Interventions
What do Arterial Blood Gases show?
PaO2, PaCo2, Lactate, pH, HCO3, electrolytes, haemoglobin
VBG dont show PaO2 but this can be taken from SaO2
How are arterialised blood samples obtained?
- Ear lobe
-Usually from Radial artery with herparinised syringe
What demonstrates respiratory acidosis
High PaCO2, low pH, low ventilation
what corrects respiratory acidosis
hyperventilation
what demonstrates respiratory alkalosis
low PaCO2, high pH, increased ventilation
what causes respiratory alkalosis
hyperventilation
alkalosis is caused by lost acid- hyperventilation causes more CO2 to be expelled
what action does respiratory acidosis call for
observations every hour until resolved
what demonstrates metabolic acidosis?
low PaCO2, low pH, low HCO3
what causes metabolic acidosis?
low cardiac output, DKA, AKI
what demonstrates metabolic alkalosis
high PaCO2, high pH, high HCO3
what causes metabolic alkalosis
vomiting or diuretics
what does ROME stand for
(R)esp problem? PaCO2 moves in (O)pposite direction to the pH value (M)etabolic problem? HCO3 moves in (E)qual direction to the pH value
how does bicarbonate act as a buffer?
main buffer in extracellular fluid, helps regulate pH by accepting H+ ions, regulated by kidneys
how to use positioning to help respiratory effort
is the patient supine, slumped or upright?
Laid down= VQ/ ventilation/perfusion mismatch. air floats to the top of the lungs, blood gravitates towards the bottom, so less blood is oxygenated
Gravity also affects the expansion of the lungs
Elevate the head of the bed 20-30 degrees- fowlers position
Frequent repositioning essential as patient may slip down
Supine patients can have a collapse of small airways with loss of S/A for gas exchange
oxygen
should always be prescribed, with a saturation target identified by medical staff, but administered immediately in emergencies
simple mask/ nasal cannulae
- 40-60%
- O2 recieved depends on the volume the person breathes
- simple face mask but not be used at flow rates under 5L p/min as this may result in carbon dioxide rebreathing
venturi mask
fixed% based on colour coded valve, dilutes O2, used in COPD
Non rebreathe mask
- 60-90% at 15L
- negative pressure opens valve, pure O2 inhaled, used for
- emergencies ie sats under 85- 10-15L p/min
what oxygen saturation target should there be with a risk of hypercapnia?
88-92%
when is humidifcation not necessary?
- low flow oxygen
- high flow oxygen for short term use
How are bronchodilators delivered?
Hand held inhalers
Nebulisers
Examples of beta 2 adrenergic agonists
salbutamol, terbutaline
what do beta 2 adrenergic agonists do?
stimulate beta 2 receptors on smooth muscle cells, ausing relaxation of airways
side effects of tachycardia, palpitations and muscle tremors
used for rapid onset
what do antimuscarinic bronchodilators do?
block nerve impulses, airways relax, mostly used in COPD, sometimes asthma
example of an antimuscarinic bronchodilators
tiotropium
chest drains
response to tension pneumothorax- medical emergency- needle inserted into pleural cavity to remove air, pus or blood, connected to underwater seal system
situations where non-invasive ventilation may be beneficial
- pulmonary oedema with hypoxaemia
- COPD with respiratory acidosis
- Hypercapnic failure
- Obstructive sleep apnoea
- Pneumonia
- Post operative hypoxaemia
- Where hypoxaemia and hypercapnia are not controlled by other means then NIV may be beneficial
- For patients w hypoxaemia in absence of hypercapnia, CPAP
- Patients w hypercapnia, BiPAP recommended
Advantages of NIV
- Increase tidal volume, functional residual capacity, surface area for gaseous exchange, lung compliance
- Recruitment of alveoli
- Reduced work of breathing and risk of infection
- Sedation avoided
What type of respiratory failure is CPAP beneficial for?
Type 1- acute hypoxemic respiratory failure
What type or respiratory failure is BiPAP beneficial for?
Type 2- acute hypercapnic respiratory failure
contraindications for NIV
GCS under 8
confusion/ agitation
cognitive impairment that warrants enhanced observation
(British Thoracic Society 2016)
Fluid balance in respiratory failure
waterloss greater with increased respiratory rate
skin turgor, urine output and condition or oral mucous membranes and tongue must be monitored
when is an ECG needed?
- should always be considered in any patient with chest pain
- first line diagnostic tool
- patients with acute coronary syndrome may or may not have changes on the ECG
- enables identification of raised ST segment MI or non raised ST segment MI
- the ST segment can be elevated or depressed, which can be caused by myocardial ischaemia or infarction
- 12 leads crucial in emergent scenarios
- NICE Guidelines (2014) 12 lead ECG an important diagnostic tool
ABGs in possible cardiovascular failure
- rise in lactate- caused by anaerobic respiration, tissues of the body arent recieving enough oxygenated blood
test for blood markers
Troponin
- specific for heart muscle, levels are normally low and will increase when the heart is damaged
- myocardial injury causes release of the proteins into the blood, levels peak at 12 hours, proportional to the infarct size
- may remain elevated for up to 2 weeks
- Creatinine- muscle breakdown- heart attack
CXR
- gives dimensions of the left heart to confirm acute MI and rules out other causes
- gives information on cardiac congestion
echocardiograph
Non invasive diagnostic test, confirms if chest pain is acute MI and shows how well the ventricle wall is oving during contraction
angiograph
invasive rescue procedure to diagnose extent of occluion and treat with insertion of stent
What to do if sats are low?
Recheck with an ear probe, move sats monitor
What do you look for in blood gases relating to the heart?
Hyper/hypokalaemia- even small changes can affect heart function, lactate shows anaerobic resp, lack of oxygenated blood to tissues
What do you give diuretics for in the cardiovascular system?
Oedema caused by left heart failure
What do ace inhibitors do?
Help relax the veins and arteries and lower blood pressure
What do beta blockers do?
Block the effects of the hormone epinephrine, causing the heart to beat less slowly and with less force
Who analgesic ladder
1986
1. First step: mild pain- non-opioid analgesics ie NSAIDS
2. Second step: moderate pain- weak opioids ie codeine
3. Third step: severe, persistent pain- potent opioids ie morphine, fentanyl, oxycodone
WHat is an angiograph?
A type of Xray used to check blood vessels
Which fluid (crystalloid or colloid) is favourable for fluid resuscitation?
Crystalloid (NICE Guidelines,
What is shown on a urine dipstick?
leucocytes, nitrate, pH, proteins, glucose, ketones, erythrocytes
What do ketones in the urine show?
The body cells cant get enough glucose, so the body breaks down fat for energy instead, producing the acid ketones. High ketone levels in the urine show that the body is too acidic
what do leucocytes in urine show?
Can indicate an infection or inflammation in the urinary tract
What does a high pH urine show?
High urine pH= kidneys not properly removing acids from bloodstream: kidney failure
What do proteins in urine show?
Kidneys are not filtering properly. Early sign of shronic kidney disease
What does nitrate in the urine mean?
Normally points to a UTI
What do erythrocytes in the urine show?
Kidney or urinary tract infections or kidney stones
What medications put patients at risk for AKI?
Diuretics, Ace inhibitors, metformin, NSAIDs- NHS England 2016- Think Kidney Guideline
How does blood sugar effect eGFR?
Hyperglycaemia, causes high eGFR
What does glucose in the urine show?
A high level of urine glucose may show that the blood glucose is high too and that could be a sign of diabetes
eGFR calculation
creatinine level x age x ethnicity x sex
What justifies catheterisation?
For bladder volume 600ml< urethral catheterisation recommended Darrah et al 2009
What medications may contain potassium?
Lisinopril- for high blood pressure
Airway collapse after surgery
post operative atelectasis
Patient controlled analgesia
On demand, intermittent IV administration of an opioid analgesia
gives a specific dose in a preset time
unsuitable without cognitive ability
MUST nutritional tool
Malnutrition Advisory Group 2003
- 5 step screening tool to identify adults who are malnourished or obese
- malnutrition universal screening tool
- if a person is severely unwell ie sepsis they are at risk from further deterioration due to their illness
- Assesses aspects such as weight and BMI
SBAR
situation, background, assessment, recommendation
What fluid should you give to someone with high blood glucose
isotonic saline
What Iv to give someone with hypothyroidism
Levothyroxine sodium IV
Treatment for hypoglycaemia, and blood sugar level needed for treatment
- treat all bg under 70 with or without symptoms
- quick sugar, 10-15g carb
- recheck bg 15 to 20 mins later
- if normal blood glucose, eat a protein meal or snack
- if you have symptoms but bg is over 70, have a snack
What are the sepsis 6?
- take bloods
- take urine
- take lactate
- give fluids
- give broad spectrum antibiotics
- give oxygen
What else should you do with sepsis?
neuro obs, escalate to doctor
How should you respond to a temperature in sepsis?
Sepsis trust 2022- temp is natural response, not recommended to treat
What indicates a raised mortality rate in sepsis?
When acute coronary syndrome is not present, but raised troponin levels are (BCS, 2019)
FAST assessment for stroke
- Face
- Arms
- Speech
- Time
Kleindorfer et al, 2007
What causes neuro deterioration that can be detected by an ABG?
Hyponatraemia
Cushings response?
tachycardia, bradypnea, hypertension
What is fowlers position?
Raises the head of the bed 90 degrees
What level of GCS becomes dangerous and may need intubation?
8
What are the paediatric sepsis 6?
Sepsis Trust Paediatric Group, 2015
Within 1 hour, best practice 15 mins
- give high flow O2
- obtain IV or IO access for blood cultures, glucose, lactate
- give IV or IO antibiotics broad spectrum
If shocked consider
- Give fluid resuscitation
-Consider early inotropic support ie adrenaline, discuss w PICU if commenced
- Involve senior clinicians/ specialists early
Signs of sepsis in children
- core temp under 36 or over 38 in last 4 hours
- inappropriate tachycardia
- altered mental state
- altered peripheral perfusion
Children at higher risk of sepsis
- under 3 months
- immunocompromised, long term steroids
- recent surgery
- indwelling devices/ lines
- complex neurodisability/ long term conditions
- significant parental concern
symptoms of sepsis in adults
-hyperthermia or hypothermia
-tachycardia
-tachypnea
-altered mental status
-oliguria or anuria
-hypoxia
-cyanosis
-ileus
- may have hypotension- but may be in compensated stage of shock
GCS
Glascow coma scale Teasdale and Jennett 1974
E- 4 V- 5 M- 6
Treatment for AKI
- Relieve obstruction
- Renal replacement therapy
Children's normal maintenance fluid requirements
100ml/kg for first 10kg of weight
50ml/kg for second 10kg of weight
20ml/kg for every 20kg after that
What causes raised calcium
renal failure (Horrox 2002)
Interventions for DKA
- Ger senior help and call a doctor, consider crash call
- Monitor observations
- O2 PRN
- NBM
- May need NG tube to aspirate, full stomach, prevent vomiting
- Bloods and cannula
- Blood gas
- IV fluid bolus
- Maintenance fluids
- Insulin through IV infusion once patient is stabilised, about 1-2 hours after starting IV fluids, give as prescribed
- Fluid balance chart
- Monitor blood glucose and ketones
Goals:
Admit to PICU
Involve diabetes nurse
Explain age friendly
Stand w parent in initial intense care
-
Interventions for major trauma
primary survey
- establish IV access- consider IO, use gauze, saline and clingfilm to prevent bone from drying out
- bloods and blood gas
- may need fluid bolus
- may need blood
- manage major wounds
- x rays and ct scans
- accompanied by qualified nurse and poss dr for scans
secondary survey
- hypothermia- bear hugger
- member of staff assigned to support family
- support and explanations