Cardiac Arrest Management & ACLS Guide

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Questions and Answers

In post-ROSC care, what is the oxygenation target, and why is it important to avoid hyperoxia?

Titrate FiO2 to SpO2 ≥94%, Avoid PaO2 >300 mmHg to prevent oxygen toxicity.

What are the two first-line antiarrhythmics given in the setting of refractory VF/pVT and what are their initial doses?

Amiodarone (300mg IV/IO first dose), Lidocaine (1-1.5 mg/kg first dose)

Describe how end-tidal CO2 (ETCO2) is used to assess the effectiveness of CPR and predict ROSC.

ETCO2 <10 mm Hg indicates ineffective CPR; a sudden rise from <10 mmHg to >40 mmHg suggests ROSC.

List three dynamic measures that can be used to assess volume responsiveness in a post-arrest patient.

<p>IVC collapse, Passive leg raise, Pulse pressure variation</p> Signup and view all the answers

What is the preferred vasopressor and its infusion rate for pseudo-PEA?

<p>Norepinephrine infusion (0.1-0.5 mcg/kg/min)</p> Signup and view all the answers

What are three contraindications to initiating hypothermia therapy in a patient after cardiac arrest?

<p>Active bleeding, DNR status, Terminal illness (relative)</p> Signup and view all the answers

What are the three components of the mnemonic "ABCs of ROSC" for post-arrest care priorities?

<p>A - ACS evaluation, B - BP management, C - Cooling/TTM, S - Seizure prevention</p> Signup and view all the answers

List three complications related to ECPR.

<p>Limb ischemia, Hemorrhage, Renal failure requiring RRT</p> Signup and view all the answers

What is the timeframe for lactate clearance monitoring post-arrest, and why is monitoring lactate trends important?

<p>Q2-4h initially (decrease &gt;10%/hour). Decreasing serial levels indicate improving perfusion.</p> Signup and view all the answers

  1. What is the significance of a 3rd-degree or new bifascicular block on ECG in a post-ROSC patient, and what intervention should be considered?

<p>Requires transcutaneous pacing</p> Signup and view all the answers

What is the sodium bicarbonate dose for a TCA overdose?

<p>1-2 mEq/kg IV</p> Signup and view all the answers

When is immediate PCI indicated in a patient post-ROSC?

<p>STEMI on ECG or suspicion of ACS without non-cardiac cause.</p> Signup and view all the answers

Why is dobutamine contraindicated in HOCM?

<p>↑ Contractility → worsens obstruction → hemodynamic collapse.</p> Signup and view all the answers

Outline three parameters to monitor for CPR quality.

<p>Rate (100-120/min), Depth (2-2.4&quot;), Recoil (complete)</p> Signup and view all the answers

Describe the permissive hypertension strategy post-ROSC including the target blood pressure.

<p>Permissive hypertension initially (MAP 65-90mmHg)</p> Signup and view all the answers

What is the dextrose dose for treating hypoglycemia in an arrest situation?

<p>25-50g IV (D50W standard).</p> Signup and view all the answers

What is the preferred beta blocker in labile post-arrest patients, and why is it preferred?

<p>Esmolol drip (short-acting, titratable).</p> Signup and view all the answers

How long should therapeutic hypothermia be maintained after reaching the target temperature?

<p>24 hours minimum before rewarming.</p> Signup and view all the answers

What ultrasound finding is diagnostic for pseudo-PEA?

<p>Cardiac activity on echo without palpable pulses.</p> Signup and view all the answers

  1. What is the post-ROSC ScvO2 goal?

<blockquote> <p>65% (adequate oxygen delivery).</p> </blockquote> Signup and view all the answers

What is a key target CPP value during CPR and what pressures are used to calculate CPP?

<p>Minimum 15-20 mmHg (aortic diastolic - right atrial pressure).</p> Signup and view all the answers

What are three symptoms of HOCM?

<p>Chest pain, Syncope, Sudden cardiac death (arrhythmias).</p> Signup and view all the answers

What are the three HTTM target temperature parameters?

<p>32-36°C, Maintained for 24 hours, Rewarm at 0.5°C/hour.</p> Signup and view all the answers

What Scv02 value predicts no ROSC during CPR?

<p>&lt;40% (100% negative predictive value).</p> Signup and view all the answers

What is the mnemonic for epinephrine dosing?

<p>&quot;1-3-5 Rule&quot;: 1 mg every 3-5 minutes during CPR.</p> Signup and view all the answers

What is the mnemonic for calcium doses?

<p>&quot;1-3 Rule&quot;: 1g chloride or 3g gluconate.</p> Signup and view all the answers

What is the mnemonic for HOCM risks?

<p>&quot;HOCM&quot;: Heart Obstructed Contractility Caputs Muscle → avoid inotropes.</p> Signup and view all the answers

What is the first-line treatment (drug class) for Hypertrophic Obstructive Cardiomyopathy (HOCM)?

<p>Beta-blockers (e.g., metoprolol) or non-DHP calcium channel blockers.</p> Signup and view all the answers

What is the vasopressor and dose for cardiac arrest?

<p>Epinephrine 1 mg IV/IO every 3-5 minutes or Vassopressin 40 units IV push (alternative).</p> Signup and view all the answers

  1. What are the first-line benzodiazepine doses for post-arrest seizures?

<p>Lorazepam 0.1 mg/kg IV (max 4mg)or Midazolam 0.2 mg/kg IM (max 10mg).</p> Signup and view all the answers

What is the post-ROSC anticoagulation caution during CPR?

<p>Monitor for CPR-related injuries (rib fractures, liver/spleen trauma).</p> Signup and view all the answers

What is the absolute contraindication for fibrinolytics post-ROSC?

<p>CPR-related trauma (e.g., pneumothorax/pulmonary hemorrhage).</p> Signup and view all the answers

What should you monitor for any patient who has undergone ECPR?

<p>Limb ischemia (femoral cannulation).</p> Signup and view all the answers

What should you see on EtCO2 used when there is successful needle decompression of tension pneumothorax?

<p>Rise after needle decompression confirms success.</p> Signup and view all the answers

What are the three predictors of poor neurologic outcome?

<p>No pupillary/corneal reflexes at 72h, Myoclonus status, or NSE &gt;60ng/mL. (Pupillary/corneal reflexes assesses brainstem functions. Myoclonus involves sporadic involuntary twitches. NSE greater than 60 nanograms/ml indicates damage to neurons.)</p> Signup and view all the answers

What key information is provided by an echocardiogram for someone with HOCM?

<p>Echocardiogram (asymmetric septal hypertrophy + outflow gradient).</p> Signup and view all the answers

What do you do if youre managing post-ROSC hypertension?

<p>Permissive hypertension initially (MAP 65-90mmHg).</p> Signup and view all the answers

What post-ROSC anticoagulation is administered for ACS?

<p>Dual antiplatelets: aspirin + ticagrelor (preferred over clopidogrel).</p> Signup and view all the answers

When do you begin implementing PCI timing with HTTM?

<p>Proceed with PCI immediately - don't delay cooling.</p> Signup and view all the answers

  1. What is the genetic pattern of HOCM?

<p>Autosomal dominant (MYH7/MYBPC3 mutations).</p> Signup and view all the answers

Explain the rationale for permissive hypertension in the immediate post-ROSC period, including the target MAP range.

<p>Permissive hypertension (MAP 65-90 mmHg) balances the need for adequate cerebral perfusion with the risk of exacerbating bleeding or cardiac dysfunction. It allows for a higher blood pressure to overcome potential vasoconstriction or edema while avoiding excessive strain on the heart.</p> Signup and view all the answers

Describe the '1-3-5 Rule' in the context of cardiac arrest management. Include the medications, dosages and frequency.

<p>1 mg Epinephrine every 3-5 minutes during CPR. For calcium dosing, administer 1g Calcium Chloride IV or 3g Calcium Gluconate</p> Signup and view all the answers

How does the physiological mechanism of dynamic left ventricular outflow tract obstruction in Hypertrophic Obstructive Cardiomyopathy (HOCM) contraindicate the use of dobutamine?

<p>Dobutamine increases myocardial contractility, which can worsen the outflow obstruction in HOCM, leading to reduced cardiac output and potential collapse. The increased contractility exacerbates the narrowing of the outflow tract.</p> Signup and view all the answers

Outline three key differences in post-ROSC care for a patient who had a witnessed arrest with bystander CPR and initial shockable rhythm, compared to a patient without these factors, justifying each difference.

<ol> <li>ECPR candidacy: Witnessed arrest, bystander CPR, and initial shockable rhythm are all ECPR candidate criteria. 2. EEG Monitoring Duration: Post-arrest EEG monitoring duration should be at least 24-48h since 20% have delayed seizures. 3. PCI Timing w/ HTTM: proceed immediately - don't delay cooling.</li> </ol> Signup and view all the answers

Explain the significance of monitoring limb ischemia as a potential complication of ECPR (Extracorporeal Cardiopulmonary Resuscitation) involving femoral cannulation.

<p>Femoral cannulation during ECPR can compromise blood flow to the leg, leading to limb ischemia. Monitoring is crucial to detect early signs of ischemia (e.g., pain, pallor, pulselessness, paresthesia, paralysis), allowing for timely intervention to prevent irreversible damage or amputation.</p> Signup and view all the answers

What hemodynamic parameters are targeted when titrating chest compressions and vasopressor therapy during CPR, according to animal models?

<p>Systolic blood pressure of 90 mm Hg and a coronary perfusion pressure (CPP) of 20 mm Hg.</p> Signup and view all the answers

During CPR, how is coronary perfusion pressure (CPP) defined, and why is its measurement challenging in most ED resuscitations?

<p>CPP is defined as the difference between aortic and right atrial pressures during relaxation (CPR diastole). It is challenging to measure because it requires placement of both arterial and central venous catheters, which is often impractical in emergency scenarios.</p> Signup and view all the answers

In the context of VF or pVT refractory to defibrillation, what anti-arrhythmic drugs are recommended as first-line agents, and what are their initial dosages?

<p>Amiodarone (300 mg IV/IO) or lidocaine (1 to 1.5 mg/kg IV/IO) are recommended.</p> Signup and view all the answers

Beyond bradycardia, when is the administration of atropine considered beneficial according to this text?

<p>Routine administration of atropine outside the setting of bradycardia is not beneficial.</p> Signup and view all the answers

  1. Besides CPR performance parameters, what specific physiologic monitoring techniques can help optimize CPR quality for an individual patient?

<p>CPP, end-tidal carbon dioxide (ETco2), and central venous oxygen saturation (Scvo2) monitoring.</p> Signup and view all the answers

Why does electrocardiographic (ECG) monitoring have limitations during cardiac arrest?

<p>ECG monitoring indicates the presence or absence of electrical activity but not mechanical activity.</p> Signup and view all the answers

How does end-tidal carbon dioxide (PETco2) monitoring provide insights into cardiac output during CPR, and what is its clinical significance?

<p>PETco2 correlates well with CPP and cerebral perfusion pressure during CPR. Increased cardiac output during CPR will significantly increase PETco2, when minute ventilation is held constant and no exogenous CO2 is introduced.</p> Signup and view all the answers

During CPR, what PETco2 value should prompt clinicians to enhance the quality of CPR?

<p>PETco2 values less than 10 mm Hg.</p> Signup and view all the answers

How can PETco2 monitoring aid in the diagnosis and treatment of PEA (Pulseless Electrical Activity)?

<p>Elevated PETco2 levels in PEA may indicate mechanical heart activity, suggesting pulsatile flow undetectable by pulse palpation. This indicates the need for volume expansion or use of vasopressors and inotropes.</p> Signup and view all the answers

What is the significance of central venous oxygen saturation (Scvo2) monitoring during CPR, and how does it reflect oxygen delivery to tissues?

<p>Changes in Scvo2 reflect changes in oxygen delivery by means of changes in cardiac output, because oxygen consumption remains relatively constant during CPR, as does arterial oxygen saturation (Sao2) and hemoglobin.</p> Signup and view all the answers

What Scvo2 value during CPR has a negative predictive value for ROSC of almost 100%?

<p>Failure to achieve an Scvo2 of 40% or greater during CPR.</p> Signup and view all the answers

How does echocardiography aid in the diagnosis and management of cardiac arrest?

<p>Echocardiography helps distinguish EMD from pseudo-EMD, diagnose mechanical causes of PEA, and guide pericardiocentesis. In the post-arrest period it evaluates myocardial dysfunction to determine need for mechanical assistance of the failing heart.</p> Signup and view all the answers

What are the key factors for successful implementation of ECPR (Extracorporeal Cardiopulmonary Resuscitation) for refractory OHCA (Out-of-Hospital Cardiac Arrest)?

<p>Timely arterial and venous access, placement of cannulas, and initiation of ECPR support within 60 minutes of cardiac arrest onset.</p> Signup and view all the answers

Besides Scvo2, what other laboratory findings are typically observed during CPR, and how do they influence resuscitation therapy?

<p>Typical blood gas findings during CPR demonstrate venous respiratory acidosis and arterial respiratory alkalosis. Sao2 is usually greater than 94% during CPR and is of little value in titrating resuscitation therapy, except in the case of massive pulmonary embolism or unrecognized esophageal intubation.</p> Signup and view all the answers

  1. While titrating resuscitation efforts to arterial relaxation (diastolic) pressure can be helpful, it also has limitations. Explain why.

<p>Improper CPR (e.g., leaning on the chest during CPR diastole and hyperventilation) can cause undetected elevations in the right atrial pressure, reducing coronary perfusion.</p> Signup and view all the answers

What is the significance of arterial and central venous catheter placement during the post-cardiac arrest phase of care, especially considering the risk of re-arrest?

<p>10% to 20% of patients initially achieving ROSC will re-arrest, making these modalities helpful during the patient’s subsequent resuscitation.</p> Signup and view all the answers

What are the two primary goals of management following ROSC (Return of Spontaneous Circulation) in a cardiac arrest victim?

<p>Rapid diagnosis and treatment of the disorders that caused the arrest and complications of prolonged global ischemia.</p> Signup and view all the answers

What specific inclusion criteria were used in the studies that showed improved survival and functional outcome with Hypothermic Targeted Temperature Management (HTTM)?

<p>These studies enrolled only comatose survivors of OHCA that were witnessed arrests and had an initial rhythm of VF.</p> Signup and view all the answers

Epinephrine is recommended during resuscitation. Detail the rationale behind its use, including the recommended dosage and frequency of administration.

<p>Epinephrine at 1 mg every 3 to 5 minutes is recommended to due improved survival and ROSC demonstrated in randomized clinical trials.</p> Signup and view all the answers

Discuss the advantages, if any, of using vasopressin as a substitute for epinephrine in cardiac arrest scenarios, considering the evidence presented.

<p>Vasopressin offers no advantage as a substitute for epinephrine in cardiac arrest.</p> Signup and view all the answers

Explain the physiological basis behind targeting an arterial relaxation pressure of at least 20 to 25 mm Hg during CPR, and why this is important for patient outcomes.

<p>Titrating vasopressors to an arterial relaxation pressure of at least 20 to 25 mm Hg supports the recommendation of CPP of 20 mm Hg, which demonstrated improved outcomes in animal models.</p> Signup and view all the answers

In cases of VF or pVT refractory to defibrillation, amiodarone and lidocaine are recommended. Summarize the comparative effectiveness of these two drugs based on recent clinical trials.

<p>Only lidocaine resulted in an increased rate of ROSC, although neither therapy resulted in statistically significant improvements in survival.</p> Signup and view all the answers

Describe specific clinical scenarios, beyond electrolyte imbalances, where the administration of magnesium sulfate, calcium, sodium bicarbonate, or dextrose may be warranted during resuscitation.

<p>Magnesium sulfate in torsades de pointes, calcium in hyperkalemia, sodium bicarbonate in tricyclic antidepressant overdose, and dextrose in hypoglycemia.</p> Signup and view all the answers

What are the limitations of relying solely on palpation of carotid or femoral artery pulses for monitoring during CPR, and why is it considered unreliable?

<p>Myocardial blood flow does not depend on the palpated arterial pressure during chest compression (CPR systole), but rather on CPP. Although these two monitoring modalities may be the best attainable in certain circumstances, they do not provide reliable information regarding the effectiveness of CPR and interventions or prognosis.</p> Signup and view all the answers

  1. Explain the relationship between PETco2, CO2 production, alveolar ventilation, and pulmonary blood flow during CPR and how changes in these parameters can inform clinical decision-making.

<p>PETco2 depends on CO2 production, alveolar ventilation, and pulmonary blood flow (i.e., cardiac output) and correlates well with CPP and cerebral perfusion pressure during CPR. When minute ventilation is held constant and no exogenous CO2 is introduced only increased cardiac output during CPR will significantly increase PETco2.</p> Signup and view all the answers

Discuss the clinical implications of using PETco2 monitoring to detect ROSC at any time during the chest compression cycle, and why this is advantageous over traditional pulse checks.

<p>ROSC causes immediate and significant increases in PETco2. Therefore, PETco2 monitoring can detect ROSC at any time during the chest compression cycle, providing valuable guidance for pharmacologic therapies and minimizing the need for a pulse check when organized rhythms are detected.</p> Signup and view all the answers

In the context of PEA, how can PETco2 monitoring differentiate between true PEA and pseudo-PEA, and what are the corresponding treatment implications?

<p>Patients in a state of PEA with mechanical heart activity may have pulsatile flow that simply cannot be detected by palpation of a pulse. In such cases, PETco2 levels may be elevated, even without compressions. Use of ultrasound in such cases can identify corresponding cardiac activity. In these cases, volume expansion or the use of vasopressors and inotropes is indicated.</p> Signup and view all the answers

Explain how continuous Scvo2 monitoring provides a dynamic assessment of oxygen delivery during CPR and how it can be used to guide resuscitative measures in real-time.

<p>Because oxygen consumption remains relatively constant during CPR, as does arterial oxygen saturation (Sao2) and hemoglobin, changes in Scvo2 reflect changes in oxygen delivery by means of changes in cardiac output.</p> Signup and view all the answers

Describe the relationship between Scvo2, oxygen consumption, arterial oxygen saturation (Sao2), and hemoglobin levels during CPR and explain how changes in Scvo2 reflect changes in oxygen delivery to tissues.

<p>Oxygen consumption remains relatively constant during CPR, as does arterial oxygen saturation (Sao2) and hemoglobin, changes in Scvo2 reflect changes in oxygen delivery by means of changes in cardiac output.</p> Signup and view all the answers

What are the potential limitations and challenges associated with implementing transesophageal echocardiography (TEE) during CPR, and how does it compare to transthoracic echocardiography in this context?

<p>Transesophageal echocardiography (TEE) during CPR is an area of active research and has been associated with shorter chest compression pauses than transthoracic echocardiography.</p> Signup and view all the answers

Besides survival rates, what other long-term complications and challenges are associated with ECPR (Extracorporeal Cardiopulmonary Resuscitation) that need to be considered when implementing this rescue therapy?

<p>Common complications include coagulopathy, hemorrhage, limb ischemia, vascular injury, renal replacement therapy, and stroke.</p> Signup and view all the answers

Discuss the clinical significance of typical arterial and venous blood gas findings during CPR, and how these findings influence therapeutic decisions and interventions.

<p>Typical blood gas findings during CPR demonstrate venous respiratory acidosis and arterial respiratory alkalosis. Sao2 is usually &gt;94% during CPR and is of little value in titrating resuscitation therapy, except in the case of massive pulmonary embolism or unrecognized esophageal intubation.</p> Signup and view all the answers

Given the limitations of single-point-in-time laboratory measurements during CPR, how can continuous, oximetric Scvo2 monitoring provide a more comprehensive and informative assessment of CPR adequacy?

<p>Although Scvo2 indicates adequacy of CPR, a single measurement may not be as useful as continuous, oximetric Scvo2 monitoring.</p> Signup and view all the answers

Explain why successful resuscitation extends beyond achieving ROSC (Return of Spontaneous Circulation), and describe the key components of post-cardiac arrest care necessary for optimizing survival and neurological recovery.

<p>Management includes rapid diagnosis and treatment of the disorders that caused the arrest and complications of prolonged global ischemia. Simultaneous management of these two entities makes caring for a post–cardiac arrest patient particularly challenging. A comprehensive, goal- directed program of post–cardiac arrest care is necessary to optimize survival and neurologic recovery.</p> Signup and view all the answers

  1. What is the primary mechanism by which hypothermic targeted temperature management (HTTM) improves survival and functional outcomes in comatose survivors of cardiac arrest?

<p>The text does not explain the mechanism.</p> Signup and view all the answers

How does arterial blood pressure monitoring (specifically invasive monitoring) contribute to guiding resuscitation, and what are the benefits and limitations of using arterial diastolic blood pressure as a surrogate for CPP?

<p>Invasive arterial blood pressure monitoring alone can be helpful in guiding resuscitation and should be used when an indwelling arterial pressure catheter is already in place. When adequate personnel are available, it is often feasible to cannulate the femoral artery during CPR, especially with ultrasound guidance.</p> Signup and view all the answers

Describe how use of ultrasound may aid clinical decision making during resuscitation from cardiac arrest. Provide specific examples.

<p>Ultrasound identifies corresponding cardiac activity in patients experiencing Pulseless Electrical Activity (PEA). Another example is the use of ultrasound guidance to cannulate the femoral artery during CPR.</p> Signup and view all the answers

When might intermittent arterial and venous blood sampling for gas or chemistry analysis be of value during CPR? Explain your answer.

<p>Other laboratory studies during CPR are typically not available in time to guide therapy but may serve to confirm a diagnosis following successful resuscitation. Serum electrolyte levels may be ordered to rule out hyperkalemia, hypokalemia, hypomagnesemia, hypercalcemia, and hypocalcemia</p> Signup and view all the answers

Define End-Tidal Carbon Dioxide (ETCO2). How does ETCO2 relate to coronary perfusion pressure during CPR?

<p>The partial pressure of CO2 in exhaled air at the end of expiration (PETco2). PETco2 depends on CO2 production, alveolar ventilation, and pulmonary blood flow (i.e., cardiac output) and correlates well with CPP and cerebral perfusion pressure during CPR.</p> Signup and view all the answers

During CPR, how does end-tidal carbon dioxide (PETco2) monitoring assist in the diagnosis and treatment of pulseless electrical activity (PEA)?

<p>PETco2 levels may be elevated in PEA with mechanical heart activity, indicating pulsatile flow not detectable by pulse palpation. This suggests a need for volume expansion, vasopressors, or inotropes.</p> Signup and view all the answers

Explain how coronary perfusion pressure (CPP) is calculated during CPR and why it's a critical parameter to monitor, even though direct measurement is often impractical in emergency department resuscitations.

<p>CPP is calculated by subtracting right atrial diastolic pressure from aortic diastolic pressure. It's critical because a minimum CPP of 15 mm Hg is necessary to achieve ROSC if initial defibrillation attempts have failed.</p> Signup and view all the answers

Describe the clinical utility of monitoring central venous oxygen saturation (Scvo2) during CPR and how failure to achieve a specific Scvo2 threshold correlates with the likelihood of achieving return of spontaneous circulation (ROSC).

<p>Scvo2 reflects oxygen delivery adequacy during CPR. Failure to achieve an Scvo2 of 40% or greater during CPR has a very high negative predictive value for ROSC, indicating that resuscitation efforts may need to be adjusted.</p> Signup and view all the answers

In the context of refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), contrast the recommendations for using amiodarone and lidocaine as first-line antiarrhythmic agents, referencing the clinical trial mentioned in the text regarding return of spontaneous circulation (ROSC).

<p>Both amiodarone and lidocaine are recommended as first-line agents. However, a recent trial showed only lidocaine resulted in an increased rate of ROSC, although neither therapy significantly improved survival.</p> Signup and view all the answers

Explain why intermittent arterial and venous blood sampling for gas or chemistry analysis is of limited utility during CPR, and under what specific circumstances might Sao2 be valuable in titrating resuscitation therapy?

<p>Blood gas analysis is often of limited use during CPR because the results are not available in time to guide therapy. Sao2 is typically high and uninformative, except in suspected cases of massive pulmonary embolism or unrecognized esophageal intubation.</p> Signup and view all the answers

  1. What specific patient positioning is required for accurate IVC diameter measurement during an IVC collapse assessment?

<p>Supine position</p> Signup and view all the answers

Explain why the passive leg raise (PLR) maneuver is considered a dynamic assessment of volume responsiveness.

<p>PLR simulates a fluid bolus, shifting blood to the central circulation, allowing for observation of immediate cardiovascular response.</p> Signup and view all the answers

How is pulse pressure variation (PPV) calculated, and what physiological principle does it reflect?

<p>PPV is calculated as [(PPmax - PPmin) / PPmean] x 100, reflecting the impact of respiration on arterial pressure and, indirectly, cardiac preload.</p> Signup and view all the answers

In the context of IVC assessment, what distinguishes the criteria for volume responsiveness in spontaneously breathing patients versus mechanically ventilated patients?

<p>Spontaneously breathing patients: &gt;50% collapse suggests volume responsiveness; Mechanically ventilated patients: &gt;18% distensibility suggests volume responsiveness</p> Signup and view all the answers

Describe how the clinical interpretation of volume responsiveness, determined through dynamic measures, impacts the decision-making process for fluid therapy in post-arrest patients.

<p>It guides fluid administration by indicating if cardiac output will increase with fluids, helping to optimize tissue perfusion while avoiding over-resuscitation.</p> Signup and view all the answers

What specific ultrasound probe frequency is recommended for visualizing the IVC during an IVC collapse assessment?

<p>A low-frequency ultrasound transducer.</p> Signup and view all the answers

Detail the step-by-step procedure for performing the passive leg raise (PLR) technique to assess volume responsiveness.

<ol> <li>Place patient in semi-recumbent position (45 degrees); 2. Measure baseline blood pressure and heart rate; 3. Passively raise legs to 45-degree angle; 4. Maintain elevation for 1-2 minutes, monitoring BP and HR changes.</li> </ol> Signup and view all the answers

Identify the specific patient conditions that must be present to accurately interpret pulse pressure variation (PPV) as an indicator of volume responsiveness.

<p>Mechanically ventilated patients with normal heart rhythm and tidal volumes of 6-8 mL/kg.</p> Signup and view all the answers

Describe how factors such as patient positioning, intrathoracic pressure, and underlying medical conditions can confound the interpretation of IVC diameter and collapse.

<p>Patient positioning &amp; intrathoracic pressure may affect IVC diameter and collapse. Medical conditions can influence IVC compliance &amp; response to volume changes.</p> Signup and view all the answers

Explain the potential adverse outcomes associated with over-resuscitation during fluid therapy, particularly in the context of post-arrest care.

<p>Pulmonary edema and ARDS.</p> Signup and view all the answers

  1. What actions should be taken if the increase in systolic blood pressure is equal to 9 mmHg after performing the passive leg raise (PLR) technique?

<p>Consider other factors and assessments to determine volume responsiveness.</p> Signup and view all the answers

Explain how positive pressure ventilation influences IVC diameter and collapsibility, and how these effects are accounted for when interpreting IVC assessments in mechanically ventilated patients.

<p>Positive pressure increases intrathoracic pressure, reducing IVC collapsibility. The distensibility index (&gt;18%) is used in ventilated patients to account for these pressure effects.</p> Signup and view all the answers

In patients with significant tricuspid regurgitation or pulmonary hypertension, how might the interpretation of IVC collapsibility as an indicator of volume responsiveness be affected?

<p>Tricuspid regurgitation and pulmonary hypertension increases right atrial pressure, leading to IVC distention and reduced collapsibility, even in hypovolemic patients.</p> Signup and view all the answers

Describe the physiological rationale behind using changes in pulse pressure during mechanical ventilation to predict fluid responsiveness.

<p>Respiration-induced changes in intrathoracic pressure affect venous return, ventricular preload, and stroke volume, resulting in pulse pressure variation predictive of fluid responsiveness. Changes in pulse pressure reflect degree to which cardiac output is dependent on preload during mechanical ventilation.</p> Signup and view all the answers

How does the presence of spontaneous respiratory efforts in a mechanically ventilated patient affect the reliability and interpretation of pulse pressure variation (PPV) as a marker of volume responsiveness?

<p>Spontaneous respiratory efforts compromises PPV reliability as the ventilator no longer delivers consistent tidal volumes and pressures.</p> Signup and view all the answers

What are the limitations of relying solely on the passive leg raise (PLR) technique in patients with intra-abdominal hypertension or those in a Trendelenburg position?

<p>Intra-abdominal hypertension can restrict blood return from the legs, while Trendelenburg position already maximizes venous return, reducing the sensitivity of PLR.</p> Signup and view all the answers

Outline a strategy for integrating IVC assessment, passive leg raise (PLR), and pulse pressure variation (PPV) to create a comprehensive and nuanced evaluation of volume responsiveness in a complex post-arrest patient.

<p>Assess IVC; if inconclusive, perform PLR; in mechanically ventilated patients, use PPV. Integrate all with clinical assessment to guide fluid therapy.</p> Signup and view all the answers

In the context of post-arrest care, how does understanding volume responsiveness contribute to preventing secondary organ damage and improving overall patient outcomes?

<p>Optimizes cardiac output and tissue perfusion, reducing the risk of ischemia, acute kidney injury, and other complications.</p> Signup and view all the answers

How might significant changes in intrathoracic pressure, caused by conditions such as tension pneumothorax or severe asthma exacerbation, affect the accuracy of IVC diameter measurements and subsequent interpretation of volume responsiveness?

<p>Changes in intrathoracic pressure affects venous return, making IVC results less reliable for assessing volume responsiveness.</p> Signup and view all the answers

Discuss the ethical considerations involved in using dynamic measures of volume responsiveness in post-arrest patients who are unable to provide informed consent.

<p>Must balance the need for accurate assessment with the principles of beneficence, non-maleficence, and respect for patient autonomy.</p> Signup and view all the answers

  1. How can the accuracy of IVC diameter measurements be optimized using ultrasound to minimize errors introduced by improper probe placement or patient movement?

<p>Proper probe placement and minimal patient movement ensures greater accuracy of the IVC diameter measurements.</p> Signup and view all the answers

Explain how the timing of dynamic assessments (IVC collapsibility, PLR, PPV) relative to interventions such as vasopressor administration or changes in ventilator settings can influence their interpretation.

<p>Vasopressors can affect cardiac output, and ventilator settings can alter intrathoracic pressure, influencing the IVC measurements.</p> Signup and view all the answers

In patients with pre-existing heart failure or significant valvular disease, how might the interpretation of dynamic measures of volume responsiveness (IVC, PLR, PPV) differ compared to patients with normal cardiac function?

<p>Valvular disease impacts cardiac filling and contractility which may affect the accuracy and interpretation of the measurements.</p> Signup and view all the answers

How can point-of-care ultrasound (POCUS) be utilized to enhance the assessment of volume status and guide fluid management decisions in post-arrest patients, beyond simply measuring IVC diameter?

<p>It can evaluate cardiac function, assess for pulmonary edema, and identify other factors influencing hemodynamic stability.</p> Signup and view all the answers

Describe the steps that should be taken to ensure the reliability and reproducibility of pulse pressure variation (PPV) measurements, particularly in situations where multiple providers are involved in patient care.

<p>Ensure proper arterial line placement, consistent ventilator settings, and standardized measurement techniques to minimize variability.</p> Signup and view all the answers

Discuss the potential challenges and limitations associated with using dynamic measures of volume responsiveness in morbidly obese patients.

<p>Obesity can affect IVC diameter measurement, PLR, and PPV.</p> Signup and view all the answers

Explain how the use of vasopressors or inotropes might affect the interpretation of the passive leg raise (PLR) technique in assessing volume responsiveness.

<p>Vasopressors can alter vascular tone and cardiac contractility, affecting the response to PLR; Inotropes improve cardiac function, which may affect the accuracy of the procedure.</p> Signup and view all the answers

How can the principles of shared decision-making be applied when discussing fluid management strategies and the use of dynamic measures of volume responsiveness with family members of post-arrest patients?

<p>Provide clear explanations of the benefits, risks, and limitations of fluid therapy. Acknowledge concerns to make appropriate decisions.</p> Signup and view all the answers

In patients with chronic obstructive pulmonary disease (COPD) or other conditions characterized by increased intrathoracic pressure, how might the interpretation of IVC collapsibility or distensibility be affected?

<p>COPD results in chronically elevated intrathoracic pressure, which may diminish IVC collapsibility, regardless of the patient's volume status.</p> Signup and view all the answers

What specific adjustments to the passive leg raise (PLR) technique might be necessary when assessing volume responsiveness in patients with lower extremity fractures or other musculoskeletal injuries?

<p>Modifications to reduce pain and prevent further injury.</p> Signup and view all the answers

  1. Describe how the choice of mechanical ventilation mode (e.g., pressure control vs. volume control) and settings (e.g., tidal volume, PEEP) can influence the accuracy and reliability of pulse pressure variation (PPV) as an indicator of volume responsiveness.

<p>Volume control can allow for a standardized tidal volume. Higher PEEP can decrease venous return affecting the reliability of PPV as an indicator of volume responsiveness.</p> Signup and view all the answers

In patients with elevated intra-abdominal pressure (IAP), how is the interpretation of IVC collapsibility affected, and what alternative assessment methods might be more reliable?

<p>Elevated IAP increases pressure on the IVC, reducing its collapsibility. Alternative assessments include cardiac output monitoring or stroke volume variation. Alternative assessments that may not be affected by IAP, are recommended for accurate determination of the volume status.</p> Signup and view all the answers

Explain how the presence of significant arrhythmias, such as atrial fibrillation, can confound the interpretation of pulse pressure variation (PPV) as a marker of volume responsiveness.

<p>Arrhythmias cause irregular pulse pressure, making the measurement of PPV unreliable.</p> Signup and view all the answers

In the context of limited resources or equipment, what are the most practical and readily available methods for assessing volume responsiveness in post-arrest patients?

<p>Clinical assessment and passive leg raise may be the most readily available method.</p> Signup and view all the answers

How does the concept of 'fluid stewardship' relate to the use of dynamic measures of volume responsiveness in post-arrest care, and what strategies can be implemented to promote responsible fluid administration practices?

<p>It emphasizes that fluid administration should be based on accurate assessment to avoid both hypovolemia and hypervolemia.</p> Signup and view all the answers

In a patient with severe sepsis and septic shock, how might the interpretation of IVC collapsibility or distensibility as a marker of volume responsiveness be complicated by factors such as increased venous capacitance and endothelial dysfunction?

<p>Sepsis results in increased venous capacitance, reducing IVC collapsibility regardless of actual volume status.</p> Signup and view all the answers

What are the key steps involved in developing a standardized protocol for assessing volume responsiveness in post-arrest patients within a specific hospital or healthcare setting?

<p>Establish a multidisciplinary team. Select appropriate assessment measures. Provide training, and implement the protocol.</p> Signup and view all the answers

Describe how the principles of 'goal-directed therapy' (GDT) can be integrated with dynamic measures of volume responsiveness to optimize fluid management and improve outcomes in post-arrest patients.

<p>GDT involves using dynamic measures to guide fluid administration to achieve specific hemodynamic targets.</p> Signup and view all the answers

In patients with acute respiratory distress syndrome (ARDS), how might the interpretation of dynamic measures of volume responsiveness (e.g., PPV, IVC collapsibility) be affected by ventilator settings and strategies such as prone positioning?

<p>Prone positioning affects venous return potentially altering measures of volume responsiveness. (Prone position is a body orientation where an individual lies flat with their chest down and back up. In this position, the face is usually turned to one side, allowing for breathing, positionedcomfortably.)</p> Signup and view all the answers

In the context of IVC assessment for volume responsiveness, how might significant intra-abdominal hypertension confound the interpretation of IVC diameter and collapsibility measurements?

<p>Elevated intra-abdominal pressure can compress the IVC, reducing its diameter and potentially leading to a false positive result for volume responsiveness, even if the patient is not actually volume-responsive.</p> Signup and view all the answers

  1. Explain how the presence of tricuspid regurgitation could influence the accuracy of IVC collapsibility as a predictor of volume responsiveness.

<p>Tricuspid regurgitation can lead to elevated right atrial pressures, which are transmitted to the IVC, potentially causing it to appear more distended and less collapsible, even in a volume-responsive patient. This could lead to a false negative result.</p> Signup and view all the answers

How does the passive leg raise (PLR) technique simulate a fluid bolus, and what are the key physiological mechanisms underlying its effectiveness in predicting volume responsiveness?

<p>PLR simulates a fluid bolus by shifting venous blood from the lower extremities into the central circulation, increasing preload. This increase in preload will increase cardiac output, if the patient is volume responsive, and will result in an increase in systolic blood pressure &gt;10 mmHg.</p> Signup and view all the answers

Describe a clinical scenario where pulse pressure variation (PPV) might be unreliable in assessing fluid responsiveness, and explain the physiological reasons for its unreliability in this context.

<p>PPV may be unreliable with spontaneous breathing or cardiac arrhythmias. Spontaneous breathing can cause irregular changes in intrathoracic pressure, affecting pulse pressure independent of volume status. Arrhythmias lead to inconsistent stroke volumes, making it difficult to interpret PPV as an indicator of volume responsiveness.</p> Signup and view all the answers

A patient presents with septic shock and is mechanically ventilated. Their initial IVC distensibility index is 15%. After a fluid bolus, it decreases to 10%, but their blood pressure remains unchanged. How would you interpret these findings in the context of volume responsiveness, and what additional steps might you take to guide further fluid management?

<p>The initial IVC distensibility index of 15% suggests that the pt may not be volume responsive. The decrease to 10% after a fluid bolus, along with the unchanged blood pressure, suggests pt is not volume responsive and that further fluid administration may not be beneficial. Additional assessments such as echocardiography to assess cardiac function or other dynamic measures (e.g., pulse pressure variation) could provide further insights.</p> Signup and view all the answers

Explain how the principles of spectrophotometry are applied in pulse oximetry to determine SpO2.

<p>Pulse oximetry uses spectrophotometry by emitting red and infrared light through tissue. The differential absorption of these wavelengths by oxygenated and deoxygenated hemoglobin allows the device to calculate SpO2.</p> Signup and view all the answers

Describe the physiological mechanisms that can cause discrepancies between SpO2 and PaO2 values in a patient.

<p>Conditions like carbon monoxide poisoning, methemoglobinemia, and severe anemia can cause SpO2 to overestimate true oxygen saturation, leading to discrepancies with PaO2. Additionally, peripheral vasoconstriction can affect SpO2 accuracy.</p> Signup and view all the answers

Outline the preprocedure and postprocedure steps involved in performing an arterial blood gas (ABG) test to measure PaO2, emphasizing the importance of pre- and post-procedure considerations.

<p>ABG involves arterial puncture, typically in the radial artery. Pre-procedure, assess collateral circulation via Allen's test. Post-procedure, apply pressure to prevent hematoma and monitor for complications like arterial spasm or nerve damage.</p> Signup and view all the answers

Analyze the impact of altitude on normal SpO2 and PaO2 ranges, and explain the underlying physiological adaptations.

<p>At higher altitudes, both SpO2 and PaO2 ranges decrease due to lower atmospheric pressure. Physiological adaptations include increased ventilation, erythropoiesis, and increased 2,3-DPG levels improving oxygen unloading.</p> Signup and view all the answers

Discuss the limitations of using SpO2 as the sole indicator of adequate tissue oxygenation in critically ill patients. What other parameters should be considered?

<p>SpO2 does not reflect oxygen delivery (DO2) or consumption (VO2). Other parameters like arterial pH, lactate levels, central venous oxygen saturation (ScvO2), and clinical assessment of end-organ function should be considered.</p> Signup and view all the answers

What are the key differences in clinical applications between SpO2 monitoring and PaO2 measurement?

<p>SpO2 is used for continuous, non-invasive monitoring, suitable for routine assessments and screening. PaO2, obtained via ABG, is used for accurate evaluation of oxygenation and acid-base balance in critical care settings.</p> Signup and view all the answers

  1. Describe how vasoconstriction or peripheral hypoperfusion can affect the accuracy of SpO2 readings.

<p>Vasoconstriction or hypoperfusion reduces blood flow to the periphery, leading to a weaker pulse signal. This can result in inaccurate SpO2 readings, often underestimating the true arterial oxygen saturation.</p> Signup and view all the answers

Explain the concept of the oxyhemoglobin dissociation curve and its relevance in interpreting SpO2 and PaO2 values.

<p>The oxyhemoglobin dissociation curve illustrates the relationship between PaO2 and hemoglobin saturation (SpO2). Shifts in the curve due to factors like pH, temperature, and 2,3-DPG levels affect oxygen loading and unloading in tissues.</p> Signup and view all the answers

How does the presence of dyshemoglobins (e.g., carboxyhemoglobin, methemoglobin) affect SpO2 readings obtained by pulse oximetry?

<p>Dyshemoglobins like carboxyhemoglobin and methemoglobin absorb light at similar wavelengths as oxyhemoglobin, leading to falsely elevated SpO2 readings despite reduced oxygen-carrying capacity.</p> Signup and view all the answers

Describe the role of pulse oximetry in managing patients with chronic obstructive pulmonary disease (COPD) and the potential risks of relying solely on SpO2 targets.

<p>In COPD, pulse oximetry guides oxygen therapy, but over-reliance can lead to hypercapnia and respiratory acidosis. Titrate oxygen to maintain SpO2 targets (e.g., 88-92%) while monitoring for signs of CO2 retention (Headache, drowsiness, confusion, tremor (asterixis), flushed skin, tachypnea, hypertension, or paradoxical breathing</p> Signup and view all the answers

Explain how ambient light and motion artifact can interfere with pulse oximetry readings, and describe methods to minimize these interferences.

<p>Ambient light and motion artifact can cause inaccurate pulse oximetry readings by interfering with the detection of pulsatile blood flow. Shielding the sensor from light, ensuring proper sensor placement, and using signal averaging techniques can minimize these interferences.</p> Signup and view all the answers

  1. Discuss the ethical considerations involved in using pulse oximetry as a screening tool for hypoxemia in resource-limited settings.

<p>Ethical considerations include ensuring access to appropriate follow-up care for those identified with hypoxemia, avoiding unnecessary anxiety and resource utilization in false-positive cases, and addressing potential disparities in access to pulse oximetry technology.</p> Signup and view all the answers

Describe the physiological basis for the pulse oximeter's ability to differentiate between arterial and venous blood flow.

<p>Pulse oximetry relies on detecting the pulsatile changes in light absorption caused by arterial blood flow. The device filters out the constant absorption from venous blood and other tissues, focusing on the arterial component.</p> Signup and view all the answers

Explain the impact of anemia on SpO2 readings. How can anemia mask or alter the interpretation of hypoxemia?

<p>In anemia, SpO2 can be normal despite reduced total oxygen content in the blood. The PaO2 might be normal, and thus SpO2 is normal, but the oxygen carrying capacity is decreased. This can mask the presence of hypoxemia and impair oxygen delivery.</p> Signup and view all the answers

Describe the effects of hypothermia on pulse oximetry readings and explain the underlying mechanisms.

<p>Hypothermia causes peripheral vasoconstriction, reducing blood flow to the extremities. This can lead to inaccurate SpO2 readings, often underestimating the true arterial oxygen saturation due to poor signal quality.</p> Signup and view all the answers

Explain the concept of 'pulse pressure variation' (PPV) and its potential impact on the accuracy of pulse oximetry readings.

<p>PPV refers to the change in pulse pressure during mechanical ventilation. High PPV can indicate hypovolemia and reduced peripheral perfusion, leading to inaccurate SpO2 readings due to inconsistent signal quality.</p> Signup and view all the answers

  1. Describe the role of pulse CO-oximetry in differentiating between various forms of hemoglobin, and explain how it improves diagnostic accuracy compared to standard pulse oximetry.

<p>Pulse CO-oximetry measures different forms of hemoglobin (e.g., oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, methemoglobin) by using multiple wavelengths of light. This allows for accurate detection of dyshemoglobinemias, which standard pulse oximetry cannot distinguish.</p> Signup and view all the answers

Discuss the limitations of using SpO2 as a surrogate marker for PaO2 in patients with acute respiratory distress syndrome (ARDS). What additional monitoring techniques are recommended?

<p>In ARDS, the relationship between SpO2 and PaO2 can be unpredictable due to V-Q mismatch and intrapulmonary shunting. Additional monitoring techniques include arterial blood gas analysis, venous oximetry, and assessment of respiratory mechanics. A comprehensive approach is necessary for managing oxygenation and guiding ventilator settings in ARDS patients.</p> Signup and view all the answers

Explain how nail polish or artificial nails can affect pulse oximetry readings, and describe methods to mitigate these interferences.

<p>Dark nail polish or artificial nails can absorb light, interfering with the pulse oximeter's ability to detect pulsatile blood flow. Removing nail polish or using alternative monitoring sites (e.g., earlobe) can improve accuracy.</p> Signup and view all the answers

Describe the role of 'fractional inspired oxygen' (FiO2) in the context of SpO2 and PaO2 management in mechanically ventilated patients.

<p>FiO2 represents the percentage of oxygen in the gas mixture delivered to the patient. Adjusting FiO2 is crucial for achieving target SpO2 and PaO2 levels while minimizing the risk of oxygen toxicity and lung injury.</p> Signup and view all the answers

Explain the concept of 'oxygen delivery' (DO2) and its relationship to SpO2, PaO2, and cardiac output. How can DO2 be optimized in critically ill patients?

<p>DO2 represents the amount of oxygen delivered to the tissues per minute. It depends on hemoglobin concentration, arterial oxygen saturation (SpO2), PaO2, and cardiac output. Optimizing DO2 involves ensuring adequate hemoglobin levels, optimizing oxygen saturation, and maintaining adequate cardiac output through fluid management and inotropic support.</p> Signup and view all the answers

  1. Describe the limitations of using SpO2 as an indicator of tissue perfusion in patients with peripheral vascular disease (PVD). What alternative assessment methods are recommended?

<p>In PVD, SpO2 may be normal despite reduced blood flow to the extremities. Alternative assessment methods include ankle-brachial index (ABI), pulse volume recording (PVR), and transcutaneous oxygen monitoring (TcPO2).</p> Signup and view all the answers

Explain the concept of 'venous admixture' and its effect on the relationship between SpO2 and PaO2. How does venous admixture impact oxygen delivery to the tissues?

<p>Venous admixture refers to the mixing of deoxygenated venous blood with oxygenated arterial blood, reducing the overall oxygen content. It causes a greater drop in PaO2 for a given SpO2, impairing oxygen delivery to the tissues.</p> Signup and view all the answers

Describe the use of pulse oximetry in neonatal intensive care units (NICU) and explain the unique challenges associated with SpO2 monitoring in premature infants.

<p>In NICUs, pulse oximetry is used for continuous monitoring of oxygenation in newborns. Challenges include motion artifact, poor perfusion, and sensitivity to ambient light. Preductal SpO2 monitoring is often preferred to assess oxygenation to the brain.</p> Signup and view all the answers

Explain the concept of 'shunt fraction' and its influence on the interpretation of SpO2 and PaO2 values in patients with acute lung injury (ALI).

<p>Shunt fraction represents the proportion of cardiac output that bypasses ventilated alveoli, resulting in deoxygenated blood entering the systemic circulation. A high shunt fraction can cause severe hypoxemia despite high FiO2 and relatively normal SpO2.</p> Signup and view all the answers

Describe the use of pulse oximetry in sleep apnea monitoring and explain the significance of oxygen desaturation index (ODI) in diagnosing sleep-disordered breathing.

<p>In sleep apnea monitoring, pulse oximetry detects episodes of nocturnal oxygen desaturation. ODI represents the number of desaturation events per hour of sleep and is used to assess the severity of sleep apnea.</p> Signup and view all the answers

  1. Explain the role of 'positive end-expiratory pressure' (PEEP) in improving oxygenation in patients with acute respiratory failure and its impact on SpO2 and PaO2 levels.

<p>PEEP increases alveolar recruitment, reducing intrapulmonary shunting and improving oxygenation. It increases both SpO2 and PaO2 levels by maintaining alveolar patency and enhancing gas exchange.</p> Signup and view all the answers

Describe the use of pulse oximetry in assessing the effectiveness of bronchodilator therapy in patients with asthma exacerbation and explain the expected changes in SpO2 following bronchodilator administration.

<p>In asthma exacerbation, pulse oximetry monitors oxygenation during bronchodilator therapy. Following bronchodilator administration, SpO2 is expected to increase as airway obstruction decreases and ventilation improves.</p> Signup and view all the answers

Explain the relationship between the 'alveolar-arterial oxygen gradient' (A-a gradient) and the interpretation of SpO2 and PaO2 values in patients with respiratory disease.

<p>The A-a gradient reflects the difference between alveolar and arterial oxygen tension, indicating the efficiency of gas exchange. A widened A-a gradient suggests impaired gas exchange, causing hypoxemia despite adequate SpO2 levels.</p> Signup and view all the answers

What is the significance of esmolol's short half-life in emergency settings?

<p>Esmolol's short half-life allows for rapid titration and adjustment of dosage in unstable patients, making it beneficial for managing acute blood pressure and heart rate changes effectively without prolonged effects.</p> Signup and view all the answers

What is the typical loading dose of esmolol in adults?

<p>The typical loading dose of esmolol in adults is 500 mcg/kg administered over 1 minute. This initial dose may vary based on clinical protocols and specific patient needs.</p> Signup and view all the answers

How is esmolol administered after the loading dose?

<p>After the loading dose, esmolol is given as a continuous infusion, typically starting at 50 mcg/kg/min. The dose can be titrated based on the patient's response, in increments of 25-50 mcg/kg/min every 4-10 minutes.</p> Signup and view all the answers

What are some contraindications for esmolol in emergent situations?

<p>Contraindications include severe bradycardia, hypotension, decompensated heart failure, cardiogenic shock, and asthma. These conditions can worsen with beta-blockade and require cautious consideration.</p> Signup and view all the answers

Why is caution advised when administering esmolol to asthma patients?

<p>Although esmolol primarily targets beta-1 receptors, caution is advised for asthma patients because it can still impact beta-2 receptors, potentially leading to bronchoconstriction and worsening respiratory issues.</p> Signup and view all the answers

What should clinicians monitor while administering esmolol?

<p>Clinicians should closely monitor heart rate and blood pressure during esmolol administration to ensure effective management and to adjust the dosage as necessary based on the patient's hemodynamic response.</p> Signup and view all the answers

What is the initial target MAP post-ROSC?

<p>65-90 mmHg</p> Signup and view all the answers

Can higher blood pressures be allowed post-ROSC?

<p>True (A)</p> Signup and view all the answers

What is the formula to calculate MAP?

<p>MAP = Diastolic BP + 1/3 (Systolic BP - Diastolic BP)</p> Signup and view all the answers

What is the general MAP goal post-ROSC?

<p>65-100 mmHg</p> Signup and view all the answers

Why is it important to maintain adequate perfusion after resuscitation?

<p>To ensure the viability of vital organs.</p> Signup and view all the answers

What should clinicians avoid in the immediate post-resuscitation period?

<p>Aggressive treatment causing excessively high blood pressure.</p> Signup and view all the answers

What is the priority in hypertension management after ROSC?

<p>To ensure sufficient perfusion to vital organs.</p> Signup and view all the answers

Are there variations in guidelines for targeted MAP levels?

<p>True (A)</p> Signup and view all the answers

What is the key target CPP value during CPR?

<p>Minimum coronary perfusion pressure of 15-20 mmHg.</p> Signup and view all the answers

Why is CPP clinically significant during CPR?

<p>It ensures adequate blood flow to the coronary arteries for myocardial perfusion.</p> Signup and view all the answers

How can aortic diastolic pressure be measured in an unstable ROSC patient?

<p>Use an arterial line for continuous blood pressure monitoring.</p> Signup and view all the answers

How can right atrial pressure be measured?

<p>Place a central venous catheter in the right atrium.</p> Signup and view all the answers

What is the importance of maintaining adequate CPP during ROSC?

<p>It reflects the ability to effectively perfuse the myocardium, influencing outcomes.</p> Signup and view all the answers

Why is myoclonus considered a predictor of poor neurological outcome in ROSC patients?

<p>Myoclonus can indicate severe brain injury and ongoing brain dysfunction after cardiac arrest.</p> Signup and view all the answers

What does myoclonus following ROSC suggest about brain damage?

<p>It may indicate widespread brain damage due to lack of oxygen during cardiac arrest.</p> Signup and view all the answers

How is the persistence of post-anoxic myoclonus related to neurological prognosis?

<p>Persistent myoclonus suggests ongoing brain injury and poorer outcomes of severe neurological disabilities.</p> Signup and view all the answers

What has research shown about the association between myoclonus and patient outcomes?

<p>Studies have linked post-anoxic myoclonus to higher mortality rates and worse severe neurological disabilities or remaining in a vegetative state.</p> Signup and view all the answers

Why is myoclonus a sign of a more severe brain injury in ROSC patients?

<p>It may indicate critical brain areas affected, impacting motor control and consciousness.</p> Signup and view all the answers

In what situations may dual antiplatelet therapy with aspirin and ticagrelor not be administered after CPR?

<p>Dual antiplatelet therapy may be withheld if the patient has active bleeding, a history of hemorrhagic stroke, a high risk of bleeding, contraindications to these medications, or physical injuries from CPR such as rib fractures or organ damage.</p> Signup and view all the answers

Why might healthcare providers choose not to administer aspirin and ticagrelor post-CPR?

<p>The decision may be based on bleeding risks, underlying injuries like rib fractures or organ trauma, contraindications to antiplatelet medications, the need for urgent surgery, or individual patient factors that outweigh the benefits of dual antiplatelet therapy.</p> Signup and view all the answers

How is ticagrelor dosed for treating acute coronary syndrome (ACS), including those who are post-ROSC or post-CPR?

<p>Initial 180 mg loading dose, followed by 90 mg twice daily maintenance dose for prevention of blood clots.</p> Signup and view all the answers

What is the trade name of ticagrelor, used in post-ROSC patients for anticoagulation to prevent clot formation?

<p>Ticagrelor, known as Brilinta, is a medication used in post-ROSC and post-CPR patients to prevent blood clot formation and reduce cardiovascular risk.</p> Signup and view all the answers

What does Scv02 reflect during CPR?

<p>Scv02 reflects changes in oxygen delivery to tissues via cardiac output. Clinically, monitoring ScvO2 levels during CPR can provide valuable information about the effectiveness of chest compressions and circulation.</p> Signup and view all the answers

Why does VO2 remain constant during CPR?

<p>Limited metabolic processes keep oxygen consumption stable.</p> Signup and view all the answers

How does ScvO2 change with cardiac output?

<p>Increased cardiac output raises Scv02, while decreased output lowers it. Changes in central venous O2 saturation (ScvO2) reflect alterations in oxygen delivery to tissues through changes in cardiac output. ScvO2 represents amount of oxygen left in the blood after passing through tissues and is returning to the heart.</p> Signup and view all the answers

What does a decrease in Scv02 during CPR indicate?

<p>Inadequate oxygen delivery to tissues.</p> Signup and view all the answers

What intervention may be needed if ScvO2 is low in CPR?

<p>Adjust compression techniques or other interventions for improved oxygen delivery.</p> Signup and view all the answers

What does ScvO2 stand for?

<p>Central venous oxygen saturation</p> Signup and view all the answers

What does ScvO2 monitoring help assess during CPR?

<p>Adequacy of oxygen delivery to tissues</p> Signup and view all the answers

During CPR, what does a low ScvO2 value typically indicate?

<p>Inadequate oxygen delivery</p> Signup and view all the answers

Name one factor that can affect ScvO2 during CPR.

<p>Cardiac output, Hemoglobin levels, Arterial oxygen saturation (SaO2), Oxygen consumption, Venous return</p> Signup and view all the answers

What is the typical range for normal ScvO2?

<p>65% to 75%</p> Signup and view all the answers

What is one potential cause of low ScvO2 during CPR?

<p>Ineffective chest compressions, Hypovolemia, Severe vasoconstriction, Hypoxemia</p> Signup and view all the answers

What is one intervention that can be used to improve low ScvO2 during CPR?

<p>Optimizing chest compression technique, Administering intravenous fluids, Using vasopressors, Adjusting ventilation</p> Signup and view all the answers

Name a technique used for monitoring ScvO2.

<p>Central Venous Catheterization, Continuous ScvO2 Monitoring, Near-Infrared Spectroscopy (NIRS)</p> Signup and view all the answers

What might a high ScvO2 value during CPR indicate?

<p>Excessive oxygen delivery relative to oxygen consumption, Microcirculatory dysfunction, Shunting of blood away from tissues</p> Signup and view all the answers

What can a sustained increase in ScvO2 indicate during CPR?

<p>Improved oxygen delivery and tissue perfusion</p> Signup and view all the answers

In continuous ScvO2 monitoring, a central venous catheter is typically inserted into the superior vena cava via the subclavian, internal jugular, or ______ vein.

<p>femoral</p> Signup and view all the answers

An oximetric catheter equipped with fiber optic sensors measures the oxygen saturation of the blood and continuously transmits data to a ______, displaying real-time ScvO2 values.

<p>monitor</p> Signup and view all the answers

When interpreting ScvO2 values, trends should be evaluated in conjunction with the patient’s overall clinical condition, including vital signs, lab results, and other ______ data.

<p>relevant</p> Signup and view all the answers

Regularly assessing the catheter insertion site for signs of infection or other ______ is crucial to prevent complications associated with central venous catheter use.

<p>complications</p> Signup and view all the answers

A normal ScvO2 value typically ranges between 65% and 75%, reflecting that the tissues are extracting an ______ amount of oxygen from the blood.

<p>appropriate</p> Signup and view all the answers

Higher than normal ScvO2 values (e.g., >75%) may indicate decreased oxygen consumption, potentially caused by sepsis, cyanide toxicity, hypothermia, or a ______-to-right shunt.

<p>left</p> Signup and view all the answers

In cases of sepsis, tissues may be unable to effectively extract oxygen, leading to higher than normal ScvO2 values due to impaired ______ utilization.

<p>oxygen</p> Signup and view all the answers

Cyanide toxicity impairs oxygen utilization at the cellular level, resulting in higher than normal ScvO2 values as tissues are unable to effectively use the ______ delivered.

<p>oxygen</p> Signup and view all the answers

Hypothermia reduces metabolic demands, decreasing oxygen consumption and potentially leading to higher than normal ______ values.

<p>ScvO2</p> Signup and view all the answers

A left-to-right shunt results in recirculation of oxygenated blood, which can lead to higher than normal ScvO2 values due to the increased ______ content in the central venous circulation.

<p>oxygen</p> Signup and view all the answers

What is a common Pa02 value in pulmonary embolism (PE)?

<p>Typically &lt; 60 mmHg.</p> Signup and view all the answers

What pH level is associated with respiratory alkalosis in PE?

<p>Generally &gt; 7.45.</p> Signup and view all the answers

What bicarbonate (HCO3-) value indicates possible metabolic acidosis in severe PE?

<p>Typically &lt; 22 mEq/L.</p> Signup and view all the answers

What is a common Pa02 value in esophageal intubation?

<p>Often &lt; 60 mmHg.</p> Signup and view all the answers

What pH level indicates respiratory acidosis in esophageal intubation?

<p>Generally &lt; 7.35.</p> Signup and view all the answers

What is the bicarbonate (HCO3-) value in esophageal intubation?

<p>It may be normal or slightly decreased.</p> Signup and view all the answers

What are the expected blood gas findings for pulmonary embolism (PE)?

<p>PaO2 &lt; 60 mmHg, SaO2 &lt; 90%, pH &gt; 7.45, PaCO2 &lt; 35 mmHg, HCO3- &lt; 22 mEq/L in severe cases.</p> Signup and view all the answers

What are the expected blood gas findings for esophageal intubation?

<p>PaO2 &lt; 60 mmHg, SaO2 &lt; 90%, PaCO2 &gt; 45 mmHg, pH &lt; 7.35, HCO3- may be normal or slightly decreased.</p> Signup and view all the answers

Can you express mean arterial pressure (MAP) using different formulas?

<p>Yes, MAP can be calculated as: MAP = Diastolic Pressure + 1/3(Systolic Pressure - Diastolic Pressure) or MAP = (PPmax + 2 × PPmin) / 3.</p> Signup and view all the answers

How does the alternative formula for MAP emphasize the cardiac cycle?

<p>It starts with diastolic pressure and adds one-third of the difference between systolic and diastolic pressures. The other way is MAP = (PPmax + 2 × PPmin) / 3, showing weights for diastole and systole.</p> Signup and view all the answers

What is the simplified version of the alternative MAP formula?

<p>MAP = (2/3) × Diastolic Pressure + (1/3) × Systolic Pressure, while the other method is MAP = (PPmax + 2 × PPmin) / 3.</p> Signup and view all the answers

Why is the second formula for MAP less commonly used?

<p>The first formula, MAP = (PPmax + 2 × PPmin) / 3, is more intuitive for clinicians regarding the relationship between pressures and the cardiac cycle, unlike the other method.</p> Signup and view all the answers

Do both MAP formulas yield similar results?

<p>Yes, both MAP = Diastolic Pressure + 1/3(Systolic Pressure - Diastolic Pressure) and MAP = (PPmax + 2 × PPmin) / 3 account for the time spent in each phase of the cardiac cycle and will provide similar results.</p> Signup and view all the answers

What are the four steps to manually measure blood pressure at the bedside?

<ol> <li>Prepare the patient in a comfortable position (supine or sitting). 2. Use a manual sphygmomanometer, placing the cuff around the upper arm, about 1 inch above the elbow. 3. Inflate the cuff to 20-30 mmHg above expected systolic pressure. 4. Slowly deflate while listening for Korotkoff sounds; record systolic (first sound) and diastolic (last sound) pressures.</li> </ol> Signup and view all the answers

What is pulse pressure?

<p>Pulse pressure is the difference between systolic and diastolic blood pressure, calculated as PP = SBP - DBP.</p> Signup and view all the answers

What is the normal range for pulse pressure?

<p>Normal pulse pressure typically ranges from 40 to 60 mmHg.</p> Signup and view all the answers

What does a narrowed pulse pressure indicate?

<p>A narrowed pulse pressure (less than 40 mmHg) may indicate hypovolemia or poor cardiac output.</p> Signup and view all the answers

What does a widened pulse pressure suggest?

<p>A widened pulse pressure (greater than 60 mmHg) can indicate adequate volume status or conditions like aortic regurgitation.</p> Signup and view all the answers

How does mechanical ventilation affect pulse pressure?

<p>Positive pressure ventilation can increase intrathoracic pressure, reducing venous return and affecting preload.</p> Signup and view all the answers

Why is it important to monitor pulse pressure trends?

<p>Monitoring trends over time can help identify sudden changes in hemodynamic status, such as compromise.</p> Signup and view all the answers

What should be considered alongside pulse pressure?

<p>Evaluate other hemodynamic parameters, such as heart rate, mean arterial pressure, and central venous pressure.</p> Signup and view all the answers

What does a persistently narrow pulse pressure suggest?

<p>It may suggest hypovolemia, reduced intravascular volume, or cardiac dysfunction.</p> Signup and view all the answers

What might a widened pulse pressure indicate?

<p>It could indicate adequate intravascular volume or increased stroke volume due to heightened cardiac output.</p> Signup and view all the answers

How should clinical context influence interpretation of pulse pressure?

<p>Always assess pulse pressure in the context of the patient's overall clinical condition and medications.</p> Signup and view all the answers

What is a fluid challenge?

<p>A fluid challenge involves administering a small bolus of fluid, then observing changes in pulse pressure and hemodynamics.</p> Signup and view all the answers

What indicates fluid responsiveness in a patient?

<p>An increase in pulse pressure after a fluid bolus suggests that the patient is volume responsive and may benefit from more fluids.</p> Signup and view all the answers

Why is regular re-evaluation of volume status critical?

<p>Continuous assessment is essential in dynamic situations like those seen in critically ill and ventilated patients.</p> Signup and view all the answers

What is the normal diameter of the IVC?

<p>The normal diameter of the IVC is typically around 1.2 to 2.5 cm.</p> Signup and view all the answers

What IVC diameter suggests fluid overload?

<p>An IVC diameter greater than 2.5 cm may suggest fluid overload.</p> Signup and view all the answers

What IVC diameter indicates hypovolemia?

<p>An IVC diameter less than 1.2 cm may indicate hypovolemia.</p> Signup and view all the answers

What position should the patient be in for IVC measurement?

<p>The patient should be in a supine or semi-recumbent position.</p> Signup and view all the answers

What ultrasound probe is used to measure the IVC?

<p>A low-frequency abdominal probe (2-5 MHz) is used.</p> Signup and view all the answers

Where is the IVC measured?

<p>The IVC is typically measured at the level of the hepatic vein, just before it enters the right atrium.</p> Signup and view all the answers

How is the IVC diameter measured?

<p>Measure the widest diameter of the IVC during expiration and the diameter at the end of inspiration.</p> Signup and view all the answers

What is IVCmax?

<p>IVCmax is the widest diameter of the IVC measured during expiration.</p> Signup and view all the answers

What is SpO2? What is its normal range? How is it measured?

<p>SpO2 refers to peripheral capillary oxygen saturation, its a measure of amount of oxygen bound to hemoglobin in the blood. It is typically expressed as a percentage. An SpO2 level of 95% to 100% is generally considered normal, while levels below this may indicate a deficiency in oxygenation, which can be a sign of respiratory or circulatory issues. SpO2 is commonly measured using a pulse oximeter, a non-invasive device that clips onto a fingertip or earlobe.</p> Signup and view all the answers

How do you calculate the collapsibility index?

<p>Collapsibility Index = (IVCmax - IVCmin) / IVCmax × 100.</p> Signup and view all the answers

What does a large IVC that collapses little during inspiration indicate?

<p>It suggests hypervolemia.</p> Signup and view all the answers

What does a small IVC that collapses significantly during inspiration suggest?

<p>It typically indicates hypovolemia.</p> Signup and view all the answers

What should be considered in conjunction with IVC measurements?

<p>Combine IVC measurements with clinical signs, blood pressure, heart rate, and urine output.</p> Signup and view all the answers

What is pulse pressure variation (PPV)?

<p>PPV is a dynamic parameter used to assess fluid responsiveness in mechanically ventilated patients.</p> Signup and view all the answers

How do you integrate IVC size with patient management?

<p>Use IVC size and collapsibility with clinical assessment to guide fluid therapy and resuscitation.</p> Signup and view all the answers

What does SpO2 measure?

<p>The amount of oxygen bound to hemoglobin in the blood</p> Signup and view all the answers

How is SpO2 expressed?

<p>As a percentage</p> Signup and view all the answers

What is considered a normal SpO2 level?

<p>A level between 95% and 100%</p> Signup and view all the answers

What can low SpO2 levels indicate?

<p>A deficiency in oxygenation, possibly due to respiratory or circulatory issues</p> Signup and view all the answers

How is SpO2 commonly measured?

<p>Using a pulse oximeter</p> Signup and view all the answers

Where is a pulse oximeter typically placed?

<p>It is clipped onto a fingertip or earlobe</p> Signup and view all the answers

How does carbon monoxide poisoning affect SpO2 readings?

<p>Carbon monoxide binds to hemoglobin, leading pulse oximeters to misinterpret carboxyhemoglobin as oxyhemoglobin, causing falsely elevated SpO2 readings.</p> Signup and view all the answers

What is the impact of methemoglobinemia on SpO2 accuracy?

<p>Methemoglobin can't bind oxygen and mimics oxyhemoglobin absorption, leading pulse oximeters to overestimate SpO2 levels, causing inaccurate readings.</p> Signup and view all the answers

Why does severe anemia affect SpO2 readings?

<p>Severe anemia lowers hemoglobin levels, so even with a normal-looking SpO2 percentage, the total oxygen transport is inadequate, leading to discrepancies with PaO2.</p> Signup and view all the answers

How does peripheral vasoconstriction influence SpO2 accuracy?

<p>Peripheral vasoconstriction reduces blood flow to extremities, making pulse oximeters less reliable, potentially resulting in inaccurate or overestimated SpO2 readings.</p> Signup and view all the answers

What is the consequence of having carboxyhemoglobin in the blood?

<p>Carboxyhemoglobin prevents oxygen transport, causing hypoxia and possible confusion in pulse oximetry, leading to falsely elevated SpO2 readings.</p> Signup and view all the answers

How does methemoglobinemia occur?

<p>Methemoglobinemia occurs when iron in hemoglobin is oxidized to the ferric state, often due to exposure to certain drugs/chemicals, making oxygen binding ineffective.</p> Signup and view all the answers

What are common causes of severe anemia?

<p>Common causes include blood loss, nutritional deficiencies (iron, vitamin B12), and bone marrow disorders impairing red blood cell production.</p> Signup and view all the answers

Why is it important to consider PaO2 alongside SpO2?

<p>PaO2 provides a direct measure of oxygen in the blood, revealing true oxygenation status when SpO2 accuracy is compromised.</p> Signup and view all the answers

What is the step-by-step guide to performing a radial arterial puncture?

<ol> <li><strong>Pre-procedure</strong>: Assess collateral circulation using the Allen's test to ensure adequate blood flow.</li> <li><strong>Positioning</strong>: Hyperextend the patient's wrist over a rolled towel to expose the radial artery.</li> <li><strong>Cleanse</strong>: Sterilize the site with an antiseptic (e.g., chlorhexidine).</li> <li><strong>Anesthesia</strong>: Optional local anesthetic (e.g., lidocaine) to minimize pain.</li> <li><strong>Puncture</strong>: Insert a heparinized syringe/needle at a 45° angle into the radial artery.</li> <li><strong>Aspiration</strong>: Allow arterial pressure to fill the syringe; avoid air bubbles.</li> <li><strong>Post-procedure</strong>: Apply firm pressure for 5-10 minutes to prevent hematoma.</li> <li><strong>Label &amp; transport</strong>: Place the sample on ice (if delayed analysis) and label with patient details.</li> <li><strong>Monitor</strong>: Check for complications (e.g., arterial spasm, nerve damage, or ischemia).</li> </ol> Signup and view all the answers

What is the first step in performing a radial arterial puncture?

<p>Assess collateral circulation using the Allen's test to ensure adequate blood flow.</p> Signup and view all the answers

How should the patient's wrist be positioned to expose the radial artery?

<p>Hyperextend the patient's wrist over a rolled towel.</p> Signup and view all the answers

What should be used to sterilize the site before a radial arterial puncture?

<p>An antiseptic, such as chlorhexidine.</p> Signup and view all the answers

What type of local anesthetic can be used to minimize pain during a radial arterial puncture?

<p>Lidocaine.</p> Signup and view all the answers

At what angle should a heparinized syringe/needle be inserted into the radial artery?

<p>45 degrees.</p> Signup and view all the answers

What should be avoided during aspiration when performing a radial arterial puncture?

<p>Air bubbles.</p> Signup and view all the answers

How long should firm pressure be applied post-procedure to prevent hematoma?

<p>5-10 minutes.</p> Signup and view all the answers

How should the blood sample be stored and transported if there is a delay in analysis?

<p>Place the sample on ice and label with patient details.</p> Signup and view all the answers

What complications should be monitored for after performing a radial arterial puncture?

<p>Arterial spasm, ischemia, or nerve damage.</p> Signup and view all the answers

What is cooximetry?

<p>A lab test measuring hemoglobin types (e.g., O2Hb, COHb, MetHb) to assess oxygen-carrying capacity and detect poisoning.</p> Signup and view all the answers

How is a blood sample prepared for cooximetry?

<p>Arterial blood is drawn, heparinized to prevent clotting, and sometimes hemolyzed to release hemoglobin.</p> Signup and view all the answers

What device performs cooximetry analysis?

<p>A co-oximeter, a spectrophotometer using multiple light wavelengths to differentiate hemoglobin species.</p> Signup and view all the answers

Why does cooximetry use multiple wavelengths?

<p>Each hemoglobin type absorbs light uniquely; specific wavelengths target variants like COHb (548 nm) or MetHb (535 nm).</p> Signup and view all the answers

What conditions does cooximetry diagnose?

<p>Carbon monoxide poisoning (high COHb), methemoglobinemia (high MetHb), and hidden hypoxia.</p> Signup and view all the answers

How does cooximetry differ from pulse oximetry?

<p>Cooximetry detects dysfunctional hemoglobins (COHb/MetHb), while pulse oximetry often misses them, risking false-normal readings.</p> Signup and view all the answers

What is measured in cooximetry results?

<p>Percentages of hemoglobin types (O2Hb, HHb, COHb, MetHb) and true oxygen saturation (SaO2).</p> Signup and view all the answers

Why is arterial blood preferred for cooximetry?

<p>Arterial samples reflect oxygen levels delivered to tissues more accurately than venous blood.</p> Signup and view all the answers

What clinical role does cooximetry have?

<p>Guides treatment for CO poisoning, methemoglobinemia, or unclear hypoxia by revealing hemoglobin abnormalities.</p> Signup and view all the answers

What hemoglobin types does cooximetry identify?

<p>Oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, methemoglobin, and rarely sulfhemoglobin.</p> Signup and view all the answers

Flashcards

Epinephrine use in Arrest?

First-line vasopressor for cardiac arrest; dose is 1 mg IV/IO every 3-5 minutes, or Vasopressin 40 units IV push (alternative).

Antiarrhythmics for refractory VF/pVT?

Amiodarone (300mg IV/IO first dose, 150mg second) or Lidocaine (1-1.5 mg/kg first dose, 0.5-0.75 mg/kg second).

Treatment for torsades de pointes?

Magnesium sulfate 2-4g IV push.

Calcium dose for hyperkalemia?

1g calcium chloride IV or 3g calcium gluconate IV

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Ineffective CPR indicated by PETCO2?

Less than 10 mm Hg prompts CPR quality improvement.

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ScvO2 predicting no ROSC during CPR?

Less than 40% (100% negative predictive value).

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CPP target during CPR?

Minimum 15-20 mmHg (aortic diastolic - right atrial pressure).

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Two mechanical causes of PEA to assess?

Pericardial tamponade or Pulmonary embolism.

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ECPR time window for OHCA?

Initiate flow within 60 minutes of arrest onset.

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Three HTTM target temperature parameters?

32-36°C maintained for 24 hours then rewarm at 0.5°C/hour.

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First-line benzodiazepine doses for post-arrest seizures?

Lorazepam 0.1 mg/kg IV (max 4mg) or Midazolam 0.2 mg/kg IM (max 10mg).

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Immediate PCI post-ROSC indicated when?

STEMI on ECG or High suspicion of ACS without non-cardiac cause.

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Oxygenation target post-ROSC?

Titrate FiO2 to SpO2 ≥94% (avoid PaO2 >300 mmHg).

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Two lactate trends indicating improving perfusion?

Decreasing serial levels or Rising ScvO2 >65%.

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Mnemonic for epinephrine dosing during CPR?

"1-3-5 Rule": 1 mg every 3-5 minutes during CPR.

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Vasopressin ADVANTAGE over epinephrine?

None no survival benefit (consider if epinephrine fails).

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ETCO2 spike indicates what event?

ROSC - sudden ↑ from <10 mmHg to >40 mmHg.

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Three CPR quality improvements if ETCO2 <10?

Adjust compression rate, Adjust depth, Ensure recoil.

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Ultrasound finding in pseudo-PEA?

Cardiac activity on echo without palpable pulses.

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ECPR complication requiring monitoring?

Limb ischemia (femoral cannulation).

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Post-ROSC anticoagulation for ACS?

Dual antiplatelets: aspirin + ticagrelor (preferred over clopidogrel).

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Absolute contraindication for fibrinolytics post-ROSC?

CPR-related trauma (e.g., pneumothorax/pulmonary hemorrhage).

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Three methods to induce HTTM in ED?

Ice packs, Cooling blankets, 4°C saline infusion (1-2L).

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How long maintain HTTM after target reached?

24 hours minimum before rewarming.

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Mnemonic for calcium doses?

"1-3 Rule": 1g chloride or 3g gluconate.

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Sodium bicarbonate dose in TCA overdose?

1-2 mEq/kg IV.

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Dextrose dose for hypoglycemia in arrest?

25-50g IV (D50W standard).

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Post-ROSC Scv02 goal?

65% (adequate oxygen delivery).

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Three dynamic measures of volume responsiveness?

IVC collapse <50%, Passive leg raise, Pulse pressure variation.

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First intervention for venous hyperoxia (Scv02 >80%)?

Reduce vasopressors and Optimize volume status.

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ECG finding requiring transcutaneous pacing?

3rd-degree block or New bifascicular block post-ROSC.

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Preferred beta blocker in labile post-arrest patients?

Esmolol drip (short-acting, titratable).

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Timeframe for lactate clearance monitoring?

Q2-4h initially (decrease >10%/hour).

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Three contraindications to HTTM?

Active bleeding, DNR status, Terminal illness (relative).

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PCI timing with HTTM?

Proceed immediately – don't delay cooling.

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Post-ROSC anticoagulation caution?

Monitor for CPR-related injuries (rib fractures, liver/spleen trauma).

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Mnemonic for post-arrest care priorities?

ACS evaluation, BP management, Cooling/TTM, Seizure prevention.

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Three CPR parameters to monitor?

Rate (100-120/min), Depth (2-2.4"), Recoil (complete).

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ETCO2 use in tension pneumothorax?

Rise after needle decompression confirms success.

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Vasopressor choice in pseudo-PEA?

Norepinephrine infusion (0.1-0.5 mcg/kg/min).

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Post-ROSC hypertension management?

Permissive hypertension initially (MAP 65-90mmHg).

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Three predictors of poor neurologic outcome?

No pupillary/corneal reflexes at 72h, Myoclonus status, NSE >60ng/mL.

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ECPR candidate criteria?

Witnessed arrest, Bystander CPR, Initial shockable rhythm.

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Epinephrine timing in cardiac arrest?

Administer ASAP in non-shockable rhythms, after failed defibrillation attempts in shockable ones.

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Hemodynamic-directed resuscitation?

Adjust compressions and vasopressors to systolic BP of 90 mm Hg, arterial relaxation pressure of 20-25 mm Hg.

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Coronary Perfusion Pressure (CPP)?

Difference between aortic and right atrial pressures during diastole.

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Electrocardiographic (ECG) monitoring during CPR?

Monitors electrical activity but not mechanical function. May show activity without effective pumping.

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PETco2 determinants?

Depends on CO2 production, alveolar ventilation, and pulmonary blood flow (cardiac output).

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PETco2 measurement?

Waveform capnography after intubation.

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PETco2 monitoring use during CPR?

Helps assess CPR inadequacy and guide improvements in compression rate, depth, or recoil.

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Echocardiography use during PEA?

Distinguishes EMD from pseudo-EMD; diagnoses tamponade/PE; guides pericardiocentesis.

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Blood gas role during CPR?

Arterial and venous blood sampling for gas or chemistry analysis has limited value. Sao2 typically above 94% during CPR.

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CPP calculation?

Calculated by subtracting right atrial diastolic pressure from aortic diastolic pressure.

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IVC Collapse Assessment

Change in Inferior Vena Cava diameter with respiration, assessed via ultrasound to evaluate volume responsiveness.

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IVC Diameter Measurement

Evaluates IVC diameter during inspiration and expiration.

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IVC Collapse Threshold

In spontaneously breathing patients, >50% diameter decrease suggests responsiveness.

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IVC Distensibility Index

In mechanically ventilated patients, >18% distensibility suggests responsiveness.

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Passive Leg Raise (PLR)

Simulates a fluid bolus by shifting blood from legs to central circulation.

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PLR Technique

Lay flat and lift legs to 45 degrees for 1-2 minutes to observe BP/HR changes.

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PLR Response Indicator

A systolic blood pressure increase >10 mmHg indicates volume responsiveness.

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Pulse Pressure Variation (PPV)

Difference between max and min pulse pressure during respiratory cycle.

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PPV Calculation

[(PPmax - PPmin) / PPmean] x 100.

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PPV Threshold for Responsiveness

PPV >13% typically indicates volume responsiveness.

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Volume Responsiveness

Cardiac output will likely increase with fluid administration

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Fluid Therapy Guidance

Using dynamic measures alongside overall patient assessment.

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Over-Resuscitation Risks

Avoid fluid overload, which can lead to lung issues.

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Volume Responsiveness Goal

Optimizing heart function and blood flow to organs.

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Factors Affecting IVC

Patient's position, chest pressure, and existing health issues.

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PPV Requirements

Requires arterial line, mechanically ventilated, normal rhythm, 6-8 mL/kg tidal volume.

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Pulse Oximetry

A noninvasive method measuring the percentage of oxygen saturation in the blood.

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SpO2

Saturation of oxygen in peripheral blood, measured by pulse oximetry.

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PaO2

Partial pressure of oxygen in arterial blood, measured via arterial blood gas (ABG).

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SpO2 vs. PaO2

SpO2 is non-invasive; PaO2 is invasive and direct.

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Normal SpO2 Range

SpO2 ranges from 95% to 100%.

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Normal PaO2 Range

PaO2 ranges from 80 to 100 mmHg.

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Esmolol's short half-life significance?

Esmolol's short half-life allows rapid titration and dosage adjustments in unstable patients, effectively managing acute blood pressure and heart rate without prolonged effects.

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Esmolol loading dose (adults)?

The typical loading dose of esmolol for adults is 500 mcg/kg, administered over 1 minute.

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Esmolol administration post-loading?

After the loading dose, esmolol is administered as a continuous infusion, typically starting at 50 mcg/kg/min. Titrate in increments of 25-50 mcg/kg/min every 4-10 minutes based on patient response.

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Esmolol contraindications?

Contraindications include severe bradycardia, hypotension, decompensated heart failure, cardiogenic shock and asthma, which can worsen with beta-blockade.

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Esmolol caution with asthma?

Caution is advised due to potential impact on beta-2 receptors, potentially leading to bronchoconstriction and worsening respiratory issues.

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Monitoring during esmolol use?

Closely monitor heart rate and blood pressure during esmolol administration; adjust dosage as necessary based on the patient's hemodynamic response.

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Initial MAP target post-ROSC?

Optimal MAP range post-ROSC is typically 65-90 mmHg initially.

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Formula to calculate MAP?

MAP = Diastolic BP + 1/3 (Systolic BP - Diastolic BP).

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General MAP goal post-ROSC?

General MAP goal is 65-100 mmHg post ROSC.

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Importance of adequate perfusion?

Adequate perfusion after resuscitation helps maintain organ viability.

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Avoid in post-resuscitation?

Avoid aggressive treatment causing excessively high blood pressure.

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Priority post-ROSC hypertension?

Ensure sufficient perfusion to vital organs.

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MAP target variations?

Some suggest 65-90 mmHg; others up to 100 mmHg.

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Higher BP allowed post-ROSC?

Higher blood pressures are acceptable as long as overly aggressive treatment is avoided.

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Key target CPP value during CPR?

Minimum coronary perfusion pressure of 15-20 mmHg.

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Why is CPP clinically significant during CPR?

Ensures adequate blood flow to the coronary arteries for myocardial perfusion.

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How to measure aortic diastolic pressure in unstable ROSC?

Use an arterial line for continuous blood pressure monitoring.

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How to measure right atrial pressure?

Place a central venous catheter in the right atrium.

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Importance of adequate CPP during ROSC?

Reflects the ability to effectively perfuse the myocardium, influencing outcomes.

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Myoclonus significance post-ROSC?

Myoclonus indicates severe brain injury and dysfunction after cardiac arrest, predictive of poor neurological outcomes in ROSC patients.

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ROSC Myoclonus Implies?

Myoclonus post-ROSC suggests widespread brain lack of oxygen during the arrest.

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Post-anoxic myoclonus persistence?

Persistence post-anoxic myoclonus indicates ongoing brain damage, and disability.

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Outcomes of Post-Anoxic Myoclonus?

Post-anoxic myoclonus in studies linked to higher mortality, severe disabilities, and vegetative state.

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Myoclonus severe brain injury sign?

Indication of severely affected critical brain areas, impacting control, awareness.

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DAPT after CPR - Contraindications

Active bleeding, history of hemorrhagic stroke, high bleeding risk, contraindication to medications, or physical injuries from CPR may warrant withholding dual antiplatelet therapy after CPR.

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Reasons to avoid DAPT post-CPR

Dual antiplatelet therapy might not be given post-CPR because bleeding risks, underlying injuries, contraindications to antiplatelet medications, need for urgent surgery or individual patient factors outweigh its benefits.

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Ticagrelor Dosage for ACS

For ACS patients (including post-ROSC/CPR), administer an initial 180 mg loading dose, followed by 90 mg twice daily for maintenance to prevent blood clots.

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Brilinta (Ticagrelor)

Ticagrelor, also known as Brilinta, helps prevent blood clot formation and reduce cardiovascular risk in post-ROSC and post-CPR patients.

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ScvO2 during CPR

During CPR, ScvO2 reflects changes in oxygen delivery to tissues via cardiac output.

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VO2 constant during CPR?

Limited metabolic processes during CPR keep oxygen consumption stable, maintaining VO2 levels.

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Cardiac output effects on ScvO2

Increased cardiac output raises ScvO2, while decreased cardiac output lowers ScvO2 levels.

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Decreased ScvO2 in CPR

A decrease in ScvO2 during CPR indicates inadequate oxygen delivery to the tissues.

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Low ScvO2 intervention in CPR

Adjustments to compression techniques or other interventions may be needed to improve oxygen delivery when ScvO2 is low during CPR.

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ScvO2 (Central Venous Oxygen Saturation)

Reflects the balance between oxygen delivery and consumption in the body, providing insights into the effectiveness of resuscitation efforts.

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Cardiac Output Impact on ScvO2

Adequate chest compressions are crucial for generating sufficient cardiac output and oxygen delivery.

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Hemoglobin Levels Impact on ScvO2

Anemia can limit oxygen-carrying capacity, lowering measureable saturation.

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Near-Infrared Spectroscopy (NIRS)

Measures regional oxygen saturation (rSO2) in specific tissues, such as the brain or muscles, providing complementary information about oxygen delivery.

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Normal ScvO2 Range During CPR

A normal ScvO2 range is typically between 65% and 75%. During CPR, maintaining ScvO2 within this range suggests adequate oxygen delivery.

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Low ScvO2 During CPR

A ScvO2 value below 65% indicates inadequate oxygen delivery due to ineffective compressions, hypovolemia, vasoconstriction or hypoxemia

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High ScvO2 During CPR

A ScvO2 value above 75% may indicate excessive oxygen delivery or a microcirculatory issue.

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ScvO2 Trends During CPR

A sustained increase in ScvO2 may indicate improved oxygen delivery and tissue perfusion.

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ScvO2 in Predicting ROSC

Higher ScvO2 values during CPR are associated with a greater likelihood of ROSC.

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ScvO2 Monitoring Goal During CPR

Continuously monitor ScvO2 during CPR and aim to maintain it between 65% and 75%.

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Continuous ScvO2 Monitoring

Measures central venous oxygen saturation continuously, aiding in assessing oxygen delivery vs. consumption in critical patients.

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Central Venous Catheter Placement

Inserted into the superior vena cava to ensure precise ScvO2 readings.

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Oximetric Catheter

Specialized catheter with fiber optics that measures blood oxygen saturation and transmits real-time ScvO2 values.

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Continuous Monitoring Display

Displays ScvO2 values as a percentage, continuously tracking a patient's oxygen saturation, and alerting when values deviate from norms.

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Data Interpretation of ScvO2

Interpret ScvO2 trends considering the full clinical picture: check vital signs, lab results, and medical history for context.

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Normal Range of ScvO2

Normal ScvO2 values typically range from 65% to 75%, indicating appropriate oxygen extraction from tissues.

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High ScvO2 Values

Values exceeding 75% suggest decreased oxygen consumption, possibly due to sepsis, cyanide toxicity, hypothermia, or left-to-right shunt.

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PaO2 in Pulmonary Embolism (PE)?

Typically less than 60 mmHg.

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SaO2 in Pulmonary Embolism (PE)?

Often less than 90%.

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pH in Respiratory Alkalosis (PE)?

Generally greater than 7.45.

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PaCO2 in Pulmonary Embolism (PE)?

Usually less than 35 mmHg.

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Bicarbonate in Metabolic Acidosis (PE)?

Typically less than 22 mEq/L.

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PaO2 in Esophageal Intubation?

Often less than 60 mmHg.

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SaO2 in Esophageal Intubation?

Frequently less than 90%.

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PaCO2 in Esophageal Intubation?

Typically greater than 45 mmHg.

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pH indicates Respiratory Acidosis?

Generally less than 7.35.

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Bicarbonate in Esophageal Intubation?

May be normal or slightly decreased.

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Mean Arterial Pressure (MAP)

Average arterial pressure throughout one cardiac cycle; crucial for organ perfusion.

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MAP formulas

MAP = Diastolic Pressure + 1/3(Systolic Pressure - Diastolic Pressure) or MAP = (PPmax + 2 × PPmin) / 3

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Simplified MAP formula

MAP = (2/3) × Diastolic Pressure + (1/3) × Systolic Pressure

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Steps to measure BP

Prepare patient, use sphygmomanometer, inflate cuff, deflate slowly while listening.

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Korotkoff sounds

Sounds heard during blood pressure measurement that indicate systolic and diastolic pressures.

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Manual BP measurement

Position patient comfortably, use manual sphygmomanometer, inflate cuff above expected systolic pressure, listen for Korotkoff sounds during deflation.

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Systolic Pressure

The pressure of blood in the arteries when the heart muscle contracts.

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Steps to manually taking bp

  1. Prepare patient, 2. Apply cuff, 3. Inflate cuff, 4. Auscultate while deflating.
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Pulse Pressure

The difference between systolic and diastolic blood pressure (PP = SBP - DBP).

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Normal Pulse Pressure

Typically ranges from 40 to 60 mmHg.

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Narrowed Pulse Pressure

May indicate hypovolemia or poor cardiac output.

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Widened Pulse Pressure

Can indicate adequate volume status or aortic regurgitation.

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Mechanical Ventilation Effect

Can increase intrathoracic pressure, reducing venous return and preload.

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Pulse Pressure Trend Monitoring

Helps identify sudden changes in hemodynamic status, such as compromise.

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Alongside Pulse Pressure

Evaluate heart rate, mean arterial pressure, and central venous pressure.

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Persistently Narrow Pulse Pressure

May suggest hypovolemia, reduced intravascular volume, or cardiac dysfunction.

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Widened Pulse Pressure Indication

Could indicate adequate intravascular volume or increased stroke volume.

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Fluid Challenge

Administering a small bolus of fluid, then observing changes in pulse pressure and hemodynamics.

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Normal IVC Diameter

Typically around 1.2 to 2.5 cm.

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IVC Diameter Indicating Fluid Overload

An IVC diameter greater than 2.5 cm.

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IVC Diameter Indicating Hypovolemia

An IVC diameter less than 1.2 cm

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Patient position for IVC measurement

Supine or semi-recumbent.

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Ultrasound probe to measure IVC

A low-frequency abdominal probe (2-5 MHz).

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Location of IVC Measurement

At the level of the hepatic vein, just before it enters the right atrium.

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How to measure IVC diameter

Measure the widest diameter during expiration and the diameter at the end of inspiration.

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What is IVCmin?

The diameter of the IVC measured at the end of inspiration.

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Collapsibility Index formula

(IVCmax - IVCmin) / IVCmax × 100.

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Large IVC with Little Collapse Indicates

It suggests hypervolemia.

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IVC diameter suggesting fluid overload?

An IVC diameter greater than 2.5 cm may indicate fluid overload.

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IVC measurement location?

At the level of the hepatic vein, just before it enters the right atrium.

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How to calculate collapsibility index?

Collapsibility Index = (IVCmax - IVCmin) / IVCmax × 100.

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SpO2 meaning?

Peripheral capillary oxygen saturation.

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SpO2 measures?

The amount of oxygen bound to hemoglobin in the blood.

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How to read SpO2?

As a percentage.

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Normal SpO2 level?

A level between 95% and 100%.

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Low SpO2 shows?

A deficiency in oxygenation, possibly due to respiratory or circulatory issues.

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How to measure SpO2?

Using a pulse oximeter.

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Where place Pulse Oximeter?

It is clipped onto a fingertip or earlobe.

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What is SpO2?

Peripheral capillary oxygen saturation, measures percentage of oxygen-saturated hemoglobin.

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What is PaO2?

Arterial oxygen partial pressure, representing dissolved oxygen in plasma, measured in mmHg.

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CO poisoning on SpO2?

Carbon monoxide binds to hemoglobin, misinterpreted as oxyhemoglobin, showing falsely elevated SpO2.

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Methemoglobinemia effect?

Methemoglobin can't bind oxygen, mimics oxyhemoglobin absorption, inflating SpO2 readings.

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Anemia impact on SpO2?

Severe anemia lowers hemoglobin, misleading normal SpO2 with inadequate total oxygen transport.

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Vasoconstriction effect?

Reduces blood flow, pulse oximeters less reliable, inaccurate or overestimated SpO2 readings result.

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Carboxyhemoglobin consequence?

Prevents oxygen transport, causes hypoxia, potentially elevated SpO2 readings result.

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How methemoglobinemia occurs?

Occurs with iron oxidizes, impairs oxygen binding from certain drugs/chemicals.

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Anemia causes?

Anemia causes include blood loss, poor nutrition, and/or bone marrow disorders.

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Why consider PaO2?

PaO2 provides a direct measure, revealing actual oxygenation when SpO2 accuracy is compromised.

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Arterial Puncture: Pre-procedure

Assess collateral circulation in the radial artery using the Allen's test.

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Arterial Puncture: Wrist Position

Hyperextend the patient's wrist over a rolled towel to expose the radial artery.

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Arterial Puncture: Site Preparation

Sterilize the site with an antiseptic solution (e.g., chlorhexidine).

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Arterial Puncture: Anesthesia

Optional local anesthetic (e.g., lidocaine) can be used to minimize pain.

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Arterial Puncture: Needle Insertion

Insert a heparinized syringe/needle at a 45° angle into the radial artery.

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Arterial Puncture: Aspiration

Allow arterial pressure to fill the syringe; avoid air bubbles.

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Arterial Puncture: Post-Procedure

Apply firm pressure for 5-10 minutes to prevent hematoma.

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Arterial Puncture: Preservation

Place the sample on ice (if delayed analysis) and label with patient details.

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Arterial Puncture: Complication Monitor

Check for complications (e.g., arterial spasm, nerve damage, or ischemia).

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What is cooximetry?

A lab test measuring hemoglobin types to assess oxygen-carrying capacity and detect poisoning.

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Cooximetry blood sample prep?

Arterial blood drawn, heparinized to prevent clotting, sometimes hemolyzed to release hemoglobin.

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Device for cooximetry analysis?

A co-oximeter, a spectrophotometer using multiple light wavelengths. Differentiates hemoglobin species.

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Why use multiple wavelengths?

Each hemoglobin type absorbs light uniquely; specific wavelengths target variants.

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Conditions cooximetry diagnoses?

Carbon monoxide poisoning, methemoglobinemia, and hidden hypoxia.

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Cooximetry vs pulse oximetry?

Detects dysfunctional hemoglobins, while pulse oximetry often misses them, risking false-normal readings.

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Cooximetry results measure?

Percentages of hemoglobin types and true oxygen saturation (SaO2).

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Why arterial blood preferred?

Arterial samples reflect oxygen levels delivered to tissues more accurately than venous blood.

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Clinical role of cooximetry?

Guides treatment CO poisoning, methemoglobinemia, or unclear hypoxia by revealing hemoglobin abnormalities.

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Hemoglobin types identified?

Oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, methemoglobin, and rarely sulfhemoglobin.

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Study Notes

  • Cooximetry is a lab test to measure hemoglobin types (O2Hb, COHb, MetHb) and assess oxygen-carrying capacity, useful for detecting poisoning.
  • During cooximetry, arterial blood is drawn and heparinized to prevent clotting, and sometimes hemolyzed to release hemoglobin.
  • A co-oximeter - a type of spectrophotometer using multiple light wavelengths - performs cooximetry analysis to differentiate hemoglobin species.
  • Cooximetry uses multiple light wavelengths because each hemoglobin type absorbs light uniquely; specific wavelengths target variants like COHb (548 nm) or MetHb (535 nm).
  • Cooximetry diagnoses carbon monoxide poisoning (high COHb), methemoglobinemia (high MetHb), and hidden hypoxia.
  • Cooximetry detects dysfunctional hemoglobins (COHb/MetHb), which pulse oximetry often misses and risks false-normal readings.
  • Cooximetry results measure percentages of hemoglobin types (O2Hb, HHb, COHb, MetHb) and true oxygen saturation (SaO2).
  • Arterial blood is preferred for cooximetry because arterial samples reflect oxygen levels delivered to tissues more accurately than venous blood.
  • Cooximetry guides treatment for CO poisoning, methemoglobinemia, or unclear hypoxia by revealing hemoglobin abnormalities.
  • Cooximetry identifies oxyhemoglobin, deoxyhemoglobin, carboxyhemoglobin, methemoglobin, and, rarely, sulfhemoglobin.

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