CPSS final review - part 2 my last will and testament 157 Questions with Verified Answers,100% CORRECT

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CPSS final review - part 2 my last will and testament 157 Questions with Verified Answers No breath sounds on affected side + trachea shifted to non-affected side - CORRECT ANSWER tension pneumot... horax What is the puncture site for an emergent chest needle thoracostomy for: Pediatric Adult - CORRECT ANSWER Pediatric: 2nd ICS midclavicular Adult: 5th ICS in anterior axillary line (to avoid the long thoracic nerve) What gauge angiocath is used for an emergent chest needle thoracostomy and where in the ICS do you insert the angiocath? If no air is noted when you insert the angiocath, what does this mean? Once catheter is secured into place, what do you do with the catheter? - CORRECT ANSWER 14 gauge angiocath over top of inferior rib perpendicular to skin no air = you have just created an open pneumothorax establish a water seal with the catheter If, after an emergent chest needle thoracostomy, the air collection reaccumulates, what do you do & with what equipment?? - CORRECT ANSWER Perform chest tube placement with 28-32 Fr. chest tube What is the purpose of a water seal with regards to a chest tube? - CORRECT ANSWER to provide a one way valve for air to escape & allows us to identify a leak in the system or pt What is the function of the three bottle collection system? What is the difference between the 3 bottle and a pleur-evac? How can you confirm suction is being provided to a pt using the pleur evac? How does an emerson pump differ from the above two systems? - CORRECT ANSWER provides a collection trap, water seal, and a bottle for regulation of suction (20cm of water pressure suction) pleur evac is the same system but contained in one unit. bubbles flowing in the suction control portion of pleur evac confirms suction emerson pump only has collection chamber and water seal. the pump itself provides the suction. suction system is not mutually exclusive with the collection & water seal. Drug assisted intubation or conscious sedation for chest tube placement: What meds are used and how can you reverse them? - CORRECT ANSWER Demerol Versed Demerol -> narcan (intranasal or rapid IV push) Versed -> Romazicon Pts with a chest tube will complain of side, shoulder, back pain that worsens with movement and inspiration. What should you encourage them to use? - CORRECT ANSWER tri-flow incentive spirometry (helps keeps lungs active throughout recovery & prevents pneumonia) Chest tube procedure: Identify what site? secure tube how? how do you check for placement? - CORRECT ANSWER find 5th ICS for adults secure with purse string suture CXR for placement. Complications of chest tube placement: how does damage to large vessels occur? what nerves could be damaged? don't drain > ___ cc at initial chest tube placement if treating an effusion. what is the max amt of cc you can drain before going to the OR? - CORRECT ANSWER damage to vessels occurs if trocar is used nerves often damaged include long thoracic or intercostal pulm edema: 1200 cc drainage max. > 1500 needs OR Assess daily pt progress with a chest tube how? Indications for chest tube removal? Technique to remove chest tube? Post op wound care? - CORRECT ANSWER daily CXR to remove -> pt stable and PTX resolved. drainage < 100cc/day positive pressure removal - pt blows against pursed lips w finger in mouth airtight dressing 24-48 hrs 7 P's of chest tube complications - CORRECT ANSWER Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia, or recreate pneumothorax A life-threatening hemopneumothorax in an adult requires immediate chest tube decompression through what intercostal site? a. 6th rib space, anterior axillary line b. 5th rib space, anterior to mid-axillary line c. 3rd rib space, mid-axillary line d. 1st rib space, mid axillary line e. 4th rib space, mid-clavicular line - CORRECT ANSWER b. 5th rib space, anterior to mid-axillary line Insert 28-32 size chest tube. Avoid long thoracic nerve. A life-threatening tension in an adult pneumothorax requires immediate chest tube decompression through what intercostal site? A.6th rib space, anterior axillary line B.5th rib space, above the 6th rib C.3rd rib space, mid-axillary line D.1st rib space, mid axillary line E.4th rib space, mid-clavicular line - CORRECT ANSWER B. fifth intercostal rib space anterior to mid-axillary line A life-threatening tension pneumothorax in a child requires immediate chest needle decompression through what intercostal site? A.6th rib space, anterior axillary line B.2nd rib space, mid-clavicular line C.3rd rib space, mid-axillary line D.1st rib space, mid axillary line E.4th rib space, mid- clavicular line - CORRECT ANSWER B. 2nd rib space, mid clavicular line Indications for thoracentesis? - CORRECT ANSWER -Effusion w/o secure clinical dx or small quantity -Diagnostic for those w/ abnormal amounts of fluid accumulation in the pleural space Preferred site: for thoracentesis vs for chest tube thoracostomy vs thoracentesis for pt on a ventilation - CORRECT ANSWER thoracentesis: 7-9th interspace midway between posterior axillary line and midline chest tube: 5th ICS anterior to mid axillary line on ventilator thoracentesis: 5th or 6th ICS at a site close to surface of bed What approach is best for thoracentesis? How should pt be positioned? - CORRECT ANSWER posterior approach pt straddling a chair, leaning forward What is the major and most common complication of thoracentesis? What are the 2 types? - CORRECT ANSWER pneumothorax benign PTX from introduction of air from outside. no tx needed accidental puncture of lung resulting in PTX. Observe w serial CXR. If a pt c/o shoulder pain during thoracentesis, what is your concern? - CORRECT ANSWER needle is piercing diaphragmatic pleura and site is too low. Include a description of what in your post-thoracentesis procedure note? Are tests routinely done following uncomplicated thoracentesis? - CORRECT ANSWER gross appearance of fluids red = bloody yellow = cholesterol milky white = chyle no tests needed if uncomplicated The primary concern in loculated effusions is??? When could you rely on PEx to select the site of loculation? Best method for thoracentesis site location if there is loculation? - CORRECT ANSWER selection of thoracentesis site use PEx if suspect empyema use U/S localization Is this a transudate or exudate: fluid/serum protein ratio > 0.5 fluid/serum LDH ratio > 0.6 fluid LDH > 2/3 upper limit of normal serum LDH - CORRECT ANSWER exudates have 1 or more of these characteristics (transudates have none!!) If LDH is the only abnormal, consider - CORRECT ANSWER parapneumonic effusion Protein in the thoracentesis fluid may confuse what possible pathologies? - CORRECT ANSWER CHF liver disease renal disease Protein is normally < 3g/dL, but may be 3-4g/dL in what cases? - CORRECT ANSWER if pt uses diuretics, or is chronic or recurrent Transudate fluid aspirated + fever > 101.5 24 - 48 hours after surgery = - CORRECT ANSWER atelectasis What are the main causes of transudates? - CORRECT ANSWER CHF, cirrhosis, peritoneal dialysis, urinothorax, nephrotic syndrome, atelectasis In the adult pt, what is the gold standard for emergent airway management? How often should you give breaths with this airway? - CORRECT ANSWER endotracheal intubation ventilate every 6 seconds (10 breaths/ min) Confirm accurate placement of ETT by checking what PEx? What is the preferred way to check placement? How do you know it's working? - CORRECT ANSWER 5 point auscultation - apices, axillary, stomach (for gurgling) preferred -> quantitative continuous waveform capnography. if yellow - working!! blue is bad. What is the most common incorrect placement of an ETT? What is the most lethal incorrect placement? - CORRECT ANSWER right mainstem bronchus - hear decreased breath sounds on the LEFT side lethal -> esophageal Anticipate vomiting in all pts by having what equipment available? How can you avoid hypoxia from suctioning? - CORRECT ANSWER yankeur suction at back of mouth oxygenate prior to suction & suction for < 10 seconds & suction only on the way OUT An unrestrained passenger/driver who sustained maxillofacial trauma gets what airway? - CORRECT ANSWER surgical cricothyroidotomy using #10 blade w surgical emergent tracheostomy tube placement How to tell if a pt is unstable? How to tx unstable pt? - CORRECT ANSWER CASH chest pain AMS SOB hypovolemic shock tx with VOMIT - vitals - O2 - monitor pulse ox & EKG - IV or IO fluids - Tx the pt H's and T's - CORRECT ANSWER H's Hypoxia Hypovolemia Hypo or Hyperkalemia H ion acidosis Hypothermia T's Tension pneumothorax Cardiac tamponade Toxins Thrombosis coronary MI Thrombosis Pulmonary DVT PE What is the most common cause of airway obstruction esp in the unconscious pt? What tool is used to remove foreign objects from airway? - CORRECT ANSWER the tongue remove FBs w magill forceps Do not use what technique to open the airway in pts with suspected c spine injury? Instead use what technique - CORRECT ANSWER do not use head tilt chin lift use jaw thrust What tool to maintain the airway can be used in conscious, semiconscious, or unconscious pts? How do you measure it? insert it how? - CORRECT ANSWER NPA or trumpet tip of nose to earlobe w diameter same size as pt's pinky insert it perpendicular to facial plane What tool can be used in unconscious pts w/o a gag reflex? How is it measured? - CORRECT ANSWER OPA angle of jaw to corner of mouth What tidal volume is needed using a bag valve mask to prevent over-inflation & gastric distention? - CORRECT ANSWER 500-600mL or 5-6mL/kg What definitive airway is used in spontaneously breathing drug OD in respiratory distress to secure an emergent airway? - CORRECT ANSWER nasotracheal For ETT placement: Which blade is curved vs straight? Hold these blades with what hand? The ETT is placed ____ cm above where? What is the max amt of time you can take to place it? What size tube? Avoid using what technique while placing? What is the best position to obtain direct alignment for placement through vocal cords? - CORRECT ANSWER McIntosh curved Miller straight Hold blades w left hand - place tip in vallecula 2.5cm above carina max of 30 seconds #8 ETT avoid using cricothyroid pressure use sniffing position for best alignment In an adult, to check proper ETT, the black line of proximal ETT will be at what level? - CORRECT ANSWER at the level of the corner of the mouth at 22 from vocal cords What can we do to achieve the maximal cellular o2 level? - CORRECT ANSWER 90-100% o2 at 12-15L per min by non rebreathing mask w/ oxygen reserve What % oxygen does each provide and at how many L/min: non rebreathing mask nasal cannula simple mask - CORRECT ANSWER nonrebreather: 90 -100% @ 12-15 L/min nasal cannula 24-40% @ 1-6L/min simple mask 40-60% @10-12 L/min What airway adjunct is used for pts with COPD, bronchitis, or emphysema who breathe by hypoxic drive? - CORRECT ANSWER venturi mask The criteria for when to intubate a pt is with a PaO2 of __%. - CORRECT ANSWER 88% AND clinical signs of respiratory distress 90mmHg PaO2 = ___ % O2 sat 60mmHg PaO2 = ___ % O2 sat - CORRECT ANSWER 90 mmHg = 100% 60 mmHg = 90% Laryngeal Mask Airway.... where does the cuff go over? Where is the king airway used? - CORRECT ANSWER LMA over hypopharynx king airway used by local EMS [Aseptic/sterile] is free from pathogenic microorganisms while [aseptic/sterile] is free from microorganisms. - CORRECT ANSWER aseptic - pathogenic microbes sterile - all microbes What is the method in which we maintain asepsis throughout the duration of a procedure? - CORRECT ANSWER sterile technique What are the guidelines to maintain sterility of an operating room? There must be enough space for what? What type of filter is used for ventilation in an OR? What does this filter filter out? - CORRECT ANSWER minimum 20 by 20 feet -space for gowning of team, for draping patient, to move around w/o contamination of sterile areas use HEPA filter - filters bacteria, fungi, viruses What face mask is considered a HEPA filter? - CORRECT ANSWER N95 UV lighting can be used in ORs and hospital rooms (and in new york subways) to do what? Which UV method is specifically used in ORs? - CORRECT ANSWER UV lighting disinfects for ORs -> UVGI (UV germicidal irradiation) On the pt, what is the primary source of infection and contamination & what is the key organism? How can pt clean themselves before surgery? How does staff prep skin if hairy? - CORRECT ANSWER pts skin and nares - staphylococci pt showers w hibiclens (antibacterial prep) electric clippers for hair on pt What is the most important method to decrease rate of infection in a surgical pt? - CORRECT ANSWER skin prep What antimicrobial preparation for intact skin is: broad-spectrum antimicrobial agent against fungi, viruses, gram + and - . sticky and stains chemical antiseptic that is bactericidal, bacteriostatic, and effective against fungi & viruses Which is the most common? - CORRECT ANSWER antimicrobial - iodophors (betadine) chemical antiseptic - hibiclens MC: depends on surgeon. betadine vs chloraprep Technique of skin preparation before incision how is betadine applied? do you wait before draping? vs how is chloraprep applied? do you wait before draping? - CORRECT ANSWER betadine: widening circles or rectangular motion. NO WAIT. chloraprep: apply back and forth motion. YES WAIT - flammable!!! What portion of the drape is considered unsterile? if hole is found in drape after placement, do what? If drape needs to be readjusted, do what? - CORRECT ANSWER below waist or table level if hole -> cover w 2nd drape or tegaderm readjusted -> don't. discard or cover w new drape What PPE do you need on before entering the operating room? - CORRECT ANSWER OR Scrubs, surgical masks, eye protection, surgical cap, shoe covers What are the general steps if using an alcohol scrub for your hands? - CORRECT ANSWER if using alcohol scrub, prewash hands and forearms w nonantimicrobial soap & dry them, then apply alcohol product. let dry fully before donning gloves How to hand scrub - first open your scrub brush packet. and place on top of sink. now what? - once washed, touch what? - what surfaces - how many strokes per surface - goal time - how to rinse? - CORRECT ANSWER wash hands w normal soap and water first 30-60 sec touch only ur brushie and your nail pick Alternate between left and right 5 fingers → 5 fingers hand → hand forearm → forearm 2" above elbow → 2" above elbow 10 strokes per surface 5 mins goal. 2 min 30 sec per extremity rinse w hands up up up so water drips down down down now go to OR What part of gown is considered sterile? - CORRECT ANSWER waist to xiphoid. forearms to 2 inches above elbows State whether a sterile gown is indicated or not: suturing minor lacs repairing a large wound cardiac catheterization joint aspiration invasive surgical procedures lumbar puncture - CORRECT ANSWER Yes: Repairing a large wound, cardiac catheterization, invasive surgical procedures No: minor lacerations, doing joint aspiration, or performing a lumbar puncture - only need sterile gloves for these Indicator gloves - worn on [top/bottom]? - what color? - what glove size? - CORRECT ANSWER worn on bottom - have blue or green indicator 1/2 size larger than actual glove size Doffing in the OR - CORRECT ANSWER 1. top pair of sterile gloves 2. gown and indicator gloves 3. remove shoe covers When out of OR in sub sterile area 4. goggle/face shield 5. mask/respirator 6. wash hands While self gloving, where should your hands be? - CORRECT ANSWER in your sleeves like a FREAK For assisted gloving, When putting hand in glove, go [straight down/in an angle]. Which glove first? For assisted gowning, spin towards or away from the person? - CORRECT ANSWER straight down to the floor right hand first spin away from the person When can you break scrub? What can you wear while rounding? - CORRECT ANSWER when surgeon says ok. - now u can go to PACU while rounding, can wear scrubs and lab coat. no other PPE In general, how is a laparoscopy performed? - CORRECT ANSWER ports are inserted into the abdomen which is then insufflated with CO2 gas. instruments can be put through the ports to do the procedure In general, how is robotic surgery performed? - CORRECT ANSWER 3D view with multiple instruments to control tips of instruments What is the biggest difference between laparoscopy and robotic surgery? - CORRECT ANSWER the instruments used - the tips of the instruments on robotics articulate so you can move the tips around like you would with your wrist while in laparoscopy, the instruments have straight tips doctor is at console What is the purpose of "the tower"? - CORRECT ANSWER a place to hold the HD monitor, CO2 insufflation unit, light source unit, digital video storage Cameras exist to fit in laparoscopic ports. What size lens would go into the 5mm port? the 10mm port? - CORRECT ANSWER 5mm lens in 5mm port 10mm lens in 10mm port Which angle provides a better view during laparoscopy if you are having a difficult time seeing something: 0 or 30 degrees? - CORRECT ANSWER 30 can give you a wider angle view What components of the laparoscopic camera must be assembled? - CORRECT ANSWER lens + light source together gray knob focuses blue knob zooms The light source of the camera must be set to what setting? At this point, what materials can the light source touch? - CORRECT ANSWER 100% - initially will be on standby do not let light source touch any material while on 100%!!! Before starting laparoscopic surgery, how must you prep the assembled camera? - CORRECT ANSWER perform white balance clean camera lens and port What are the 2 methods to clean the camera lens and port? - CORRECT ANSWER Defogger solution (fred) sprayed on green cushion & then dip tip of lens Camera cleaner (the house) - stick 10mm camera through the hole. 5mm camera you need to lock it up to become size of 5mm port The camera should be held with the buttons facing where? - CORRECT ANSWER towards the ceiling For laparoscopic surgery, you must try to use what size trocars? - CORRECT ANSWER as many 5mm as you can How is the introducer port introduced into the pt? The gas port should be [open/closed] before inserting into the pt. What must be done to the gas port while a surgeon is cauterizing? - CORRECT ANSWER introducer -> goes inside trocar and then inserted into pt gas port CLOSED before inserting into pt while cauterizing, open gas port to release steam & gas What do you do with insufflation tubing? - CORRECT ANSWER disc part gets thrown off the sterile field and attached to tower opposite side gets screwed into trocar w gas port then open valve to let CO2 flow into pt On the CO2 insufflation device what does the first number on the left mean? the middle number? What is the safe/average for each number? - CORRECT ANSWER left: CO2 volume going into pt - avg of 15mmHg. 18mmHg if large pt but can paralyze diaphragm middle: flow rate - 10-20 L/ min What suture, stitch, and # of stitches are used for each trocar incision: 5mm 8mm 10,11,12mm - CORRECT ANSWER 5mm: 4-0 monocryl simple interrupted buried intradermal stitch x1 8mm: 4-0 monocryl simple interrupted buried intradermal stitch x2 10,11,12mm: close fascia layer w figure 8 stitch. multiple interrupted or running intradermal w aberdeen knot to close incision How is mastosol used vs dermabond? - CORRECT ANSWER mastosol -> poured on side of incision, wait for it to dry then place steri strips dermabond - poured ONTO incision line & it dries w heat and light but incision needs to be dry. What suture type & stitch is used to close the facia layer? - CORRECT ANSWER figure 8 stitch using vicryl or ethibond Most laparoscopic procedures prefer [staples/sutures]. - CORRECT ANSWER buried sutures with skin glue or mastosol and steri strips Staples are used typically for what type of incision? What surgeries are exceptions to this? - CORRECT ANSWER larger incisions such as with a laparotomy avoid with hernia and thyroid procedures. do running subcuticular buried stitch in dermis then skin glue or mastosol + steri strips Skin sutures are usually used in what setting? - CORRECT ANSWER ET pts & anyone with a traumatic incision that has potential for infection What stitch is used to ligate blood vessels? - CORRECT ANSWER figure 8 - strangulates an artery or can use stick tie ligation or hand tie ligation What does each cautery setting mean: Yellow Blue - CORRECT ANSWER yellow - cuts using vibration blue - coagulates using burns During a laparoscopic cholecystectomy, pt typically has what ports - CORRECT ANSWER 4 ports - 3 5mm ports and 1 12mm port What is the purpose of the intra-operative cholangiogram? - CORRECT ANSWER To identify the common bile duct anatomy and any retained stones Thread catheter into the cystic duct and then insert dye into the biliary tree; serial x-rays Before you draw blood, what should you check about the pt? - CORRECT ANSWER Pt ID!!! Inpt: Full name & check armband. No armband = no draw. Outpt: name and verify DOB Equipment for phlebotomy: - what kind of gloves? - standard gauge needle? - clean skin how? - CORRECT ANSWER exam gloves 21-22 G needle clean skin w alcohol wipe (bactericidal) and LET FULLY DRY Leave the tourniquet on for a max of ___. Should pt pump the hand while tourniquet is on? What may occur if you leave the tourniquet on too long? What labs could be a sign that this has occurred? - CORRECT ANSWER tourniquet on for 1-2 mins do not pump hand hemoconcentration may occur causing hemolysis of the specimen Significant increases can be found in total protein, aspartate aminotransferase (AST), total lipids, cholesterol, iron For pHlebotomy - bevel faces.... What needles can you use? - CORRECT ANSWER UP butterfly needle or vacuum system (dual needle system) What info goes on the blood sample label - CORRECT ANSWER your initials date time of collection Patient's surname, first and middle Patient's ID number What additive does each tube contain based on cap color: Red Orange Yellow Green Light green Purple Light blue Black Grey - CORRECT ANSWER Red: no additive Orange: coagulant Yellow: coagulant and separation gel Green: Heparin sodium Light green: Heparin lithium Purple: EDTA anticoagulant Light blue: sodium citrate 1:9 Black: Sodium citrate 1:4 Grey: Potassium oxalate monohydrate and sodium fluoride If you see a red top what do you think? Which one do we use for our CBC? Which one do you use to draw lithium levels? Which one do you use for coags? If you see a light green top what do you think? Which color tube top is the most common? What tests? - CORRECT ANSWER type and screen or type and cross - red top CBC - purple top lithium - DARK green coags -> light blue cardiac enzymes - light green BMP & stat tests - most common - tiger top What additive does the gold tiger top have? mode of action uses - CORRECT ANSWER gel silica serum separator tube - gel at bottom to separate blood from serum on centrifuge chemistries -> BMP & stat tests what is the order of blood draw? - CORRECT ANSWER blood cultures coags type and cross/screen routine chemistry stat chemistry CBC, ESR type and cross/screen again lactic acid, glucose What arm do you start phlebotomy on? What is a contraindication to this? - CORRECT ANSWER start at non dom hand do not draw from non dom if pt is scheduled for AV fistula in that arm How do you palpate for a vein? What is the most common vein used for venous puncture? Where is this vein? What is an alternative for this vein? What part of the veins do you avoid? Which veins are last resort? - CORRECT ANSWER use index finger pad to feel vein bounce and roll median cubital vein - most common median cephalic vein is the alternate. avoid vein connections bc valves are often there last resort is foot vein Areas to be avoided when choosing a phlebotomy site - CORRECT ANSWER extensive scars UE on side of mastectomy hematomas IV therapy blood transfusion IV cannula/ AV fistula/ heparin lock edematous extremities / infections Phlebotomy procedure key points: *put on ur little glovies!!* - pt ARM position? - once in position, apply tourniquet WHERE to find a vein? - remove tourniquet and get set up. once done, apply tourniquet again. best vein to get? - once you've found the vein, clean it w alcohol wipe and wait how long? - get your needle ready. anchor vein with ___. - hold vacuutainer how? - CORRECT ANSWER arm hyperextended tourniquet 3-4 inches above puncture site best vein - median cubital (pinky side) wait 15-30 seconds for EtOH to dry hold vacutainer thumb on top, 2-3 fingers under More phlebotomy procedure points: - insert needle at what angle? once needle is in, pop the blood collection tube in - remove what first when the tube is halfway filled? then the? - put gauze over the site and remove ___ last. - apply pressure. mix the tubes. put on bandaid - CORRECT ANSWER needle at 15-30 degree angle remove TOURNIQUET FIRST then the TUBE gauze over site then remove the NEEDLE last. Can you puncture this vein: Lacks resilience, feels cord-like, and rolls easily - CORRECT ANSWER no - this vein is thrombosed What type of needle can you use if you don't have a steady hand? If blood doesn't flow as fast as others? if pts are difficult sticks or peds or scared? - CORRECT ANSWER butterfly needle How to treat vasovagal syncope? - CORRECT ANSWER bend them forward and bring their head between their knees or Lay them down on the floor and lift their legs up Avoid hematoma or blown vein how? - CORRECT ANSWER release tourniquet first then withdraw needle then apply firm pressure ___: Induration of a superficial vein +/- surrounding erythema How is it treated? - CORRECT ANSWER superficial thrombophlebitis - not a DVT!! tx w warm compress and NSAID What phlebotomy complication occurs in patients who are IV drug users, diabetics, immunocompromised, HIV, carriers of MRSA, pts in the hospital w IV in place? Tx? - CORRECT ANSWER cellulitis or abscesses give dicloxacillin if large and severe abscess w surrounding cellulitis. bactrim if healthy pt Elevated potassium on labs - first rule out... - CORRECT ANSWER hemolysis of specimen What precautions & PPE are required for phlebotomy? - CORRECT ANSWER universal/standard precautions exam gloves & lab coat or gown What type of line is this: located in periphery. single lumen. used for basic administration of IV meds and fluids. placed by RN - CORRECT ANSWER peripheral IV Where in the periphery can midline IVs be placed? The distal tip of the midline is where? How many lumens? How is it placed? - CORRECT ANSWER basilic, brachial, cephalic vein distal tip just proximal to axilla single or double lumen placed w US and seldinger's technique Where does a PICC line end vs midline? - CORRECT ANSWER PICC - IVC midline - axilla What is an A line? Check collateral circulation how? An A line can be connected to what monitoring? - CORRECT ANSWER peripheral line inserted into radial artery check circulation with Allen's test FloTrac to measure stroke volume and cardiac output What line gives info on volume status? - CORRECT ANSWER A line What is a central venous catheter? Where can it be placed? Where is the distal tip located? Why would you choose a CVC over a PIV? What measurements can be taken with CVCs? Other than meds & fluids, what can CVCs be used for? - CORRECT ANSWER long catheter placed into a large vein in neck (internal jugular), upper chest (subclavian), or groin (femoral) distal tip located within SVC near the right atrium CVC is more durable & less able to be displaced. Better able to deliver fluids & meds rapidly measure pressures, take frequent blood samples can be used for TPN, dialysis Where is the distal tip for: PICC lines Non tunneled catheters tunneled catheters***??? Implanted ports - CORRECT ANSWER PICC - at superior vena cava preferably at junction with right atrium (Cavoatrial junction) non tunneled - at superior vena cava tunneled - cavoatrial junction port - at SVC at cavoatrial junction How does a port differ from other central lines? How is it placed? - CORRECT ANSWER totally located under the skin placed under skin usually in upper chest by a surgeon Biggest complication with CVC placement? How to ensure this didn't happen? - CORRECT ANSWER collapsed lung/ pneumothorax verify placement with CXR Tunneled or non tunneled: short term use vs long term use accounts for most central line associated bloodstream infections vs lower rate of CLABSI - CORRECT ANSWER short & high CLABSI - nontunneled long & low CLABSI - tunneled Which CVC has the lowest risk of CLABSI? - CORRECT ANSWER Implantable port (note: PICC has a lower rate than nontunneled as well) Relative contraindications for CVCs? - CORRECT ANSWER infection at site of insertion coagulopathy newly inserted pacemaker wires Which internal jugular vein has a straight in-line course to right atrium? - CORRECT ANSWER Right IJ What is the preferred technique for CVC insertion? - CORRECT ANSWER seldinger technique - sterile US guidance with a catheter over a wire WHOOPS!!! You accidentally punctured an artery during CVC placement. What is the tx for each needle size: 22 G 18 G large bore introducer - CORRECT ANSWER 22G: no problem 18G: hematoma risk - hold pressure x 5min large bore: hold pressure x 30 min or surgical consult After CVC placement, always confirm venous access how? - CORRECT ANSWER check blood gas or.. hook up to fluid column & look at waveform - if BP of 5-10 = vein - if BP Of 100/60 = artery CVP = central venous pressure. What is a normal CVP range? CVP is more useful as trend or as an absolute value? What 2 main things can you assess with CVP? - CORRECT ANSWER 5-15mmHg note: CVP more useful as a trend!! CVP measures right ventricular filling pressure and right ventricular function (using starling's law can figure out LV function) You connect the transducer of the CVC to the CVP monitor. The pressure transducer has what reference point? - CORRECT ANSWER level of the heart Patients with CHF who have dysfunctional heart muscle would have what changes on the CVP? - CORRECT ANSWER abnormally high CVP due to a depressed cardiac function curve & a right-shifted venous function curve Pts w hypovolemia or sepsis (decreased venous tone) would have what changes on CVP? - CORRECT ANSWER abnormally LOW CVP due to left shifted venous function curve Explain what each wave means in CVP waveform: a wave c wave x descent v wave y descent - CORRECT ANSWER a wave: right atrial contraction - Occurs after the P wave on the ECG but before the first heart sound c wave: Right ventricular contraction -Caused by the bulging of the tricuspid valve into the atrium x descent: Downward movement of the ventricle and tricuspid valve during ventricular contraction - Atrial relaxation v wave: atrium fills against a closed tricuspid valve y descent: tricuspid valve opens and blood passively enters the ventricle What is swan ganz catheter? What does it help differentiate? - CORRECT ANSWER pulmonary artery catheter differentiates between the various mechanisms of shock - use in critically ill pts The tip of a swan ganz is where? - CORRECT ANSWER through right atrium -> rv -> pulmonary artery ____: the intensity and duration of pressure generated by the inspiratory muscles ____: interval between beginning of intake of air to when max tidal volume is reached - CORRECT ANSWER Pmus - intensity and duration of pressure inspiration time - intake of air to max TV What controls expiratory time (interval from beginning of inspiratory flow to beginning of next inspiration)? - CORRECT ANSWER medulla Mechanical ventilation replaces the actions of what muscles? - CORRECT ANSWER inspiratory & neural control of breathing What type of respiratory cycle is this: ventilator controls the entire inspiratory phase or totally replaces respiratory muscle effort and neural control - CORRECT ANSWER controlled cycle ex. volume cycled ventilation What type of respiratory cycle is this: ventilator only assists the inspiratory muscles that are active - CORRECT ANSWER assisted cycle What variables can be controlled during inspiration? - CORRECT ANSWER time flow volume or pressure Volume cycled ventilation vs Pressure cycled ventilation - CORRECT ANSWER Volume - cycle that ends when it reaches a predetermined tidal volume Pressure - a timed cycle During a volume controlled cycle (an example of controlled respiratory cycle), what determines how long expiration lasts? - CORRECT ANSWER PEEP - positive end expiratory pressure once alveolar pressure hits the PEEP value, expiration stops. cycle restarts A volume controlled cycle needs what predetermined value to work? How do you calculate this? - CORRECT ANSWER calculate Tidal volume 12mL by the ideal body weight What are the 3 basic ventilatory modes? - CORRECT ANSWER Assist/ control ventilation A/C Pressure support ventilation PSV Synchronized intermittent mandatory ventilation - a hybrid of the two What ventilatory mode is this: characterized by offering controlled and/or assisted cycles, depending on the settings programmed for the minimum respiratory rate (RR) delivered to the patient. - CORRECT ANSWER A/C mode What ventilatory mode would be used: immediately after tracheal intubation when the patient is sedated or under a neuromuscular blocker. - CORRECT ANSWER A/C - VCV What ventilatory mode is easier to determine respiratory mechanics? - CORRECT ANSWER A/C - VCV What ventilatory mode has alveolar pressure under greater control? - CORRECT ANSWER A/C - VCV What ventilatory mode is able to use a protective ventilation strategy for pts with ARDS? - CORRECT ANSWER A/C VCV uses low tidal volumes in pts with ARDS What ventilatory mode has ONLY assisted cycles? - CORRECT ANSWER PSV mode it is triggered by the pt. no mechanical triggers What ventilatory mode is used for pts that exhibit good recovery from an underlying disease and sedation is reversed? - CORRECT ANSWER PSV What ventilatory modes is typically used for weaning? - CORRECT ANSWER PSV mode [Show More]

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