Ass: 5-10 sec ABC’s: 1˚-color, LOC& position, neck/chest, subj.

c/o,rhythm&pressure,IV,pulse,skin,caprefill,edema,analysis 2˚-auscultate,pupil,LE,abd,back,VS,hx,pul asses. ABG: acidosis handled well, alk tolerated poorly Compensatory Mech: Buffer systems: weakens strong acids/bases paCO2- 35-45 ↑ acid reflect of alveolar ventilation –rate&depth Pulmonary Sys: 1-3 min: eliminates/retains CO2 pH- 7.35-7.45 acd ↓ alk ↑ blood-measures free H+ ions. fatal: 6.8,7.8 Renal Sys: 24-48 hrs: elimn/retains HCO3, elim acids- (chronic) HCO3- 22-26 alk ↑ met/renal part. Base Excess: only reflects balance/not problem pH WNL=complete compens. pH outside= partial compens. PaO2 & SaO2:oxygenation of bld. OK:60-100 & >92%Resp acid=hypovent/CO2 ↑ tx:ventilate! Met acid= acc of acids- anion gap PaO2: parenchymal fxn, O2 avail->tissue; nl: 80-100 <60yrs; drops 1 q year; 65yo= acidosis(high) ex Lactic Acidosis vs loss Resp alk= hypervent/CO2 ↓ tx: under 75 , 80yo=60 -aff by paCO2, pH, temp SaO2: nl: >95% OK >92% of bases non anion gap acidosis ex diarh lying cause. i.e. anxiety nl paO2/fiO2: = >300 tells shape of lungs (vent/CPAP); <300 ALI, <200 ARDS Na-(Cl +HCO3)= 8-16 nl- non anion Shift to L: ˆpH, ˇDPG, ˇtemp bound resp failure= paO2<55-60 paCO2 25-35 saO2 <90% tx- airway, lowest FIO2, cause Tx : cause, NaHCO3 or Lactate Shift to R: ˇpH, ˆDPG inc the abi of impaired O2 perfusion, lung vent, ↓ pulm circu, inspired oxy, blood O2 Met alk=usu loss of acids ex:↓K/ ↑bases RBCs to release oxy,ˆtemp dissolved ex: antacids tx: cause, KCl-, NH3Cl CV ↓CO=↓HR ↓SV ↓PL ↑AL ↓ CNT Afterload: force ejection Contractility: inotropy Norepi-alpha must oppose – WKLOAD! Preload: stretch created by volume in vent just EF- echo/cath nl: 57-73% <50%bad Epi-beta and alpha before they contract- LVEDV&RVEDVnl: 2-8 mmHg Nl: 800-1400 dynes/sec/cm <35% worse Alpha- peripheral vessels/stim ↓ AL=↑CNT ↑AL=↓ CNT -SV ratio to EDV: % ejected vasoconstriction tx= low: fluids/vasopressor high:diuretics, vasoRV AL: pulm vas res CO= SV x HR: Beta1: myocardium dilator,UF (SBP= DBP + PP) PVR-100-250 -C.O./C.I: 4-8L/min C.I./BSA: 2.5-4.5L Stim: ˆino/chrono/dromo/automat, RV Preload: RVEDP: RAP or CVP -Stroke Work Index LVSWI/RVSWI LV AL: systemic SVR coronary vasodilation LV Preload: LVEDP: LAP or PAOP/PAWP/PCWP Nl: 50-62 g-m/m2 most sensitive indic tx= low: same preload Beta2: peri vessels/bronchioles nl: 6-12 mHg MAP- actual perfusion pressure ↑CO= ↑HR ↑SV =↑PL ↓ AL ↑ CNT high: vasodilator/ tx agg f Stim: vasodilat/bronchodilat {(2x DBP) + SBP}/3 (PP=SBP-DBP) Transducer maintenance leveling/zeroing phlebostatic axis (4th ICS/ ½ AP diameter 1 cm above= 0.73 mmHg decrease/ 1 inch+ 1.87 mm Hg dec Fast-flush Square Wave Test: Right Dominant Circulation: R coronary NL: 1-2 osc <.12 sec arteryRA(SA/AV node) + RV +inferior LV—Posterior Overdamped: no ringing-blunted/ no osc below baseline descending artery PDA false low SBP/false high DBP air bubbles, compliant L main coronary arteryLcircumflexLA+lateral wall—L tubing, low/open connections, low fluid level in flush bag anterior descending LADanterior wall of RV, apical wall Underdamped: mult osc above & below baseline Left Dominant Circulation: PDA fed by circumflex artificially spiked false high SBP/fals e low DBP artery- L circumflex LA+lateral wall+anterior wall of small air bubbles, tubing too long, defective transducer RV+apical wall+inferior wall PAC: CO/CI, preload, contractility/afterload©, 02 delivery & consumption RAP=CVP: 2-8 mm Hg/ 8-10 cm H2O R side preload RV=20-30/0-8 mmHg sys-RV ejection diast-RVEDP same as (RAP) PAP= pulm artery pressure- 20-30/8-15 mmHg PAP mean- 10-20 mmHg sys- RVejet RV PA RA PCW diastHIGH pulm HTN, pul Dx, hypervolemia LOW hypovolemia PAS= pulm artery sys- 20-30 RV ejection PAD= pulm artery diast (mean)-10 20 PA vasc tone PCWP/PAOP/PAWP: nl: 6-12 PCWP=LAP=LVEDP=LV prload High: ↑volume, ↓contract, mitral regurg or stenosis Low: hypvolemia, RV failure PAD= PCWP if NL condition w/o meds/pulm issues

Distal: PA Proximal: RA Balloon: wedging Thermistor: for C.O. VIP fluid port CVC: preload, contractility/afterload©,02 delivery & consumpt* CVC Complication: electrical, infection, -indicator: circulatory vol, venous return, RV compliance circ impairment: hemorrhage- disconnect, dislodge, open stopcock High- inc preload, inc volume, failure of ventricle air embolism: 1)mill wheel murmur (churning) d/t R vent outflow 2) gasp reflex d/t hypoxemia tx: Low- low preload, hypvolemic, dec venous return d/t vasodilators L lateral trendelenberg- air to apex where it can be aspirated/reabsorb hydrothorax: loss of breath sounds- catheter in pleural space A-Line SC/IJ: BP, CO/CI*,contractility/afterload©, Allen test ADHF: dyspnea,fatigue, fluid retention ADHF TX: #1 Preload: IV Diuretics, IV Vasodilator( NTG, Nesiritide (BNP), nitroprusside -S/E not for liver), Slow Ultrafiltration #2 Afterload #3 InotropesSys HF: ↓contraction, ↓ ejection, EF<40% Dias HF: ↓vent filling, ↓relaxation; EJ nl Milirone: potent Dobutamine: beta drug of choice inc contract & vasodilation, No NSAIDs & TZDs:Actos & Avandia d/t fluid retention dopamine- dose specific >10 mcg vasoconstriction thus inc. AL. BNP: >100pg/ml: hf, 100-500 tx with IV diuretics, add nesiritide if >500 admit tx asap confirmed pul congest, borderline hemodynamic instability, imp. Renal fx., Pulm edema: + pressure O2 CPAP,preload&afterload reduction, intotropes --Cong/↓Perf @ rest C&D, PCW ↓, CI ↓= inotrop. C&W, PCW ↑=vasodilator Cardio shock (inad. Tissue perf): C.I. <2.2 tx: maintain O2 vent, preload&afterload tx: OXY-(CPAP, intubation prn), PRELOAD, AFTERLOAD, INOTROPES-contract reduction, introtropics necessary, IABP/mech assist SV= nl: 60-100ml ACS: dyspnea, nausea, cold sweats, sense of doom, fatigue Guidelines STEMI: same as UA/STEMI MS:2-4,8prn but Revascularize: BB: blks adrenaline PCI or Thrombolytics is preferred intervention. Unstable angina: nonocclusive, no cell injury, T wave inversion ACEI: blocks ACE and/or ST depression, Cardiac Enz: NL Tx Goals (ACS): 1. Inc. coronary blood supply-restore blood flow ARB: blks agioten II Anti-plt therapy: ASA, Anti-thrombin Agents, Nitrates, STEMI: NSTEMI: nonocclusive, ishc->partial thickness nontransmural MCC: blks release of ALD revascularize via PCI/thrombolytics 2. Dec. Myocardial O2 demand-limit necrosis, t wave inversion and/or ST depress, cardiac enz: high Alpha blker: blk NEPI infarct size –Dec workload-Beta-Blockers, pain relief, nitrates. Goal: PCI: Guidelines UA/NSTEMI: d/c NSAIDS, O2, ASA 162Cablk: ↓HR ↓bp ↓o2 dem w/ in 12hrs &Door-Balloon <90 min-unless: inexperienced ctr, or >1hr 325mg,NTG SL/spray q5minx3-IVdrip till sx relief, MS, BB, Cardiac Enzymes: Plavix, Antithrombin, GPllb/lla inhibitor, ACEI-only if HTN/DM, delay > than expected time to thrombolytics; Thrombolytic Tx: w/in 12hrs Myoglob Angiography/ Revascularization. & Door Drug <30 mi-only if sx dur </= 3hrs & expected time to balloon Troponin 1,T >1hr than expected time to thrombolytics. STEMI: Injury: occlusive, transmural/full thickness cell necrosis, CKMB ST elev. (MI in prog), cardiac enz: high, AMI= ST elevation w/ Q wave ARDS:Acute, ALI/ARDS p/F <=300/200,bilat diffuse infiltrates,PCWP<18,refract ARF: inadequate gas exchange/ hypoxemia- ↓paO2, ↑ pCO2 Shunt: hypoxemia Mgmt: ventilator low vol 6-8 ok hypercapnia pCO2 >80, PEEP, alveoli blocked, cap perf. Ǿ respond to O2 need CPAP VQ MM: alv semi IRV,maintain C.O. but keep dry, proning ↑PaO2 >10 or ↑ p/f >20% w/in 2 hrs= blocked,responds to O2 Dead space: vent/ Ǿperf. Mgmt: O2>90%, responder. bronchdil,steroids,sed,neuroblock,analge.Pose good lung down, plan activity/ ADHF: rest,hydrate to loose secretion, pul-exer:C/DB hold 3secs x10/hr. Congestion @ rest, Low perf @ rest: Cold & wet, PCW ↑, CI ↓ = Vasodilator (NTG) ФCongestion @ rest, Low perf @ rest: Cold & dry, PCW ↓/nl, CI ↓= Inotropes

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