Questions and Answers
Which of the following conditions is contraindicated for the use of V/Q scans?
What is the main purpose of administering anticoagulants in the treatment of pulmonary embolism?
Which symptom is NOT typically associated with a pulmonary embolism?
What should be monitored when a patient is receiving heparin therapy in the context of pulmonary embolism?
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An embolectomy would be considered in which scenario?
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Which statement correctly describes fully compensated arterial blood gases?
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In which condition is the pH level expected to be less than 7.35?
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What is the expected arterial blood gas finding in a patient experiencing Kussmaul respirations?
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Which condition is associated with a high pH (> 7.45) and elevated bicarbonate (HCO3 > 26)?
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What pattern of arterial blood gases would indicate a patient with COPD is experiencing hypoventilation?
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What is the maximum duration allowed for suctioning a patient on mechanical ventilation in one pass?
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Which setting should be increased if a patient exhibits signs of respiratory acidosis due to decreased respiratory rate?
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What is the appropriate action if there is a suspected dislodgment of the endotracheal (ET) tube?
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If a patient is experiencing asynchronous breathing while on a ventilator, what might be the necessary action?
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What is the potential risk associated with increasing PEEP to a higher level?
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What does a rising end-tidal CO2 level indicate in a mechanically ventilated patient?
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In the context of BiPAP ventilation, when is it essential to avoid the intervention?
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If PIP is noted to be elevated (above 35), what should be correlated with this finding?
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What is the primary purpose of monitoring SpO2% in a patient on mechanical ventilation?
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When weaning a patient from mechanical ventilation, which parameter is typically decreased?
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Study Notes
Pulmonary Embolism Overview
- A pulmonary embolism occurs when a blood clot travels to the lung, obstructing blood flow.
Risk Factors (R/F)
- Atrial fibrillation (A-Fib) can lead to blood clots.
- Fractures (Fx), especially of long bones, increase risk due to potential fat embolism.
- Immobilization after surgery heightens susceptibility.
- Smoking is a significant risk factor for clot development.
Symptoms (SS)
- Patients may experience anxiety, often described as an impending sense of doom.
- Sudden onset of dyspnea is a common sign.
- Angina, or chest pain, may be present.
- Hemoptysis (coughing up blood) can occur with embolism.
- Patients often show decreased fever and low blood oxygen levels (decreased O2).
Diagnostics
- D-Dimer test indicates the presence of a clot in the bloodstream.
- Ventilation/Perfusion (V/Q) scan with inhaled radioactive material is employed for imaging.
- Proceed cautiously with V/Q scans if the patient is not alert and oriented (A+O/Awake).
Contraindications (CI)
- Patients should avoid D-Dimer testing if allergic to shellfish or iodine.
- Decreased kidney function is a concern in managing medications.
- Caution with Metformin due to potential complications.
Treatment
- Anticoagulants help prevent clot enlargement:
- Heparin is monitored with partial thromboplastin time (PTT).
- Warfarin usage is guided by prothrombin time/international normalized ratio (PT/INR).
- Enoxaparin should be administered in a high dose for effective anticoagulation.
- Thrombolytic therapy for breaking down clots involves:
- Tissue Plasminogen Activator (tPA) used in catheter-guided procedures.
- Inferior vena cava (IVC) filters are deployed to catch clots, requiring cautious use alongside blood thinners.
- Embolectomy may be performed if tPA or anticoagulants cannot be used.
Arterial Blood Gases Overview
- Measures the concentration of oxygen (O2) in the blood.
- Essential for evaluating acid-base balance and respiratory function.
Acid-Base Compensation Mechanisms
- Compensation indicates the body's attempt to maintain pH within normal range.
- Uncompensated: pH is out of range while either CO2 or HCO3 is normal.
- Partially compensated: pH is out of range with both CO2 and HCO3 abnormal.
- Fully compensated: pH is normal, despite both CO2 and HCO3 being abnormal.
Respiratory Alkalosis
- Characterized by pH > 7.45 and CO2 > 45.
- Symptoms include decreased respiratory rate and hypoventilation.
- Leads to increased CO2 retention and decreased pH.
- Common causes include Chronic Obstructive Pulmonary Disease (COPD), pneumonia (PNA), and asthma.
- Treatment approaches:
- Non-invasive ventilation (BiPAP).
- Intubation as a last resort.
Metabolic Alkalosis
- Defined by pH > 7.45 and HCO3 > 26.
- Often results from decreased respiratory rate.
- Common etiologies include vomiting and nasogastric (NG) tube drainage.
- Excess bicarbonate (HCO3) is excreted.
Metabolic Acidosis
- Identified by pH < 7.35 and HCO3 < 22.
- Observable respiratory pattern includes Kussmaul breathing (deep gasping).
- Common conditions include Diabetic Ketoacidosis (DKA), alcohol (ETOH) intoxication, and diarrhea.
- The body excretes excess acid to compensate for the acidosis.
Mechanical Ventilation Overview
- BiPAP assists in carbon dioxide elimination, particularly beneficial for COPD patients.
- To prevent abdominal distention, BiPAP should be avoided; patients must be conscious and able to breathe independently.
Suctioning Techniques
- Suctioning is performed via tracheostomy as needed (PRN).
- Hyper-oxygenate before proceeding with suction to maintain oxygen saturation.
- Use a maximum of 10 seconds for suction; limit to 2 passes with 30-60 seconds rest between each.
- Rotate the suction catheter during withdrawal to minimize trauma.
DOPE Assessment for Ventilator Failure
- Dislodged/Displaced: Check for ET tube misalignment.
- Obstruction: Assess for mucous plugs.
- Pneumothorax: Confirm with X-ray imaging.
- Equipment Malfunction: Identify kinks or blockages in tubing.
Intubation Protocol
- Endotracheal (ET) tube placement confirmed by observing chest rise and breath sounds.
- Tube color change from purple to gold indicates proper placement.
- Utilize end-tidal CO2 monitoring, and X-ray for verification.
- Position ET tube 2-6 cm from the carina; maintain ambu-bag and suction equipment within reach.
Monitoring and Maintenance
- Conduct lung assessments every 4 hours; monitor sedation levels closely.
- Inflate cuff to prevent air leaks and monitor blood pressure due to analgesics.
- Ensure IV access for potential medication administration (three medications).
Alarm Awareness
- High alarms triggered by biting, gagging, coughing, kinked tubing, secretions, pulmonary edema, or bucking.
- Low alarms indicate issues like leaks, extubation, apnea, or low battery.
Ventilator Modes
- AC Mode: Four settings: tidal volume (TV), FiO2, respiratory rate (RR), and PEEP; assists with all breaths.
- SIMV Mode: Five settings: TV, FiO2, pressure support (PS), RR, and PEEP; allows patient-initiated breaths.
- PEEP: Set between 3-10 cm H2O to keep alveoli open; increases the risk of increased intracranial pressure, decreased cardiac output, and barotrauma.
Oxygen and Ventilation Management
- FiO2 levels can be adjusted between 21-100%; avoid prolonged settings above 60%.
- Target RR is 10-20 breaths per minute; alteration can affect CO2 retention and respiratory acidosis or alkalosis.
- Set tidal volume between 6-8 mL/kg based on ideal body weight; this ensures adequate lung expansion.
Assessing Pressure and Weaning Strategies
- Peak inspiratory pressure (PIP) should remain between 18-35 cm H2O; higher pressures could cause lung injury.
- Alter settings based on oxygenation and ventilation needs; increase FiO2 or PEEP in response to low O2, and adjust RR or TV for high CO2 levels.
- Reduce PEEP during weaning as tolerated.
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Description
Explore the critical aspects of pulmonary embolism, including risk factors, symptoms, diagnostics, and treatment options. Understand the role of anticoagulants and the management of patients at risk. Ideal for healthcare professionals and students in medical fields.
