Respiratory Notes: Respiratory Therapist's Pocket Guide (Davis's Notes)

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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Copyright © 2008 by F. A. Davis Company

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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

For a convenient and refillable note pad

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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)

01White (F)-01 4/6/07 11:22 AM Page 2

3

BASIC

S

Age-Specific Considerations (Continued)



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.


01White (F)-01 4/6/07 11:22 AM Page 3

4

BASIC

SAge-Specific Considerations (Continued)



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.

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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.


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.


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


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


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?

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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.

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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


Pursed lipbreathing

↑ A-P Dia


↑ A-P Dia

↓ 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


↑ 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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24

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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26

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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27

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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28

■ 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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30

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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31

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.

36

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


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.


72 inches

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44

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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48

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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49

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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51

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


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57

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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58

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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59

ADVASSESS

Static Lung Capacities

Definition Normal*

Vital capacity (VC)Inspiratory capacity (IC)Functional residual

capacity (FRC)Total lung capacity

(TLC)


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%)


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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60

ADV

ASSE

SS

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61

ADV

ASSE

SS

Flow Volume Loop

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62

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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63

ADV

ASSE

SS

Diffusion Tests

Single Breath DLCO

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64

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


�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


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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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PROC

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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PROC

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


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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)


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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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PROC

■ 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


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PROC

Hyperinflation Techniques (Continued)


Positive ex-piratorypressure(PEP)

OscillatingPEPtherapy


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)


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,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.


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PROC

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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PROC

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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86

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


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88

Left Lateral Segment of the Lower Lobes

■ Position the patient on the right side with the foot of the bedelevated 18 to 20 inches


Right Lateral Segment of the Lower Lobes

■ Position the patient on the left side with the foot of the bedelevated 18 to 20 inches


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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92

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


Complications are uncommon, but can occur.■ Pneumothorax■ Hemorrhage■ Vasovagal response■ Infection

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96

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


■ 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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98

■ 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


■ 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


■ 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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102

■ 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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104

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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112

■ 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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114

ECG


Hemodynamic Monitoring


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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116

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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117

CRITCARE

Pressure-Controlled Ventilation

(Pressure is the Control Variable)



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

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)



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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Mode Selection

Control

Strategy Variable Advantages Disadvantages Considerations

Pressure-ControlledVentilation

Dual-ControlledVentilation

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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.

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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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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.

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-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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Mandatory Breath

A mandatory (machine) breath is seen where neither pressure orflow changes resulted in breath delivery (time triggered).

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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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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.

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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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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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Mandatory Breath

A mandatory (machine) breath is seen where neither pressure orflow changes resulted in breath delivery (time triggered).

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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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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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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

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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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Increased Airway Resistance (Raw)Increased Airway Resistance in Volume Loops

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Increased Airway Resistance in Scalar Waveforms

Flo

wP

ress

ure

Vol

ume

Time

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Decreased Airway Resistance (Raw)Decreased Airway Resistance in Volume Loops

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Decreased ComplianceDecreased Compliance in Volume Loops

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Decreased Compliance in Scalar WaveformsCR

ITCA

RE

Flo

wP

ress

ure

Vol

ume

Time

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Increased ComplianceIncreased Compliance in Volume Loops

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Increased Compliance in Scalar WaveformsCR

ITCA

RE

Flo

wP

ress

ure

Vol

ume

Time

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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.

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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.

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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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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.)

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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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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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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


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Yes

Yes

Yes

Yes

No

No

No

Are there signs of severe airway obstruction?

Ask: Are you choking?

Perform abdominal thruststo remove foreign body




Monitor thevictim

Child Foreign Body Airway Obstruction

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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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Two-Man Infant CPR

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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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Infant Foreign Body Airway Obstruction

Yes

Yes

No Are there signs of severe airway obstruction?

Perform back slaps and abdominal thruststo remove foreign body




Monitor thevictim

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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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Notes

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Not shockable

Notshockable

Shockable

Shockable

Shockable

Give 5 cycle of CPR*



No

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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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.


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Bradycardia Algorithm


162

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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

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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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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.


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166

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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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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:

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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

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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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189

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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190

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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191

NEOPEDS

Notes

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192

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





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Sympathomimetic Agents (Continued)

Generic Name


levalbuterol(Xopenex)

metaproterenolsulfate (Alupent,Metaprel)

pirbuterol (Maxair)

racemicepinephrine(Micronefrin,Vaponefrin)


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)






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MSympathomimetic Agents (Continued)

Generic Name


salmeterol(Serevent)

terbutaline(Brethaire,Brethine, Bricanyl)

Anticholinergic Agents

Generic Name


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)




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Anticholinergic Agents (Continued)

Generic Name


Ipratropiumbromide(Atrovent)

ipratropiumbromide ANDalbuterol sulfate(DuoNeb,Combivent)

tiotropium bromide(Spiriva)

1. Inhalant solution2. Metered dose

inhaler (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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MXanthine

Generic Name


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


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



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MPulmonary Combination Product

Generic Name


fluticasone propi-onate andsalmeterol(Flovent andSerevent)

Nasal Inhaled Corticosteroids

Generic Name


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)



Contact dermatitis, wheezing,nasal septum irritation,↑ intraocular pressure

Same as for beclomethasone



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Nasal Inhaled Corticosteroids (Continued)

Generic Name


mometasone(Nasonex)

triamcinolone aceto-nide (Nasacort)

Nonsteroidal Asthma Medications

Generic Name


cromolyn sodium(Intal)

montelukast(Singulair)

MDI

MDI

50 mcg/spray (2 sprayseach nostril once daily)




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


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Nonsteroidal Asthma Medications (Continued)

Generic Name


omalizumab(Xolair)

zafirlukast(Accolate)

zileuton(Zyflo)

Mucous Agents

Generic Name


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


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Mucous Agents (Continued)

Generic Name


N-acetylcysteine(Mucomyst)

sodium bicarbonate

Surfactant Agents

Generic Name


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


pentamidineisethionate(Pentamidine)

ribavirin (Virazole)

tobramycin (Tobi)

zanamivir(Relenza)

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Cardiac Pharmacology

Cardiac Glycosides

Generic Name


digoxin (Lanoxin)

digitoxin(Purodigin)

Antiarrhythmic Agents

Generic Name


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)


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Antiarrhythmic Agents (Continued)

Generic Name


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)


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Generic Name


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)


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Generic Name


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)


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Generic Name


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


dobutamine(Dobutrex)

dopamine(Inotropin)


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


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Vasopressor and Inotropic Agents (Continued)

Generic Name


phenylephrine(Neo-Synephrine)

vasopressin(Pitressin)

Calcium Channel Blockers

Generic Name


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


Calcium Channel Blockers (Continued)

Generic Name


isradipine(DynaCirc)

nicardipine(Cardene)

nifedipine(Procardia)

nisoldipine(Sular)

verapamil(Isoptin)

Vasodilators

Generic Name


nesiritide(Natrecor)

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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


nitroglycerin

sodium nitro-prusside(Nitroprusside)

Anticoagulants

Generic Name


enoxaparin(Lovenox)

heparin sodium(Heparin)

warfarin(Coumadin)

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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


abciximab(ReoPro)

aspirin

clopidogrel(Plavix)

dipyridamole(Persantine)

eptifibatide(Integrilin)

ticlopidine(Ticlid)

tirofiban(Aggrastat)

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IV

IV

IV

IV

IV

Hemorrhage, allergicreactions

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


alteplase(Activase)

reteplase(Retavase)

streptokinase

tenecteplase(TNKase)

urokinase

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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)


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

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217

PHAR

M

Advanced Cardiac Life Support (ACLS) Drugs (Continued)

Trade Name


diltiazem(Cardizem)

dobutamine(Dobutrex)

dopamine(Intropin)


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


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

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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

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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

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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

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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

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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


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


Name

Address

Telephone/Fax

Contact Person


08White (F)-08 4/6/07 11:22 AM Page 226

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TOOL

SFrequently Used Home Care Companies (continued)

Name

Address

Telephone/Fax

Contact Person


Name

Address

Telephone/Fax

Contact Person


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


Name

Address

Telephone/Fax

Contact Person


08White (F)-08 4/6/07 11:22 AM Page 228

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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 ■

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230

TOOL

S Schedule Planner/Organizer month_________

ACLS NRP Misc. Misc.

PALS CPR Misc. Misc.

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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

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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

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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

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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

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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

08White (F)-08 4/6/07 11:22 AM Page 238

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TOOLS

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

08White (F)-08 4/6/07 11:22 AM Page 239

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TOOLS

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

09White (F)-Index 4/6/07 11:20 AM Page 240

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TOOLS

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


242

TOOLS

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


243

TOOLS

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


244

TOOLS

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


Documents

Respiratory Notes: Respiratory Therapist's Pocket Guide (Davis's Notes)