12/17/08

Nasotracheal Intubation

• Blind
• Pt must be breathing spontaneously
• Indications
  • Conscious patients
  • Possible spinal injury
  • Trismus (clenched teeth)
• Contraindications
  • Head injury
• Equipment
  • Smaller size tube
  • No scope
• Technique
  • Preoxygenate
  • Advise to inhale
  • Lube with KY
  • Aim tip towards ear
  • Position just above glottis opening
  • Auscultate and otherwise confirm placement

Digital Intubation

• No scope
• Blood
• Bite block
• Left hand open epiglottis using index and middle fingers along right side of mouth, advance tube with right hand along left side of mouth
• Pass tube 2 inches past your fingers
• Use bite block
• Not for peds

   

ET Suction

• Sterile technique
• May cause arrhythmias and vagal response
• Avoid unless causing obstruction
• Pre and post oxygenate
• Pour sterile water down ET tube
• Introduce catheter and engage suction on way out for <15 sec

Extubation

• Hyperogygenate
• Have equipment
• Confirm responsiveness
• Lean forward
• Suction oropharynx
• Deflate cuff
• Extubate as pt coughs or exhales

Pediatrics

• Miller blade (floppy epiglottis)
• Preemie – size 0
• Size of pinky or >1 year age/4+4= size
• Use Braslow tape
• Smaller size are cuffless
• Curve stylet upwards, airway more anterior and superior
• Can cause parasympathetic response – counter with Atropine Sulphate
• Sniffing position
• Record depth of tube
• Confirm proper placement
• Breath sounds travel easily in children

DOPE (troubleshooting a deteriorating patient)

• Displacement – re-auscultate
• Obstruction – suction
• Pneumothorax – absent sounds on one side
• Equipment failure –

CPAP (Continuous Positive Airway Pressure)

• Used in CHF, obvious difficulty, oxygenated (maintain own airway)- increases pressure in the alveoli to keep fluid in vascular space and out of lungs
• Contraindications
  • AMS
  • No patent airway
  • COPD
  • More…
• Connect to o2 tank. Set pressure to 5cm at minimum – increase to 10cm max.
• Introduce slowly to patient

Chest decompression

• Evacuate air in the pleuritic space
• Indications (all required)
  • JVD
  • Obvious dyspnea
  • Tracheal deviation

Procedure

• Landmark: 2^nd intercostal space – (above third rib – below ribs contains vasculature and nerves)
• Listen for air escape
• Create a flutter valve – use a glove finger

12/08/08

Dr G

Document and share your findings

• Quantifiable objective information obtained from patient
• Vital signs
• Head to toe survey

Exam techniques

• Scene survey
  
  • Your safety
  • Look at bystanders, read faces, etc get clues
  • Sick or not sick
  • Signs of significant distress
  • Other aspects worth noting; dress, hygiene, expression, size, posture, odors, overall state of health
  • Skin; quickest and most reliable initial evaluation tool, color, moisture, temp
  • Mental status, AVPU
• Inspection
  
  • Look at the patient
  • General or specific area
• Palpation
  
  • Ask patient to point out area of pain, where it started, etc
  • Touching or the purpose of obtaining information
  • Tenderness, deformity, crepitance, masses, pulse quality, organ enlargement
• Percussion
  
  • Listen for level of organ (hollow vs. solid)
  • i.e. lungs , pleural effusion will sound very dull
  • bowel obstruction, can sound very typaninic (like a drum)
  • normal lungs sounds
  • bone sounds
  • muscle sounds
• Auscultation
  
  • High pitched and low pitched sounds
  • Bowel sounds, listen for normal peristaltic sounds
  • Paralytic illus – bowel not working properly (look up)
• Vital
  signs
  • Need baseline and changes
  • Pulse rate rhythm and quality (brady – could be head trauma, tachy, fever, fluid loss, etc. ) (thyroidism – hypo vs hyper , slows body vs quickens vitals)is pulse present at extremity? Check diabetics for distal pulses
    • Check pulse vs. apical heart rate
    • Basic way evaluate perfusion and CO
    • Carotid = 70 -BP
    • Radial = 90-100 BP
    • Maximum Sustainable Heart Rate – 220 – Age
  • Respiratory rate rhythm and quality (tachycardia and tachypnea – until proven otherwise don’t miss pulmonary embolism (smokers, travelers) any head issues can affect resp rate, cva, head injury, etc. Also secondary to pulmonary problems, asthma, pneumonia, etc
    • Try to distract patient
    • Look at chest, look for abdominal breathing, accessory muscle use, nasal flaring
    • Quality of efforts
    • Cheyne-Stokes – real fast and deep and then apnea and repeat
  • Blood pressure –(orthostatic changes – can be due to GI bleed or other internal bleed, dehydration, fluid loss, some meds) (Unequal BP or pulses could be sign of aortic or abdominal aneurism)use right size cuffs – will affect reading
  • Temp – febrile? OD (cocaine will raise temp) hyperthyroidism, infection – Lower – hypothyroidism, drowning, hypothermia, sepsis
  • Spo2 – don’t trust the machine; always look at your patient! Weather, peripheral circulation, etc,
• Skin, Hair & Nails
  
  • Largest organ system
  • Regulates temp of body
  • Transmits info about the environment to the brain
  • Exam by inspection and palpation
  • Color, moisture, temp, texture, turgor, significant lesions, mottling, crepitus
  • Vasodilation – Blushing, body trying to let heat escape,
  • Hair – inspect and palp, quantity, texture, distribution, recent hair loss, thinning,
  • Nails – Color, shape, texture, pitting, cracked, etc.
• HEENT
  
  • Head: brain, eyes, sensory organs, upper airway
    
    • Cranium
      
      • Foramen magnum
      • Occiput
      • Temporal areas
      • Layer of muscle covers skull
      • Scalp
      • Meninges
      • Dura matter
      • Arachnoid and pia matter
      • CSF
    • Face – DCAP-BTLS (if orbital bones are broken could affect eye movement by entrapment of ocular muscles)
  • Eyes: both motor and sensory functions, (20% of population have unequal pupils)
    
    • Hyphema – blood across middle of eye – transport sitting up – serious injury
    • PEARL
    • Pain, loss of vision, diplopia, photophobia (seen in migraines, meningitis), burring, discharge, contact lens
    • Lids, Lashes tear ducts, foreign bodies, clarity, conjunctivae, extra ocular range of motion,
  • Ears: Check for changes in hearing, balance –
    look for Blood , fluid, CSF
  • Nose: sensory organ, important role in breathing – look anteriorly and inferiorly – asymmetry, deformity, wounds, foreign bodies, discharge, etc
    
  • Throat: respiratory and digestive systems,
    • inspect back of oropharynx
    • overall hydration status
    • foreign body or aspiration
    • begin with lips
    • (Adult thrush – could be HIV)
    • Gums – pink. Tongue size color and moisture, uvula for swelling
    • External anatomy, posterior – tracheal deviation, etc, posterior.
    • If trauma , maintain C-spine
    • JVD – sign of increased venous pressure – seen in CHF
• C-Spine
  
  • Spinal cord exits head
  • Spinal nerves emanate and innervate the rest of the body
  • Spine supported by large mass of muscle
  • Evaluation – MOI, Pain, AMS, inspect and palpate, midline posterior tenderness – most concerning
  • Pain tenderness or tingling – stop and protect – transport immediately
  • Range of motion – first passively then actively – find something; stop
• Chest
  
  • Base of neck to diaphragm (costal arch)
  • Inspect for DCAP-BTLS, paradoxical motion, symmetry
  • Expose, inspect percuss, palpate and auscultate
  • Breath sounds, equal and bilateral, stridor, rubs, diminished or absent
  • Heart, lungs….
  • Heart sounds (bruit, mumurs)
• Abdomen
  
  • Divided into quadrants
  • Umbilicus is center ref point
  • Diaphragm at top, pelvis at bottom
  • Abdominal wall
  • Peritoneum
  • Intraperitoneal organs
  • Extraperitoneal organs
  • Abdominal pain is very common – History relevant to incident is critical – OPQSRT, SAMPLE – make patent comfortable
  • Inspect, palpate percuss, auscultate –
  • Guarding
  • Aneurisms, hernias – common
• Female Genitalia
  
  • Suspect ectopic pregnancy – can kill patient
  • Discreet, partner of same sex as patient
  • Limit to inspection only
• Male genitalia
  
  • Viagra – extended erections
  • Infections
  • Testicular torsion – especially minors, very severe emergency
  • Discharge, swelling, lesions, inflammation
  • Priapism
• Anus
  
  • Inspection – hemorrhoids, foreign objects etc
• Musculoskeletal
  
  • DCAP-BTLS, pulses, temp, perfusion, shortening, rotation,
  • Structure and function, range of motion, PMS, asymmetry, atrophy
  • Five Ps of acute arterial insufficiencies
    • Pain
    • Pulselessness
    • Pallor
    • Paresthesias/Paralysis
    • Polar sensation (coldness)
• Neuro exam
  
  • Not needed in every case – cases specific, mental status, PMS, reflexes
  • Initial posture, body position, body motions
  • Strength, ROM, abduction, adduction flexion
  • Sensation , relative to where
  • Deep tendon reflexes
  • AMS –acute or chronic, delirium, dementia
  • Global changes – intracranial, local changes – spinal injury

12/7/08

Patient Airway – No airway, no patient

Upper Airway – Major function, warmer, filter and humidly air.

Turbinates – three bony shelves in nasal passage – increases surface area

Sinuses – Cavities formed by the cranial bones

• Fractures of these bones may cause cerebrospinal fluid to leak from the nose or the ears.
• Significant bleeding from sinus fractures
• Prevent contaminants from entering the respiratory tract

LeFort Fractures – facial fractures

Hyoid bone, beneath mandible, anchors tongue, only non articulating bone in the body, attached with tendons

Palate – Hard and Soft

Adenoids and tonsils : lymphatic tissue that filter bacteria, severe swelling can cause airway obstruction

Vallecula – between base of tongue and epiglottis –It is an important landmark in intubation;

Larynx – divides upper and lower airways

• Anatomy – In order, Superior to inferior;
  • Laryngeal prominence (Adam’s Apple)
  • Thyroid Cartilage (V shape, shield) –Directly anterior to glottic opening
  • Cricothyroid membrane – site for surgical access to airway – bordered laterally and inferiorly by thyroid gland
  • cricoid cartilage – lowest portion of larynx – first ring of trachea, only upper airway structure that forms a complete ring
• Interior Airway Structures
  • Glottis – space between vocal cords – narrowest point of adult airway
  • Arytenoid cartilage – posterior attachment of vocal cords
  • Pyriform fossae – Two pockets of tissue on the lateral borders of the larynx – may cause tenting if tube placed there inadvertently

     

• Sellick Maneuver or BURP (Backward Upward Rightward Pressure)used to manipulate the larynx into view during intubation
• If you don’t see landmarks, you may be looking down the esophagus, pull back on laryngoscope and epiglottis should come into view

Lower airway

• Externally from 4^th cervical vertebrae to xyphoid process
• Trachia,(enters lung at hilum) Bronchi, smaller bronchi, bronchioles, alveoli (functional site for respiration (i.e. gas exchange)
• Trachia bifurcates at the Carina
• R has 3 lobes, L has 2 lobes
• Visceral pleura and parietal pleura
• Ventilation vs Respiration
• Shunting (blood bypasses the alveoli and does not exchange gasses)
• Alveoli lined with surfactant
• Atelectasis
• Avg adult 6L of air volume
• Tidal volume (Vt), 5-7Ml/kg adult, 6-8mL/kg (500 mL)
• Alveolar volume = tidal volume minus dead space(Vd)
• Minute volume (Vm)– amount of air that passes over a minute (Vt – Vd x Resp Rate)
• Functional reserve capacity – amount you can force out in single exhalation – (about 1200mL)
• Ventilation- Inhalation 1/3^rd Exhalation 2/3

Regulation of ventilation

• Primary reglated by PH levels in CSF
• Phrenic nerve- innervates the diaphragm
• Intercostals nerves – innervates the intercostals muscles
• Hering-Bruer reflex –stretch receptors tells the brain that the chest wall is fully expanded – ending inspiration
• Apneustic center – increase respiratory rate
• Pneumotaxic center – counters by inhibiting inspiration
• Chemoreceptors – monitor CO2, O2 and PH levels
• Respiratory drive – primary drive – driven by CO2
• Hypoxic drive – secondary drive driven by O2 (seen in COPD patients)
• Inhalation, muscles contract, pressure decreases – move air into lungs via negative pressure
• Exhalation, muscles relax – pressure increases, air forced out of lungs (passive)

Respiration

• Diffusion
• SaO2 measures saturation of hemoglobin, can be O2 or Co2 – use a pulse oximeter
• Hypercarbia
• Hypocarbia

Abnormal CO2 Concentrations

• As metabolic rate goes up more CO2 is produced
• Hypoventilation – co2 production exceeds body’s ability to eliminate it (hypercarbia)
• Hyperventilation – co2 elimination exceeds production (hypocarbia)
• Minute volume – decreased minute volume causes a decrease in co2 elimination

ET Tube

• Sizes 5.5 up have pilot cuff –
• 5.5 and down are cuffless – for peds
• Age + 16 / 4 = tube size (pediatrics)
• Keep spo2 above 90, hyperventilate before attempts

ETT Verification

• Seeing pass through cords
• Moisture in tube
• Etco2
• Auscultate lungs and abdomen
• Esophageal detector

Tape and secure. Put an oral airway in to hold tongue and prevent biting, record placement level

12/3/08

Fluids display such properties as:

• Not resisting deformation, or resisting it only lightly (viscosity), and
• The ability to flow (also described as the ability to take on the shape of the container).
• Flow from high pressure to low pressure

Types of fluid

• Gases
• Liquids

Pressure

• Force – push or pull (The action of a force against some obstacle or opposing force)
• Force over a specific area
  

Hemodynamics (the study of blood flow or the circulation)

Structure

• Internal – Tunica Interna – (tunica intima) simple squamus epithelia, endothelium, smooth. (atherosclerosis causes deposits that interrupts smoothness of vessel wall)
• 2^nd layer – Tunica Media – smooth muscle tissue –elastic tissues MUCH THICKER IN ARTERIES THAN VEINS
• Outer – Tunica externa -(tunica adventitia) Smooth muscle tissue , elastic fibers, collagen fibers (aneurysm – when blood flows between 2^nd and outer layer) (Aortic aneurism – sudden sharp abdominal pain, hx of HTN, absent dorsalis pedis pulse)
• Veins- Little muscle, very elastic – also called capacitance vessels
• Arteries (Resistance vessels)(BP measures the resistance against these arteries)
  • Elastic artery –elastic layer in tunica interna (found in
    aorta, brachial, femoral, – largest arteries) Expands as pulse wave passes through –pushing it along.
  • Muscular artery –Larger amount of muscle, smaller arteries/
  • Arterioles –
• Capillaries – one squamus cell thick, one RBC through at a time)(Where artery meets vein)have gaps in walls, mediators between tissues and vascular system
  • Precapillary sphincters – control flow to particular capillaries/tissues
• See graphic on page 469 for comparison of different vessel sizes
• 64% of blood found in veins
• 7% Heart

• Blood Pressure – force of blood against walls of blood vessels
  • Systolic – Pressure during a pulse wave – heart contracts and blood goes out as a pulse wave, greater volume and higher pressure.
  • Diastolic – Pressure that remains in the vessel when heart is at rest
• Systemic BPs – Aorta /Muscular artery – 120/80, small arteries 100/80mm, artery side arteriole 40mm, capillaries 20mm, venous side 15mm, right atrium 0mm
  • Cardiac output (CO)– stroke volume x Heart rate (stroke volume -amount of blood ejected with each pulse wave- avg 70cc)
    (lower CO causes decrease BP)
  • Total peripheral resistance – (TPR) is the sum of the resistance of all peripheral vasculature in the systemic circulation.
    • arteriosclerosis – hardening of arteries – increase TPR – heart pumps harder, cardiomegaly, cardiac hypertrophy)
    • anaphylaxis, neurogenic shock, cardiogenic shock, reduce TPR thereby reducing BP – (reverse by giving epi causing vasoconstriction)
    • increase TPR – Increase BP
    • TPR regulation – vasoconstriction and vasodilation

Venous BP is 15mm – how does it move up the body – from distal to proximal?

• Voluntary muscular contractions – (walking, rolling at night, movement while sitting , etc)
• Valves – open and close during muscle contraction (one way valves) (varicose veins – caused by damaged valves, loss of strength causing bulge, can become static and then CLOT or thrombophlebitis)
• Intrathoracic pressure chambers – affects right atrium

Also see Baroreceptors

From wiki….

In cardiovascular physiology, the baroreflex or baroreceptor reflex is one of the body’s homeostatic mechanisms for maintaining blood pressure. It provides a negative feedback loop in which an elevated blood pressure reflexively causes blood pressure to decrease; similarly, decreased blood pressure depresses the baroreflex, causing blood pressure to rise.

The system relies on specialized neurons (baroreceptors) in the aortic arch, carotid sinuses, and elsewhere to monitor changes in blood pressure and relay them to the brainstem. Subsequent changes in blood pressure are mediated by the autonomic nervous system.

12/1/08 (Also see previous post)

Drugs. Used to reverse, prevent or control disease

• History/allergies
• Physical findings
• Formulate a plan

   

Sources

• Plants , opiates, atropine, digitalis (purple foxglove)
• Animals
• Minerals
• Laboratory

Drug Standards and legislation

• Pure Food and Drug act of 1906 – first legislation in US
• Harrison narcotic act of 1914 – regulated import of narcotics
• Federal food drug and cosmetic act – 1938 – required labeling, side effects, habit forming, etc
• Narcotic control act 1956 – increased penalties for breaking Harrison act
• Controlled substance act 1970 – categorized drugs , storage and record keeping rules, supersedes Harrison act, created drug schedules based on abuse potential, etc
  • Schedule I – high abuse, no accepted medical use – LSD, Cocaine, heroin, Marijuana
  • Schedule II – high abuse , accepted medical use – may lead to severe addiction – opiates, amphetamines, barbiturates,
  • Schedule III – lower abuse potential, some physical or psychological dependence –
  • Schedule IV – lower abuse potential, some physical or psychological dependence –Phenobarbital, valium
  • Schedule V – lowest potential for abuse. Cough meds with codeine
• Drug Names
  • Chemical name: describes drug’s chemical makeup
  • Generic name: general name for drug, usually named by company that originally manufactured the drug, many times a shortened version of chemical name
  • Trade name: Unique name given by original manufacturer and registered with the FDA (Capitlaized)
  • Official name: after generic name is approved and drug is approved by the FDA it is listed in the USP and call generic name USP

Black box warnings

PNS > Autonomic NS

Nerve fibers

• Visceral afferent (sensory) organs to CNS
• Visceral efferent (motor) from CNS to internal organs , glands, smooth and cardiac muscle

Double set of nerve fibers

• Sympathetic (adrenergic) exits from thoracic and lumbar regions
  • Norepinephrine
  • Epinephrine
  • Receptors (produce when stimulated)
    • Alpha 1 – peripheral vasoconstriction, mild bronchoconstriction, speed metabolism (Smooth Muscle, blood vessels etc)
    • Alpha 2 – release of Norepinephrine (bladder, prostate)
    • Beta 1 – increase heart rate, cause cardiac muscle to contract, produce automaticity, triggers cardiac electrical conduction
    • Beta 2 – vasodilatation, bronchodilation

   

• Parasympathetic (cholinergic) exits from cranial and sacral regions
  • Acetylcholine (Ach) –Neurotransmitter
  • Receptors (produce when stimulated)
    • Muscarinic – SLUDGEM if over stimulated – The specific antidote is atropine – also give 2-Pam (Pralidoxime Chloride)
    • Nicotinic – excitatory response, dilated pupils (mydriasis) MTWT(h)FS – mydriasis, tachycardia, weakness, hypertension, fasciculations, sweating

Both function continuously, occasionally reciprocally, most organs dominated by one system

Path of a nerve impulse: Preganglionic neuron > Ganglia> postganglionic neuron >neuroeffector transmitter > organ

Classes

• Cholinergic – parasympathomimetic
• Anticholinergic – parasympatholytic
• Adrenergic – sypathomimetic
• Adrenergic blocking – sympatholytic

Terms

• Dissolution
• Pharmacokinetics
• Pharmacodynamics
• Drug absorption
• Solubility
• PH 7.35 – 7.45
• Concentration
• Therapeutic Level
• Dosage forms (Drug Forms – AAOS page 7.15)
• Blood brain barrier
• Placental barrier
• Biotransformation
• Potentiation – To enhance or increase the effect of (a drug). To promote or strengthen (a biochemical or physiological action or effect).
• Agonist – triggers an action (provoke physiological response)
• Antagonist – blocks action (prevent physiological response)
• Affinity
• Efficacy
• Peak level
• Therapeutic level
• Half life
• Onset of action

Therapeutic index