arm, left leg). Leftand right hip may be substituted for lead placement onthe legs.
■ Precordial leads—V1 and V2 (4th intercostal space adja-cent to sternum), V4 (5th intercostal space mid-clavicularline), V3 (between V2 and V4), V5 (5th intercostal spaceanterior axillary line), V6 (5th intercostal space mid-axillaryline)
V1
RA LA
RL LL
V2V3
V4V5
V6
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ADVASSESS
Artifacts
■ Patient motion: irregular appearance of the ECG. Try tominimize motion if possible.
■ Wandering baseline: poor contact with electrodes. Changeelectrodes, prep skin with isopropyl alcohol.
■ 60 Hz artifact (common mode interference): poor ground,current leakage or faulty electrical outlet. Change outlets,ground ECG instrument, change leads.
ECG Assessment
■ Rate:■ 60–100/min—Normal■ �60—Bradycardia■ 100—Tachycardia
■ Rhythm: Regular? Irregular? Regularly irregular?■ P waves: One P wave with every QRS complex?■ P-R Interval: 0.12–0.2 seconds■ QRS: 0.08–0.12 seconds■ ST Segment: Isoelectric? Depressed? Elevated?■ Extra: Any abnormal or extra complexes?
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ADVASSESS
Common Arrhythmias
Sinus Bradycardia
■ Rate: �60/min■ Rhythm: Regular■ P waves: 1:1 with QRS■ P-R Interval: 0.12–0.2 seconds■ QRS: 0.08–0.12 seconds
Atrial Fibrillation
■ Rate: Irregular (R-R interval)■ Rhythm: Irregular■ P waves: Absent■ QRS: Normal (0.08–0.12 seconds)
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ADVASSESS
Premature Ventricular Contraction (PVC)
■ Rate: Can be irregular■ Rhythm: Long pause (compensatory pause)
between PVC and next P-QRScomplex
■ P waves: Absent■ P-R Interval: N/A since P wave is absent with
complex■ QRS: Wide (0.12 seconds)
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Ventricular Tachycardia
■ Rate: 100–250/min (ventricular rate)■ Rhythm: Can be irregular■ P waves: Absent during PVC runs■ P-R Interval: N/A (no P waves)■ QRS: Wide (0.12 seconds)
Ventricular Fibrillation
■ Rate: Irregular and rapid■ Rhythm: Irregular■ P waves: Absent■ P-R Interval: N/A (no P waves)■ QRS: Absent
50
ADVASSESS
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ADVASSESS
1� AV Block
■ Rate: Normal■ Rhythm: Regular■ P waves: Present (1:1 with QRS)■ P-R Interval: Long (0.2 seconds)■ QRS: 0.08–0.12 seconds
2� AV Block (Wenckebach or Mobitz type I)
■ Rate: Slow (�100)■ Rhythm: Regular■ P waves: Present■ P-R Interval: Gradual lengthening of P-R interval
until it fails to trigger a QRScomplex. Then the rhythm repeatsitself.
■ QRS: Normal (0.08–0.12 seconds)
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ADVASSESS
2� AV Block (Mobitz type II)
■ Rate: Bradycardic (�60 /min)■ Rhythm: Regular■ P waves: Present but they don’t conduct to
the ventricles (no QRS)■ P-R Interval: When conduction occurs, normal■ QRS: 0.08–0.12 seconds
3� AV Block
■ Rate: Atrial and ventricular rates are different(ventricular slower)
■ Rhythm: Atrial and ventricular rhythms are regular■ P waves: Present but they don’t conduct to the ventricles■ P-R Interval: Irregular since the atria and ventricles are
paced independently■ QRS: Usually 0.12 seconds
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ADVASSESS
Asystole
■ Rate: None■ Rhythm: None■ P waves: None■ P-R Interval: N/A (no P waves)■ QRS: None
Hemodynamic Monitoring
Arterial Pressure Monitoring
Noninvasive monitoring can be accomplished using automatedsphygmomanometer equipment. Blood pressures can be moni-tored at set time intervals, with alarm limits and digital displays.
Indwelling Arterial Pressure Lines
Indwelling Arterial Lines■ Permit continuous real time monitoring of arterial pressures
and waveforms. In addition, the lines may be used for arterialblood draws for labs or blood gases.
■ Sites: radial, ulnar, brachial, axillary, or femoral artery.■ Arterial pressure waveform.
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Central Venous Pressure (CVP) Lines■ Monitor pressures in the vena cava or right atrium. Right
atrial pressures are reflective of blood volume and venousreturn, which are helpful in evaluating right heart function.
■ Sites: antecubital fossa, basilica, internal jugular, andsubclavian veins.
■ Central venous pressure waveform.
54
ADVASSESS
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55
ADVASSESS
Pulmonary Artery Catheter (Swan-Ganz)■ Monitors pressures in the pulmonary artery and when
wedged, left ventricular end diastolic pressure. The line mayalso be used for cardiac output determination (thermaldilution) and IV infusion.
■ Sites: antecubital fossa, basilica, internal jugular, andsubclavian veins.
■ Pulmonary artery pressure waveform.
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Normal Hemodynamic Values
Arterialpressures
Venouspressures
56
ADVASSESS
Blood pressure
Mean arterial pressureCentral venous pressure
Right atrial pressureRight ventricular pressureRight ventricular end
diastolic pressure
100–140 mmHgsystolic, 60–80mmHg diastolic
80–100 mmHg6 mmHg CVP �
12 mmHg2–6 mmHg20–30/0–5 mmHg2–6 mmHg
(Text continued on following page)
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ADVASSESS
Normal Hemodynamic Values (Continued)
Pulmonaryarterypressures
Hemodynamic Equations
Stroke volume index(SVI)
Cardiac index (CI)
Right ventricularstroke work index(RVSWI)
Left ventricular strokework index (LVSWI)
Pulmonary vascularresistance (PVR)
Systemic vascularresistance (SVR)
Pulmonary arterypressure
Mean pulmonaryartery pressure
Pulmonary capillarywedge pressure
Left atrial pressureLeft ventricular pressureLeft ventricular end
diastolic pressure
20–30/6–15 mmHg
10–20 mmHg
4–12 mmHg
4–12 mmHg100–140/0–5 mmHg
5–12 mmHg
SVI � BSSVA
Normal: 40–50 mL/beat/m2
CI � BCSOA
Normal: 2.5–4 L/min/m2
RVSWI � SVI � (PA � CVP) � 0.013 gm/mL
Normal 4–12 gm/m/m2
LVSWI � SVI � (MAP � PCWP )� 0.013 gm/mL
Normal: 40–75 gm/m/m2
PVR � PA �
CPO
CWP � 80
Normal: 20–200 dynes·sec·cm�5
SVR � MAP
C�
OCVP
� 80
Normal: 800–1600 dynes·sec·cm�5
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ADVASSESS
↓↓↓↓↓
↑↑↑↑↑
↓↑↑Normal↓
↓Normal↑↑↓
Maximum volume inhaledafter a normal inspiration
Amount of air inhaled orexhaled during restingventilation
Maximum amount of airthat can be exhaled aftera normal exhalation
Amount of air left in thelungs following acomplete exhalation
3100 mL
500 mL
1200 mL
1200 mL
Basic Hemodynamic Interpretation
Right Left
Ventricular Ventricular
Hypovolemia Hypervolemia Failure Failure
BPRAPAPPAWPCO
Pulmonary Function Testing
Static Lung Volumes
Definition Normal*
Inspiratory reservevolume (IRV)
Tidal volume (VT)
Expiratory reservevolume (ERV)
Residual volume(RV)
*Normal values are based on 72 inch male, 21 years old.
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ADVASSESS
Static Lung Capacities
Definition Normal*
Vital capacity (VC)Inspiratory capacity (IC)Functional residual
capacity (FRC)Total lung capacity
(TLC)
*Normal values are based on 72 inch male, 21 years old.
Forced Spirometry
Definition Normal*
Forced vitalcapacity (FVC)
Forced expiredvolume in 1second (FEV1)
FEV1/FVC %
Forced expiredflow200-1200
(FEF200-1200)Forced expired
flow25-75%
(FEF25-75%)
*Normal values are based on 72 inch male, 21 years old.
ERV � VT� IRVVT � IRVERV � RV
RV � ERV � VT � IRV
4800 mL3600 mL2400 mL
6000 mL
Amount of air that canbe exhaled forcefullyfollowing a completeinspiration
Amount of air exhaled inthe first second duringan FVC maneuver
(FEV1 divided by theFVC)�100
Expiratory flow ratebetween 200 and 1200 mLduring the FVC maneuver
Expiratory flow during themiddle 50% of the FVCmaneuver
4800 mL
3600–4080 mL
75–85%
6–7 L/sec
4–5 L/sec
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ADV
ASSE
SS
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61
ADV
ASSE
SS
Flow Volume Loop
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ADV
ASSE
SS
SB02
Distribution Tests
◆ Single Breath Oxygen Test (Fowler’s Distribution Test)Nitrogen delta (N2 750-1250 mL) 1.5% or less
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ADV
ASSE
SS
Diffusion Tests
Single Breath DLCO
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ADVASSESS
↑ ornormal
↓
↓
↓
↓
↓
↓
↓
↓ ornormal
↓ ornormal
↓
↓
↓
↓ ornormal
↓ ornormal
↑
↑
↑
↓
↓
↓
↓
↓
↓
↓
↑
↑
↑
↓ ornormal
↓ ornormal
■ Single breath diffusion (DLCO) 25–30 mL/min/mmHgLung Mechanics
■ Resistance (RAW) 0.6–2.4 cmH2O/L/sec■ Conductance (GAW) 0.42–1.67 L/sec/cmH2O■ Maximal inspiratory pressure (MIP) –60 cmH2O■ Maximal expiratory pressure (MEP) 80 cmH2O■ Compliance 0.1 L/cmH2O
Basic Pulmonary Function Patterns in Disease
FEV1/
FVC FEV1 FVC FRC DLCO RAW
Asthma
Emphy-sema
Bron-chitis
Sarcoido-sis
Asbesto-sis
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PROC
Oxygen Therapy
Oxygen therapy is indicated for documented hypoxemia or whenhypoxemia is suspected.
Oxygen Therapy Indications
PaO2 SaO2 Other
Acute Care Hospital
Adults, children,infants �28days old
Infants �28days old
Home or Extended Care
Adults, children,infants �28 days old
�60 mmHgbreathingroom air
�50 mmHgbreathingroom air
�90%breathingroomair
�88%breathingroom air
Severe traumaAcute myocardial
infarctionShort-term therapy
(post anesthesia,etc.)
PcO2 �40 mmHg(capillary bloodgas)
56 mmHg �PaO2
�59 mmHg orSaO2 � 89% inassociation withcor pulmonale,congestive heartfailure, erythro-cythemia, etc.
SaO2 �88% duringexercise, sleep,or other activ-ities when SaO2
values do notqualify for oxy-gen when at rest
�88%breathingroom air
�55 mmHgbreathingroom air
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PROC
Medicare Home Oxygen Guidelines: Group I (12 months
or by physician prescription whichever is less)
PaO2 SpO2 Other Qualification
Adults
Adults
Adults
Adults
PaO2 �55 mmHgwhile awakeon room air atrest
PaO2 �56 mmHgwhile awake atrest
PaO2 �56 mmHgwhile awake atrest on roomair
PaO2 �55 mmHgduringexercise onroom air
SpO2 �88 % whileawake at rest onroom air
SpO2 �89% onroom air whileawake at rest
SpO2 �89% onroom air whileawake at rest
SpO2�88% duringexercise on roomair
PaO2 �55 mmHg orSpO2 �88% for 5minutes whilesleeping
A decrease in PaO2
�10 mmHg ordecrease in SpO2
�5% for 5 minuteswhile sleeping. Withdocumentation ofcor pulmonale, CHF,erythrocytosis, etc.
Must document literflow required tocorrect hypoxemia
Continuous O2
Continuous O2
Continuous O2
O2 duringexercise
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Medicare Home Oxygen Guidelines: Group II (3 months
or by physician prescription whichever is less)
PaO2 SpO2 Other
Adults
Contraindications to Oxygen Therapy
No contraindications exist if clinical indications exist.
Oxygen Administration Devices
Approximate
Devices Liter Flow FIO2
Low-Flow Oxygen Devices
Nasal cannulaTranstracheal catheterSimple oxygen maskPartial rebreathing mask
Non-rebreathing mask
High-Flow Oxygen Devices
Venturi or Venti mask
56–59 mmHg atrest, duringsleep (5minutes), orexercise onroom air
�89% at rest,during sleep(5 minutes),or exerciseon room air
Dependent edema(CHF), pulmhypertension,cor pulmonale,erythrocythemia
24–44%24–44%35–55%up to 60%
up to 80%
30–50%
1–6 L/min0.25–0.5 L/min6–10 L/minTo keep bag open
during inspiration(typically �10 L/min).Never run �6 L/min
To keep bag openduring inspiration(typically �10 L/min)
3–15 L/min (permanufacturer fordesired FIO2)
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Cylinder Duration
Contents Contents
Cylinder (cu ft) (liters) Duration
“E”
“H” or“K”
Liquid System Duration
■ In the absence of a calibrated scale use the following formulato approximate duration.
Duration (in min)�
Factor �Pres. � ft3 (28.3 L/ft3)
2200 psiFactor � 0.28 L/psi
Time (min) �
Time �Pres. � ft3 (28.3 L/ft3)
2200 psiFactor � 3.14 L/psi
Time (min) �
Factor (Pressure)
Liter Flow
22 ft3
244 ft3
623 L
6905 L
0.8[(Weight � Empty Weight) � 343L/Lb Liquid Oxygen]
Liter Flow (L/min)
Factor (Pres.)
Liter Flow
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PROC
■ The factor of 0.8 allows a 20% “fudge factor” prior toexhausting the contents of the reservoir. Empty weight is theweight of the reservoir without any liquid oxygen in it(owners’ or service manual data).
Hazards/Complications of Oxygen Administration
■ Ventilatory depression with PaO2 �60 mmHg in patients withchronic hypercarbia (elevated PaCO2)
■ Absorption atelectasis, oxygen toxicity with FIO2 �0.50■ Retinopathy of prematurity in preterm infants with PaO2 �80
mmHg■ Fire hazard elevated with increased oxygen concentrations■ Infection hazard increased with application of some
humidification devices
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Oxygen Administration Algorithm
PROC
Yes
Yes
No
No
Yes
No
Yes
No
Oxygen Protocolis Ordered
Potential forcomplications?
Short-term(severe trauma,
post-anesthesia),or acute MI?
Check SpO2 (<90%) orPaO2 (<60 mmHg)?
Suspect patient isCO2 retainer?
Initiate low-flowoxygen therapy
Reevaluate SpO2 or PaO2
and titrate oxygen liter flow/FIO2 to keep SpO2 >90%
or PaO2 >60 mmHg
Reassess andmonitor patientevery 24 hours
Contact MDor Provider
Nasal cannula/low-flow device
to keepSpO2 >92%
No oxygen therapyis indicated
Obtain ABG toassess PaCo2 andacid/base balance
Keep SpO2 88–90%on low-flow deliverysystem or consider
high-flow(Venturi) device
Reassess andmonitor patientevery 24 hours
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PROC
Humidity/Aerosol Therapy
Humidity/aerosol therapy is applied to hydrate inspissated retained secretions or to humidifyanhydrous medical gases.
Indications for Humidity/Aerosol Therapy
Metered Dose
Inhaler (MDI), Dry
Cool Heated Heat Moisture Powder Inhaler
Bland Bland Exchanger (DPI), Small Volume
Indication Aerosol Aerosol Humidity (HME) Nebulizer (SVN)
Laryngotracheo-bronchitis
Subglottic edemaPostextubation
edemaPostoperative
airway man-agement
Artificial airway(bypassedupper airway)
X
X Heatedhumidifier
X
X�96 hours or
transport
(Text continued on following page)
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PROC
Indications for Humidity/Aerosol Therapy (Continued)
Metered Dose
Inhaler (MDI), Dry
Heated Heat Moisture Powder Inhaler
Cool Bland Bland Exchanger (DPI), Small Volume
Indication Aerosol Aerosol Humidity (HME) Nebulizer (SVN)
Sputum induction
Low-flow oxygen �4L/min (nasalcannula, etc.)
Administration ofpharmacologicagents to thelower respira-tory tract
X
XBubble
humidifier
X(Hypertonic
saline)
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PROC
Contraindications for Humidity/Aerosol Therapy
■ Bronchoconstriction■ Airway hypersensitivity■ Specific contraindications to pharmacologic agents (see
package insert)■ HME contraindications:
■ Thick copious or bloody secretions■ Exhaled volumes �70% delivered (bronchopulmonary
fistula, cuff leak)■ Hypothermia (�32 degrees Celsius)■ High minute volumes (�10 L/min)
Types of Humidifiers/Nebulizers and Their Application
Device Application Liter Flow/Setting
Room humidi-fier
Aerosol tent
Bubble humidi-fier
Heated humidi-fier withalarms
Increase relativehumidity of a room
Pediatrics (laryngotra-cheobronchitis,epiglottitis, etc.)
Low-flow oxygendelivery (nasalcannula, simplemask, etc.)
Mechanicalventilation, bilevelpositive airwaypressure, CPAP, arti-ficial airway, infanthood or headboxfor neutral thermalenvironment
Fill reservoir, connectto electrical outletand turn unit on
Fill reservoir, maximumflow to achieve adense mist, titrateFIO2 to maintainSpO2 �92%
Set liter flowto achieveSpO2 �90 %
31–35 degrees Celsiusat the airway or setfor a neutral thermalenvironment (infantapplication)
(Text continued on following page)
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PROC
Types of Humidifiers/Nebulizers
and Their Application (Continued)
Device Application Liter Flow/Setting
Heat and moistureexchanger (HME)
Small volumenebulizer (SVN)
Respiguard SVN
Metered doseinhalers (MDI),dry powderinhalers (DPI)
Large volumenebulizer
HEART (continuous)nebulizer
Ultrasonic nebulizer
Artificial airwaywith short-termmechanicalventilation (�96hours)
Delivery ofpharmacologicagents to thelower respiratorytract
Delivery ofpentamidine
Delivery ofpharmacologicagents to thelower respira-tory tract
Administration ofbland aerosol(cool or heated)
Continuousadministration ofbronchodilator
Administration ofbland aerosol
Monitor forincreased airwayresistance (airwaypressures, useof accessorymuscles, etc.)
6–8 L/min
6–8 L/min
Use holding chamber(MDI)
Titrate liter flow andFIO2 to maintainSpO2 �90%
Set liter flow permanufacturer fordesired mg/hrdelivery
Fill reservoir, setoutput control fora dense aerosol,use caution withasthmatic patients
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PROC
Humidity/Aerosol Therapy Algorithm
Yes
No
Yes
No
Yes
Yes
No
Yes
NoArtificialairway?
HME if duration isless than 96 hours
Heated humidifierwith temperature
display and alarms
Medicationdelivery?
SVN, MDI,or DPI
If patient requirescontinuous bronchodilator
therapy, us a HEARTcontinuous nebulizer
Secretionhydration?
Large volumenebulizer
Bubblehumidifier
Ultrasonic nebulizer(contraindicated with
bronchospasm/asthma)
Subglotticedema?
Adults: cool aerosolvia large volume
nebulizer
Nasal cannula>4 L/min?
Pediatrics:mist tent
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Hazards/Complications of Humidity and Aerosol Therapy
■ Humidity Therapy■ Electrical shock (heated humidifiers)■ Hypothermia (HME devices)■ Thermal injury (heated humidifiers)■ Swelling of inspissated secretions (heated or cool humidity)■ Increased airway resistance (HME devices)■ Infection
■ Aerosol Therapy■ Bronchospasm■ Infection■ Overhydration■ Airway edema■ Exposure of caregivers to secondhand aerosol
Hyperinflation Therapy
Hyperinflation therapy is used to achieve lung expansion toreverse or prevent atelectasis, to mobilize secretions, to promoteeffective coughing, and to improve delivery of medications.
Indications for Hyperinflation Therapy
■ Atelectasis, predisposition for atelectasis (upper abdominal orthoracic surgery)
■ Restrictive lung defect (neuromuscular)■ Inability to clear secretions■ Reduce air trapping in chronic obstructive pulmonary disease■ Optimize delivery of bronchodilators
Contraindications to Hyperinflation Therapy
■ Incentive spirometry■ Patient cannot be instructed or supervised■ Patient is uncooperative or cannot understand instructions■ Patient unable to deep breathe (VC �10 mL/kg)
PROC
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■ PEP/oscillating PEP therapy/CPAP/bilevel positive airwaypressure■ Patient unable to tolerate increased work of breathing■ Increased intracranial pressure■ Cardiovascular compromise (myocardial ischemia,
decreased venous return)■ Gastric distension or risk of vomiting■ Claustrophobia■ Facial skin breakdown from use of a mask■ Pulmonary barotraumas
■ Intermittent positive pressure breathing (IPPB)■ Absolute contraindication: Untreated pneumothorax■ Intracranial pressure �15 mmHg■ Hemodynamic instability■ Recent facial, oral, sinus, or skull surgery■ Tracheoesophageal fistula■ Recent esophageal surgery■ Hemoptysis■ Nausea/vomiting/gastric distension■ Active untreated tuberculosis■ Evidence of blebs on chest x-ray
Hyperinflation Techniques
Technique Indications Clinical Goal Comments
Incentivespirometry
Atelectasis,predispositionfor atelectasis,or neuromus-cular restric-tive lungdefect
Some patientsmay lackventilatorymusclestrength toperformtherapy.Patient canperformtechniqueindependently.
Increasetransairwaypressureimprovinglungvolumes
(Text continued on following page)
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PROC
Hyperinflation Techniques (Continued)
Technique Indications Clinical Goal Comments
Positive ex-piratorypressure(PEP)
OscillatingPEPtherapy
(Text continued on following page)
Patient mustbe able tocooperate(spontaneouslybreathing). Canbe combinedwith SVN forsimultaneousmedicationdelivery. Patientcan performtechniqueindependently.
Patient must beable to coop-erate (sponta-neouslybreathing). Canbe combinedwith SVN forsimultaneousmedicationdelivery. Patientcan performtechniqueindependently.
Splint airwaysopen duringexhalation,improvingdistributionand abilityto mobilizesecretions(↑ FRC)
Splint airwaysopen duringexhalationwith oscillat-ing pressure.Improve dis-tribution ofventilationand mobilizesecretions(↑ FRC)
Atelectasis, re-tained secre-tions, airtrappingassociatedwith COPD
Atelectasis,retainedsecretions,air trappingassociatedwith COPD
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Hyperinflation Techniques (Continued)
Technique Indications Clinical Goal Comments
Intermittentpositivepressurebreathing(IPPB)
Continuouspositiveairwaypressure(CPAP)
Bilevelpositiveairwaypressure
Pulmonaryatelectasis(followingfailure ofother tech-niques),mobilizesecretions,delivermedications,short-termventilatorysupport
Applicationof positivepressure(10–20 cmH2O) duringinhalationand exhala-tion
Application ofinspiratoryandexpiratorypositiveairwaypressure
Applicationof positivepressure duringinspiration tohyperinflate thelungs whilesimultaneouslydelivering amedication
Increase FRC andhyperinflate thelungs
Increase FRC andhyperinflate thelungs
Application ofpositive pres-sure duringinspirationto hyper-inflate thelungs whilesimultane-ously deliv-ering amedication
Increase FRCand hyper-inflate thelungs
Increase FRCand hyper-inflate thelungs
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PROC
Yes
Yes
No
No
Hyperinflation TherapyProtocol is Ordered
Contraindications?
Patient’s VC >10 mL/kg andable to follow directions?
Consider IPPB therapy(volume oriented) to
25%> spontaneous volume
Consider intermittentapplication of bilevel
positive airway pressurevia mask
Evaluate goals:Improved breath sounds?
Resolving atelectasis?Improved vital signs?
Improved VC?Improved SpO2 or PaO2? Consider CPAP therapy
via mask intermittently
Evaluate goals:Improved breath sounds?
Resolving atelectasis?Improved vital signs?
Improved VC?Improved SpO2 or PaO2?
Continue ormodify therapy
Continue ormodify therapy
Contact MDor Provider
Incentivespirometry,
PEP therapy
Hyperinflation Algorithm
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Hazards/Complications of Hyperinflation Therapy
■ Hyperventilation (hypocarbia)■ Barotrauma (positive pressure techniques)■ Hypoxemia (if supplemental oxygen is removed for extended
period during therapy)■ Increased intracranial pressures (positive pressure techniques)■ Cardiovascular compromise (positive pressure techniques)■ Gastric insufflation (positive pressure techniques)
Bronchial Hygiene
Bronchial hygiene techniques are used to improve coughing andfacilitate mobilization of secretions. Many of these techniquesoverlap some of the hyperinflation therapy techniques.
Indications for Bronchial Hygiene
■ Presence of or predisposition for atelectasis■ Retained secretions or inability to effectively mobilize
secretions■ Evidence of cystic fibrosis, bronchiectasis, or cavitating lung
disease■ Difficulty clearing secretions with sputum production �25–30
mL/day (adult)■ Evidence of retained secretions with the presence of an
artificial airway
Contraindications to Bronchial Hygiene Therapy
■ PEP/Flutter valve therapy/CPAP/bilevel positive airwaypressure■ Patient unable to tolerate increased work of breathing■ Increased intracranial pressure■ Cardiovascular compromise (myocardial ischemia,
decreased venous return)
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■ Gastric distension or risk of vomiting■ Claustrophobia■ Facial skin breakdown from use of a mask■ Pulmonary barotraumas
■ Chest physiotherapy and postural drainage (CPPD)■ Patient positioning
■ Absolute contraindications◆ Unstable cervical fractures◆ Hemorrhage with hemodynamic instability
■ Relative contraindications◆ Increased intracranial pressure (�20 mmHg)◆ Recent spinal surgery◆ Acute spinal injury◆ Untreated empyema◆ Bronchopulmonary fistula◆ Pulmonary edema associated with congestive
heart failure◆ Pleural effusion◆ Patient unable to tolerate positional changes◆ Rib fractures◆ Uncontrolled hypertension◆ Frank uncontrolled hemoptysis◆ Aspiration risk
■ External chest wall manipulation■ Subcutaneous emphysema■ Recent epidural or spinal anesthesia■ Recent skin grafts■ Burns, open wounds, or skin infections■ Recent pacemaker implantation■ Suspected pulmonary tuberculosis■ Lung contusion■ Osteomyelitis of the ribs■ Osteoporosis■ Coagulopathy■ Complaint of chest wall pain
PROC
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Bronchial Hygiene Techniques
Technique Indications Clinical Goals Comments
Positive ex-piratorypressure(PEP)
Oscillat-ing PEPtherapy
Chest phys-iotherapyand pos-turaldrainage(CPPD)
Atelectasis,retainedsecretions,air trappingassociatedwith COPD
Atelectasis,retainedsecretions,air trappingassociatedwith COPD
Atelectasis,retainedsecretions,problemsclearingsecretions
Splint airwaysopen duringexhalationimprovingdistributionand abilityto mobilizesecretions(FRC)
Splint airwaysopen duringexhalationwith oscillat-ing pressure.Improvedistributionof ventila-tion andmobilizesecretions(↑ FRC)
Patient posi-tioning tofacilitatepulmonarydrainagewith externalchest wallmanipulation
Patient must beable to cooperate(spontaneouslybreathing). Canbe combinedwith SVN forsimultaneousmedicationdelivery. Patientcan performtechniqueindependently.
Patient mustbe able tocooperate(spontaneouslybreathing). Canbe combinedwith SVN forsimultaneousmedicationdelivery. Patientcan performtechniqueindependently.
Clinical efficacy islargely basedupon anecdotalevidence.
(Text continued on following page)
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Bronchial Hygiene Techniques (Continued)
Technique Indications Clinical Goals Comments
High-frequencychest walloscillation(The Vest7)
Intrapulmonarypercussiveventilation(IPV)
Secretions,problemsclearingsecretions
Secretions,problemsclearingsecretions
External manip-ulation of thechest wallusing high-frequencypressurepulsesthrough apneumaticvest worn bythe patient
Use of a high-frequencyventilator toincreasemean airwaypressureswhile mobi-lizing secre-tions withpressurepulses
Patient mayperformtherapy inde-pendently.Equipment isexpensive.
Can be used forsimultaneousmedicationdelivery.Patient maybe instructedto performtherapy inde-pendently.
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Postural Drainage Positions
Posterior Apical Segments of the Right andLeft Upper Lobes
■ Position the patient sitting and leaning forward at about a45-degree angle
■ Area for percussion is just above the scapula with the fingersextending up onto the shoulders
Anterior Apical Segments of the Right andLeft Upper Lobes
■ Position the patient sitting and leaning back at about a45-degree angle
■ Area for percussion is just below the clavicle
Anterior Segments of the Right and Left Upper Lobes
■ Position the patient supine with the bed flat■ Area for percussion is just above the nipple
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Posterior Segment of the Left Upper Lobe
■ Position the patient 1/4 turn from prone and resting on theright side with the head of the bed elevated 18 inches
■ Area for percussion is just over the left scapula
Posterior Segment of the Right Upper Lobe
■ Position the patient 1/4 turn from prone and resting on the leftside with the bed flat
■ Area for percussion is just over the right scapula
Left Lingula
■ Position the patient 1/4 turn from supine and resting on theright side with the foot of the bed elevated 12 inches
■ Area to percuss is just above the left nipple and under thearmpit
PROC
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PROC
Right Middle Lobe
■ Position the patient 1/4 turn from supine with the foot of thebed elevated 12 inches
■ Area to percuss is just above the right nipple and underthe armpit
Anterior Basal Segments of the Right and Left Lung
■ Position the patient supine with the foot of the bed elevated18 to 20 inches
■ Area to percuss is over the lower ribs
Posterior Basal Segments of the Right and Left Lung
■ Position the patient prone with the foot of the bed elevated18 to 20 inches
■ Area to percuss is over the lower ribs
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Left Lateral Segment of the Lower Lobes
■ Position the patient on the right side with the foot of the bedelevated 18 to 20 inches
■ Area to percuss is over the lower ribs
Right Lateral Segment of the Lower Lobes
■ Position the patient on the left side with the foot of the bedelevated 18 to 20 inches
■ Area to percuss is over the lower ribs
Superior Segments of the Right and Left Lower Lobes
■ Position the patient prone and with the bed flat■ Area to percuss is over just below the lower margin of the
scapula
PROC
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PROC
Bronchial Hygiene Care Plan
Yes
No
Reevaluate patient after 24 hours
Bronchial Hygiene Protocol is Ordered
Contraindications?
Assess patient, are indications present:
Sputum prod >25 mL/day?Decreased or absent breath sounds?
Atelectasis on chest x-ray?Tachypnea or tachycardia?
Abnormal ABGs?
Assess outcomes:
Sputum prod <25 mL/day?Improved breath sounds?
Improved chest x-ray?Improved vital signs?
Improved ABGs?
Select mode/technique:PEP therapy?Flutter valve?
CPPD?HFCWO?
IPV?
Continue or modify therapy?Discontinue therapy?
Consult MDor Provider
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Hazards/Complications of Bronchial Hygiene Therapy
■ Hyperventilation (hypocarbia)■ Barotrauma (positive pressure techniques)■ Hypoxemia (if supplemental oxygen is removed for extended
period during therapy) or from ventilation/perfusionmismatching with patient positioning
■ Increased intracranial pressures (positive pressure techniquesand dependent head positions, excessive coughing)
■ Cardiovascular compromise, hypotension (positive pressuretechniques and dependent head positions)
■ Gastric insufflation (positive pressure techniques)■ Vomiting/aspiration
Tracheostomy Care
The primary goals of tracheostomy and stoma care are to reduceinfections and preserve airway patency.
Infection Control (tracheostomy site care)
■ Auscultate chest for bilateral breath sounds and correcttracheostomy placement. Assess the patient for suctioningand suction prior to the procedure if required.
■ Remove soiled dressing and tracheostomy ties (stabilize thetracheostomy tube at all times to prevent decannulation).
■ Clean the stoma site and surrounding skin with 50/50 mixtureof hydrogen peroxide and sterile water using 2�2 gauze padsand cotton tipped swabs. Observe for redness, pus, or othersigns of infection.
■ Rinse the cleansed site with sterile water after use ofhydrogen peroxide mixture using 2�2 gauze pads and cottontipped swabs.
■ Pat the area dry with sterile 2�2 gauze pads.■ Apply clean tracheostomy ties and secure them.■ Apply a clean dressing, slipping it under the tracheostomy
flange from below the tracheostomy tube (inferior).
PROC
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PROC
■ Remove the inner cannula (if it has a removable innercannula) and clean it in hydrogen peroxide. Rinse with sterilewater after it is cleaned and shake dry before reinsertion.
■ Auscultate the chest following the procedure to assesstracheostomy position.
Airway Patency
■ Routine cleaning of the inner cannula (removable innercannula) or replacement (disposable inner cannula) preservesthe patency of the tracheostomy tube.
■ Routine suctioning (when indicated by adventitious breathsounds).
Fiberoptic Bronchoscopy Assisting
Fiberoptic bronchoscopy is an invasive procedure that allowsvisual examination of the tracheobronchial tree and collection ofspecimens for laboratory analysis.
Therapeutic Indications
■ Removal of excessive secretions from the airway■ Foreign body retrieval■ Evaluation of or placement of an artificial airway
Diagnostic Indications
■ Obtain lower respiratory tract secretions for cytology,histology, or microbiology studies
■ Evaluation of lesions (seen on x-ray or computed tomography[CT] scan)
■ Evaluation of positive sputum cytology results■ Evaluation of injury from aspiration or inhalation of toxic
agents■ Evaluation of hemoptysis
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Absolute Contraindications to Fiberoptic Bronchoscopy
■ Lack of signed patient consent for the procedure■ Lack of proper facilities (resuscitation equipment, personnel,
etc.)■ Inability to adequately oxygenate the patient
Relative Contraindications to Fiberoptic Bronchoscopy
■ Lack of patient cooperation■ Recent myocardial infarction or unstable angina■ Partial tracheal obstruction■ Moderate to severe hypoxemia■ Pulmonary hypertension■ Lung abscess■ Need for laser therapy■ Known or suspected pregnancy if fluoroscopy (radiation) is
needed during the procedure
Assisting During Fiberoptic Bronchoscopy
Prepare and Organize Equipment■ Bronchoscope and light source■ Suction source (verify operation and tubing connections)■ Check code cart and resuscitation supplies■ Oxygen therapy equipment (flowmeter, mask[s], nasal
cannula)■ Labeled fixative/sample solutions (95% alcohol, formalin,
Saccomanno’s solution, normal saline, or Ringer’s lactate)■ Microscope slides■ Suction traps (diagnostic collection traps)■ Biopsy forceps, brushes, and Wang needle■ Labeled 50 mL normal saline (have 500 mL container
available)■ Labeled 50 mL 2% lidocaine (below the vocal cords)■ Labeled 20 mL 1:20,000 epinephrine■ Labeled 4-mL syringes of acetylcysteine
PROC
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PROC
■ 10, 20, and 50 mL syringes■ Bite block (oral route)■ Intravenous therapy supplies
Establish Appropriate Patient Monitoring■ Automated noninvasive blood pressure monitoring■ ECG monitoring■ Continuous pulse oximetry monitoring■ Organize record keeping forms/charts
Patient Anesthesia/Analgesia■ Apply personal protective equipment.■ Aerosolize 4 mL of 4% lidocaine with 2.5–5.0 mg albuterol via
SVN.■ Aerosolized lidocaine may be followed by Cetacaine or
Hurricane spray to further dull upper respiratory tract reflexes.■ Cotton tipped swabs dipped in 4% lidocaine jelly can be used
to dull sensations in the nares/nasal passages.■ Establish IV access and administer diazepam, midazolam, or
lorazepam for analgesia. Consult your local policy andprocedure manual for IV access and conscious sedation.
Assisting During the Procedure■ Establish supplemental oxygen (mask or nasal cannula)■ Administer analgesia per physician request■ Administer saline lavage per physician request (temporarily
pinch off suction line)■ Assist physician with biopsy sampling (brush, forceps, Wang
needle)■ Prepare samples for laboratory analysis (slides, brushes,
tissue samples, etc.)■ Collect aspirate as requested in Lukens traps■ Assist in patient monitoring
Post Procedure■ Continue to monitor the patient, ensuring the patient is stable■ Prepare all documentation■ Perform initial cleaning of the bronchoscope■ Ensure correct labeling and documentation of all laboratory
samples
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Hazards/Complications
Fiberoptic bronchoscopy is an invasive procedure. It does havepotential hazards and complications that you must be aware of.■ Hypoxemia■ Hypercapnia■ Wheezing■ Hypotension■ Laryngospasm, bronchospasm, bradycardia■ Bleeding/hemorrhage■ Increased airway resistance■ Infection
Thoracentesis Assisting
Thoracentesis is a procedure used to remove fluid from thepleura for laboratory analysis. It is performed using a needle,puncturing the pleural space transcutaneously, and aspirating asample for analysis.
Indications
■ Relieve respiratory insufficiency from pleural effusion■ Obtain samples for cytology and cancer staging
Contraindications
■ Lack of signed patient consent■ Lack of patient cooperation■ Coagulopathy■ Respiratory insufficiency■ Hemodynamic or cardiac instability or unstable angina
PROC
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PROC
Assisting During the Procedure
■ If the patient is unstable, establish appropriate monitoring(automated noninvasive blood pressure, ECG, continuousoximetry)
■ Assemble supplies:■ Iodine antiseptic■ Sterile drape■ Sterile gloves■ 2% lidocaine■ Large bore 16–19 gauge needle(s)■ Three-way stopcock■ Sample tubes with 0.1 mL of aqueous heparin■ Oxygen therapy equipment (flowmeter, mask, or nasal
cannula)■ Prepare all documentation forms/records
■ Assist the physician as requested■ Appropriately label all samples collected and prepare
laboratory forms
Post Procedure
■ Dispose of any unneeded supplies■ Monitor the patient ensuring stability■ Order a chest x-ray
Hazards/Complications
Complications are uncommon, but can occur.■ Pneumothorax■ Hemorrhage■ Vasovagal response■ Infection
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Capnography
Capnography is the noninvasive measurement of end-tidal CO2
using infrared sensors. An adapter is placed at the airway, wherethe sample is measured directly (mainstream) or drawn distallyto a remote monitor (side stream).
Indications
■ Evaluation of exhaled CO2
■ Monitoring the severity of pulmonary disease■ Evaluating placement of an endotracheal tube (tracheal or
esophageal)■ Monitoring the patency of the ventilator/airway circuit■ Evaluating efficiency of ventilatory support■ Monitoring adequacy of pulmonary and coronary blood flow■ Graphic evaluation of the ventilator/patient interface
Contraindications
■ None
Capnography Monitoring
■ Obtain the required equipment:
■ End-tidal CO2 monitor■ Airway adapter(s)/tubing (per manufacturer)■ Calibration gases (per manufacturer)
■ Connect the monitor to an electrical outlet (preferably onethat is on a back-up power supply)
■ Calibrate the monitor according to manufacturer’s directions/specifications
■ Connect the monitor to the patient’s airway and observe forcorrect graphic and numeric response
■ Correlate the monitor’s data with arterial blood gases
PROC
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PROC
Hazards/Complications
■ Potential increase in dead space if the adapter is too largerelative to the airway and patient
■ Potential extubation or torque on the airway due to weight ofthe sensor
Portable Sleep Monitoring
Portable sleep monitoring has increased in the past decade inthe evaluation of patients with breathing-related sleep disorders.Multichannel monitors allow noninvasive measurement of ECG,airflow, respiratory effort, and pulse oximetry.
Indications
■ Patients present with severe symptoms and standardpolysomnography (PSG) monitoring is not available
■ Patients who cannot be studied in a traditional PSG sleeplaboratory
■ Used for follow up following diagnosis by a PSG laboratory
Contraindications
■ No absolute contraindications exist■ A qualified practitioner is not available for intervention (CPAP)
if the study is unattended
Setting Up a Portable Sleep Monitor
■ Obtain required equipment■ Multichannel sleep monitor■ Disposable oximeter probe■ Disposable airflow sensor■ Disposable ECG leads■ Cables/interface for monitor probes
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■ Connect the monitors to the patient■ Attach ECG leads between the clavicle and the fourth
intercostal space along the midaxillary line (white on rightside, black on left side)
■ Secure the respiratory effort band snuggly around thepatient’s abdomen
■ Place the oximeter probe on a finger and secure it withtape
■ Place the airflow sensor on the patient’s upper lip with theprobes just entering the nares (similar to a nasal cannula)
■ Attach the snore microphone adjacent to the larynx with aself-adhesive disk and reinforce its attachment withbandage tape
■ Connect the cable(s) to the monitor■ Connect the monitor to an electrical outlet and turn on the
monitor
Hazards/Complications
■ No hazards/complications exist for home sleep monitoring■ Limitations to unattended home monitoring
■ Loss of control over the sleep environment■ Patients can engage in maladaptive sleep habits■ Bed partners can disturb the outcome of the study■ A qualified practitioner is not available to intervene if
required■ Higher rate of data loss due to technical/patient difficulties
Exercise Testing for the Evaluation
of Oxygen Desaturation
Exercise testing may be performed to evaluate whether and howmuch a patient may desaturate during exercise. It may also beused to determine what a patient’s oxygen requirements areduring exercise.
PROC
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PROC
Indications
■ The need to quantify the adequacy of arterial oxygensaturation during exercise
■ The need to quantify the response to therapeutic intervention(oxygen therapy) during exercise
■ The need to titrate supplemental oxygen during exercise■ The need to assess disability or evaluate the patient for
disability purposes■ Preoperative assessment for lung resection/transplantation
Contraindications
Absolute Contraindications■ Acute ECG changes (ischemia, serious arrhythmias, etc.)■ Unstable angina■ Recent myocardial infarction■ Aneurysm (heart or aorta)■ Uncontrolled hypertension■ Deep venous thrombosis■ Recent systemic or pulmonary embolism■ Acute pericarditis■ Symptomatic aortic stenosis■ Uncontrolled heart failure■ Uncontrolled or acute asthma■ Pulmonary edema■ Respiratory failure
Relative Contraindications■ Invalid data from pulse oximetry■ Noncompliant patient■ Severe pulmonary hypertension■ Known electrolyte disturbances■ Resting BP (diastolic �110mmHg; systolic �200mmHg)■ Neuromuscular, musculoskeletal, or rheumatoid disorders
that prevent or are exacerbated by exercise■ Complicated or advanced pregnancy■ SpO2 or SaO2 �85 mmHg on room air■ Cardiomyopathy
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Performing Exercise Oximetry Evaluations
■ Assemble the required equipment
■ Treadmill, exercise ergometer, or other exercise media■ ECG monitor■ Pulse oximeter■ Noninvasive manual or automated blood pressure monitor■ ABG collection equipment■ Defibrillator and emergency resuscitation equipment■ Oxygen therapy equipment and flowmeter(s)
■ Appropriately instrument the patient for monitoring
■ ECG■ SpO2
■ Blood pressure■ Assemble and have ready ABG supplies if indicated
■ Initiate exercise testing (ramp or steady state protocol)■ If patient SpO2 �88%, initiate oxygen therapy and titrate
oxygen to maintain SpO2 �90%■ Document all monitoring data, work load, duration, and
oxygen therapy intervention
Hazards/Complications
■ ECG changes (ST elevation or depression, arrhythmias,ventricular tachycardia, etc.)
■ Severe desaturation (SpO2 �80%)■ Angina■ Hypotension■ Light-headedness■ Fatigue■ Muscle cramping
PROC
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CRITCARE
Assessment of the Critically Ill Patient
Vital Signs
Heart Rate
Respiratory Rate
Blood Pressure
Temperature
Physical Findings
■ Inspection■ Work of breathing?■ Color?■ Nasal flaring, retractions, accessory muscle use?■ Distressed, increased respiratory rate?■ Able to speak in complete sentences?■ Diaphoresis?■ Jugular vein distention?
■ Palpation■ Symmetrical chest motion (possible flail)?■ Areas of pain or tenderness (contusion)?■ Subcutaneous emphysema?
■ Percussion■ Dullness or flatness (possible consolidation/fluid)?
6 years—75–120/min10 years—50–90/min16 years—50–90/minAdult—60–100/minGeriatric—60–100/minPediatric—20–40/minAdolescent—15–20/minAdult—12–20/min6 years—95/57 mmHg10 years—95/57 mmHg16 years—120/80 mmHgAdult—120/80 mmHgGeriatric—120/80 mmHgPediatric—36.1�–37.7�CAdolescent—35.8�–37.3�CAdult—35.5�–37.5�C
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■ Hyperresonance (possible pneumothorax)?■ Diaphragmatic excursion?
■ Auscultation■ Adventitious breath sounds (fluid, bronchospasm, edema,
consolidation)?
Ventilatory Assessment
Tidal volumeMinute volumeRapid shallow breathing
index (frequency/tidalvolume [L])
PaCO2
PECO2
Dead space (VD ana, VD/VT)
Maximal inspiratorypressure (MIP)
Oxygenation Assessment
Oxygen contentCaO2 � SaO2(Hb � 1.34)
� (PaO2 � 0.003)PaO2
SpO2
Oxygen deliveryDO2 � QT � (CaO2 � 10)Arterial-venous oxygen
content difference(CaO2 – CvO2)
CRITCARE
Normal: 4–7 mL/kgNormal: 5–7 L/min (adult)Normal: �100
Normal: 35–45 mmHgNormal: 35–43 mmHgAnatomic: Normal 1 mL/lb body
weightVD/VT: Normal 0.25–0.35Normal �–50 cmH2O
Normal: 20 mL/dLRange 15–24 mL/dL
Normal: 80–100 mmHgNormal: �90%Normal: 1000 mL/min
Normal: 5 mL/dLRange 4–6 mL/dL
(Table continued on following page)
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CRITCARE
Oxygenation Assessment (continued)
PaO2/FIO2
PaO2/PAO2
Oxygen consumptionVO2 � QT (Ca-vO2 � 10)Oxygen extraction ratio
O2ER �
Pulmonary shunt
QS/QT �
Cardiovascular Assessment
Capillary refill
Jugular venousdistention
Cardiac outputCardiac indexCVPPCWPMean PA pressureECG
Normal: �200Normal: 0.8–0.9Normal: 250 mL/min
Normal: 0.25
Normal: �0.20
CaO2 � CvO2
CaO2
CcO2 � CaO2
CcO2 � CvO2
Normal: �3 secondsIncreased: �3 seconds (low cardiac
output or peripheral perfusion)Normal: �3–4 cm above the sternal angle
Normal: 4–8 L/minNormal: 2.5–4.4 L/min/m2
Normal: 0–6 cmH2ONormal: 4–12 mmHgNormal: 8–12 mmHgRate, rhythm, P-waves, P-R interval, QRS,
ST segment, extra?
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Neurological Assessment
Glasgow Coma Score
Response Eye Opening Best Verbal Best Motor
6
5
4
3
2
1
Guidelines: Glasgow Coma Score (GCS) of 14 � normal. GlasgowComa Score (GCS) of 3 � profound coma.
Fluid and Electrolytes
■ Urine output■ Normal: 1200 mL/day (minimum 12mL/hr)
■ Signs of pedal edema?■ Electrolytes (Normals)
■ Na� 137–147 mEq/L■ K� 3.5–5 mEq/L■ Mg� 1.8–3.0 mEq/L■ Cl� 98–105 mEq/L■ Total CO2 24–30 mEq/L
CRITCARE
None
None
Spontaneous
To speech
To pain
None
None
Oriented
Confused
Inappropriate
Incomprehen-sible
None
Obeys simplecommands
Attempts to removepainful stimuli
Attempts to withdrawfrom painful stimuli
Nonpurposeful elbowflexion
Elbow extension,wrist flexion,shoulder rotation
None
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CRITCARE
Classification of Ventilatory Failure
Ventilatory failure is the respiratory system’s inability to provideadequate oxygenation and/or to adequately excrete carbondioxide produced by metabolism.
Type I Respiratory Failure
Normocapnic Respiratory Failure
pH 7.35–7.45PaCO2 25–40 mmHgHCO3
� 22–26 mEq/LPaO2 40–59 mmHg
Causes of Type I Respiratory Failure■ Pulmonary shunt■ Diffusion defect■ Inadequate systemic blood flow■ Anemia, cyanide poisoning, methemoglobinemia
Type II Respiratory Failure
Hypercapnic Respiratory Failure
pH �7.35PaCO2 �50 mmHgHCO3
� Normal or ↑PaO2 �50 mmHg
Causes of Type II Respiratory Failure■ Neurological disorders (CNS depression, drug overdose,
spinal cord injury, myasthenia gravis, Guillian-Barré, etc.)■ Respiratory muscle disorders (fatigue, muscular dystrophy,
polio, etc.)■ Chest wall impairment (pneumothorax, flail chest,
kyphoscoliosis, hemothorax, pleural effusion, etc.)■ Airway obstruction (upper or lower)■ Pulmonary disease (COPD, pneumonia, pulmonary fibrosis,
pulmonary edema)■ Hypercapnia (sepsis, burns, etc.)
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Mouth
A
B
Pharynx
Trachea
Mouth
Trachea
Pharynx
106
Airway Management
Airway management is important in the maintenance of a patentairway in the presence of respiratory failure or pending respiratoryfailure. A patent airway must be quickly established so that ventila-tion (spontaneous or artificial) may be resumed or continued.
Positional Maneuvers to Open the Airway
■ Head tilt■ Anterior mandibular displacement
CRITCARE
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CRITCARE
Manual Resuscitators
Manual resuscitators can provide temporary ventilatoryassistance to patients with or without an artificial airway.
Self-Inflating Manual Resuscitators■ Assemble the resuscitator/mask device■ Connect to an oxygen flowmeter and set the flow to 10–15
L/min■ Apply mask to the patient’s face or connect the resuscitator to
the artificial airway■ Deliver manual breaths with adequate tidal volumes and a
rate of 12–20 /min.■ Assess the patient for cyanosis, gastric distention, or
vomiting
Simple Airways
■ Nasopharyngeal airway■ Oropharyngeal airway
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Advanced Airways
Combitube Airway
This airway is inserted blindly (usually into the esophagus) andhas two cuffs and two lumens. Ventilation must be carefullyassessed to ensure the correct lumen is being used.
Laryngeal Mask Airway (LMA)
Commonly used in the anesthesia setting. The airway is insertedinto the oropharynx into the esophagus resting against theupper esophageal sphincter.
CRITCARE
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CRITCARE
Endotracheal Tube
This airway is inserted into the trachea (position verified withend tidal CO2 monitoring, breath sounds, and chest x-ray).
Double Lumen Endotracheal Tubes
Carlens’ tubeRobertshaw tube
Intubation
Indications for Intubation■ Traumatic upper airway obstruction■ Apnea■ Need to protect the airway■ Cardiopulmonary arrest■ Airway hemorrhage■ Laryngeal or upper airway edema
Contraindications■ Existence of signed legal documents (advance directive or
living will) stating that intubation/resuscitation is not desired
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Intubation Procedure■ Obtain required equipment
■ Oxygen flowmeter■ Manual resuscitator (bag/mask)■ Laryngoscope and blades■ Yankauer suction and suction catheter/kit■ Endotracheal tubes (multiple sizes)■ 20 mL syringe■ Stylet■ 4% Xylocaine jelly■ Suctioning supplies■ Personal protective equipment■ Commercial endotracheal tube holder■ End-tidal CO2 monitor or chemical colorimetric indicator
■ Position the patient supine (head in a sniffing or “vulture”position)
■ Ventilate/oxygenate the patient with the bag/mask resuscitator■ Insert the laryngoscope and visualize the vocal cords■ Pass the endotracheal tube through the vocal cords■ Inflate the cuff with air using a 20-mL syringe■ Stabilize the tube until it is secured with a commercial holding
device■ Verify the tube’s position
■ Auscultate the chest■ Observe for equal bilateral expansion■ Verify end-tidal CO2
■ Note position (depth) of the tube at the teeth or gum line incentimeters
■ Order a portable chest x-ray to verify tube’s position (2 cmabove the carina)
Care of an Artificial Airway
Routine care of the artificial airway is required to maintain airwaypatency, protect the lower airway from aspiration of secretions andreduce infection.
Techniques■ Keep head of bed elevated 30 degrees■ Suction as needed to remove accumulated secretions
CRITCARE
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CRITCARE
■ Use closed suction catheters and minimize breaking theventilator circuit
■ Once each shift perform oral care and verify endotrachealtube’s security
■ Monitor cuff pressures and maintain minimal leak or minimalocclusion volume
■ Obtain daily chest x-rays to verify tube’s position
Suctioning■ Indications
■ Atelectasis (retained, inspissated secretions causingatelectasis)
■ Remove accumulated secretions (evidenced by auscultation,increased airway resistance, increased airway pressures)
■ Obtain lower respiratory secretions for culture/sensitivity■ Contraindications
■ Worsening or exacerbation of the patient’s condition(hypoxemia, vago-vagal response, etc.)
■ Suctioning procedure■ Obtain required equipment
◆ Vacuum regulator, suction canister, and suction tubing◆ Suction catheter/kit or closed suction system◆ Sterile water◆ Normal saline (unit dose “bullets”)
■ Assess the need for suctioning (peak pressure, RAW,auscultation)
■ Oxygenate/hyperinflate the patient before the procedure■ Slowly advance the catheter into the airway until a cough
reflex is obtained■ Apply vacuum upon withdrawal (80–120 mmHg)■ Oxygenate/hyperinflate following aspiration■ Instill normal saline as required to hydrate secretions for
removal■ Repeat aspiration as required■ Assess patient following procedure (HR and rhythm,
auscultation, SpO2, peak pressure, RAW)■ Hazards/complications
■ Atelectasis■ ECG arrhythmias (PVCs, etc.)
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■ Hypoxemia■ Bronchospasm■ Bradycardia/tachypnea■ Hypotension■ Mucosal trauma■ Infection
Monitoring the Critical Care Patient
Vital Signs
Routine monitoring of vital signs is important in the manage-ment of the critically ill patient. The following table highlightsnormal values for the vital signs and potential causes forabnormal values.
Adult
Normal Increased Decreased
Heart rate
Respiratoryrate
Blood pres-sure
Tempera-ture
CRITCARE
60–100/min
12–20/min
110–130/70–90
36.5�–37.5�C
Tachycardia (pain,anxiety, hypoxe-mia, stress, fever,medication)
Tachypnea (pendingrespiratoryfailure, hypoxia,anxiety, fatigue)
Hypotension(hypovolemia,sepsis, shock,right or left heartfailure, increasedintrathoracicpressure)
Hyperthermia (infec-tion, sepsis, medi-cation, increasedmetabolism)
Bradycardia (suction-ing, hypoxia, vagalstimulation, heartblocks, medication)
Bradypnea (medica-tion, head trauma,hypothermia)
Hypertension(hypervolemia,anxiety, pain, CHF,increased systemicvascular resistance,polycythemia)
Hypothermia (CNSinjury, medication,postoperative)
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CRITCARE
Breath Sounds
See Bedside Assessment Tab
Fluid Balance
Positive pressure ventilation and the resulting positiveintrathoracic pressures can result in reduction in urine outputand concomitant fluid retention.
Normal Oliguria Polyuria
Urineoutput
Anion Gap
Anion gap is the difference between the positive ions (cations)and the negative ions (anions).■ Anion gap � (Na� � K �)�(Cl� � HCO3
�)■ Normal range: 10–14 mEq/L
Arterial Blood Gases
■ Oxygenation assessment■ Ventilation assessmentSee Advanced Assessment Tab
Oximetry and Capnography
See Advanced Assessment Tab
50–60 mL/hr or1200–1440mL/day
Decreased renalperfusion, dehydra-tion, renal failure,shock, decreasedcardiac output
Furosemide(Lasix),diabetes,increasedfluid intake
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ECG
See Advanced Assessment Tab
Hemodynamic Monitoring
See Advanced Assessment Tab
Initiation Of Mechanical Ventilation
Once the decision to initiate mechanical ventilation has beenmade, an airway must be established. Endotracheal intubation isthe preferred airway for interfacing the mechanical ventilatorwith the patient.
Indications for Mechanical Ventilation
■ Apnea or pending respiratory arrest■ Acute exacerbation of COPD (PaCO2 acutely above patient’s
baseline and pH �7.30), Type II failure■ Acute severe asthma■ Neuromuscular disease■ Acute hypoxemic respiratory failure (Type I failure)■ Heart failure and cardiogenic shock■ Acute brain injury■ Flail chest
CRITCARE
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CRITCARE
Physiologic Measurements (Parameters)
Indicating Ventilatory Failure
Pending
Ventilatory
Normal Failure
Tidal volume (VT)Minute volume (VE)Respiratory rateRapid shallowbreathing index (RSBI)Vital capacity (VC)Maximal inspiratory
pressure (MIP)PaCO2
PA-a O2(FIO2 � 1.0)PaCO2/PAO2
QS/QT
VD/VT
Modes of Mechanical Ventilation
A ventilator mode is the means by which a ventilator achievesventilation of the lungs. A mode can be classified according toits control variable, control type, and phase variables (pressure,volume, flow, or time) during the breath cycle.
5–7 mL/kg5–8 L/min12–20/min≤100
65–75 mL/kg�80 to �120
cmH2O35–45 mmHg30–50 mmHg0.8–0.92–5%0.25–0.40
�5 mL/kg�10 L/min�35/min�105
�10–15 mL/kg� �20 to �30
cmH2O�50 mmHg�350–450 mmHg�0.15�20%�0.6
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Volume-Controlled Ventilation (Volume is the Control Variable)
Trigger Limit Cycle Alarm
Mode Variable Variable Variable Cycle
CMV (volume control)
CMV-Assist (assistedventilation, assist/control volumeventilation, volumeassist mechanicalventilation)
VC-SIMV (volumecontrol synchronizedmandatoryventilation)
VC-SIMV � PressureSupport (volumecontrol synchronizedmandatory ventila-tion � pressuresupport)
Mandatory MinuteVentilation (mini-mum mandatoryventilation,augmented minuteventilation, extendedmandatory minuteventilation)
CRITCARE
M, T
M, T, P, F
M, T, P, F
M, T, P, FF, P(spont)
M, T, P, FP, F(spont)
F, V
F, V
F, V, P
F, V, PP(spont)
P, V, FP(spont)
T
T
T
TP, F(spont)
T, FP,F(spont)
P
P
P, T
P, T
P, T
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CRITCARE
Pressure-Controlled Ventilation
(Pressure is the Control Variable)
Trigger Limit Cycle Alarm
Mode Variable Variable Variable Cycle
Pressure-ControlledAssist Ventilation(pressure control,pressure assistmechanicalventilation)
Pressure-ControlledSynchronizedIntermittentMandatoryVentilation
Pressure-ControlledInverse RatioVentilation
Airway PressureRelease Ventilation(bi-level positiveairway pressure,variable positiveairway pressure)
Bilevel (BiPAP,biphasic)
Pressure SupportProportional Assist
Ventilation(proportionalpressure support)
M, T, P, FP, F(spont)
M, T, P, FP, F(spont)
M, T
M, T, F
T, P, F
P, FM, T, P, F
FP(spont)
F, V, PP(spont)
P
P
P
PP
T
T, FP, F(spont)
T
T, F
F
FT
P
P
P
None
None
P, TP
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118
CRITCARE
M, T, PP, F(spont)TP, F(spont)
T, P, FP, F(spont)T, FP, 0(spont)T, P, FP, F(spont)
P, FP, F(spont)T,P,FP,F(spont)
F
P, FP, F(spont)P, FP, F(spont)
PP, V(spont)P
P
PP, V(spont)PP(spont)
P
F, TV, F(spont)V, FV, F(spont)
T, F
T
T
FF,T(spont)T,FT, F, P
(spont)F
None
P
P
P, V
None
T,V
P
None
Dual Control (Either Volume or Pressure is a Control Variable)
Trigger Limit Cycle Alarm
Mode Variable Variable Variable Cycle
PressureAugmentation
Volume AssuredPressureSupport(volumeassisted pres-sure support)
Adaptive SupportVentilation
Autoflow
Pressure Regu-lated VolumeControl
Volume Support
Adaptive Support
TubeCompensation
Initial Ventilator Settings
A practitioner must establish and decide upon the mode, tidalvolume, minute ventilation, rate, FIO2, pressure support, inspira-tory flow pattern, and alarm limits when initiating mechanicalventilation. Initial ventilator settings based upon desired clinicalgoals or protocols are becoming more common than simplymaking specific individual ventilator settings or parameters.
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Mode Selection
Control
Strategy Variable Advantages Disadvantages Considerations
Volume-ControlledVentilation
Volume 1. May cause over-distention andstretch lung injury.
2. If peak pressures≥40 cmH2O orplateau pressures≥30 cmH2O, consi-der pressure-controlledventilation.
3. Careful setting ofthe pressure limit/alarm is importantto safety.
Patient may be lesssynchronous withthe ventilator.
Direct control ofVT and VE
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120
Mode Selection
Control
Strategy Variable Advantages Disadvantages Considerations
Pressure-ControlledVentilation
Dual-ControlledVentilation
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CARE
Pressure
Volume orPressure
1. High and lowVT and VE
alarms areimportant tosafety.
2. May need toaccept permis-sive hypercap-nia.
Proper setting ofthe highpressure alarmis important tosafety.
VT and VE varies
System leaks orpatient ventilatoryefforts may limitthe ventilator’sability to measuresystem com-pliance.
1. Can reduce thepatient’s work ofbreathing.
2. Can spare normallung units fromoverdistention.
Optimizes deliveryof VT by ventilatoralgorithms
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Tidal Volume■ Tidal volume is either set on a basis of milliliters per kilogram
of ideal body weight or set by a target plateau pressure limit.■ Ideal Body Weight (males) � 106 � (6 � [height in inches
�60])■ Ideal Body Weight (females) � 105 � (5 � [height in inches
�60])■ NOTE: IF HEIGHT IS �60 INCHES, IGNORE NUMBERS IN
PARENTHESES■ VT � 4–12 mL/kg and■ VT that maintains a plateau pressure ≤30 cmH2O
Minute VentilationMinute ventilation is adjusted to meet the oxygen and carbondioxide transport requirements of the patient. Increasing minuteventilation decreases carbon dioxide and increases alveolarPAO2.■ Men: VE � 4.0 � Body Surface Area (BSA)■ Women: VE � 3.5 � Body Surface Area (BSA)
Rate (frequency)■ The rate is set to maintain the desired minute ventilation and
optimal cycle time. Caution must be observed when increas-ing the rate so that the expiratory time does not becomeshortened excessively.
■ Choose a rate and manipulate minute volume to achieve adesired PaCO2.
Fraction of Inspired Oxygen (FIO2)Initially, the FIO2 is set between 0.6 and 0.9 upon ventilatorcommitment (if patient’s ability to oxygenate is unknown). After20 minutes, arterial blood gases should be drawn to assessventilation and oxygenation.■ Maintain SpO2 ≥90%■ Positive end expiratory pressure (PEEP) can be established at
5 cmH2O initially. Higher PEEP may be required for patientswith increased shunt fractions to maintain adequateoxygenation.
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Pressure SupportInitial setting of between 8 and 20 cmH2O adjusted to overcomeairway resistance or augment spontaneous volumes. Maintain aplateau pressure ≤30 cmH2O.
Inspiratory Flow Pattern■ Pressure-Controlled Ventilation: The variable flow pattern that
is characteristic of this mode of ventilation may be moresynchronous in patients with active ventilatory drives.
■ Volume-Controlled Ventilation: Establish the flow rate highenough to meet the patient’s demands. Adjust the flow toallow adequate time for exhalation and to prevent auto PEEP.
Alarm LimitsAdjust the alarm limits using the following guidelines:■ Low/High Exhaled Tidal Volume 100 mL of set VT
■ Low/High Exhaled Minute Volume 20% or 2.0 L■ Low/High Pressure Alarm 10–15 cmH2O■ Low/High Rate Alarm 10–15 breaths/minute■ Apnea Alarm 20 second delay■ High/Low FIO2 Alarm 5–10%
Ventilator Waveforms
Contemporary ventilators all display graphically real timewaveforms of flow, pressure, and volume on a breath-by-breathbasis. It is important to be able to rapidly interpret andunderstand the morphology or shape of what is being displayedand how it relates to the patient’s condition.
ScalarsScalar wave forms are graphic depictions of flow, pressure, orvolume displayed versus time.
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Flow Scalar
The flow scalar waveform depicts flow versus time. Inspiration is above the iso-flow line whileexpiration is below it. If one were to integrate the area under the inspiratory portion of thegraphic, it would equal the volume delivered (flow multiplied by time).
Time (seconds)
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Pressure Scalar
The pressure scalar waveform depicts pressure versus time. Note the following points; A, peakinspiratory pressure (PIP); B, plateau pressure (PALV) or alveolar pressure; and C, alveolaropening pressure (PAO). If one were to integrate the area under the pressure curve (inspiration),it would represent the mean airway pressure.
CRIT
CARE
Time (seconds)
Pre
ssur
e (c
mH
20)
2 4 6
A
BC
8 10 12 14
2220
18
16
14
12
10
8
6
4
2
0
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Volume Scalar
The volume scalar waveform depicts volume versus time. By reading the volume scale at peakinspiration, one may determine tidal volume delivery for that breath.
Time (seconds)
Vol
ume
(ml)
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126
LoopsLoops are helpful inthat pressure versusvolume or flow versusvolume may be dis-played. Loops arehelpful in assessinginspiratory work,changes in resistanceor compliance andthe effects of bron-chodilators (changein resistance), leaks,trigger sensitivity,and overdistention.
Pressure Versus
Volume LoopThe pressure versusvolume loop is helpfulin assessment of ven-tilatory work. Patienteffort or inspiratorywork is depicted bythe deflection of thewaveform into thesub-ambient regionof the loop (left of theiso-pressure line). Byminimizing the de-flection or the loopto the left, ventilatorywork can be reduced.
CRITCARE
-16-14-12
200
400
600
800
Vol
ume
(ml)
-10 -8 -6 -4 -2 -0 2 4 6 8 10 12 14 16
Pressure (cmH2O)
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Flow Versus Volume LoopThe flow versusvolume loop ishelpful in asses-sing airwayresistance andchanges in com-pliance. Airwayresistance is thehysteresis (dif-ference) betweenthe inspiratoryand expiratoryportions of theloop. Decreasedairway resistancecauses the de-flection of theexpiratory por-tion of the loopto be greater,reflecting im-proved expira-tory flow.
200
100
Volume (ml)
Flo
w (
lpm
)
0200 400 600 800 1000 1200 1400 1600 1800
-100
-200
-300
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50403020100
2 4 6 8 10 12 14
2 4 6 8 10 12 14
20 4 6 8 10 12 14Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
-10-20-30-40-50-60121086420
-2-4-6-8
-10
800
600
400
200
0
128
Normal Ventilator Graphics
Volume-Controlled VentilationFlow, pressure, and volume are three scalar waveforms normallydisplayed on a ventilator’s monitoring screen.
Pressure Triggered Spontaneous Breath
A spontaneous breath was pressure triggered when the pressuregraph deviated below baseline prior to the mandatory (ventilator)breath being initiated.
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Flow Triggered Spontaneous Breath
A spontaneous breath was flow triggered when the flow wave-form deviated from the baseline, initiating a mandatory(machine) breath.
50403020100
2 4 6 8 10 12 14
2 4 6 8 10 12 14
20 4 6 8 10 12 14Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
-10-20-30-40-50-60
121086420
-2-4-6-8
-10800
600
400
200
0
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130
Mandatory Breath
A mandatory (machine) breath is seen where neither pressure orflow changes resulted in breath delivery (time triggered).
CRITCARE
50403020100
2 4 6 8 10 12 14
2 4 6 8 10 12 14
20 4 6 8Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
10 12 14
-10-20-30-40-50-60121086420
-2-4-6-8
-10800
600
400
200
0
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PEEP
The addition of PEEP is shown where the pressure waveformbaseline becomes elevated above ambient pressure.
30
20
10
-10
-20
-30
-40
-50-60
16
14
12
10
8
6
4
2
0
800
600
400
200
0
02 4 6 8 10 12 14
20 4 6 8 10 12 14
20 4 6 8 10 12 14Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
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132
Pressure-Controlled VentilationFlow, pressure, and volume are three scalar waveforms normallydisplayed on a ventilator’s monitoring screen during pressure-controlled ventilation.
Pressure Triggered Spontaneous Breath
A spontaneous breath was pressure triggered when the pressuregraph deviated below baseline prior to the mandatory (ventilator)breath being initiated.
CRITCARE
30
40
20
10
-10
-20-30
-40-50
1412
10
8
6
42
0
-2-4
400
300
500
200
100
0
02 4 6 8 10 12 14
2 4 6 8 10 12 14
20 4 6 8 10 12 14Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
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CRITCARE
Flow Triggered Spontaneous Breath
A spontaneous breath was flow triggered when the flow wave-form deviated from the baseline, initiating a mandatory(machine) breath.
3020
10
-10
-20-30
-40-50
-60
16
14
12
10
8
6
4
2
0
800
600
400
200
0
02 4 6 8 10 12 14
20 4 6 8 10 12 14
20 4 6 8 10 12 14Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
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134
Mandatory Breath
A mandatory (machine) breath is seen where neither pressure orflow changes resulted in breath delivery (time triggered).
CRITCARE
3020
10
-10
-20-30
-40
-50-60
16
14
12
10
8
6
4
2
0
800
600
400
200
0
02 4 6 8 10 12 14
20 4 6 8 10 12 14
20 4 6 8 10 12 14
Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
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135
CRITCARE
PEEP
The addition of PEEP is shown where the pressure waveformbaseline becomes elevated above ambient pressure.
30
5040
2010
-10-20-30-40-50
14
12
10
8
64
2
0
-2
-4
600
500
400
300
200
100
0
02 4 6 8 10 12 14
2 4 6 8 10 12 14
20 4 6 8 10 12 14
Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
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136
Abnormal Ventilator Graphics
Air-trapping (Auto-PEEP)Air-trapping (Auto-PEEP) may be associated with high ventilatorrates, low inspiratory flow rates, high tidal volumes, or low orequal I:E ratios (1:1).
Air-trapping in Flow Volume Loop
CRITCARE
80
60
40
20
0
-20
-40
-60
-80
200 400 600 800 1000 1200
Flo
w (
lpm
)
Volume (ml)
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80
60
40
20
-20
-40
-80
-60
14
12
10
8
6
4
2
0
1200
1000
400
600
800
200
0
02 4 6 8 10 12 14
20 4 6 8 10 12 14
20 4 6 8 10 12 14
Time (seconds)
Vol
ume
(ml)
Pre
ssur
e (c
mH
2O)
Flo
w (l
pm)
Air-trapping in Scalar Waveforms
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138
Increased Airway Resistance (Raw)Increased Airway Resistance in Volume Loops
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139
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Increased Airway Resistance in Scalar Waveforms
Flo
wP
ress
ure
Vol
ume
Time
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140
Decreased Airway Resistance (Raw)Decreased Airway Resistance in Volume Loops
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141
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Decreased ComplianceDecreased Compliance in Volume Loops
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142
Decreased Compliance in Scalar WaveformsCR
ITCA
RE
Flo
wP
ress
ure
Vol
ume
Time
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143
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Increased ComplianceIncreased Compliance in Volume Loops
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144
Increased Compliance in Scalar WaveformsCR
ITCA
RE
Flo
wP
ress
ure
Vol
ume
Time
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145
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Overdistention
Overdistention is best observed in the volume versus pressure loop. Notice the “beaking” thatoccurs where there is little or no volume change for an increase in pressure.
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Trigger Asynchrony
Trigger asynchrony occurs when the trigger sensitivity (pressure or flow) is adjustedinappropriately causing increased patient effort or failure of the ventilator to initiate a breath.
CRIT
CARE
Flo
wP
ress
ure
Vol
ume
Time
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Discontinuance of Ventilatory Support
Discontinuance of mechanical ventilation reduces the risk of lunginjury, reduces the risk of ventilator-associated pneumonia,improves patient comfort, and will decrease costs. Therefore,discontinuance of mechanical ventilatory support is essential inimproving patient outcomes as soon as the patient has demon-strated the ability to sustain ventilation spontaneously andmaintain airway patency.
Assessment for Weaning
Prior to initiating a formal spontaneous breathing trial, thepatient should be assessed to determine if he or she is a candi-date for ventilator discontinuance. The following table summa-rizes the criteria that may be assessed prior to a spontaneousbreathing trial. These criteria should be individualized for eachpatient and careful assessment of the patient is important to asuccessful spontaneous breathing trial.
Acceptable Criteria for
Assessment Spontaneous Breathing Trial
Gas exchangePaO2/FIO2
FI O2
PEEPpHHemodynamic
stability
Ventilatory drive
SpO2 ≥85–90%�150–200 mmHg�0.40–0.50�5–8 cmH2O≥7.25Absence of clinically significant hypotension,
administration of only low-dose vasopres-sors (dopamine or dobutamine �5mcg/kg/min), absence of active myocardialischemia
Able to initiate a spontaneous breath
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Spontaneous Breathing Trial
A spontaneous breathing trial is a short 30–120 minute period oftime that the patient is allowed to breathe spontaneously withno or little ventilatory support. Most complications occur in thefirst 30 minutes of trial, therefore careful monitoring is importantearly in the trial.
Methods
CPAP (continuous positive airwaypressure)
Pressure supportAerosol T-piece
FailureFailure of a spontaneous breathing trial may be manifested inthe criteria summarized in the following table.
Rapid shallow breathingindex
Respiratory rateHeart rate
Respiratory patternHemodynamic instabilityPatient comfort
Return to Mechanical VentilationIf a patient fails a spontaneous breathing trial the patient shouldbe returned to mechanical ventilation and provided withadequate support to rest the patient and the ventilatory muscles.After a period of 24 hours, a spontaneous breathing trial shouldbe repeated to assess readiness for ventilator discontinuanceand extubation.
CRITCARE
5 cmH2O
5–7 cmH2OAdequate flow and FIO2
�105
�30–35/min�120/min or increased over 20%
from baselineIncreased work of breathingSystolic BP �90 or �180 mmHgUncomfortable, diaphoretic,
anxious, agitated
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Recommended Modes■ SIMV■ SIMV � Pressure Support■ Pressure Support■ Volume Support■ Volume Assured Pressure Support■ Mandatory Minute VentilationThe selection of a specific mode does not influence the outcomeof further spontaneous breathing trials. The goal should be toprovide a stable, nonfatiguing, comfortable form of ventilatorysupport for 24 hours before repeating a spontaneous breathingtrial.
Extubation
Once the patient has successfully demonstrated the ability tobreathe spontaneously, removal of the endotracheal tube shouldbe the next consideration. Successful removal of the artificialairway is dependent upon the patient’s ability to have a patentand protected airway.
Criteria for Assessment of Successful Extubation■ Cuff leak �110 mL while on assist-controlled ventilation with
the cuff deflated■ Spontaneous peak expiratory flow �160 L/min■ Absence of excessive secretions or need for frequent
suctioning
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150
Basic Life Support
Adult One-Man CPR
(From: 2005 American Heart Association Guidelines for Cardiopul-monary Resuscitation and Emergency Cardiovascular Care. Circulation2005 112 [Suppl I]: IV-22, © 2005 American Heart Association, withpermission.)
CRITCARE
Definitepulse
No pulse
Shockable Not shockable
Open AIRWAY, check BREATHING
If not breathing, give 2 BREATHS that make chest rise
Check rhythm. Shockable rhythm?
Resume CPR immediately for 5 cyclesCheck rhythm every 5 cycles;continue until ALS providers
take over or victim starts to move
Give 1 shockResume CPR immediately
for 5 cycles
No movement or response
AED/defibrillator ARRIVES Give 1 breathevery 5 to 6 secondsRecheck pulse every
2 minutes
Give cycle of 30 COMPRESSIONS and 2 BREATHSuntil AED/defibrillator arrives, ALS providers
take over, or victim starts to move
Push hard and fast (100/min) and release completelyMinimize interruptions in compressions
PHONE 911 or emergency numberGet AED or second rescuer (if available) to do this
If no response, check pulse:Do you DEFINITELY feel pulse within 10 seconds?
Note that boxes bordered by dotted lines are performedby health-care providers and not by lay rescuers.
1
2
3
4
5
6
7
89 10
5a
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Adult Foreign Body Airway Obstruction
Yes
Yes
Yes
No
No
No
Are there signs of severe airway obstruction?
Ask: Are you choking?
Perform abdominal thruststo remove foreign body
1. Activate EMS System2. Initiate CPR3. When opening the airway,
if object is observed, remove it
Is the victim unconsciousor unresponsive?
Monitor thevictim
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CRITCARE
Definitepulse
No pulse
Open AIRWAY, check BREATHING
If not breathing, give 2 BREATHSthat make chest rise
One Rescuer: Give cycles of 30 COMPRESSIONS and 2 BREATHS
Push hard and fast (100/min) and release completelyMinimize interruptions in compressions
Two Rescuers: Give cycle of 15 COMPRESSIONS and 2 BREATHS
No movement or responseSend someone to phone 911, get AED
Lone Rescuer:For SUDDEN COLLAPSE,
phone 911, get AED
Give 1 breath every3 seconds
Recheck pulse ever2 minutes
If no response, check pulse:DEFINITE pulse within 10 seconds?
1
2
3
4
5
5a6
Child One-Man CPR
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CRITCARE
Shockable Not shockable
Child >1 year:Check rhythm. Shockable rhythm?
Resume CPR immediately for 5 cyclesCheck rhythm every 5 cycles;continue until ALS providers
take over or victim starts to move
Give 1 shockResume CPR immediately
for 5 cycles
Note that boxes bordered by dotted lines are performedby health-care providers and not by lay rescuers.
If not already done, PHONE 911, for child get AED/defibrillator
Infant (<1 year): Continue CPR until ALS responders take over or victim starts to move
Child (>1 year): Continue CPR; use AED/defibrillator after 5 cycles of CPR(Use AED as soon as it is available for sudden, witnessed collapse)
7
8
9 10
(From: 2005 American Heart Association Guidelines for Cardiopul-monary Resuscitation and Emergency Cardiovascular Care. Circulation2005 112 [Suppl I]: IV-158, © 2005 American Heart Association, withpermission.)
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154
CRITCARE
Yes
Yes
Yes
Yes
No
No
No
Are there signs of severe airway obstruction?
Ask: Are you choking?
Perform abdominal thruststo remove foreign body
1. Activate EMS System2. Initiate CPR3. When opening the airway,
if object is observed, remove it
Is the victim unconsciousor unresponsive?
Monitor thevictim
Child Foreign Body Airway Obstruction
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155
CRITCARE
Victim isunresponsive
Victim isNot Breathing
Victim isBreathing
Yes
No
Assess Responsiveness
Assess Breathing
Activate EMS
Open the airway:1. Head tilt-chin lift2. Jaw-thrust
Check pulse< 60/min
(brachial or femoral)
Begin chest compressions:30 compression (100 per minute)
to 2 rescue breaths
After 5 cycles, reassess the patient1. Resume CPR or2. Provide rescue breathing or3. Place patient in recovery position
Perform rescue breathing:2 slow breaths (1 second per breath)
Place victim inrecovery position
and observevictim
Continue rescuebreathing, 1 breathevery 3–5 seconds
One-Man Infant CPR
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156
Two-Man Infant CPR
CRITCARE
Victim isUnresponsive
Victim isNot Breathing
Victim isBreathing
Yes
No
Assess Responsiveness
Assess Breathing
Activate EMS
Open the airway:1. Head tilt-chin lift2. Jaw-thrust
Check pulse< 60/min
(brachial or femoral)
Begin chest compressions:15 compression (100 per minute)
to 2 rescue breaths
After 5 cycles, reassess the patient1. Resume CPR or2. Provide rescue breathing or3. Place patient in recovery position
Perform rescue breathing:2 slow breaths (1 second per breath)
Place victim inrecovery position
and observevictim
Continue rescuebreathing, 1 breathevery 3–5 seconds
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157
CRITCARE
Infant Foreign Body Airway Obstruction
Yes
Yes
No Are there signs of severe airway obstruction?
Perform back slaps and abdominal thruststo remove foreign body
1. Activate EMS System2. Initiate CPR3. When opening the airway,
if object is observed, remove it
Is the victim unconsciousor unresponsive?
Monitor thevictim
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158
Automated External Defibrillator (AED) Algorithm
CRITCARE
Yes
No
Airway and Breathing1. Check breathing2. Open airway3. Give 2 rescue breaths
Circulation:1. Check pulse2. Begin compressions 30:2
Monitor the patient for:1. Breathing2. Pulse and circulation
Automated External Defibrillator1. Place AED next to victim,
turn on power2. Attach pads at sternum and apex3. Clear victim and press “ANALYZE”4. Clear victim and “SHOCK”
if advised5. Don't touch victim and “ANALYZE”6. Check carotid pulse and continue
CPR if indicated
Is the victim unresponsive?Monitor thevictim
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CRITCARE
Notes
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160
CRITCARE
Not shockable
Notshockable
Shockable
Shockable
Shockable
Give 5 cycle of CPR*
Give 5 cycle of CPR*
Give 5 cycle of CPR*
No
Check rhythmShockable rhythm?
Check rhythmShockable rhythm?
Check rhythmShockable rhythm?
Asystole/PEAVF/VT
• BLS Algorithm: Call for help; give CPR• Give oxygen when available• Attach monitor/defibrillator when available
PULSELESS ARREST
Continue CPR while defibrillatoris charging
Give 1 shock• Manual biphasic: device specific
(same as first shock or higher)Note: If unknown, use 200J
• AED: device specific• Monophasic: 360 JResume CPR immediatelyafter the shockWhen IV/IO available, give vasopressorduring CPR (before or after the shock)• Epinephrine 1 mg IV/IO
Repeat every 3 to 5 min or• May give 1 dose of vasopressin
40 U IV/IO to replace first orsecond dose of epinephrine
Give 1 shock• Manual biphasic: device specific
(typically 120 to 200 J)Note: If unknown, use 200J
• AED: device specific• Monophasic: 360 JResume CPR immediately
Resume CPR immediatelyfor 5 cycles
When IV/IO available,give vasopessor
• Epinephrine 1 mg IV/IORepeat every 3 to 5 min or
• May give 1 dose or vasopressin40 U IV/IO to replace first orsecond dose of epinephrine
Consider atropine 1 mg /IV/IOfor asystole or slow PEA rateRepeat every 3 to 5 min(up to 3 doses)
1
23
5
6
49
10
11
Advanced Cardiac Life Support
Pulseless Arrest Algorithm
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161
CRITCARE
Shockable
NoCheck rhythmShockable rhythm?
Go toBox 4
Continue CPR while defibrillator is chargingGive 1 shock• Manual biphasic: device specific
(same as first shock or higher dose)Note: If unknown, use 200J
• AED: device specific• Monophasic: 360 JResume CPR immediately after the shockConsider antiarrhythmics; give during CPR
(before and after the shock)amiodarone (300 mg IV/IO once, then consider additional 150 mg IV/IO once) or lidocaine(1 to 1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, maximum 3 doses or 3 mg/kg)
Consider magnesium, loading dose 1 to 2 g IV/IO for torsades de pointes
After 5 cycle of CPR,* go to Box 5 above
• Push hard and fast (100/min)• Ensure full chest recoil• Minimize interruptions in
chest compressions• One cycle of CPR: 30 compressions
then 2 breaths; 5 cycles = 2 min• Avoid hyperventilation• Secure airway and confirm placement• Rotate compressors every 2 min with
rhythm checks• Search for and treat possible
contributing factors:
– Hypovolemia– Hypoxia– Hydrogen ion (acidosis)– Hypo-/hyperkalemia– Hypoglycemia– Hypothermia– Toxins– Tamponade, cardiac– Tension pneumothorax– Thrombosis (coronary or pulmonary)– Trauma
• If asystole, go to Box 10• If electrical activity, check
pulse. If no pulse go to Box 10• If pulse present, begin
postresuscitation care
7
8
12 13
During CPR
* After an advance airway is placed rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pauses for breaths. Give 8 to 10 breaths/minute. Check rhythm every 2 miniutes.
(From: 2005 American Heart Association Guidelines for Cardiopul-monary Resuscitation and Emergency Cardiovascular Care. Circulation2005 112 [Suppl I]: IV-59, © 2005 American Heart Association, withpermission.)
05White (F)-05 4/6/07 5:18 PM Page 161
Bradycardia Algorithm
(From: 2005 American Heart Association Guidelines for Cardiopul-monary Resuscitation and Emergency Cardiovascular Care. Circulation2005 112 [Suppl I]: IV-68, © 2005 American Heart Association, withpermission.)
162
CRITCARE
Adequate Perfusion Poor Perfusion
Signs or symptoms of poor perfusion caused by the bradycardia?(e.g., acute altered mental status, ongoing chest pain,
hypotension or other signs of shock)
Observe/Monitor
• Maintain patent airway; assist breathing as needed• Give oxygen• Monitor ECG (identify rhythm), blood pressure, oximetry• Establish IV access
• Prepare for transcutaneous pacing;use without delay for high-degree block (type II second-degree block or third-degree AV block)
• Consider atropine 0.5 mg IV while awaiting pacer. May repeat to a total dose of 3 mg. If ineffective, begin pacing
• Consider epinephrine (2 to 10 μg/min) or dopamine (2 to 10 μg/kg per minute) infusion while awaiting pacer or if pacing ineffective
• If pulseless arrest develops, go to Pulseless Arrest Algorithm• Search for and treat possible contributing factors:
• Prepare for transvenous pacing• Treat contributing causes• Consider expert consultation
BRADYCARDIAHeart rate <60 bpm and
inadequate for clinical condition
– Hypovolemia– Hypoxia– Hydrogen ion (acidosis)– Hypo-/hyperkalemia– Hypoglycemia– Hypothermia
– Toxins– Tamponade, cardiac– Tension pneumothorax– Thrombosis (coronary
or pulmonary)– Trauma (hypovolemia,
increased ICP)
Reminders
1
2
3
4a
5
4
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163
CRITCARE
Notes
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164
CRITCARE
Symptoms Persist
Stable
Unstable
Wide (>0.12 sec)
Irregular
Regular
NARROW QRS*:Is Rhythm Regular?
Does rhythm convert?Note: Consider
expert consultation
WIDE QRS*:Is Rhythm Regular?
Expert consultation advised
TACHYCARDIA with Pulses
• Assess and support ABCs as needed• Give oxygen• Monitor ECG (identify rhythm), blood pressure, oximetry• Identify and treat reversible causes
• Establish IV access• Obtain 12-lead ECG
(when available)or rhythm strip
Is QRS narrow(<0.12 sec)?
• Attempt vagal maneuvers• Give adenosine 6 mg
rapid IV push. If no conversion, give 12 mg rapid IV push; may repeat 12 mg dose once
Perform immediate synchronized cardioversion• Establish IV access and
give sedation if patient is conscious; do not delay cardioversions
• Consider expert consultation
• If pulseless arrest develops, see Pulseless Arrest Algorithm
Irregular Narrow-Complex Tachycardia
Probable atrial fibrillation orpossible atrial flutter or MAT (multifocal atrial tachycardia)
• Consider expert consultation• Control rate (e.g., dilitazem,
ß-blockers; use ß-blockers with caution in pulmonary disease or CHF)
Is patient stable?Unstable signs include altered mental status, ongoing chest pain, hypotension or other
signs of shockNote: rate-related
symptoms uncommon if heart rate <150/min
1
2
3
612
7
8
11
45
Narrow
Tachycardia Algorithm
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165
CRITCARE
Does Not ConvertConvert
Regular Irregular
If rhythm converts, probable reentrySVT (reentry supraventricular tachycardia):• Observe for recurrence• Treat recurrence with
adenosine or longer-actingAV nodal blocking agents (e.g., dilitazem, ß-blockers)
If ventricular tachycardia or uncertain rhythm:• Amiodarone 150 mg IV
over 10 minRepeat as needed to maximum dose of 2.2g/24 hours
• Prepare for electivesynchronized cardioversion
If SVT with aberrancy• Give adenosine
(go to Box 7)
If atrial fibrillation with aberrancy:• See Irregular Narrow-Complex Tachycardia
(Box 11)
If pre-excited atrial fibrillation (AF + WPW)• Expert consultation advised• Avoid AV nodal blocking agents (e.g.,
adenosine, digoxin, dilitazem, verapamil)• Consider antiarrhythmics (e.g., amiodarone
150 mg IV over 10 min)If recurrent polymorphic VT, seek expert
consultationIf torsades de pointes, give magnesium
(load with 1-2 g over 5-60 min, then infusion)
If rhythm does NOT convert, possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia:• Control rate (e.g.,
dilitazem, ß-blockers;use ß-blockers with caution in pulmonary disease or CHF)
• Treat underlying cause• Consider expert
consultation9
13 14
10
• Secure, verify airway and vascular access when possible
• Consider expert consultation
• Prepare for cardioversion
– Hypovolemia– Hypoxia– Hydrogen ion (acidosis)– Hypo-/hyperkalemia– Hypoglycemia– Hypothermia
– Toxins– Tamponade, cardiac– Tension pneumothorax– Thrombosis (coronary or
pulmonary)– Trauma (hypovolemia)
During Evaluation Treat contributing factors:
* Note: If patient become unstable go to Box 4.
(From: 2005 American Heart Association Guidelines for Cardiopul-monary Resuscitation and Emergency Cardiovascular Care. Circulation2005 112 [Suppl I]: IV-70, © 2005 American Heart Association, withpermission.)
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166
CRITCARE
Chest Discomfort/Ischemia Algorithm
Review initial 12-lead ECG
Chest discomfort suggestive of ischemia
EMS assessment and care and hospital preparation:• Monitor, support ABCs. Be perpared to provide CPR and defibrillation• Administer oxygen, aspirin, nitroglycerin, and morphine if needed• If available, obtain 12-lead ECG; if ST-elevation:
– Notify receiving hospital with transmission or interpretation– Begin fibrinolytic checklist
• Notified hospital should mobilize hospital resources to respond to STEMI
Immediate ED assessment (<10 min)• Check vital signs; evaluate oxygen
saturation• Establish IV access• Obtain/review 12-lead ECG• Perform brief, targeted history,
physical exam• Review/complete fibrinolytic
checklist; check contraindications• Obtain initial cardiac marker levels,
initial electrolyte and coagulation studies
• Obtain portable chest x-ray (<30
min)Immediate ED general treatment• Start oxygen at 4 L/min; maintain
02 sat >90%• Aspirin 160 to 325 mg (if not given
by EMS)• Nitroglycerin sublingual, spray, or IV• Morphine IV if pain not relieved by
nitroglycerin
ST elevation or new or presumably new
LBBB; strongly suspicous for injury
ST-Elevation MI(STEMI)
Normal or nondiagnostic changes in ST
segment or T waveIntermediate/Low-Risk UA
ST depression or dynamic T-wave inversion; strongly suspicious for ischemia
High-Risk Unstable Angina/Non-ST-Elevation
MI (UA/NSTEMI)
1
2
3
4
5 9 13
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CRITCARE
(From: 2005 American Heart Association Guidelines for Cardiopul-monary Resuscitation and Emergency Cardiovascular Care. Circulation2005 112 [Suppl I]: IV-90, © 2005 American Heart Association, withpermission.)
Yes
Yes
<12 hours>12 hours
No
No
Time from onset ofsymptoms <12 hours?
Admit to monitored bedAssess risk status
(Tables 3, 4)
Reperfusion strategy:Therapy defined by patient and other criteria (Table 2)• Be aware of
reperfusion goals:– Door-to-balloon
inflation (PCI) goalof 90 min
– Door-to-needle inflation(fibrinolysis) goal of 30 min
• Continue adjunctive therapies and:– ACE inhibitor/
angiotensinreceptor blocker (ARB) within 24 hours of symptom onset
– HMG CoA reductase inhibitor(statin therapy)
High-risk patient (Tables 3, 4 for risk stratification:• Refractory ischemic
chest pain• Recurrent/persistent
ST deviation• Ventricular tachycardia• Hemodynamic instability• Signs of pump failure• Early invasive strategy,
including catheterization and revascularization for shock within 48 hours of an AMI
Continue ASA, heparin, and other therapies as indicated• ACE inhibitor/ARB• HMG CoA reductase
inhibitor (statin therapy)Not at high risk: cardiology
Start adjunctive treatments asindicated (see text for contrainidcations)Do not delay reperfusion• ß-Adrenergic
receptor blockers• Clopidogrel• Heparin (UFH or
LMWH)
Start adjunctive treatments as indicated (see text for contrainidcations)• Nitroglycerin• ß-Adrenergic receptorblockers• Clopidogrel• Heparin (UFH or LMWH)• Glycoprotein IIb/IIIa
Consider admission to ED chest pain unit or to monitored bed in EDFollow:• Serial cardiac markers
(including troponin)• Repeat ECG/
continuous ST segment monitoring
• Consider stress test
Develops high or intermediate risk
criteria (Tables 3, 4) OR troponin-positive?
Develops high or intermediate risk
criteria (Tables 3, 4) OR troponin-positive?
If no evidence of ischemia or infarction,
can discharge with follow-up
6
7
8
11
12
10 14
15
16
17
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168
Assessment of the Newborn
Vital Signs
Normal Vital Signs
Blood Blood
Pressure Pressure SpO2
Birthweight (mmHg) (mmHg) Heart Respiratory (Desired
(g) Systolic Diastolic Rate Rate Range)
500–700 50–60 26–36700–1000 48–58 24–361000–1500 47–58 25–351500–2000 47–60 23–352000–3000 51–72 27–46Term 64–72 50–55
Neonatal Arterial Blood Gas ValuespH: 7.30–7.45PaCO2: 35–45 mmHgPaO2: 50–70 mmHgHCO3
�: 20–26 mEq/L
Apgar Score
The Apgar score, named after Dr. Virginia Apgar, provides a quickassessment for depression upon delivery, performed at 1 and 5minutes after birth. The Apgar score can be remembered withthe acronym Appearance, Pulse, Grimace (reflexes), Activity(muscle tone), and Respiratory effort.
AppearancePink torso and Extremities 2Pink torso cyanotic extremities 1Cyanotic all over 0
1 Minute 5 Minutes
120–170 30–60 88–94%
NEOPEDS
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169
NEOPEDS
PulsePulse �100 2Pulse �100 1Absent 0Grimace (reflexes, irritability)Active, moving, crying 2Frown or grimace if stimulated 1No response to stimuli 0ActivityActively moving, resistance to 2
extension of extremitiesLimited movement, some flex- 1
ion of the extremitiesFlaccid or limp 0Respiratory effortCrying, vigorous breathing 2Irregular, weak, hypoventilating 1Absent 0Totals8–10 Normal, 4–6 Moderate Depression, 0–3 Immediate
Resuscitation Indicated
1 Minute 5 Minutes
1 Minute
1 Minute
5 Minutes
5 Minutes
1 Minute 5 Minutes
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170
NEO
PEDS
NEUROMUSCULAR MATURITYNEUROMUSCULARMATURITY SIGN
POSTURE
SQUARE WINDOW(Wrist)
ARM RECOIL
POPLITEAL ANGLE
SCARF SIGN
HEEL TO EAR
-1 0 1 2SCORE
-90° 90°
180°
180° 160° 140° 120°
140°-180° 110°-140°
60° 45°
Ballard Gestational Age Assessment
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171
NEO
PEDS
3 4 5SCORE
100° 90° <90°
90°-110° <90°
30° 0°
RECORD SCOREHERE
MATURITY RATING
SCORE Neuromuscular: Physical: Total:
TOTAL NEUROMUSCULARMATURITY SCORE
-10
-5
0
5
10
15
20
25
30
35
40
45
50
20
22
24
26
28
30
32
34
36
38
40
42
44
Score Weeks
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172
NEO
PEDS
PHYSICAL MATURITYPHYSICALMATURITY SIGN
SKIN
LANUGO
PLANTAR SURFACE
BREAST
EYE/EAR
GENITALS (Male)
GENITALS (Female)
-1 0 1 2SCORE
Sticky, friable,transparent
Clitoris prominentand labia flat
None
Heel-toe40–50 mm:-1<40 mm:-2
Lids fusedLoosely:-1Tightly:-2
Imperceptible
Scrotum flat, smooth
Gelatinous, red,translucent
Prominent clitorisand small labia minora
Sparse
>50 mmno crease
Lids openPinna flat
Stays folded
Barely perceptible
Scrotum emptyfaint rugae
Smooth pinkvisible veins
Prominent clitoris andenlarging minora
Abundant
Faint red marks
Sl. curved pinna;soft; slow recoil
Flat areola,no bud
Testes in upper canal,rare rugae
Superficial peelingand/or rash, few veins
Majora and minoraequally prominent
Thinning
Anterior transversecrease only
Well-curved pinna;soft but ready recoil
Stippled areola,no bud
Testes descending,few rugae
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173
NEO
PEDS
Cracking, pale areas,rare veins
Majora large, minora small
Bald areas
Creases ant. 2/3
Formed and firmInstant recoil
Raised areola3–4 mm bud
Testes down,good rugae
Parchment, deepcracking, no vessels
Majora cover clitoris and minora
Mostly bald
Creases overentire sole
Thick cartilage,ear stiff
Full areola,5–10 mm bud
Testes pendulous,deep rugae
Leathery, crackedwrinkled
3 4 5SCORE RECORD SCORE
HEREMATURITY RATING
SCORE Neuromuscular: Physical: Total:
TOTAL PHYSICALMATURITY SCORE
-10
-5
0
5
10
15
20
25
30
35
40
45
50
20
22
24
26
28
30
32
34
36
38
40
42
44
Score Weeks
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Evaluation of Respiratory Status: Silverman
and Andersen Index
Feature Score 0 Score 1 Score 2
Chest movement
Intercostal retractionXiphoid retractionNasal flaringExpiratory grunt
Acute Care of the Newborn
General Consideration in the Care of the Newborn
Thermoregulation
Heat loss in newborns
Environmental
Infection control
174
NEOPEDS
Equal
NoneNoneNoneNone
Respiratory lag
MinimalMinimalMinimalAudible with
stethoscope
Seesawrespiration
MarkedMarkedMarkedAudible
■ Radiant warmer■ Incubator■ Blankets■ Cap for the head (Beanie)■ Radiation (heat loss without physical
contact)■ Conduction (heat transfer to surface
through contact)■ Convection (air currents passing over
the neonate)■ Evaporation (evaporation of water
from the skin)■ Light■ Noise■ Incubator blanket or cover■ Five-minute scrub before entering the
NICU■ Hand washing and use of alcohol
hand sanitizer
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175
NEOPEDS
Acute Care of the Newborn
General Considerations in the Care of the Newborn
Neonatal jaundice
Skin care
Airway Management
Suctioning at BirthIs the neonate meconium stained, vigorous (strong ventilatoryefforts, muscle tone, and HR �100)?■ Airway suctioning not indicated■ If the neonate is not vigorous, suction prior to positive
pressure ventilation and resuscitation
Bag/Mask Ventilation (neonateapneic, gasping or HR �100)■ Open the airway (avoid overextension of the airway)■ Seal mask over nose/mouth■ Administer positive pressure breaths (30–40 cmH2O) for initial
breaths rate of 40–60/min using 100% oxygen■ Assess chest wall movement and HR response
■ Cover gown when leaving the NICU■ Use of disposable gloves with each
patient■ Separate stethoscope for each patient■ Phototherapy■ Exchange transfusion■ Medication (phenobarbital, albumin)■ Use of cotton balls to avoid abrasion
when cleansing■ Change TCM sites at least every 8 hours■ Use transparent dressings over IV sites■ Heated humidification for very premature
infants
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Intubation■ Ventilate neonate with 100% oxygen using bag/mask■ Establish HR, and SpO2 monitors if not already in place■ Insert stylet into the endotracheal tube just short of the
tube’s tip■ Ensure neonate is supine and airway is hyperextended
(opened) but not overextended■ Insert the laryngoscope blade into the mouth, opening the
airway and visualizing the vocal cords■ Insert the endotracheal tube stopping when the tip of the tube
has passed the vocal cords■ Resume positive pressure ventilation via endotracheal tube■ Confirm the tube’s position
■ End-tidal CO2 detection■ Chest x-ray■ Auscultation■ Observation of condensation during exhalation
■ Secure the endotracheal tube
Intubation and Suctioning Guidelines
Laryngoscope Endotracheal Suction
Birth Weight Blade Size Tube Size Catheter Size
�1000 g 0 2.5 mm 5 Fr1000–2000 g 0 3.0 mm 6 Fr2000–3000 g 0–1 3.5 mm 8 Fr�3000 g 1 3.5–4.0 mm 8 Fr
176
NEOPEDS
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177
NEOPEDS
Yes
Yes Yes
No
No
Yes
Apneic or HR <100?
Give epinephrine
HR <60?
HR <60?
Provide supplemental 02
with PPV
1. Provide 02 with PPV2. Give chest compressions
1. Provide supportive care2. Monitor the patient
Breathing or HR >100?
Is neonate vigorous?Breathing or crying?Clear amniotic fluid?Good muscle tone?
Evaluate:RespirationsHeart rate
Color
Keep the neonate warm (warmer, blankets, etc.)Position and clear airway if indicated
Dry and stimulate neonate (respiratory efforts?)
Neonatal Resuscitation Algorithm
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178
NEOPEDS
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
• Intubate patient• Establish mechanical ventilation• Initiate appropriate monitoring• Establish thermoregulation and continuing care
SpO2 >88%?
SpO2 >88%?
SpO2 >88%?
Consider HFOV
Increase F102 by 0.05–0.10
• Increase PEEP• Increase IT
PaCO2 >50 mmHg?
PaCO2 >50 mmHg?
Increase Minute Ventilation(Increase rate, PIP, etc.)
Consider alternativeventilation strategy
Continue therapyand monitor the
patient
• Rate: 30/min <3 kg wt; 25/min >3kg wt• Pressure: 15–20 cmH20• T1: 0.4–0.6 seconds• PEEP: 5 cmH20• F102: Titrate for SpO2 88–92%
Establish Initial Settings:
Ventilator Management of the Newborn
Neonatal Ventilator Management Algorithm
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179
NEOPEDS
Neonatal HFOV Ventilator Management Algorithm
Yes
Yes
No
No
No
Yes
Yes
Yes
No
Yes
No
NoYes
• Intubate patient• Establish mechanical ventilation• Initiate appropriate monitoring• Establish thermoregulation and continuing care
• Increase MAP• Consult physician
• Increase ) P andlower Hz
• Consult physician
1. Continuetherapy
2. Monitorpatient
3. Progresstowardweaning
SpO2 <88%?
88<SpO2 <92%?
88<SpO2 <92%on F1O2 0.04
Increase F1O2
Attempt lung recruitment
PaCO2 >65 mmHg?
50< PaCO2 >65?
50< PaCO2 >65?
Check ET tube andsuction prn
Increase ) PDecrease the Hz
• MAP 2–4 cmH20 >conventional MAP• ) P (adequate chest wiggle)• IT – 33%• PEEP: 5 cmH20• Hz 15 Hz <1 kg wt 12 Hz 1–2 kg wt 10 Hz 2–3 kg wt 8 Hz >3 kg wt
Establish Initial Settings:
06White (F)-06 4/6/07 5:58 PM Page 179
Pediatric Respiratory Care Procedures
Oxygen Therapy
Desired Desired
Liter Flow Liter Flow SpO2 SpO2
Device Neonatal Pediatric Pediatric Neonatal
Nasal cannula
Simple mask
Non- rebreathingmask
Venturi mask
Hood or headbox
180
NEO
PEDS
0.25–1 L/min
NA
NA
NA
�7 L/min (heated andhumidified withFIO2 andtemperaturemonitoring/regulation)
1–5 L/min
4–8 L/min
Up to 15 L/min
Varies by manu-facturer (24–50%)
�7 L/min (heatedand humidifiedwith FIO2 andtemperaturemonitoring/regulation)
≥90 %
≥90%
≥90%
≥90%
≥90%
88–92% 50mmHg �PaO2
�70 mmHgNA
NA
NA
88–92%50 mmHg�PaO2�70mmHg
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181
NEOPEDS
Yes
Yes
No
No
Is there evidence of upper airway edema?1. Laryngotracheobronchitis?2. Subglottic edema?3. Post-extubation edema?
Consider:Severe Disease - Oral Dexamethasone(0.6 mg/kg) to a maximum of 10–12 mg
Mild Disease - Oral Dexamethasone(0.15–0.3 mg/kg)
Is there history for?1. Airway hyperresponsiveness?2. Bronchoconstriction?
Initiate therapy:1. Large volume nebulizer2. Mist tent3. Hood4. Ultrasonic nebulizer
Monitor the patient
Monitor the patient Monitor the patient
Pediatric: Bland Aerosol Algorithm
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Pediatric: Bronchodilator Administration Algorithm
182
NEOPEDS
Yes
No Yes
Yes
No
No
Is there evidence of bronchoconstriction?1. Wheezing2. Decreased breath sounds3. Retractions or distress4. Tachypnea5. Nasal flaring or grunting
Administer medicationusing SVN
Administer medicationusing MDI or DPI
Can the patientfollow directions?
Is VT or PEFadequate?
Monitor the patient
Monitor the patient
Monitor the patient
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183
NEOPEDS
Pediatric: Mucolytic Therapy Algorithm
Yes
No
Is there evidence of thickpulmonary secretions?1. Rhonchi2. Wheezing3. Tachypnea4. Productive cough
Administer mucolytic via SVN• Acetylcysteine with a bronchodilator• Dornase alfa with a bronchodilator
Monitor the patient
Monitor the patient
06White (F)-06 4/6/07 5:58 PM Page 183
Pediatric: Vasoconstrictor Administration Algorithm
184
NEOPEDS
No Yes
Yes
No
Is there evidence ofupper airway edema?1. Stridor2. Retractions3. Tachypnea4. “Barky” cough
Consider:1. Severe stridor: 0.6 mg/kg
oral dexamethasoneup to 10–12 mg
2. Mild stridor: 0.15–0.3 mg/kgoral dexamethasone
Consider epiglottitis:1. IV antibiotics (ceftriaxone
or cefotaxime)2. Prepare for intubation
Fever >40° C?Stridorus?Drooling?Tachycardia/tachypnea?Left shift on differential?Positive cultures?
Monitor the patient
Administer RacemicEpinephrine via SVN
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185
NEOPEDS
Pediatric: Hyperinflation Therapy Algorithm
Yes
No Yes
No
Is there evidence of atelectasis?1. Chest x-ray2. Predisposing conditions3. Neuromuscular disease4. Inability to clear secretions
Can the patientfollow directions?
Monitor the patient
Monitor the patient
Initiate therapy:1. Incentive spirometry2. PEP therapy3. Deep breathe and cough
Monitor the patient
Initiate therapy:1. CPAP2. Bilevel positive
airway pressure3. IPPB
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186
NEOPEDS
Yes
Yes
No
No
No YesYes
Is there evidence of excessive secretions?1. Atelectasis or consolidation on x-ray?2. Bronchopulmonary dysplasia?3. Ineffective cough?4. Neuromuscular disease?5. Cystic fibrosis?6. Bronchitis?7. Meconium/foreign body aspiration?
Box 1 Techniques1. PEP therapy2. Autogenic drainage3. Flutter valve therapy4. High Frequency Chest Wall
Oscillation (HFCWO)5. Chest physiotherapy6. Consider suctioning
Box 2 Techniques1. PEP therapy2. Flutter valve therapy3. Deep breathe and cough4. Forced exhalation technique
Can the patientcough effectively?
Monitor the patient
Monitor the patient
Initiate therapy(see Box 1)
Initiate therapy(see Box 2)
Encourage deep breathing andcoughing, monitor the patient
Monitorthe patient
Do symptoms improveafter coughing?
Pediatric: Secretion Mobilization Algorithm
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187
NEOPEDS
Yes
Yes No
No
Does the child show signs of shock?
Does the child show signs of shock?
Consider1. Give more fluid2. Epinephrine
(0.1–1.0 mcg/kg) or3. Dopamine
(<20 mcg/kg/min) or4. Norepinephrine
(0.1–1.0 mcg/kg/min)
Consider1. Give more fluid2. Dobutamine
(2–20 mcg/kg/min) or3. Epinephrine
(0.05–0.3 mcg/kg/min) or4. Inamrinone (loading dose
0.75–1.0 mg/kg over 5 mincan repeat up to 3 mcg/kg)Infusion 10 mcg/kg/min
5. Milrinone (loading dose50–75 mcg/kg) infusion0.5–0.75 mcg/kg/min
Administer fluid bolus(10–20 mL/kg normal salineor lactated Ringer’s solution)
Hypotensive Normal BloodPressure
Monitorthe patient
Pediatric Advanced Life
Support (PALS) Child: CPR
See Critical Care Tab
Child: Post-Resuscitation Care Algorithm
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188
NEOPEDS
Yes
Yes
No
No
Is bradycardia causing severe symptoms?
HR <60?
During CPR:• Intubate and/or verify
endotracheal tubeposition
• Check:Electrode placementPaddle positionsPacer lead positions
• Give:Epinephrine every3-5 min or considerepinephrine ordopamine infusions
• Identify/treat causesHypoxema
Hypothermia Head injury Heart block Toxins/poisons/drugs
Give epinephrine:• IV 0.01 mg/kg
(1:10000 0.1 mL/kg)• Can repeat every 5 min
at same dosage
Give atropine:• 0.02 mg/kg
(min 0.1 mg)• May repeat one time
Perform chest compressionsgive oxygen and ventilate
Consider pacing
Should pulseless arrest occurgo to Pulseless Arrest Algorithm
Monitorthe patient
Child: Bradycardia Algorithm
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NEOPEDS
VF/VT
No VF/VT(including PEAand Asystole)
VF/VT?
During CPR:• Verify ET position• Establish IV access• Check electrode/
paddle positions• Give Epinephrine
every 3-5 minConsider:• Vasopressors• Antiarrhythmics• BuffersIdentify/Treat • Hypoxemia• Hypovolemia• Hypothermia• Hyper/hypokalemia• Tamponade• Tension pneumothorax• Toxins/poisons/drugs• Thromboembolism
• Support ABCs• Give oxygen/ventilation• Attach monitor/defibrillator
Defibrillate:• <3 times• Initial 2 J/kg,
then 4 J/kg
• Amiodarone(5 mg/kg bolus)OR if noamiodaroneavailable
• Lidocaine(1 mg/kg bolus)
Defibrillate: 4 J/kg• CPR drugs
during CPR
Defibrillate: 4 J/kg• CPR, drugs
Continue CPR< 3 min
Epinephrine:• IV/IO
(0.01 mg/kg[1:100000.1 mL/kg])
Epinephrine:• IV/IO
(0.01 mg/kg[1:100000.1 mL/kg])
Child: Pulseless Arrest Algorithm
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NEOPEDS
QRS >0.08 sec?
• Support ABCs• Give oxygen/ventilation• Attach monitor/defibrillator• Obtain 12-lead ECG
Sinus tachycardia?• Hx for rhythm?• P waves
present/normal• HR varies
w/activity• Variable R-R
intervalw/constantP-R interval?
• Infants rate <220• Child rate <180
• Establish IV access• Consider Adenosine
(0.1 mg/kg IV to maxdose of 6 mg)
• May double and repeatdose once (max. 12 mg/kg)using rapid bolus
• Consult pediatric cardiologist• Cardioversion (0.5–1.0 J/kg,
can to 2 J/kg• Consider sedation• Repeat 12-Lead ECG
Consider:• Amiodarone (5 mg/kg IV
over 20–60 min) OR• Procainamide (15 mg/kg IV
over 30–60 min). Don’t giveamiodarone and procainamidetogether OR
• Lidocaine (1 mg/kgIV bolus)
Supraventriculartachycardia?• Hx for rhythm?• P waves
absent/abnormal?• HR doesn't vary
w/activity• Abrupt rate
changes?• Infants rate >220• Child rate >180
During evaluation:• Give oxygen• Support ABCs• Confirm monitor• Consider consult• Prepare for
cardioversion
Identify/Treat:• Hypoxemia• Hypovolemia• Hypothermia• Hyper/hypokalemia• Tamponade• Tension pneumothorax• Toxins/poisons/drugs• Thromboembolism
Probableventriculartachycardia
Consider vagal maneuvers
Child:Tachycardia with Adequate Perfusion Algorithm
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NEOPEDS
Notes
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NEOPEDS
Get a 12-lead ECG
Does child have a pulse?
Sinus tachycardia?• Hx for rhythm?• P waves
present/normal?• HR varies
w/activity?• Variable R-R
intervalw/constantP-R interval?
• Infants (Rate <220/min)• Child (Rate <180/min)
Supraventriculartachycardia?• Hx for rhythm?• P waves
absent/abnormal?• HR doesn't vary
w/activity?• Sudden rate
changes?• Infants (Rate >220 min)• Child (Rate >180 min)
• Give oxygen• Attach monitor/defibrillator
Evaluate rhythm Evaluate rhythm
QRS >0.08 sec?
During Evaluation:• Give oxygen and ventilate• Support ABCs• Check monitor• Get expert consult• Prepare to cardiovert
Identify/Treat:• Hypoxemia• Hypovolemia• Hypothermia• Hyper/hypokalemia• Tamponade• Tension pneumothorax• Toxins/poisons/drugs• Thromboembolism• Pain
Ventricular Tachycardia?• Cardiovert (0.5–1 J/kg)Perform vagal maneuvers
Initiate CPR
Yes
No
YesNo
Child:Tachycardia with Poor Perfusion Algorithm
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NEOPEDS
Consider:• Amiodarone (5 mg/kg
IV over 20–60 min)• Procainamide (15 mg/kg IV
over 30–60 min). Don’tgive amiodarone andprocainamide together OR
• Lidocaine (1 mg/kg IV bolus[wide complex only])
• Repeat 12-lead ECG
Immediate cardioversionw/adenosine:• Cardiovert (0.5–1 J/kg
can to 2 J/kg)• Sedate if possible• Sedation must not
delay cardioversion
Immediate IV/IO
• Adenosine (0.1 mg/kgIV/IO [max dose 6 mg])
• May double and repeat once up to 12 mg(use rapid bolus)
OR
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Bronchodilators
Sympathomimetic Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
albuterol sulfate(Proventil,Ventolin)
bitolterol(Tornalate)
epinephrine(Adrenalin)
formoterolfumarate (Foradil)
isoetharine HCl(Bronkosol,Bronkometer)
1. Metered doseinhaler (MDI)
2. Inhalant solution3. Syrup4. Tablet
MDI
Inhalant solution
Dry powder inhaler(DPI)
1. Inhalant solution2. MDI
1. 90 mcg/puff (2 puffs 4 � daily)2. 0.5% or 5mg/mL (2.5 mg
4 � daily)3. 2mg/5mL (0.4mg/mL) (2–4 mg
3 � or 4 � daily)4. 2 or 4 mg (2 or 4 mg 3 � or
4 � daily)
0.37 mcg/puff(2 puffs every 8 hr)
1% or 10 mg/mL (2.5–5 mg 4 �daily)
12 mcg/puff(1 puff 2� daily)
1. 1% or 10 mg/mL (2.5–5 mg 4 � daily)
2. 340 mcg/puff (1–2 puffs4 � daily)
Tremors, tachycar-dia, palpitations,nausea, nervous-ness, dizziness,tachyphylaxis,headache
Same as foralbuterol
Same as foralbuterol
Same as foralbuterol
Same as foralbuterol
(Text continued on following page)
PHAR
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Sympathomimetic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
levalbuterol(Xopenex)
metaproterenolsulfate (Alupent,Metaprel)
pirbuterol (Maxair)
racemicepinephrine(Micronefrin,Vaponefrin)
1. Inhalant solution2. MDI
1. MDI2. Inhalant solution3. Syrup4. Tablet
MDI
Inhalant solution
1. 0.31, 0.63 and 1.25 mg(1.25 mg every 6–8 hr)
2. 45 mcg/puff(2 puffs every 4–6 hr)
1. 0.65 mcg/puff(2–3 puffs every 4 hr)
2. 5% or 50 mg/mL(5, 10, or 15 mg 3� or 4� daily)
3. 2 mg/mL (10 mg 3� or 4� daily)4. 10 and 20 mg
(20 mg 3� or 4� daily)
0.2 mcg/puff (2 puffs every 4–6 hr)
2.25% or 22.5 mg/mL(5.625–11.25 mg 4� daily)
Same as foralbuterol
Same as foralbuterol
Same as foralbuterol
Same as foralbuterol
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PHAR
MSympathomimetic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
salmeterol(Serevent)
terbutaline(Brethaire,Brethine, Bricanyl)
Anticholinergic Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
atropine sulfate(Atropine)
Inhalant solution 0.2% or 2 mg/mL(0.025 mg/kg 3 � or 4 � daily)
Dry mouth,dysphagia,dysphonia
DPI
1. MDI2. DPI
50 mcg/puff (1 puff 2 � daily)
1. 25 mcg/puff (2 puffs every 8 hr)2. 50 mcg/puff (2 � daily)
Same as foralbuterol
Same as foralbuterol
(Text continued on following page)
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Anticholinergic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
Ipratropiumbromide(Atrovent)
ipratropiumbromide ANDalbuterol sulfate(DuoNeb,Combivent)
tiotropium bromide(Spiriva)
1. Inhalant solution2. Metered dose
inhaler (MDI)
1. Inhalant solution2. MDI
Dry powderinhaler (DPI)
1. 0.5 mg or 500 mcg (unit dose)up to 4 � daily
2. 18 mcg/puff (2 puffs 4 � daily)
1. 0.083% or 3 mg Albuterol and0.017% or 0.5 mg Atrovent(1 unit dose 4 � daily)
2. 103 mcg/puff Albuterol and18 mcg/puff Atrovent
18 mcg/capsule (1 capsuleonce daily)
Same as foratropine
Same as foratropine. Alsodizziness,headache,nausea,nervousness,palpitations,tachycardia,tachyphylaxis,tremors
Same as foratropine
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PHAR
MXanthine
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
aminophylline(Aminophylline100, Amino-phylline 360)
theophylline(Aerolate, Slo-Phyllin, Theolair,Theo-Dur)
1. Tablets2. Elixir3. Suppository
1. Capsules/tablets
2. Elixir
1. 100 mg (10–12 mcg/dLserum level)
2. 21 mg/mL (10–12 mcg/dLserum level)
3. 360 mg (10–12 mcg/dLserum level)
1. 200 mg, 260 mg, 300 mgand 400 mg (10–12mcg/dL serum level)
2. 10 mg/mL (10–12 mcg/dLserum level)
Headache, anxiety,restlessness,tremor,convulsions,nausea, vomiting,abdominal pain,diarrhea,tachypnea,palpitations,diuresis
Headache, anxiety,restlessness,tremor,convulsions,nausea, vomiting,abdominal pain,diarrhea,tachypnea,palpitations,diuresis
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Corticosteroids
Pulmonary Inhaled Corticosteroids
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
beclomethasonedipropionate(Beclovent,Vanceril)
beclomethasonedipropionateHFA (QVAR)
budesonide(Pulmicort)
flunisolide (AeroBid)
flunisolide(Flovent)
triamcinolone aceto-nide (Azmacort)
Metered doseinhaler (MDI)
MDI
1. Dry powderinhaler (DPI)
2. Inhalantsolution
MDI
1. MDI2. DPI
MDI
42 mcg/puff (2 puffs 3 � or 4 �daily)
40 mcg and 80 mcg/puff (1–2puffs 2 � daily)
1. 200 mcg/cycle (1–2 � 2 � daily)2. 0.25 mg/mL (0.5 mg once daily)
250 mcg/puff (2 puffs 2 � daily)
1. 44, 110, or 220 mcg/puff (2 puffs 2 � daily)
2. 50, 100, or 250 mcg/puff
100 mcg/puff (2 puffs 3 � or 4 �daily)
Oropharyngeal fungalinfections, dysphonia,dysphagia, cough,bronchoconstriction
Oropharyngeal fungalinfections, dysphonia,dysphagia
Oropharyngeal fungalinfections, dysphonia,dysphagia, cough,bronchoconstriction
Same as for budesonide
Same as for budesonide
Same as for budesonide
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PHAR
MPulmonary Combination Product
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
fluticasone propi-onate andsalmeterol(Flovent andSerevent)
Nasal Inhaled Corticosteroids
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
beclomethasone(Beconase,Vancenase)
budesonide(Rhinocort)
flunisolide(Nasalide)
fluticasone(Flonase)
Dry powderinhaler (DPI)
100/50, 250/50 and500/50 mcg/puffFlovent/Serevent(1 puff 2 � daily)
Bronchoconstriction, cough,dizziness, dysphonia,dysphagia, headache,nervousness, oropharyngealfungal infections, palpitations
Metered doseinhaler (MDI)
MDI
MDI
MDI
42 mcg/spray (1 inhalationper nostril 2–4 � daily)
32 mcg/spray (2 sprayseach nostril 2 � daily)
29 mcg/spray (2 sprayseach nostril 2 � daily)
32 mcg/spray (2 sprayseach nostril 2 � daily)
Contact dermatitis, wheezing,nasal septum irritation,↑ intraocular pressure
Same as for beclomethasone
Same as for beclomethasone
Same as for beclomethasone
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Nasal Inhaled Corticosteroids (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
mometasone(Nasonex)
triamcinolone aceto-nide (Nasacort)
Nonsteroidal Asthma Medications
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
cromolyn sodium(Intal)
montelukast(Singulair)
MDI
MDI
50 mcg/spray (2 sprayseach nostril once daily)
55 mcg/spray (2 sprayseach nostril 2 � daily)
Same as for beclomethasone
Same as for beclomethasone
1. Metered doseinhaler (MDI)
2. Inhalantsolution
3. Dry powderinhaler (DPI)
Tablet
1. 800 mcg/puff (2 puffs4 � daily)
2. 20 mg/unit dose (1 unitdose 4 � daily)
3. 20 mg capsule (1 dose4 � daily)
10 mg (1 tablet daily)
Nasal congestion, dermatitis,cough, wheezing, epistaxis
Diarrhea, laryngitis, pharyn-gitis, nausea, sinusitis
(Text continued on following page)
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Nonsteroidal Asthma Medications (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
omalizumab(Xolair)
zafirlukast(Accolate)
zileuton(Zyflo)
Mucous Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
dornase Alfa(Pulmozyme)
guaifenesin(Mucinex)
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Injectionsolution
Tablet
Tablet
75 mg and 150 mg vials(150–375 mg injected subcu-taneously every 2–4 weeks)
20 mg (1 tablet 2 � daily)
600 mg (1 tablet 4 � daily)
Pain, fatigue, musculoskeletalpain, dizziness, dermatitis
Headache, infection, nausea,diarrhea, abdominal pain
Headache, pain, abdominalpain, lethargy, elevatedliver enzymes
Inhalantsolution
Tablet
1mg/mL (2.5 mg oncedaily)
600 mg (1–2 tabletsevery 12 hr)
Dysphonia, pharyngitis, laryngitis,rash, cough, chest pain
Nausea, cardiac palpitations, nerv-ousness, headache, dizziness,tachycardia, diarrhea
(Text continued on following page)
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Mucous Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
N-acetylcysteine(Mucomyst)
sodium bicarbonate
Surfactant Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
beractant(Survanta)
colfosceril palmitate(Exosurf)
Inhalantsolution
Inhalantsolution
10% and 20% solution or100 and 200 mg/mL (3–5 mL[20%] or 6–10 mL [10%]nebulized 3 � or 4 � daily)
2% or 20 mg/mL (2–5 mL upto 4 � daily)
Bronchospasm, nausea,rhinorrhea, airwayobstruction
Bronchial irritation
Inhalant solution
Powder(reconstitutedin sterile water)
25 mg/mL (100 mg/kgbirth weight instilledendotracheally)
13.5 mg/mL (5 mL/kgbirth weight instilledendotracheally)
Pulmonary compliance(barotraumas), airwayocclusion, high PaO2 values,overventilation, apnea,pulmonary hemorrhage
Same as for beractant
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Dry powderreconstituted insterile water as aninhalant solution
Dry powder (6 gm)reconstituted in 30mL of sterile waterfor an inhalantsolution
Inhalant solution
Dry powder inhaler
300 mg (300 mg onceevery 4 wk)
20 mg/mL (inhaled for12–18 hr/day for 3days minimumusing a SPAGnebulizer)
300 mg unit dose (1unit dose 2 � dailyfor 28 days. Dosingshould be followedby 28 days off themedication)
5 mg/dose blisters (2inhalations 2 � dailyfor 5 days)
Cough, bronchialirritation, dyspnea,bronchospasm
Bronchospasm,hypotension, rash,conjunctivitis
Cough, pharyngitis,rhinitis, dyspnea,fever, headache,chest pain,hemoptysis,bronchospasm
Diarrhea, nausea,vomiting, bronchitis,cough, dizziness
Inhaled Antimicrobial Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
pentamidineisethionate(Pentamidine)
ribavirin (Virazole)
tobramycin (Tobi)
zanamivir(Relenza)
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Cardiac Pharmacology
Cardiac Glycosides
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
digoxin (Lanoxin)
digitoxin(Purodigin)
Antiarrhythmic Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
Class IA
1. disopyramide(Norpace)
Capsules
Capsules, IVsolution
CHF symptoms,arrhythmias,hypotension
Same as for digoxin
50, 100, 150, 200 mcg (1.2–1.6 mginitial then 0.05–0.3 mg daily)
50, 100, 200 mcg, 100 and 250mcg/mL Inj solution (0.5 mgover 5 min then 0.125–0.5 mgdaily as needed)
1. Capsules 1. Dry mouth, urinaryretention
1. 100 and 150 mg (300 mginitial then 150 mg every6 hr)
(Text continued on following page)
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Antiarrhythmic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
Class IA
2. procainamide(Procanbid)
3. quinidine(Quinaglute)
Class IB
1. lidocaine(Xylocaine)
2. mexilentine(Mexitil)
3. tocainide(Tonocard)
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2. Tablets
3. Tablets
1. IV
2. Capsules
3. Tablets
2. Nausea, vomiting,dizziness, headaches,hepatic toxicity
3. Diarrhea, rash,dizziness, headache,nausea, vomiting
1. Dyspnea, respiratorydepression, cardiacarrhythmias,hypotension
2. Palpitations, chestpain, nausea,vomiting, dizziness,tingling
3. PVCs, nausea,vomiting, dizziness
2. 500 mg (50 mg/kg daily)
3. 324 mg (2 tablets every 8 hr)
1. 4%, 10%, 20% (1 mg/kg)
2. 150, 200, and 250 mg (400 mginitial then 200 mg in 8 hr)
3. 400 mg (400 mg every 8 hr)
(Text continued on following page)
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Antiarrhythmic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
Class IC
1. flecainide(Tambocor)
2. propafenone(Rythmol)
Class II
1. esmolol(Brevibloc)
2. metoprolol(Lopressor)
3. nadolol(Corgard)
4. propranolol(Inderal)
1. Tablets
2. Tablets
1. Dizziness, dyspnea,headache, nausea
2. Nausea, vomiting,dizziness
1. 50 & 100 mg (50 mg every12 hr)
2. 150, 225, 300 mg (150 mgevery 8 hr)
1. IV
2. Tablets, IV
3. Tablets
4. Tablets, IV
1. Confusion,bradycardia, chestpain, hypotension
2. Bradycardia, fatigue,depression, blurredvision
3. Fatigue, weakness,dizziness
4. Fatigue, GI upset,hypotension,dizziness
1. 10 mg/mL (0.05 mg over 1 minthen continuous infusion 0.05mg/kg/min)
2. 20, 40, 80, and 120 mg (40–80mg daily)
3. 10, 20, 40, 60, 80 mg, 1 mg/mLInj solution (40–320 mg/dayover 3 to 4 doses, IV 1mg in 10mL over 5 min)
4. 50 mg, IV solution 1 mg/mL(PO 50 mg 2 � daily, IV 5 mg at5 min intervals up to 15 mg)
(Text continued on following page)
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Antiarrhythmic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
Class II
5. atenolol(Tenormin)
Class III
1. amiodarone(Cordarone)
2. dofetilide(Tikosyn)
3. ibutilide(Corvert)
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5. Tablets, IV 5. Bradycardia,hypotension, heartfailure, SVT, VTach
5. 2 mg/mL (5 mg slow IV pushover 5 min wait 10 min thengive a second 5 mg doseover 5 min)
1. Tablets, IV
2. Capsules
3. IV
1. Dizziness, fatigue,ARDS, pulmonaryfibrosis, CHF symp-toms, nausea, vomiting
2. Headache, chest pain,dizziness, dyspnea,nausea
3. Polymorphicventricular tachycardia,nausea, headache
1. 200 mg, 50 mg/mL inj solution(400–600 mg PO daily over1–2 doses, IV 150 mg over 10min then 360 mg over 6 hr,then 145 mg over 18 hr)
2. 125, 250, 500 mcg (125–500mcg 2 � daily depending oncreatinine clearance)
3. 0.1 mg/mL in solution (2 mgsingle infusion)
(Text continued on following page)
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Antiarrhythmic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
Class III
4. sotalol(Betapace)
Class IV
1. diltiazem(Cardizem)
2. verapamil(Calan)
4. Tablets
1. Tablets, IV
2. Tablets, IV
4. Dyspnea, bradycardia,fatigue, dizziness,nausea, vomiting
1. AV block, dizziness,nausea, vomiting,headache
2. Headache, dizziness,fatigue, nausea
4. 80, 160, and 240 mg (80 mg2 � daily can ↑ to 240–320mg/day)
1. 30, 60, 90, and 120 mg,5mg/mL inj solution (PO30–120 mg 3 � or 4 � daily,IV 0.25 mg/kg over 5 min)
2. 40, 80, and 120 mg, IV2.5 mg/mL inj solution(PO 80 mg 3 � or 4 � daily,IV 5–10 mg bolus)
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Vasopressor and Inotropic Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
dobutamine(Dobutrex)
dopamine(Inotropin)
epinephrine(Adrenalin)
inamrinone(Inocor)
isoproterenol(Isuprel)
milrinone(Primacor)
norepinephrine
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IV
IV
IV
IV
IV
IV
IV
250 mg vials (2–20 mcg/kg/min)
40 mg/mL vial (low dose 1–5mcg/kg/min, moderate dose5–10 mcg/kg/min, high dose10–20 mcg/kg/min)
1:10000 and 1:1000 (1 mg or10 mL 1:10000)
5mg/mL vial (0.75 mg/kg notto exceed 1mg/kg)
1:5000 ampules (2–10mcg/min)
1 mg in 10, 20, or 50 mL (50mcg/kg over 10 min initialthen 0.5mcg/kg/min)
1mg/mL inj solution (0.5–1.0mcg/min)
Blood pressure fluctuation,headache, nausea, vomiting
Hypertension, ↑ myocardial O2demand, nausea, vomiting,headache, ischemia
Ischemia, angina, tachycardia
Nausea, vomiting, arrhythmias,headache, dizziness, dyspnea
Nervousness, headache,dizziness, tachycardia,nausea, vomiting
Cardiac arrhythmias, headache,hypokalemia, tremors
Nervousness, headache,dizziness, tachycardia,nausea, vomiting
(Text continued on following page)
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Vasopressor and Inotropic Agents (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
phenylephrine(Neo-Synephrine)
vasopressin(Pitressin)
Calcium Channel Blockers
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
amlodipine(Norvasc)
bepridil(Vascor)
diltiazem(Cardizem)
felodipine(Plendil)
IV
IV
10 mg/mL (10 mcg/kg/min)
20 units/mL (40 units IV)
Tachycardia, nervousness,dizziness, tremor, dyspnea
Headache, nausea, vomiting,ischemia
Tablets
Tablets
Tablets, IV
Tablets
2.5 mg (5–10 mg once daily)
200, 300 mg (200–300 mgonce daily)
30, 60, 90, 120 mg, 5mg/mLinj solution (PO 30–120mg 3� or 4� daily, IV0.25 mg/kg over 5 min)
2.5 mg (2.5–5 mg oncedaily)
Headache, fatigue, nausea,edema
Headache, palpitations, nausea,drowsiness, nervousness
AV block, dizziness, nausea,vomiting, headache
Headache, palpitations, nausea,edema(Text continued on following page)
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Tablets
IV
Tablets
Tablets
Tablets
5 and 10 mg (5–10 mg oncedaily)
2.5 mg/mL inj solution (5mg/hr IV infusion)
10 and 20 mg (10–30 mg 3 �to 4 � daily)
10, 20, 30 and 40 mg (20–40mg once daily)
180 and 240 mg (240–480mg once daily)
Headache, dizziness, fatigue
Headache, hypotension, nausea
Dizziness, flushing, headaches,weakness
Edema, headache, dizziness
1�AV block, bradycardia, chestpain, dizziness
IV 1.5 mg powder for reconsti-tution (2 mcg/kg/min bolusthen 0.01 mg/kg/min infusion)
Hypotension, ventriculartachycardia, headache,dizziness, nausea, vomiting
(Text continued on following page)
Calcium Channel Blockers (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
isradipine(DynaCirc)
nicardipine(Cardene)
nifedipine(Procardia)
nisoldipine(Sular)
verapamil(Isoptin)
Vasodilators
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
nesiritide(Natrecor)
07White (F)-07 4/6/07 6:24 PM Page 212
213
PHAR
M
IV, tablets
IV
5 mg/mL inj solution, 0.3,0.4 and 0.6 mg sublingualtablets (IV 5 mcg/min, PO0.3–0.6 every 5 min)
25 mg/mL (0.1 mcg/kg/min)
Hypotension, headache, nausea,vomiting
Hypotension, hypoxicpulmonary vasoconstriction,headache, nausea, vomiting
IV
IV
IV, tablets
100 and 150 mg/mL inj solution (1 mg/kg subcutaneously every 12 hr)
1000 Units/mL (60 Units/kg bolus then12 units/kg/hour)
Powder for reconstitution to 2mg/mL,1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg tablets(2.5–10 mg/day)
Hemorrhage, nausea
Hemorrhage,hypersensitivity
Hemorrhage,hypersensitivity
Vasodilators (Continued)
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
nitroglycerin
sodium nitro-prusside(Nitroprusside)
Anticoagulants
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
enoxaparin(Lovenox)
heparin sodium(Heparin)
warfarin(Coumadin)
07White (F)-07 4/6/07 6:24 PM Page 213
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PHAR
M
IV
Tablets
Tablets
Tablets
IV
Tablets
IV
2 mg/mL inj solution (0.25mg/kg IV over 10 to 60 minthen 0.125 mg/kg/mininfusion for 12 hr)
162 and 325 mg (162–325 mgPO)
75 mg (75 mg once daily)
25, 50, and 75 mg (75–100 mgPO 4� daily)
0.75 mg/mL and 2 mg/mL injsolution vials (180 mcg/kgover 1 to 2 min, followed by2 mcg/kg/min infusion)
250 mg (250 mg PO 2 � daily)
12.5 mg/50 mL inj solution(0.4 mcg/kg/min over 30 minfollowed by 0.1 mcg/kg/min)
Hemorrhage, thrombo-cytopenia, hypotension,bradycardia, nausea,vomiting
Anorexia, nausea, epigastricpain, allergic reactions
Pain, fatigue, edema,headache, dizziness,dyspnea
Dizziness, abdominal pain,headache, rash
Hemorrhage, allergicreactions
Diarrhea, nausea,dyspepsia, rash
Edema, pelvic pain,bradycardia, dizziness
Antiplatelet Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
abciximab(ReoPro)
aspirin
clopidogrel(Plavix)
dipyridamole(Persantine)
eptifibatide(Integrilin)
ticlopidine(Ticlid)
tirofiban(Aggrastat)
07White (F)-07 4/6/07 6:24 PM Page 214
215
PHAR
M
IV
IV
IV
IV
IV
Hemorrhage, allergicreactions
Same as for alteplase
Same as for alteplase
Same as for alteplase
Same as for alteplase
50 and 100 mg vials (15 mg IV bolusover 1–2 min then 50 mg over 30min then 35 mg over 60 min)
10.4 Unit powder for reconstitution(10 Units IV over 10 min, thenrepeat in 30 min)
250,000, 750,000, and 1,500,000Unit inj solution vials (1,500,000Units IV over 60 min)
50 mg powder for reconstitution in10 mL sterile water (30–50 mgdepending on pt weight [kg])
250,000 Unit powder forreconstitution in sterile water(6000 Units/min infused intoblocked artery)
Thrombolytic Agents
Generic Name
(Trade Name) Availability Strength (Dosage) Side Effects
alteplase(Activase)
reteplase(Retavase)
streptokinase
tenecteplase(TNKase)
urokinase
07White (F)-07 4/6/07 6:24 PM Page 215
216
PHAR
MAdvanced Cardiac Life Support (ACLS) Drugs
Trade Name
(Generic Name) Availability Strength (Dosage) Side Effects
adenosine(Adenocard)
amiodarone(Cordarone)
aspirin
atenolol(Tenormin)
atropine sulfate(Atropine)
digoxin(Lanoxin)
IV
IV
Tablets
IV
IV
IV
3mg/mL (6mg IV push)
50 mg/mL inj solution (IV 150 mgover 10 min then 360 mg over6 hr, then 145 mg over 18 hr)
162 and 325 mg (162–325 mg PO)
2 mg/mL (5 mg slow IV pushover 5 min wait 10 minthen give 2nd 5-mg doseover 5 min)
0.4 and 1.0 mg/mL (0.5–1 mg IVevery 5 min)
0.1 mg/mL (10–15 mcg/kg loadingdose)
(Text continued on following page)
Flushing, light headedness,headache, diaphoresis,palpitations
Dizziness, fatigue, ARDS,pulmonary fibrosis, CHFsymptoms, nausea,vomiting
Anorexia, nausea, epigastricpain, allergic reactions
Bradycardia, hypotension,heart failure, SVT, VTach
Myocardial ischemia, PVCs,worsening AV blocks
CHF symptoms, cardiacarrhythmias, hypotension
07White (F)-07 4/6/07 6:24 PM Page 216
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PHAR
M
Advanced Cardiac Life Support (ACLS) Drugs (Continued)
Trade Name
(Generic Name) Availability Strength (Dosage) Side Effects
diltiazem(Cardizem)
dobutamine(Dobutrex)
dopamine(Intropin)
epinephrine(Adrenalin)
esmolol(Brevibloc)
lidocaine(Xylocaine)
metoprolol(Lopressor)
IV
IV
IV
IV
IV
IV
IV
5mg/mL inj solution (IV 0.25mg/kg over 5 min)
250-mg vials (2–20 mcg/kg/min)
40-mg/mL vial (low dose 1–5mcg/kg/min, moderate dose5–10 mcg/kg/min, high dose10–20 mcg/kg/min)
1:10000 and 1:1000 (1 mg or 10mL 1:10000)
10 mg/mL (0.05 mg over 1 minthen continuous infusion 0.05mg/kg/min)
4%, 10%, 20% (1 mg/kg)
IV solution 1 mg/mL ( IV 5 mg at5 min intervals to 15 mg)
AV block, dizziness, nausea,vomiting, headache
Blood pressure fluctuation,headache, nausea, vomiting
Hypertension, ↑ myocardialO2 demand, nausea, vomit-ing, headache, ischemia
Ischemia, angina, tachycardia
Confusion, bradycardia, chestpain, hypotension
Dyspnea, respiratory depres-sion, cardiac arrhythmias,hypotension
Fatigue, GI upset, hypoten-sion, dizziness
(Continued text on following page)
07White (F)-07 4/6/07 6:24 PM Page 217
Advanced Cardiac Life Support (ACLS) Drugs (Continued)
Trade Name
(Generic Name) Availability Strength (Dosage) Side Effects
morphine sulfate
nitroglycerin
propranolol(Inderal)
procainamide(Procanbid)
sodiumbicarbonate
vasopressin(Pitressin)
verapamil(Calan)
218
PHAR
M
IV
IV, tablets
IV
IV
IV
IV
IV
0.5 and 1.0 mg/mL (2–4 mg IV over1–5 min)
5 mg/mL inj solution, 0.3, 0.4, and 0.6mg sublingual tablets (IV 5 mcg/min, PO 0.3–0.6 every 5 min)
1 mg/mL inj solution (40–320 mg/dayover 3 to 4 doses, IV 1 mg in 10 mLover 5 min)
100 mg/mL (20 mg/min IV infusion)
4% or 40 mg/mL solution (1 mEq/kgIV bolus)
20 Units/mL (40 Units IV)
IV 2.5 mg/mL inj solution (IV 5–10 mgbolus)
Hypersensitivity,respiratory depression
Hypotension, headache,nausea, vomiting
Fatigue, weakness,dizziness
Nausea, vomiting,dizziness, headaches,hepatic toxicity
Metabolic acidosis,hypoxia, electrolyteimbalance, seizures
Headache, nausea,vomiting, ischemia
Hypotension, headache,dizziness, fatigue, nausea
07White (F)-07 4/6/07 6:24 PM Page 218
219
PHARM
Starting an IV
■ Gather appropriate equipment■ Exam gloves■ Iodine and alcohol swabs■ Rubber tourniquet■ IV catheter■ Tape/dressing■ IV tubing and IV solution
■ Position the patient■ Palpate potential sites■ Apply the tourniquet■ Prep the site■ Aseptically prepare catheter and IV tubing/solution■ Insert IV catheter
■ Observe for “flash”■ Advance catheter■ Apply pressure proximal to IV site■ Attach IV tubing and IV solution
■ Remove tourniquet■ Secure IV site with tape/dressing■ Establish appropriate drip rate/monitoring
Dosage Calculations
Ratio and Proportion
��Ori
A
g
m
ina
o
l
u
D
n
o
t
se� � �
De
X
s
A
ir
m
ed
ou
D
n
o
t
se�
XAmount � ��De
A
si
m
re
o
d
u
D
n
o
t
se�
Original Dose
07White (F)-07 4/6/07 6:24 PM Page 219
220
PHARM
Example: You have a stock solution of 5 mg/mL. You need a 2.5mg dose. How much do you draw up?
��Ori
A
g
m
ina
o
l
u
D
n
o
t
se� � ��
De
X
s
A
ir
m
ed
ou
D
n
o
t
se�
�
X � � 0.5 mL
5.0 mg
Percent Solutions
The key to percent solutions is to convert them to mg/mL. Onepercent equals 1 gram of active drug in one hundred millilitersdilute or solution.Example:You have a stock solution of 0.5% and need a 2.5 mg dose. Howmuch do you need?
0.5% � � �
��Ori
A
g
m
ina
o
l
u
D
n
o
t
se� � ��
De
X
s
A
ir
m
ed
ou
D
n
o
t
se�
�
X � � 0.5 mL
5.0 mg
2.5 mg�
mL
2.5 mg��XAmount
5 mg�
mL
5 mg�
mL0.005 gm��
mL5 gm�100 mL
2.5 mg�
mL
2.5 mg��XAmount
5 mg�
mL
07White (F)-07 4/6/07 6:24 PM Page 220
221
TOOLS
Frequently Used Phone Numbers
SecurityICUEmergency RoomER (Fast Track)CCUNICUPICUAdvanced Care (ECG Telemetry)PFT LABSurgeryShort Stay SurgeryCardiology/EchocardiographyX-RayRadiologyPharmacyLaboratoryMicrobiologyPathologyPhysical TherapyOccupational TherapyInfection ControlIV TherapyMedical FloorOncology FloorPsych FloorOrthopedics FloorPediatrics FloorSurgical Floor
08White (F)-08 4/6/07 11:22 AM Page 221
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TOOLS
Frequently Used Phone Numbers (Continued)
Women’s/Post PartumBiomedical DepartmentInformation Technology Help DeskAdmittingCentral Cervices/Central SupplyChaplainPatient OmbudsmanSocial Work/Case ManagementLibraryMaintenanceEmployee HealthHuman ResourcesOtherOther
Physician’s Contact Information
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
08White (F)-08 4/6/07 11:22 AM Page 222
223
TOOLS
Physician’s Contact Information (Continued)
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
Name
Specialty
Office/Cell
08White (F)-08 4/6/07 11:22 AM Page 223
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TOOLS
Physician’s Contact Information (Continued)
Name
Specialty
Office/Cell
Physician Consultation
Physician: Office Phone: Cell Phone:
Specialty:
Patient Name
Date/Time
Patient Diagnosis
Vital Signs HR RR BP Temp SpO2
Oxygenation PaO2 QS/QT
PaO2/FIO2 FIO2/liter flow
Ventilation VE VT Rate
RSBI VD/VT
Breath Sounds
ABGs pH PaCO2 HCO3�
PaO2 SaO2 Hb
Chest X-Ray
Ventilator Settings Mode Rate/Hz PIP / ▲ P
PEEP/MAP PS VT
FIO2 TI TE
I:E VE
Concerns
Suggestions
Order Changes
08White (F)-08 4/6/07 11:22 AM Page 224
225
TOOL
SFrequently Used Home Care Companies
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
Name
Address
Telephone/FAX
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
08White (F)-08 4/6/07 11:22 AM Page 225
226
TOOL
S Frequently Used Home Care Companies (continued)
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
08White (F)-08 4/6/07 11:22 AM Page 226
227
TOOL
SFrequently Used Home Care Companies (continued)
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
08White (F)-08 4/6/07 11:22 AM Page 227
228
TOOL
S Frequently Used Home Care Companies (continued)
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
Name
Address
Telephone/Fax
Contact Person
Services Provided Oxygen ■ Nebulizers ■ CPAP ■ Apnea Monitoring ■ Home Ventilators ■
08White (F)-08 4/6/07 11:22 AM Page 228
229
TOOLS
Home Care Referral Notes
Patient Name
Patient’s Date of Birth
Patient’s Address
Patient’s Telephone - Home - Cell
Patient’s SSN
Ordering Physician
Patient’s Diagnosis HX of cor pulmonale,or CHF, or erythrocythemia Y ■ N ■
Room Air SpO2
Exercise Room Air SpO2
Nocturnal Room Air SpO2
Blood Gas Results pH PaCO2 HCO3�
PaO2 SaO2 FIO2/liter flow:
SpO2 with oxygen % Device: Liter Flow/FIO2:
Oxygen referral? Yes ■ No ■
Oxygen order:Nebulizer referral? Yes ■ No ■
Medication: Frequency:CPAP referral? Yes ■ No ■
PSG Sleep study date:PSG results:CPAP pressure:Bilevel Positive Airway Pressure:Ramp:Heated Humidity Ordered?Yes ■ No ■
08White (F)-08 4/6/07 11:22 AM Page 229
230
TOOL
S Schedule Planner/Organizer month_________
ACLS NRP Misc. Misc.
PALS CPR Misc. Misc.
08White (F)-08 4/6/07 11:22 AM Page 230
231
TOOL
SSchedule Planner/Organizer month _________
ACLS NRP Misc. Misc.
PALS CPR Misc. Misc.
08White (F)-08 4/6/07 11:22 AM Page 231
232
TOOL
S Event Scheduler (Projects,Term Papers, Examinations,
Seminars, Classes, etc.)
Date/Time Event Details
08White (F)-08 4/6/07 11:22 AM Page 232
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TOOLS
Frequently Used Equations
Physiology
Oxygenation
CvO2 � SvO2 (1.34 � Hb) � (PvO2 � 0.003)
O2ER � �CaO
C2
a�
OC2
vO2�
Qs/QT � �CCccOO
2
2
�
�
CCavOO
2
2�
CaO2 � SaO2 (Hb � 1.34) � (PaO2 � 0.003)
DO2 � QT � (CaO2 � 10)
VO2 � QT (Ca-vO2 � 10)
PAO2 � FIO2 (PB � 47 mmHg) � �Pa
0
C
.8
O2�
CcO2 � 1.0 (Hb � 1.34) � (PAO2 � 0.003)
Ventilation
RSBI � �V
f
T�
VE � VT � f
Anatomic Deadspace Estimation:
VD � 1 mL � Body Weight(Lb)
Bohr Equation (deadspace to tidal volume ratio):
VD/VT � �PaCO
P2
a
�
CO
P
2
ECO2�
Alveolar Ventilation:
VA � (VD/VT � VT)f
08White (F)-08 4/6/07 11:22 AM Page 233
234
TOOLS
Static Compliance: CST �
Dynamic Compliance: CDYN �
Hemodynamics
SVI � �B
S
S
V
A�
CI � �B
C
S
O
A�
RVSWI � SVI � (PA – CVP) � 0.013 gm/mL
LVSWI � SVI � (MAP – PCWP) � 0.013 gm/mL
PVR � �PA –
C
P
O
CWP� � 80
Blood Gas Formulas
Anion Gap: AG � Na� � (CI� � HCO3�)
Winter’s Formula: PaCO2 � 1.5(HCO3�) � 8(�2)
Delta Gap: Corrected HCO3� � (HCO3
�� (AG – 12))
Metabolic Acidosis (Expected PaCO2): PaCO2 � 0.9(HCO3�)� 9
Nutritional
BMI � � 703
Anion gap � (Na� � K�)� (CI�� HCO3�)
weight in pounds���(height in inches)2
Corrected VT���Peak Pressure – PEEP
Corrected VT����Plateau Pressure � PEEP
08White (F)-08 4/6/07 11:22 AM Page 234
235
TOOLS
Equipment Calculations
Cylinder Duration
“E” Cylinder Time ���0.28[
L
P
/m
r�e
i
s
n
(psi)]
“H” Cylinder Time ��3.14[
L
P
/m
r�e
i
s
n
(psi)]
Liquid System
Duration (in min) �
Pharmacology
Ratio and Proportions: �
Percent Solution to mg/mL:
0.5% � �1500
gmm
L� � �
0.00m5Lgm
� � �5mmLg
�
Desired Dose��
XAmountOriginal Dose��
Amount
0.8 [(Weight – Empty Weight) � 343 L/Lb Liquid Oxygen]�������
Liter Flow (L/min)
08White (F)-08 4/6/07 11:22 AM Page 235
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TOOLS
Common Abbreviations
ABG . . . . . . .Arterial Blood Gasac . . . . . . . . . . . . . .Before MealsACS . . . . . . . . .Acute Coronary
SyndromeADLs . . . . . .Activities of Daily . . . . . . . . . . . . . . . . . . . .LivingAF . . . . . . . . .Atrial FibrillationAFB . . . . . . .Acid Fast BacillusALS . . . . . . . . . . .Amyotrophic
Lateral SclerosisAMA . . . . . . . .Against Medical
AdviceAMI . . . . . . .Acute Myocardial
InfarctionANT . . . . . . . . . . . . . .AnteriorA-P . . . . . . . . . . . . . .Anterior -
PosteriorARDS . . . . . .Adult Respiratory
Distress SyndromeARF . . . . . . .Acute Respiratory
FailureASD . . . . . . . . . . .Atrial Septal
DefectAV . . . . . . . . . .AtrioventricularBE . . . . . . . . . . . . .Base ExcessBBB . . . . . . . . .Bundle Branch
Blockbid . . . . . . . . . . . . .Twice DailyBiPAP . . . . . . .Bi-Level Positive
Airway PressureBMR . . . . . . . .Basal Metabolic
RateBP . . . . . . . . . .Blood Pressurebpm . . . . . . .Beats Per MinuteBS . . . . . . . . . .Breath SoundsBSA . . . . . .Body Surface Area
BUN . . . .Blood Urea Nitrogenc . . . . . . . . . . . . . . . . . . . .WithCA . . . . . . . . . . . . . . . . .CancerCABG . . . . . . .Coronary Artery
Bypass GraftCAD . . . . . . . .Coronary Artery
DiseaseCBC . . .Complete Blood CountCHF . . . . . . .Congestive Heart
FailureCHO . . . . . . . . . .CarbohydrateCMV . . . . . . . . . . .Continuous
Mechanical VentilationCNS . . . . . . . .Central Nervous
SystemCO . . . . . . . . . .Cardiac OutputCOPD . . . .Chronic Obstructive
Pulmonary DiseaseCPR . . . . . . .Cardiopulmonary
ResuscitationCPT . . . . .Chest PhysiotherapyC&S . . .Culture and SensitivityCSF . . . .Cerebral Spinal FluidCT . . . . . . . . . . .Computerized
TomographyCVA . . . . . . . . .Cardiovascular
AccidentCVP . . . . . . . . .Central Venous
PressureCW . . . . . . . . . . . . .Chest WallCXR . . . . . . . . . . .Chest X-RayDC . . . . . . . . . . . . .DiscontinueDIC . . . . . . . . . . .Disseminated
IntravascularCoagulation
08White (F)-08 4/6/07 11:22 AM Page 236
237
TOOLS
DLCO . . .Single Breath CarbonMonoxide Diffusing
CapacityDNR . . . . .Do Not ResuscitateDOA . . . . . . . .Dead on ArrivalDOB . . . . . . . . . . .Date of BirthDOE . . . .Dyspnea on ExertionDTs . . . . . . .Delirium TremensDx . . . . . . . . . . . . . .DiagnosisECF . . .Extended Care FacilityECG . . . . . .ElectrocardiogramECHO . . . . . . .EchocardiogramECMO . . . . . . . .Extracorporeal
Membrane OxygenationEEG . . .ElectroencephalogramEENT . .Eyes Ears Nose ThroatEMG . . . . . .ElectromyelogramEMS . . . . .Emergency Medical
ServiceENT . . . . . .Ear, Nose & ThroatER . . . . . . . .Emergency RoomESR . . . . . . . . . . . .Erythrocyte
Sedimentation RateET . . . . . . . .Endotracheal TubeETOH . . . . . . . . .Ethyl AlcoholFUO . . . . . .Fever of Unknown
OriginFx . . . . . . . . . . . . . . . .Fractureg, gm . . . . . . . . . . . . . . .GramGFR . . . .Glomerular Filtration
RateGI . . . . . . . . . .Gastrointestinalgr . . . . . . . . . . . . . . . . . .GrainGSW . . . . . . .Gun Shot Woundgtt . . . . . . . . . . . . . . . . .DropsGU . . . . . . . . . . .GenitourinaryGYN . . . . . . . . . . .GynecologyHAV . . . . . . . .Hepatitis A VirusHb . . . . . . . . . . . .Hemoglobin
HBV . . . . . . . .Hepatitis B VirusHct . . . . . . . . . . . . .HematocritHCV . . . . . . . .Hepatitis C VirusHEENT . .Head Eyes Ears Nose
ThroatHIV . . . . . . . .Human Immuno-
deficiency VirusHR . . . . . . . . . . . . . .Heart Ratehs . . . . . . . . . . .Hours of SleepHTN . . . . . . . . . .HypertensionHx . . . . . . . . . . . . . . . . .HistoryI&O . . . . . . .Intake and OutputIABP . . . . .Intra-aortic Balloon
PumpICP . . . . .Intracranial PressureICU . . . . . .Intensive Care UnitIDDM . . . . .Insulin Dependent
Diabetes MellitusIM . . . . . . . . . . .IntramuscularIV . . . . . . . . . . . . .IntravenousJVD . . . . . . . . .Jugular Venous
Distentionkg . . . . . . . . . . . . . . .KilogramL . . . . . . . . . . . . . .Liter or LeftLAD . . . .Left Anterior Descen-
ding (coronary artery)LAT . . . . . . . . . . . . . . . .LateralLLL . . . . . . . . .Left Lower LobeLOC . . . . . . . . . . .Level/Loss of
ConsciousnessLP . . . . . . . . .Lumbar PunctureLUL . . . . . . . .Left Upper LobeLV . . . . . . . . . . . .Left VentricleLVAD . . . . . . . .Left Ventricular
Assist DeviceMAP . . . . . . . . . .Mean Arterial
Pressure orMean Airway
Pressure
08White (F)-08 4/6/07 11:22 AM Page 237
238
TOOLS
mcg . . . . . . . . . . . .MicrogramMD . . . . .Muscular DystrophyMDI . . . . . . . . . .Metered Dose
InhalermEq . . . . . . . . .Milliequivalentmg . . . . . . . . . . . . . .MilligramMI . . . . .Myocardial InfarctionmL . . . . . . . . . . . . . . .Millilitermm . . . . . . . . . . . . .MillimetermmHg . . . . . . . .Millimeters of
MercuryMMR . . . . . .Measles-Mumps-
RubellaMRI . . . . .Magnetic Resonance
ImagingMRSA . . .Methicillin-Resistant
Staphylococcusaureus
NEB . . . . . . . . . . .Nebulized orNebulizer
NG . . . . . . . . . . . .NasogastricNGT . . . . . . .Nasogastric tubeNICU . . . . .Neonatal Intensive
Care UnitNKA . . . . .No Known AllergiesNKDA . . . . . . .No Known Drug
Allergiesnoc . . . . . . . . . . . . . .NocturnalNPO . . . . . .Nothing by Mouth
(per os)NRB . . . . . . . .Non-RebreatherOB . . . . . . . . . . . . . .ObstetricsOD . . . . . . . . . . . . . .OverdoseOR . . . . . . . . .Operating RoomOT . . . . . . . . . . . .Occupational
TherapyOTC . . . . . . .Over-the-CounterP . . . . . . . . . . . . . . . . .Pressurep . . . . . . . . . . . . . . . . . . . .After
PA..................Posterior-AnteriorPAC..................Premature Atrial
ComplexPAR...................Post Anesthesia
RecoveryPAT ................Paroxysmal Atrial
TachycardiaPDA......................Patent Ductus
ArteriosusPE .............Pulmonary EmbolusPEA .............Pulseless Electrical
ActivityPEEP ....Positive End Expiratory
PressurePFT............Pulmonary Function
TestPICC .........Peripherally Inserted
Central CatheterPIH ..............Pregnancy Induced
HypertensionPMH .........Past Medical HistoryPMI.................Point of Maximal
ImpulsePND .......Paroxysmal Nocturnal
DyspneaPO ................By Mouth (per os)prn ............................As NeededPSVT.....Paroxysmal Supraven-
tricular TachycardiaPT .................Prothrombin TimePTT........Partial Thromboplastin
TimePVC.........Premature Ventricular
Contractionq.........................................Everyqd...............................Every Dayqh .............................Every Hourq2 ........................Every 2 Hoursq3 ........................Every 3 Hours
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q4 ........................Every 4 Hoursq6 ........................Every 6 Hoursq8 ........................Every 8 Hoursq12 ....................Every 12 Hoursqid...................Four Times DailyR .........................................RightRA..........................Right AtriumRLL ................Right Lower LobeRML .............Right Middle LobeR/O ...............................Rule OutROM ...............Range of MotionRUL ...............Right Upper LobeRx............................Prescriptions .....................................WithoutSA ...............................SinoatrialSIDS .........Sudden Infant Death
SyndromeSNF ...................Skilled Nursing
FacilitySOB...................Short of BreathStaph................StaphylococcusSTAT.......................ImmediatelyStrep ...................StreptococcusSubq ...................SubcutaneousSV .......................Stroke VolumeSVR...............Systemic Vascular
ResistanceT.............................TemperatureT&A ..............Tonsillectomy and
AdenoidectomyTB ..........................TuberculosisTEE .................Transesophageal
Echocardiogram
TIA ...............Transient IschemicAttack
tid ..................Three times dailyTKO .....................To Keep OpenTLC ............Total Lung CapacityTPN...................Total Parenteral
NutritionTPR . . . . .Temperature, Pulse,
RespirationsTx . . . . . . . . . . . . . . .TreatmentUA . . . . . . . . . . . . . .UrinalysisURI . . . . . . .Upper Respiratory
InfectionUTI . . . . . . . . . . . .Urinary Tract
InfectionUV . . . . . . . . . . . . . .UltravioletVC . . . . . . . . . . .Vital CapacityVF . . . . . . . . . . . . . .Ventricular
FibrillationV/Q Scan . . . . . . . .Ventilation/
Perfusion ScanVRE . . . . . . . . . . .Vancomycin-
Resistant EnterococcusWA . . . . . . . . . . .While AwakeWBC . . . . . . .White Blood Cell
CountWNL . . . . . . . . .Within Normal
Limitsw/o . . . . . . . . . . . . . . .Withoutwt . . . . . . . . . . . . . . . . .Weightyo . . . . . . . . . . . . . . . .Year Oldyr . . . . . . . . . . . . . . . . . . . .Year
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AAbbreviations, 236–239Adolescent, 3Adults, 4, 65–67Advanced cardiac life support
algorithms for, 160–167drugs used in, 216–218pediatric, 187–190
Aerosol tent, 73Aerosol therapy, 71–76, 181African Americans, 5Age-specific considerations, 2–4Airborne precautions, 1Air-trapping, 136–137Airway management
advanced airways, 108–109intubation, 109–110manual resuscitators, 107in newborn, 175–176positional maneuvers, 106
Airway resistance, 138–139Alveolar ventilation, 20, 233Anatomic deadspace, 20, 233Anion gap, 113, 234Anterior-posterior chest x-ray, 42Antiarrhythmic drugs, 205–209Anticholinergic agents, 196–197Anticoagulants, 213Antimicrobial agents, 204Antiplatelet agents, 214Apgar score, 168–169Arab Americans, 5Arterial blood gases
assessment of, 37–41, 113formulas, 234in newborn, 168
Arterial pressure monitoring, 53Artificial airway
care of, 110–111management of. See Airway manage-
mentAsbestosis, 64Assessment, 30–33Asthma
description of, 22, 64medications for, 201–202
Asystole, 53Atelectasis, 23, 45Atrial fibrillation, 48Atrioventricular block, 51–52Auscultation
chest, 18–19heart, 25–26
Automated external defibrillator, 158Auto-PEEP, 136–137
BBag/mask ventilation, 175Ballard gestational age assessment,
170–171Basic life support, 150–158Bilevel positive airway pressure, 79Biot’s respiration, 16Blood gases. See Arterial blood gasesBlood pressure, 13–14, 24, 112Body fat, 28Body mass index, 28, 234Bohr equation, 233Bosnian Americans, 6Bradycardia
advanced cardiac life support, 162algorithms for, 162, 188sinus, 48
Bronchial hygiene, 81–90Bronchial sounds, 18Bronchitis, 22, 64Bronchodilators, 182, 194–198Bronchoscopy, fiberoptic, 91–94Bronchovesicular sounds, 18Bruits, 27
CCalcium channel blockers, 211–212Capillary refill, 24Capnography, 96–97Cardiac auscultation, 25–26Cardiac enzymes, 27Cardiac glycosides, 205
Index
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Cardiac index, 57Cardiac palpation, 25Cardiopulmonary resuscitation
in adults, 150in child, 152–153in infant, 155–156in newborn, 177
Central venous pressure lines, 54Chest
auscultation, 18–19inspection of, 15percussion of, 18symmetry assessments, 17
Chest discomfort, 166–167Chest physiotherapy and postural
drainage, 83Chest x-rays, 41–45Cheyne-Stokes respiration, 16Child, 3, 152–154Combitude airway, 108Complete blood count, 34Compliance
in scalar waveforms, 142, 144in volume loops, 141, 143
Congestive heart failure, 45Consultation, 224Contact precautions, 1Continuous positive airway
pressure, 79Conversions, 8–9Corticosteroids, 199–201Cough, 20Crackles, 18Critically ill patients
cardiovascular assessment, 103fluid and electrolytes, 104monitoring of, 112–114neurological assessment, 104oxygenation assessment, 102–103physical findings, 101–102ventilatory assessment, 102ventilatory failure, 105vital signs, 101
Cultural diversity, 5–7Cylinder duration, 235Cystic fibrosis, 23Cytology, 36–37
DDouble lumen endotracheal tubes, 109Droplet precautions, 1Dual-controlled ventilation, 118, 120Dynamic compliance, 234
EElderly, 4Electrocardiogram, 46–53Emphysema, 22, 64Endotracheal tubes, 109Equations, 233–234Eupnea, 16Event scheduler, 232Exercise testing, 98–100Expiratory reserve volume, 58Extubation, 149
FFiberoptic bronchoscopy, 91–94Flow loop, 127, 136Flow scalar waveform, 123Forced expired volume in 1 second, 59Forced vital capacity, 59Foreign body airway obstruction
in adults, 151in child, 154in infant, 157
Fraction of inspired oxygen, 121Frequently used phone numbers,
221–222Functional residual capacity, 59
GGestational age assessment, 170–171Glasgow Coma Score, 104
HHead assessment, 15Heart rate, 13–14, 24, 112Heart sounds, 25–26Heat and moisture exchanger, 74Hematocrit, 34Hematology, 34Hemodynamics, 53–58, 234Hemoglobin, 34
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Histology, 36–37Home care
frequently used companies, 225–228referral notes, 229
Humidifiers, 73–74Humidity therapy, 71–76Hyperinflation therapy, 76–81, 185
IIncentive spirometry, 77Indwelling arterial lines, 53Infants, 2, 155–157Inhaled antimicrobial agents, 204Inotropic agents, 210–211Inspiratory capacity, 59Inspiratory reserve volume, 58Intermittent positive pressure breathing,
79Interview, 11–13Intrapulmonary percussive ventilation,
84Intravenous line, 219–220Intubation, 109–110, 176Ischemia, 166–167Isolation precautions, 1
KKussmaul’s respiration, 16
LLaryngeal mask airway, 108Lateral chest x-ray, 43Left ventricular stroke work index, 57Length conversions, 8–9Life support
advanced cardiac. See Advancedcardiac life support
basic, 150–158Loops, 126–127Lung drainage, 85–88
MMandatory breath, 130, 134Manual resuscitators, 107Mean cell hemoglobin, 34Mean cell hemoglobin concentration,
34
Mean cell volume, 34Mechanical ventilation
discontinuance of, 147–149dual-controlled ventilation, 118, 120fraction of inspired oxygen, 121indications for, 114–115inspiratory flow pattern, 122loops, 126–127minute ventilation, 121modes of, 115–118, 149pressure-controlled ventilation, 117,
120, 122, 132–135return to, 148tidal volume, 121ventilator. See Ventilatorvolume-controlled ventilation, 116,
119, 122, 128–131waveforms, 122–127weaning, 147
Metabolic acidosis, 39–40, 234Metabolic alkalosis, 39–41Metered dose inhalers, 74Mexican Americans, 7Microbiology, 36Minute ventilation, 121Minute volume, 20Mucolytic therapy, 183Mucous agents, 202–203Murmurs, 27
NNasal cannula, 67, 180Nasal inhaled corticosteroids, 200–201Native Americans, 6Nebulizers, 73–74Neck assessment, 15Neurological assessment, 27–28Newborn
acute care of, 174–193airway management in, 175–176Apgar score, 168–169assessment of, 168–174bland aerosol algorithm, 181bronchodilators, 182cardiopulmonary resuscitation algo-
rithm, 177gestational age, 170–171
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HFOV ventilator management algo-rithm, 179
hyperinflation therapy in, 185mucolytic therapy, 183oxygen therapy in, 180physical maturity, 172–173respiratory care, 180respiratory status, 174secretion mobilization in, 186vasoconstrictors, 184ventilator management, 178vital signs, 168
Non-rebreathing mask, 67, 180Nonsteroidal anti-inflammatory drugs,
201–202Nutritional assessment, 28–29
OOrganizer, 230–231Overdistention, 145Oximetry, 100Oxygen therapy
description of, 65–70in newborn, 180
Oxygenation, 21, 233
PPartial rebreathing mask, 67Patient interview, 11–13Percent solutions, 220Percussion, 18Pharmacology equations, 235Phone numbers, 221–222Physician
consultation with, 224contact information for,
222–224Platelets, 34Pleural effusion, 45Pneumonia, 23Pneumothorax, 45Point of maximal impulse, 25Portable sleep monitoring, 97–98Positive expiratory pressure, 78, 83,
131, 135Posterior-anterior chest x-ray, 42Postural drainage, 85–88
Premature ventricular contraction,49
Pressure conversions, 9–10Pressure loop, 126Pressure scalar waveform, 124Pressure-controlled ventilation, 117, 120,
122, 132–135Pulmonary artery catheter, 55Pulmonary artery pressures, 57Pulmonary edema, 23, 45Pulmonary embolus, 23Pulmonary function testing, 58–64Pulmonary inhaled corticosteroids,
199–200Pulmonary secretions, 35Pulmonary vascular resistance, 57Pulseless arrest, 160–161, 189
RRed blood cells, 34Residual volume, 58Respiratory acidosis, 40Respiratory alkalosis, 40Respiratory failure, 105Respiratory rate, 13–14, 112Resuscitators, 107Retinol-binding protein, 29Rhonchi, 18Right ventricular stroke work
index, 57Rub, 18Russian Americans, 7
SSarcoidosis, 64Scalar waveforms
airway resistance in, 139compliance in, 142, 144description of, 122–123, 137
Schedule planner, 230–231Serum albumin, 29Simple oxygen mask, 67, 180Sinus bradycardia, 48Skin testing, 37Sleep monitoring, portable, 97–98Spirometry, 59–60, 77SpO2, 13–14
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Spontaneous breathflow triggered, 129, 133pressure triggered, 128–129, 132
Spontaneous breathing trial, 148Sputum, 20Static compliance, 234Stroke volume index, 57Suctioning, of airway
description of, 111–112in newborn, 175
Surfactant agents, 203Swan-Ganz catheter, 55Sympathomimetic agents, 194–196Systemic vascular resistance, 57
TTachycardia
with adequate perfusion, 190advanced cardiac life support for,
164–165algorithms for, 164–165, 192with poor perfusion, 192–193ventricular, 50
TB testing, 37Temperature, 13–14, 112Temperature conversions, 8–9Thrombolytic agents, 215Tidal volume, 20, 58, 121Toddlers, 2Total lung capacity, 59Tracheostomy care, 90–91Trigger asynchrony, 146
UUrea nitrogen, 29Urine output, 113
VVasoconstrictors, 184Vasodilators, 212–213Vasopressors, 210–211
Ventilationassessment of, 20bag/mask, 175equations, 233–234mechanical. See Mechanical
ventilationVentilator
mandatory breath, 130, 134in newborns, 178normal graphics for, 128–135settings for, 118spontaneous breath, 128–129,
132waveforms for, 122–127
Ventilatory failure, 105, 115Ventilatory patterns, 16Ventricular fibrillation, 50Ventricular tachycardia, 50Venturi mask, 67Vesicular sounds, 18Vital capacity, 59Vital signs
assessment of, 13–14in critically ill patients, 101in newborn, 168
Volume loopsairway resistance in, 140compliance in, 141, 143description of, 126–127
Volume scalar waveform, 125Volume-controlled ventilation, 116, 119,
122, 128–131
WWeaning, 147Weight conversions, 8–9Wheezes, 18Winter’s formula, 234
XXanthine, 198
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