CCRN REVIEW PART 1    “Never let what you cannot do    interfere with what you can do”    - John Wooden -                S...
CCRN REVIEW PART 1   TOPICS   Acute Coronary Syndromes         ARDS   Acute Myocardial Infarction      Chronic Lung D...
CCRN REVIEW PART 1     OBJECTIVES1.    Understand the different types of acute coronary syndromes.2.    Identify basic co...
CCRN REVIEW PART 1     OBJECTIVES13.   Understand the different stages of shock.14.   Differentiate between different typ...
Cardiovascular Conditions    Acute Coronary           Cardiomyopathy     Syndromes    Acute MI                 Heart B...
Acute Coronary Syndrome   DEFINITIONS    – Term used to cover a group of symptoms      compatible with acute myocardial i...
Acute Myocardial Infarction   DEFINITION    – Infarction occurs due to mechanical obstruction      of a coronary artery (...
Acute Myocardial Infarction   SIGNS & SYMPTOMS    – Complains Vary         May include crushing chest pain (which may or...
Acute Myocardial Infarction   SIGNS & SYMPTOMS      ↑ PAWP, ↓ CO, ↑ SVR, dysrhythmias, S4,      cardiac failure, cardioge...
Coronary Circulation
12 Lead ECGI         AVR          V1V4II        AVL     V2        V5III       AVF     V3        V6IIV
Acute Myocardial Infarction   ST ELEVATIONS    – Anterior Wall MI          Leads V1-V4                  Reciprocal chan...
Acute Myocardial Infarction   ST ELEVATIONS    – Lateral Wall MI          I, aVL, V5 and V6          Area supplied by t...
Coronary Arteries
Anterior Wall MI
Inferior Wall MI
Acute Myocardial Infarction   COMPLICATIONS    – Dysrhythmias, heart failure, pericarditis,      ventricular aneurysms, v...
Acute Myocardial Infarction   NURSING INTERVENTIONS    – O2    – Bedrest    – Serial ECG’s    – Serial cardiac enzymes   ...
Acute Myocardial Infarction   TREATMENT    – Time Is Heart Muscle    – Prompt ECG    – Goals: Relieve pain, limit the siz...
Acute Myocardial Infarction   TREATMENT    – MONA (Morphine, O2, Nitroglycerin, Aspirin),      Heparin, beta-blockers, an...
Balloon Angioplasty
Vascular Stent Deployment
Atherectomy
Acute Myocardial Infarction   SPECIFIC TREATMENTS    – Inferior Wall (IWMI)          Fluids (with RV infarct)          ...
Aortic Aneurysms   DEFINITION    – A bulge or ballooning of the aorta          When the walls of the aneurysm include al...
Aortic Aneurysms   CAUSES         Atherosclerosis         Marfan syndrome         Hypertension         Crack cocaine ...
Aortic Aneurysms Rupture  An aortic aneurysm, depending on its size, may   rupture, causing life-threatening internal ble...
Aortic Aneurysms   CLASSIFICATIONS    – Classified by shape, location along the aorta,      and how they are formed    – ...
Aortic Aneurysms
Aortic Aneurysms   SIGNS & SYMPTOMS    – Often produces no symptoms    – If an aortic aneurysm suddenly ruptures it prese...
Aortic Aneurysms   THORACIC SIGNS & SYMPTOMS    – Back, shoulder or neck pain    – Cough, due to pressure placed on the t...
Aortic Dissections   DEFINITION    – Tearing of the inner layer of the aortic wall, which      allows blood to leak into ...
Aortic Dissections  A. Dissection         B. Whenever the     beginning in the      ascending aorta     ascending aorta   ...
Aortic Dissections A. Dissection         B. Whenever the    beginning in the      ascending aorta    ascending aorta      ...
Aortic Dissections
Aortic Dissections
Aortic Aneurysms   COMPLICATIONS         Rupture         Peripheral embolization         Infection         Spontaneou...
Aortic Aneurysms   TREATMENT         Medical management           – Controlled BP (within specific range)         Surgi...
Cardiomyopathy   DEFINITION    – Diseases of the heart muscle that      cause deterioration of the function of      the m...
Cardiomyopathy   CLASSIFICATIONS    – Primary / Idiopathic (intrinsic)          Heart disease of unknown cause, although...
Cardiomyopathy    Hypertropic Cardiomyopathy    Restrictive Cardiomyopathy    Dilated Cardiomyopathy
Hypertropic Cardiomyopathy    Bizarre hypertrophy of the septum     –   Previously called IHSS            Idiopathic Hyp...
Harley
Hypertropic Cardiomyopathy    TREATMENT     – Relax the ventricles             Beta Blockers             Calcium Channe...
Restrictive Cardiomyopathy    Rigid Ventricular Wall     – Due to endomyocardial fibrosis     – Obstructs ventricular fil...
Restrictive Cardiomyopathy    TREATMENT     – Positive Inotropics     – Diuretics     – Low Sodium Diet
Dilated Cardiomyopathy     Grossly dilated ventricles without hypertrophy    –   Global left ventricular dysfunction    –...
Dilated Cardiomyopathy   TREATMENT    – Positive Inotropes    – Afterload Reducers    – Anticoagulants with Atrial Fib
Cardiomyopathies
Cardiomyopathy   GENERALIZED TREATMENT    –   Positive Inotropes           Except with Hypertropic Cardiomyopathy    –  ...
CCRN REVIEW PART 1       BREAK!
Conduction Defects   STABLE VS UNSTABLE    – Stable         Start with medications    – Unstable         Shock (cardiov...
Normal Sinus RhythmHeart Rate                 60 - 100 bpmRhythm                     RegularP Wave                     Bef...
Atrial Fibrillation   AFib    –   Multifocal atrial impulses at rate 300-600/min    –   Irregular conduction to ventricles
Atrial Flutter   AFL    –   Atrial impulses at rate of 250-350/min    –   Regularly blocked impulses at the AV node    – ...
Wandering Atrial Pacemaker   WAP    –   Multiple ectopic foci in the atria    –   Three or more p wave morphologies    – ...
Supraventricular Tachycardia     SVT     –    Supraventricular rhythm at rate 150-250     –    P waves cannot be positive...
Ventricular Tachycardia   VT    –   Ventricular rate of 100-250/min    –   Wide QRS
Torsades de Pointes   Polymorphic VT    –   VT with alternating ventricular focus    –   Often associated with prolonged ...
Heart Blocks (AV Blocks)        Sinus Rhythm with First Degree AV Block    Sinus Rhythm with Second Degree AV Block, Type ...
Heart Failure   DEFINITION    – A condition in which the heart cannot pump      sufficient blood to meet the metabolic ne...
Heart Failure   DEFINITION    – Pulmonary Edema         Fluid in the alveolus that impairs gas exchange by          alte...
Heart Failure   COMPENSATORY MECHANISMS    – Sympaththetic nervous system stimulation         Tachycardia         Vasoc...
Heart Failure   FUNCTIONAL CLASSIFICATIONS    – Class I    (without noticeable limitations)    – Class II    (symptoms up...
Heart Failure   COMPLICATIONS    – Hypotension    – Dysrhythmias    – Respiratory Failure    – Progressive Deterioration ...
Heart Failure   TREATMENT    – Improve Oxygenation    – Decrease Myocardial Oxygen Demand    – Decrease Preload    – Decr...
Vascular DiseaseAorto/Iliac Disease: Pre & Post PTA/Stent
Peripheral Vascular DiseaseSYMPTOMS         ARTERIAL                            VENOUSPAIN             Upon walking       ...
Peripheral Vascular Disease   TREATMENTS    – Medical         Are they taking ASA, Coumadin, Ticlid, Plavix,          Or...
Peripheral Vascular Disease         Bypass Grafts
Shock   DEFINITION    – Inadequate perfusion to the body tissues    – Low blood pressure with impaired perfusion      to ...
Shock   TYPES OF SHOCK    – Hypovolemic Shock    – Cardiogenic Shock    – Distributive Shock    – Obstructive Shock
Shock   COMPENSATORY MECHANISMS     –Tachycardia         Attempts to deliver more blood to the tissues     –Vasoconstric...
Types of Shock   Hypovolemic Shock    – Inadequate perfusion to the tissues due to insufficient    intravascular      vol...
Hypovolemic Shock   SIGNS & SYMPTOMS     Low BP                    Tachycardia     Orthostatic Hypotension   Restlessness...
Hypovolemic Shock   TREATMENT      –Volume (IVF, Blood)
Cardiogenic Shock   SIGNS & SYMPTOMS     Low BP                    Restlessness     Agitation (or listless)   Confusion  ...
Cardiogenic Shock   TREATMENT      Bedrest                 O2      ↑ CO                    Positive Inotropes      ↓ Prel...
Anaphylactic Shock   SIGNS & SYMPTOMS     Low BP                    Tachycardia     Restlessness              Confusion  ...
Anaphylactic Shock    TREATMENT      – Epinephrine      – IVF      – Vasoconstrictors      – Support/Maintain Airway
Obstructive Shock   SIGNS & SYMPTOMS     Low BP                    Tachycardia     Restlessness              Confusion   ...
Obstructive Shock   CAUSES     Pulmonary Embolus      Tamponade     Tension Pneumothorax   Aortic Aneurysm   TREATMENT  ...
Sepsis Syndrome            SIRS   Sepsis   Severe   Septic   MODS   DeathInfection                   Sepsis   Shock
Sepsis Syndrome   Sepsis    –   SIRS’ response with presumed/confirmed infection   Severe Sepsis    –   Sepsis associate...
Septic Shock   EARLY STAGE (Hyperdynamic)     Normal BP                 Tachycardia     Confusion                 Agitati...
Homeostasis Gets Lost
Treatment for Sepsis 1. Stabilize The Patient       –   Fluids (lots of fluids) 150ml/hr or more       –   Vasoconstrictor...
HEMODYNAMICS
Invasive PA Catheter    Contraindications   Mechanical Tricuspid or Pulmonary Valve   Right Heart Mass (thrombus and/or ...
Basic Concepts   CO = HR X SV   BP = CO x SVR   CO and SVR are inversely related    CO and SVR will change before BP ch...
Stroke Volume   Components Stroke Volume    – Preload: the volume of blood in the ventricles      at end diastole and the...
PAC Insertion Sequence
Phlebostatic Axis4th ICS Mid-chest, regardless of head elevation
Normal Hemodynamic Values   RAP (CVP)   0-8 mmHg   RVP         15-30/0-8 mmHg   PAP         15-30/6-12 mmHg   PAOP    ...
Normal Hemodynamic Values       Values normalized for body size (BSA)   CI:       2.5 – 4.5 L/min/m2   SVRI: 1970 – 239...
Mixed Venous Oxygen SaturationSvO2   End result of O2 delivery and    consumption   Measured in the pulmonary artery    ...
Measuring PA Pressures   Measure All Hemodynamic Values    at End-Expiration      –   “ Patient Peak”      –   “ Vent Val...
Measuring PA Pressures   Measure all pressures at end-expiration   At bottom curve with mechanical ventilator          –...
Spontaneous Respirations
PAOP Waveform   a-wave    – Atrial contraction    – Correct location for measurement of PAOP             Average the pea...
PAOP Waveform   c-wave    – Rarely present    – Represents mitral valve closure   v-wave    – Represents left atrial fil...
Shock Profiles    Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic    CVP/RAP          ...
CCRN REVIEW PART 1       BREAK!
Respiratory Alterations     ARDS              Chronic Lung                         Disease     Drowning                ...
ARDS   DEFINITIONS    – Severe respiratory failure associated with pulmonary      infiltrates (similar to infant hyaline ...
Acute Respiratory Distress Syndrome
ARDS   PATHOPHYSIOLOGY    – Inflammatory mediators are released causing extensive      structural damage    – Increased p...
ARDS   CXR CHARACTERISTICS    – Normal size heart    – No pleural effusion    – Ground Glass appearance    – Often normal...
ARDS
ARDS   SIGNS & SYMPTOMS    – Symptoms develop 24 to 48 hours of injury          Sudden progressive disorder          Pu...
ARDS   RISK FACTORS    Common Risk                              Other Risk Factors       Factors       Sepsis       Smoke...
ARDS   TREATMENT    – Respiratory Support    – PEEP, CPAP
Chronic Lung Disease   COPD    – Presents with hyper-inflated lung fields          Due to chronic air trapping         ...
Chronic Lung Disease   COPD TREATMENT    – Avoid overuse of oxygen (except in emergencies)    – Bronchodilators    – Ster...
Near Drowning   Salt Water    – Causes body fluids to shift into lungs          Osmosis: From low to high concentration ...
Pneumonia   Lung infection (bacterial, viral, or fungal)    – Most commonly caused by Streptococcus      pneumoniae   Sy...
Pneumothorax    DEFINITIONS     – Simple pneumothorax          Results from buildup of air or pressure in the pleural sp...
Pneumothorax
Tension Pneumothorax
Pneumothorax     CAUSES      – Barotrauma      – Injury      – Blebs
Pneumothorax    SIGNS & SYMPTOMS     – Standard Pneumothorax          Sharp "pleuritic" chest pain, worse on breathing  ...
Pneumothorax    TREATMENT    Spontaneous pneumothorax     – Depends on symptoms & size of pneumothorax     – Provide res...
Pneumothorax    TREATMENT     – Pleurodesis          Chemical or surgical adhesion of the lung           to the chest wa...
Flail Chest
Pulmonary Embolism   Definition    – Arterial embolus that obstructs blood flow to the lung   Signs & Symptoms    – Symp...
Pulmonary Embolism   Diagnostic Tests    –   CXR    –   VQ Scan    –   Spiral CT    – Pulmonary arteriogram    – Venous u...
Pulmonary Embolism    Treatment     – Requires immediate intervention     – Provide respiratory support     – Treat pain ...
Respiratory Failure   DEFINITIONS    – Failure to maintain adequate gas exchange    – Inadequate blood oxygenation or CO2...
Respiratory Failure TYPE I   Hypoxemia without hypercapnia TYPE II Hypoxemia with hypercapnia
Respiratory Failure   CAUSES    – V/Q Mismatching    – Intrapulmonary Shunting    – Alveolar Hypoventilation
Respiratory Failure   V/Q MISMATCHING    – COPD    – Interstitial Lung Disease    – Pulmonary Embolism
Respiratory Failure   PULMONARY SHUNTING    – AV fistulas/malformations    – Alveolar collapse (atelectasis)    – Alveola...
Respiratory Failure   SIGNS & SYMPTOMS    – Restlessness / Agitation    – Confusion / ↓ LOC    – Tachycardia / Dysrhythmi...
Respiratory Failure   ARTERIAL BLOOD GASES    – pH 7.30 / pO2 45 / pCO2 80    – pH 7.30 / pO2 55 / pCO2 65    – pH 7.32 /...
Respiratory Failure   TREATMENT    – Ensure Adequate Ventilation      ↑ FiO2         Ineffective with shunting         ...
CCRN REVIEW PART 1       BREAK!
Gastrointestinal Alterations     GI Bleed     Pancreatitis
Gastrointestinal Bleeding   CAUSES    – UGI Bleeding         Includes the esophagus, stomach, duodenum           – Pepti...
Gastrointestinal Bleeding
Gastrointestinal Bleeding   Hematemesis – vomiting of blood (or coffee ground    material) (indicates bleeding above the ...
Gastrointestinal Bleeding    Hematemesis – always UGI source    Melana – indicates blood has been in GI tract           ...
Gastrointestinal Bleeding   TREATMENT    – Find the underlying cause    – Fluid volume replacement    – Endoscopy or colo...
The Pancreas   The Pancreas secretes digestive enzymes,    bicarbonate, water, and some electrolytes into    the duodenum...
Pancreatitis   DEFINITION    – An autodigestive process resulting      from premature activation of      pancreatic enzymes
Pancreatitis   PATHOSHYSIOLOGY    • Inactive pancreatic enzymes are activated outside      of the duodenum    • The swell...
Pancreatitis   MANY CAUSES    – Alcoholism             – Hypercalcemia    – Biliary Disease        – Peptic Ulcer Disease...
Pancreatitis   SIGNS & SYMPTOMS    – Abdominal Pain         – Hematemesis    – Nausea & Vomiting      – Grey Turner’s Sig...
Pancreatitis   COMPLICATIONS    –   Hypocalcemia             –   Pleural Effusion (left)    –   Hypotension              ...
Pancreatitis   TREATMENT    – Stabilization             – Monitor For Complications          Correct Fluid And    – Moni...
Pancreatitis   FULMINATING PANCREATITIS    • Overwhelming form    • Necrotizing form    • Extreme symptoms    • Seen with...
Pancreatitis   FULMINATING PANCREATITIS    • Signs & Symptoms         Tachycardia & low BP (may be the only sign)      ...
CCRN REVIEW     THE END      PART 1
CCRN REVIEW PART 1     THANK YOU
References   American Heart Association. (2005). Guidelines 2005 for Cardiopulmonary    Resuscitation and Emergency Cardi...
References Continued   Urden, L., Lough, M. E. & Stacy, K. L. (2009). Thelans Critical Care Nursing:    Diagnosis and Man...
CCRN Review Part 1 (of 2)
CCRN Review Part 1 (of 2)
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CCRN Review Part 1 (of 2)

  1. 1. CCRN REVIEW PART 1 “Never let what you cannot do interfere with what you can do” - John Wooden - Sherry L. Knowles, RN, CCRN, CRNI
  2. 2. CCRN REVIEW PART 1 TOPICS Acute Coronary Syndromes  ARDS Acute Myocardial Infarction  Chronic Lung Disease Heart Blocks  Drowning Heart Failure  Pneumonia Cardiac Alterations  Pneumothorax Aortic Aneurysms  Pulmonary Embolism Cardiomyopathy  Respiratory Failure Shock States  Gastrointestinal Alterations Peripheral Vascular Disease  GI Bleeding Hemodynamics  Pancreatitis
  3. 3. CCRN REVIEW PART 1 OBJECTIVES1. Understand the different types of acute coronary syndromes.2. Identify basic coronary circulation and how it relates to different types of myocardial infarctions.3. Anticipate potential complications associated with an AMI.4. Identify the standard treatment of an AMI.5. Distinguish between various AV blocks.6. Recognize the signs & symptoms of heart failure.7. Identify the treatment of heart failure.8. Recognize the general definition and classifications of aortic aneurysms.9. Understand the different types of aortic dissections.10. Recognize the signs & symptoms of cardiomyopathy.11. Differentiate between the different types of cardiomyopathy.12. Identify the treatment for the different types of cardiomyopathy.
  4. 4. CCRN REVIEW PART 1 OBJECTIVES13. Understand the different stages of shock.14. Differentiate between different types of shock.15. Distinguish between arterial and venous peripheral vascular disease.16. Identify the various treatments for peripheral vascular disease.17. Define respiratory failure.18. Identify the various treatments for acute respiratory failure.19. Recognize the signs & symptoms and causes of various respiratory alterations.20. Identify the standard treatment for various respiratory alterations.21. Explain the common causes of gastrointestinal bleeding.22. Describe the most commonly seen treatments for GI bleeding.23. Describe the signs & symptoms of acute pancreatitis and available treatments.
  5. 5. Cardiovascular Conditions  Acute Coronary  Cardiomyopathy Syndromes  Acute MI  Heart Blocks  Aortic Aneurysms  Heart Failure  Cardiac Alterations  Shock States
  6. 6. Acute Coronary Syndrome DEFINITIONS – Term used to cover a group of symptoms compatible with acute myocardial ischemia – Acute myocardial ischemia is insufficient blood supply to the heart muscle usually resulting from coronary artery disease
  7. 7. Acute Myocardial Infarction DEFINITION – Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection. – STEMI vs. NSTEMI (non-STEMI)
  8. 8. Acute Myocardial Infarction SIGNS & SYMPTOMS – Complains Vary  May include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, SOB, nausea/vomiting and dizziness – ST elevations on ECG – Elevated cardiac enzymes
  9. 9. Acute Myocardial Infarction SIGNS & SYMPTOMS ↑ PAWP, ↓ CO, ↑ SVR, dysrhythmias, S4, cardiac failure, cardiogenic shock – Diaphoresis, pallor, referred pains – Diabetics and women often present abnormal symptoms
  10. 10. Coronary Circulation
  11. 11. 12 Lead ECGI AVR V1V4II AVL V2 V5III AVF V3 V6IIV
  12. 12. Acute Myocardial Infarction ST ELEVATIONS – Anterior Wall MI  Leads V1-V4  Reciprocal changes in leads II, III, and aVF  Area supplied by the LAD – Inferior Wall MI  Leads II, III and aVF  Reciprocal changes in leads I, and aVL  Area usually supplied by the RCA
  13. 13. Acute Myocardial Infarction ST ELEVATIONS – Lateral Wall MI  I, aVL, V5 and V6  Area supplied by the Circumflex artery – Posterior Wall MI  Reflected on the opposite walls  Opposite deflections
  14. 14. Coronary Arteries
  15. 15. Anterior Wall MI
  16. 16. Inferior Wall MI
  17. 17. Acute Myocardial Infarction COMPLICATIONS – Dysrhythmias, heart failure, pericarditis, ventricular aneurysms, ventricular thrombus, VSD, mitral regurgitation, papillary muscle (or chordae tendineae) rupture, pericardial effusions, pericarditis
  18. 18. Acute Myocardial Infarction NURSING INTERVENTIONS – O2 – Bedrest – Serial ECG’s – Serial cardiac enzymes – Keep pain free (NTG. MSO4) – MONA (Morphine, O2, Nitroglycerin, Aspirin), Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2b3a inhibitors – PCI, PTCA, IABP, CABG
  19. 19. Acute Myocardial Infarction TREATMENT – Time Is Heart Muscle – Prompt ECG – Goals: Relieve pain, limit the size of the infarction and to prevent complications (primarily lethal dysrhythmias)
  20. 20. Acute Myocardial Infarction TREATMENT – MONA (Morphine, O2, Nitroglycerin, Aspirin), Heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2b3a inhibitors – Cardiac Catheterization (with angioplasty, atherectomy and/or stent) – IABP, CABG, education
  21. 21. Balloon Angioplasty
  22. 22. Vascular Stent Deployment
  23. 23. Atherectomy
  24. 24. Acute Myocardial Infarction SPECIFIC TREATMENTS – Inferior Wall (IWMI)  Fluids (with RV infarct)  Inotropics  Afterload reducing medications – Anterior Wall (AWMI)  Diuretics  Inotropics  Afterload reducing medications
  25. 25. Aortic Aneurysms DEFINITION – A bulge or ballooning of the aorta  When the walls of the aneurysm include all three layers of the artery, they are called true aneurysms  When the wall of the aneurysm include only the outer layer, it is called a pseudo-aneurysm – May be thoracic or abdominal
  26. 26. Aortic Aneurysms CAUSES  Atherosclerosis  Marfan syndrome  Hypertension  Crack cocaine usage  Smoking  Trauma
  27. 27. Aortic Aneurysms Rupture  An aortic aneurysm, depending on its size, may rupture, causing life-threatening internal bleeding  The risk of an aneurysm rupturing increases as the aneurysm gets larger  The risk of rupture also depends on the location of the aneurysm  Each year, approximately 15,000 Americans die of a ruptured aortic aneurysm.
  28. 28. Aortic Aneurysms CLASSIFICATIONS – Classified by shape, location along the aorta, and how they are formed – May be symmetrical in shape (fusiform) or a localized weakness of the arterial wall (saccular)
  29. 29. Aortic Aneurysms
  30. 30. Aortic Aneurysms SIGNS & SYMPTOMS – Often produces no symptoms – If an aortic aneurysm suddenly ruptures it presents with extreme abdominal or back pain, a pulsating mass in the abdomen, and a drastic drop in blood pressure – An increase in the size of an aneurysm means an increased in the risk of rupture
  31. 31. Aortic Aneurysms THORACIC SIGNS & SYMPTOMS – Back, shoulder or neck pain – Cough, due to pressure placed on the trachea – Hoarseness – Strider, dyspnea – Difficulty swallowing – Swelling in the neck or arms
  32. 32. Aortic Dissections DEFINITION – Tearing of the inner layer of the aortic wall, which allows blood to leak into the wall itself and causes the separation of the inner and outer layers – Usually associated with severe chest pain radiating to the back
  33. 33. Aortic Dissections A. Dissection B. Whenever the beginning in the ascending aorta ascending aorta is not involved
  34. 34. Aortic Dissections A. Dissection B. Whenever the beginning in the ascending aorta ascending aorta is not involved
  35. 35. Aortic Dissections
  36. 36. Aortic Dissections
  37. 37. Aortic Aneurysms COMPLICATIONS  Rupture  Peripheral embolization  Infection  Spontaneous occlusion of aorta
  38. 38. Aortic Aneurysms TREATMENT  Medical management – Controlled BP (within specific range)  Surgical repair  > 4.5 cm in Marfan patients or > 5 cm in non- Marfan patients will require surgical correction or endovascular stent placement
  39. 39. Cardiomyopathy DEFINITION – Diseases of the heart muscle that cause deterioration of the function of the myocardium
  40. 40. Cardiomyopathy CLASSIFICATIONS – Primary / Idiopathic (intrinsic)  Heart disease of unknown cause, although viral infection and autoimmunity are suspected causes – Secondary (extrinsic)  Heart disease as a result of other systemic diseases, such as autoimmune diseases, CAD, valvular disease, severe hypertension, or alcohol abuse
  41. 41. Cardiomyopathy  Hypertropic Cardiomyopathy  Restrictive Cardiomyopathy  Dilated Cardiomyopathy
  42. 42. Hypertropic Cardiomyopathy Bizarre hypertrophy of the septum – Previously called IHSS  Idiopathic Hypertropic Subaortic Stenosis – Known as HOCM  Hypertropic Obstructive Cardiomyopathy Positive inotropic drugs Should Not Be Used ↑ Contractility will ↑ outflow tract obstruction Nitroglycerin Should Not Be Used – Dilation Will Worsen The Problem
  43. 43. Harley
  44. 44. Hypertropic Cardiomyopathy  TREATMENT – Relax the ventricles  Beta Blockers  Calcium Channel Blockers – Slow the Heart Rate  Increase filling time – Use Negative Inotropes  Optimize diastolic filling – Do Not use NTG  Dilation will worsen the problem
  45. 45. Restrictive Cardiomyopathy  Rigid Ventricular Wall – Due to endomyocardial fibrosis – Obstructs ventricular filling  Least common form
  46. 46. Restrictive Cardiomyopathy  TREATMENT – Positive Inotropics – Diuretics – Low Sodium Diet
  47. 47. Dilated Cardiomyopathy Grossly dilated ventricles without hypertrophy – Global left ventricular dysfunction – Leads to pooling of blood and embolic episodes – Leads to refractory heart failure – Leads to papillary muscle dysfunction secondary to LV dilation
  48. 48. Dilated Cardiomyopathy TREATMENT – Positive Inotropes – Afterload Reducers – Anticoagulants with Atrial Fib
  49. 49. Cardiomyopathies
  50. 50. Cardiomyopathy GENERALIZED TREATMENT – Positive Inotropes  Except with Hypertropic Cardiomyopathy – Vasodilators  Except with Hypertropic Cardiomyopathy – Reduce Preload & Afterload – Diuretics – Beta Blockers – Calcium Channel Blockers – IABP – Vasodilators (as indicated) – Fluid Restriction – Daily weights, prn O2, planned activities, education, and emotional support – Consider Heart Transplant
  51. 51. CCRN REVIEW PART 1 BREAK!
  52. 52. Conduction Defects STABLE VS UNSTABLE – Stable  Start with medications – Unstable  Shock (cardioversion or defibrillation)
  53. 53. Normal Sinus RhythmHeart Rate 60 - 100 bpmRhythm RegularP Wave Before each QRS & identicalPR Interval (in seconds) 0.12 to 0.20QRS (in seconds) < 0.12
  54. 54. Atrial Fibrillation AFib – Multifocal atrial impulses at rate 300-600/min – Irregular conduction to ventricles
  55. 55. Atrial Flutter AFL – Atrial impulses at rate of 250-350/min – Regularly blocked impulses at the AV node – Saw tooth flutter waves
  56. 56. Wandering Atrial Pacemaker WAP – Multiple ectopic foci in the atria – Three or more p wave morphologies – Rate < 100
  57. 57. Supraventricular Tachycardia SVT – Supraventricular rhythm at rate 150-250 – P waves cannot be positively identified Atrial Tach = supraventricular rhythm with p wave morphology that is noticeably different from the sinus p wave
  58. 58. Ventricular Tachycardia VT – Ventricular rate of 100-250/min – Wide QRS
  59. 59. Torsades de Pointes Polymorphic VT – VT with alternating ventricular focus – Often associated with prolonged QT Rate < 100
  60. 60. Heart Blocks (AV Blocks) Sinus Rhythm with First Degree AV Block Sinus Rhythm with Second Degree AV Block, Type 1 Sinus Rhythm with Second Degree AV Block, Type 2 Third Degree AV Block
  61. 61. Heart Failure DEFINITION – A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body – Pulmonary (LVF) and/or systemic (RVF) congestion is present.
  62. 62. Heart Failure DEFINITION – Pulmonary Edema  Fluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus and capillary  Acute left ventricular failure causes cardiogenic pulmonary edema  Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS)
  63. 63. Heart Failure COMPENSATORY MECHANISMS – Sympaththetic nervous system stimulation  Tachycardia  Vasoconstriction and increased SVR – Renin-angiotensin-aldosterone system activation  Hypo perfusion to the kidneys (renin)  Vasoconstriction (angiotension)  Sodium and water retention (kidneys)  Ventricular dilation
  64. 64. Heart Failure FUNCTIONAL CLASSIFICATIONS – Class I (without noticeable limitations) – Class II (symptoms upon activity) – Class III (severe symptoms upon activity) – Class IV (symptoms at rest)
  65. 65. Heart Failure COMPLICATIONS – Hypotension – Dysrhythmias – Respiratory Failure – Progressive Deterioration – Acute Renal Failure – Fluid & Electrolyte Imbalances
  66. 66. Heart Failure TREATMENT – Improve Oxygenation – Decrease Myocardial Oxygen Demand – Decrease Preload – Decrease Afterload – Increase Contractility – Manage Dysrhythmias – Educate!
  67. 67. Vascular DiseaseAorto/Iliac Disease: Pre & Post PTA/Stent
  68. 68. Peripheral Vascular DiseaseSYMPTOMS ARTERIAL VENOUSPAIN Upon walking While standingPAIN RELIEF On resting, standing or Elevation of extremities dependent position of lower limbsEDEMA None Present, edematousPULSES Decreased or absent May be difficult to palpateINTEGUMENT Hair loss Brownish pigmentation Skin shiny May be cyanotic whenCHANGES Nail thickening extremities are dependent Pallor when elevated Red when dependent Ulcers located on toes, lateral Ulcers located on ankles,ULCERS areas or site of trauma medial or pre-tibial areas Gangrene possibleSKIN TEMPERATURE Cool Normal or warmSEXUAL ISSUES Impotency Not present Sexual dysfunction
  69. 69. Peripheral Vascular Disease TREATMENTS – Medical  Are they taking ASA, Coumadin, Ticlid, Plavix, Oral Contraceptives, Hormones? – Invasive  PTA, atherectomy, stents – Surgical  Grafts
  70. 70. Peripheral Vascular Disease Bypass Grafts
  71. 71. Shock DEFINITION – Inadequate perfusion to the body tissues – Low blood pressure with impaired perfusion to the end organs – May result in multiple organ dysfunction
  72. 72. Shock TYPES OF SHOCK – Hypovolemic Shock – Cardiogenic Shock – Distributive Shock – Obstructive Shock
  73. 73. Shock COMPENSATORY MECHANISMS –Tachycardia  Attempts to deliver more blood to the tissues –Vasoconstriction  Attempts to maintain adequate BP in order to adequately perfuse the body tissues –Increased ADH Secretion  ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues
  74. 74. Types of Shock Hypovolemic Shock – Inadequate perfusion to the tissues due to insufficient intravascular volume Cardiogenic Shock – Inadequate perfusion to the tissues due to heart failure Distributive Shock – Inadequate perfusion to the tissues due to blood flow out of the intravascular space causing insufficient intravascular volume – Anaphylactic, Septic, and Spinal Shock Obstructive Shock – Inadequate perfusion to the tissues due to obstruction of blood flow
  75. 75. Hypovolemic Shock SIGNS & SYMPTOMS Low BP Tachycardia Orthostatic Hypotension Restlessness Confusion Agitation (or listless) Thirst Pallor Cool, Clammy Skin ↑ Resp. Rate ↓ UOP ↓ CO ↓ PAWP ↓ CVP ↑ SVR ↑ Lactate Levels
  76. 76. Hypovolemic Shock TREATMENT –Volume (IVF, Blood)
  77. 77. Cardiogenic Shock SIGNS & SYMPTOMS Low BP Restlessness Agitation (or listless) Confusion Tachycardia Pallor ↓ UOP ↓ CO ↑ PAWP (low with RVF) ↑ CVP ↑ SVR ↑ Lactate Levels JVD Peripheral Edema Ventricular Gallop (S3) Dyspnea Pulmonary Crackles
  78. 78. Cardiogenic Shock TREATMENT Bedrest O2 ↑ CO Positive Inotropes ↓ Preload & Afterload Diuretics ↓ Vasodilators Positioning ↓ Myocardial Demand IABP
  79. 79. Anaphylactic Shock SIGNS & SYMPTOMS Low BP Tachycardia Restlessness Confusion Agitation (or listless) Thirst Pallor Warm Feeling Pruritus Hives Angioedema Bronchoconstriction Wheezing Laryngeal Edema Dyspnea Cool, Clammy Skin ↓ UOP ↓ CO ↓ PAWP ↓ CVP ↓ SVR ↑ Lactate Levels
  80. 80. Anaphylactic Shock  TREATMENT – Epinephrine – IVF – Vasoconstrictors – Support/Maintain Airway
  81. 81. Obstructive Shock SIGNS & SYMPTOMS Low BP Tachycardia Restlessness Confusion Agitation (or listless) Pallor Cool, Clammy Skin ↓ CO , ↓ UOP Symptoms related to cause
  82. 82. Obstructive Shock CAUSES Pulmonary Embolus Tamponade Tension Pneumothorax Aortic Aneurysm TREATMENT Treat the Cause
  83. 83. Sepsis Syndrome SIRS Sepsis Severe Septic MODS DeathInfection Sepsis Shock
  84. 84. Sepsis Syndrome Sepsis – SIRS’ response with presumed/confirmed infection Severe Sepsis – Sepsis associated with organ dysfunction, hypoperfusion (lactic acidosis, oliguria, altered mental status etc.), or hypotension (SBP < 90 mmHg or ↓ SBP > 40 mmHg) Septic Shock – Sepsis with perfusion abnormalities and hypotension despite adequate fluid resuscitation
  85. 85. Septic Shock EARLY STAGE (Hyperdynamic) Normal BP Tachycardia Confusion Agitation (or listless) ↑ Respiratory Rate Temperature Normal Color Normal or ↑ UOP Normal PAWP ↑ CO ↓ SVR LATE STAGE (Hypodynamic) Low BP Tachycardia Orthostatic Hypotension Restlessness Confusion Agitation (or listless) Thirst Pallor Cool, Clammy Skin ↓ UOP ↓ CO ↓ PAWP ↓ CVP ↑ SVR ↑ Lactate Levels
  86. 86. Homeostasis Gets Lost
  87. 87. Treatment for Sepsis 1. Stabilize The Patient – Fluids (lots of fluids) 150ml/hr or more – Vasoconstrictors 2. Treat The Cause – Pan culture, antibiotics – Seek primary site of infection – Direct therapy to primary cause 3. Improve Perfusion – Prevent organ dysfunction – Treat temp as needed
  88. 88. HEMODYNAMICS
  89. 89. Invasive PA Catheter Contraindications Mechanical Tricuspid or Pulmonary Valve Right Heart Mass (thrombus and/or tumor) Tricuspid or Pulmonary Valve Endocarditis
  90. 90. Basic Concepts CO = HR X SV BP = CO x SVR CO and SVR are inversely related CO and SVR will change before BP changes
  91. 91. Stroke Volume Components Stroke Volume – Preload: the volume of blood in the ventricles at end diastole and the stretch placed on the muscle fibers – Afterload: the resistance the ventricles must overcome to eject it’s volume of blood – Contractility: the force with which the heart muscle contracts (myocardial compliance)
  92. 92. PAC Insertion Sequence
  93. 93. Phlebostatic Axis4th ICS Mid-chest, regardless of head elevation
  94. 94. Normal Hemodynamic Values RAP (CVP) 0-8 mmHg RVP 15-30/0-8 mmHg PAP 15-30/6-12 mmHg PAOP 8 - 12 mmHg
  95. 95. Normal Hemodynamic Values  Values normalized for body size (BSA) CI: 2.5 – 4.5 L/min/m2 SVRI: 1970 – 2390 dynes/sec/cm-5/m2 SVI or SI: 35 – 60 mL/beat/m2 EDVI: 60 – 100 mL/m2
  96. 96. Mixed Venous Oxygen SaturationSvO2 End result of O2 delivery and consumption Measured in the pulmonary artery  An average estimate of venous saturation for the whole body.  Does not reflect separate tissue perfusion or oxygenation
  97. 97. Measuring PA Pressures Measure All Hemodynamic Values at End-Expiration – “ Patient Peak” – “ Vent Valley”
  98. 98. Measuring PA Pressures Measure all pressures at end-expiration At bottom curve with mechanical ventilator – “Vent-Valley” Intrathoracic pressure increases during positive pressure ventilations (inspiration) – Positive deflection on waveforms Intrathoracic pressure decreases during positive pressure expiration – Negative deflection on waveforms
  99. 99. Spontaneous Respirations
  100. 100. PAOP Waveform a-wave – Atrial contraction – Correct location for measurement of PAOP  Average the peak & trough of the a-wave – Begins near the end of QRS or at the QT segment  Delayed ECG correlation from CVP since PA catheter is further away from left atrium
  101. 101. PAOP Waveform c-wave – Rarely present – Represents mitral valve closure v-wave – Represents left atrial filling – Begins at about the end of the T wave
  102. 102. Shock Profiles Parameter Hypovolemic Cardiogenic Neurogenic Anaphylactic Early Septic Late Septic CVP/RAP       PAWP      or Norm  CO       BP       SVR       HR     Norm al  Cardiogenic Shock is the only shock with  PAWP Early (Hyperdynamic) Shock is the only shock with  CO and  SVR Neurogenic Shock is the only shock with  bradycardia Anaphylactic Shock has the definitive characteristic of wheezing due to bronchospasm
  103. 103. CCRN REVIEW PART 1 BREAK!
  104. 104. Respiratory Alterations  ARDS  Chronic Lung Disease  Drowning  Pneumonia  Pneumothorax  Pulmonary  Respiratory Embolism Failure
  105. 105. ARDS DEFINITIONS – Severe respiratory failure associated with pulmonary infiltrates (similar to infant hyaline membrane disease) – Pulmonary edema in the absence of fluid overload or depressed LV function (Non-cardiogenic pulmonary edema) – Originates from a number of insults involving damage to the alveolar-capillary membrane
  106. 106. Acute Respiratory Distress Syndrome
  107. 107. ARDS PATHOPHYSIOLOGY – Inflammatory mediators are released causing extensive structural damage – Increased permeability of pulmonary microvasculature causes leakage of proteinaceous fluid across the alveolar– capillary membrane – Also causes damage to the surfactant-producing type II cells
  108. 108. ARDS CXR CHARACTERISTICS – Normal size heart – No pleural effusion – Ground Glass appearance – Often normal early in the disease but may rapidly progress to complete whiteout
  109. 109. ARDS
  110. 110. ARDS SIGNS & SYMPTOMS – Symptoms develop 24 to 48 hours of injury  Sudden progressive disorder  Pulmonary edema  Severe dyspnea  Hypoxemia REFRACTORY to O2  Decreased lung compliance  Diffuse pulmonary infiltrates – Symptoms may be minimal compared to CXR – Rales may be heard
  111. 111. ARDS RISK FACTORS Common Risk Other Risk Factors Factors Sepsis Smoke inhalation Acute Pancreatitis Massive Inhaled toxins DIC Trauma Burns Head Injury Shock Near Drowning ↑ ICP Multiple DKA Fat Emboli Transfusions Pregnancy Blood Products Pneumonia Eclampsia Heart/Lung Bypass Aspiration Amniotic Fluid Embolus Tumor Lysis Infection Drugs Pulmonary Contusion Narcotics
  112. 112. ARDS TREATMENT – Respiratory Support – PEEP, CPAP
  113. 113. Chronic Lung Disease COPD – Presents with hyper-inflated lung fields  Due to chronic air trapping  May be barrel chested – May lead to cor pulmonale (right-sided heart failure)  Due to chronic high pulmonary pressures – Often hypercarbic (high pCO2)  Often dependent upon hypoxic drive
  114. 114. Chronic Lung Disease COPD TREATMENT – Avoid overuse of oxygen (except in emergencies) – Bronchodilators – Steroids – Hydration – Education  Pursed Lip Breathing  Leaning Upright
  115. 115. Near Drowning Salt Water – Causes body fluids to shift into lungs  Osmosis: From low to high concentration  Results in hemoconcentration & hypovolemia – Results in acute pulmonary edema Fresh Water – Fluids shift into body tissues  Results in hemodilution & hypervolemia  Can result in gross edema – Damaged alveoli fill with proteinaceous fluid  May lead to pulmonary edema
  116. 116. Pneumonia Lung infection (bacterial, viral, or fungal) – Most commonly caused by Streptococcus pneumoniae Symptoms include fever, pleuretic chest pain, productive cough, and tachypnea – Often presents bronchial breath sounds over the lung area Treatment involves giving the right antibiotic
  117. 117. Pneumothorax  DEFINITIONS – Simple pneumothorax  Results from buildup of air or pressure in the pleural space – Spontaneous pneumothorax  May be due to blebs that rupture  The 2 key risk factors are increased chest length and cigarette smoking – Tension pneumothorax  Involves a buildup of air in the pleural space due to one-way movement of air  Progressively worsens  Requires immediate intervention
  118. 118. Pneumothorax
  119. 119. Tension Pneumothorax
  120. 120. Pneumothorax  CAUSES – Barotrauma – Injury – Blebs
  121. 121. Pneumothorax  SIGNS & SYMPTOMS – Standard Pneumothorax  Sharp "pleuritic" chest pain, worse on breathing  Sudden shortness of breath  Dry, hacking cough (may occur due to irritation of the diaphragm)  May cause mediastinal shift – Tension pneumothorax  Signs of standard pneumothorax with signs of cardiovascular collapse  Immediately life threatening  May cause mediastinal shift
  122. 122. Pneumothorax  TREATMENT  Spontaneous pneumothorax – Depends on symptoms & size of pneumothorax – Provide respiratory support – May need chest tube or needle decompression  Some resolve without intervention  Tension pneumothorax – Requires immediate intervention – May cause cardiovascular collapse – May need chest tube or needle decompression  2nd intercostal space
  123. 123. Pneumothorax  TREATMENT – Pleurodesis  Chemical or surgical adhesion of the lung to the chest wall  Used for multiple collapsed lungs or persistent collapse
  124. 124. Flail Chest
  125. 125. Pulmonary Embolism Definition – Arterial embolus that obstructs blood flow to the lung Signs & Symptoms – Symptoms include sudden dyspnea, cough, chest pain, hemoptysis and sinus tachycardia – Blood gas shows low pO2 & low pCO2 – May present positive Homan’s Sign – May present loud S2
  126. 126. Pulmonary Embolism Diagnostic Tests – CXR – VQ Scan – Spiral CT – Pulmonary arteriogram – Venous ultrasound of the lower extremities – ABG with low pO2 & low pCO2 – D-Dimer
  127. 127. Pulmonary Embolism  Treatment – Requires immediate intervention – Provide respiratory support – Treat pain & comfort – Usually includes intravenous heparin  Heparin reduces risk of secondary thrombus formation while clot is reabsorbed – May require embolectomy – May require thrombolysis – May need umbrella filter – May need long term anticoagulants
  128. 128. Respiratory Failure DEFINITIONS – Failure to maintain adequate gas exchange – Inadequate blood oxygenation or CO2 removal – PaO2 < 50 mmHg and/or PaCO2 > 50 mmHg and/or pH < 7.35 on Room Air
  129. 129. Respiratory Failure TYPE I Hypoxemia without hypercapnia TYPE II Hypoxemia with hypercapnia
  130. 130. Respiratory Failure CAUSES – V/Q Mismatching – Intrapulmonary Shunting – Alveolar Hypoventilation
  131. 131. Respiratory Failure V/Q MISMATCHING – COPD – Interstitial Lung Disease – Pulmonary Embolism
  132. 132. Respiratory Failure PULMONARY SHUNTING – AV fistulas/malformations – Alveolar collapse (atelectasis) – Alveolar consolidation (pneumonia) – Excessive mucus accumulation
  133. 133. Respiratory Failure SIGNS & SYMPTOMS – Restlessness / Agitation – Confusion / ↓ LOC – Tachycardia / Dysrhythmias – Tachypnea / Dyspnea – Cool, clammy, pale skin
  134. 134. Respiratory Failure ARTERIAL BLOOD GASES – pH 7.30 / pO2 45 / pCO2 80 – pH 7.30 / pO2 55 / pCO2 65 – pH 7.32 / pO2 50 / pCO2 50 – pH 7.55 / pO2 65 / pCO2 22
  135. 135. Respiratory Failure TREATMENT – Ensure Adequate Ventilation ↑ FiO2  Ineffective with shunting  Prolonged O2 > 40% causes O2 toxicity  Must use caution with CO2 retainers – Chronic hypercapnia causes CO2 retainers to use hypoxic drive – Too much O2 can depress respirations
  136. 136. CCRN REVIEW PART 1 BREAK!
  137. 137. Gastrointestinal Alterations  GI Bleed  Pancreatitis
  138. 138. Gastrointestinal Bleeding CAUSES – UGI Bleeding  Includes the esophagus, stomach, duodenum – Peptic Ulcer Disease (PUD), or Esophageal Varices – ASA, NSAID’s, Anticoagulants, Alcohol – H. Pylori – LGI Bleeding  Includes the jejunum, ileum, colon, rectum – Colorectal cancer, Polyps, Hemorrhoids, IBD
  139. 139. Gastrointestinal Bleeding
  140. 140. Gastrointestinal Bleeding Hematemesis – vomiting of blood (or coffee ground material) (indicates bleeding above the duodenum ) Melena – passage of black tarry stools > 50ml (indicates degradation of blood in the bowel) Hematochezia – passage of red blood (rectal bleeding) Occult Bleeding – bleeding that is not apparent to the patient and results from small amounts of blood Obscure Bleeding – occult or obvious but source not identified
  141. 141. Gastrointestinal Bleeding Hematemesis – always UGI source Melana – indicates blood has been in GI tract for extended periods – Mostly UGI – Small bowel – Rt colon (if bleeding relatively slow) Hematochezia – Mostly colon – Massive UGI bleeding (not enough time for degradation)
  142. 142. Gastrointestinal Bleeding TREATMENT – Find the underlying cause – Fluid volume replacement – Endoscopy or colonoscopy – Medical and /or surgical therapy  Somatostatin  IV or intra-arterial vasopressin  Sclerotherpay  Angiography with embolization  Electrocoagulation  Band ligation  Balloon tamponade (Sengstaken-Blackmore tube)
  143. 143. The Pancreas The Pancreas secretes digestive enzymes, bicarbonate, water, and some electrolytes into the duodenum via the pancreatic duct – Lipase, Amylase, Trypsin The Pancreas also produces and secretes insulin
  144. 144. Pancreatitis DEFINITION – An autodigestive process resulting from premature activation of pancreatic enzymes
  145. 145. Pancreatitis PATHOSHYSIOLOGY • Inactive pancreatic enzymes are activated outside of the duodenum • The swelling pancreas causes fluids to shift into the retro peritoneum and bowel • Fluid shifts can cause severe hypovolemia and hypotension • Inflammation cause commotion around pancreas
  146. 146. Pancreatitis MANY CAUSES – Alcoholism – Hypercalcemia – Biliary Disease – Peptic Ulcer Disease – Gallstones – Cystic Fibrosis – Infections – Vascular Disease – Hyperparathyroidism – Multiple Drugs – Hypertriglyceridemia – Much Much More
  147. 147. Pancreatitis SIGNS & SYMPTOMS – Abdominal Pain – Hematemesis – Nausea & Vomiting – Grey Turner’s Sign – Abdominal Distention – Cullen’s Sign – Jaundice – Elevated Amylase, – Malnutrition Lipase, LDH, AST, WBC’s BUN, and Glucose
  148. 148. Pancreatitis COMPLICATIONS – Hypocalcemia – Pleural Effusion (left) – Hypotension – Pulmonary Infiltrates – Acute Tubular Necrosis – Hypoxemia – DIC – Atelectasis – Obstructive Jaundice – ARDS – Erosive Gastritis – Pericardial Effusion – Paralytic Ileus – Mediastinal Abscess – Pseudocyst or Abscess – Hyperglycemia – Bowel Infarction – Internal Bleeding – Hypertriglyceridemia – Fat Necrosis – Encephalopathy
  149. 149. Pancreatitis TREATMENT – Stabilization – Monitor For Complications  Correct Fluid And – Monitor Blood Sugar Electrolyte Status – Respiratory Support – Drug Therapies – Control Pain  Somatostatin,  Demerol Anticholinergics – NG Tube – Watch For Signs Of  NPO Infection – TPN – Pray  Restricted Diet
  150. 150. Pancreatitis FULMINATING PANCREATITIS • Overwhelming form • Necrotizing form • Extreme symptoms • Seen with ESRF patients • May lead to ARDS & DIC
  151. 151. Pancreatitis FULMINATING PANCREATITIS • Signs & Symptoms  Tachycardia & low BP (may be the only sign)  Pulmonary & cerebral insufficiency  Acute diabetic ketosis or oliguria  Hemorrhagic pancreatitis may appear
  152. 152. CCRN REVIEW THE END PART 1
  153. 153. CCRN REVIEW PART 1 THANK YOU
  154. 154. References American Heart Association. (2005). Guidelines 2005 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Available at: www.americanheart.org. Bridges EJ.(2006) Pulmonary artery pressure monitoring: when, how, and what else to use. AACN Adv Crit Care. 2006;17(3):286–303. Chulay, M., Burns S. M. (2006). AACN Essentials of Critical Care Nursing. McGraw-Hill Companies, Inc., Chapter 23. Finkelmeier, B., Marolda, D. (2004) Aortic Dissection, Journal of Cardiovascular Nursing: 15(4):15–24. Hughes E. (2004). Understanding the care of patients with acute pancreatitis. Nurs Standard: (18) pgs 45-54. Sole, M. L., Klein, D. G. & Moseley, M. (2008). Introduction to Critical Care Nursing. 5th ed. Philadelphia, Pa: Saunders. Thelan, L. A., Urden, L. D., Lough, M. E. (2006). Critical care: Diagnosis and Treatment for repair of abdominal aortic aneurysm. St. Louis, Mo.: Mosby/Elsevier. pg 145-188.
  155. 155. References Continued Urden, L., Lough, M. E. & Stacy, K. L. (2009). Thelans Critical Care Nursing: Diagnosis and Management (6th ed). St. Louis, Mo.: Mosby/Elsevier. Woods, S., Sivarajan Froelicher, E. S., & Motzer, S. U. (2004). Cardiac Nursing. 5th ed. Philadelphia, Pa: Lippincott Williams & Wilkins. Wynne J, Braunwald E. (2004). The Cardiomyopathies in Braunwalds Heart Disease: A Textbook of Cardiovascular Medicine (7th Edition). Philadelphia: W.B. Saunders, vol. 2, pps. 1659–1696, 1751–1803. Zimmerman & Sole. (2001). Critical Care Nursing (3rd Edition). WB Saunders., pgs. 41-80, 176-180, 242-266. Anderson, L. (July 2001). Abdominal Aortic Aneurysm, Journal of Cardiovascular Nursing:15(4):1–14, July 2001. Irwin, R. S.; Rippe, J. M. (January 2003). Intensive Care Medicine. Lippincott Williams & Wilkins, Philadelphia: pgs. 35-548. Wung, S., Aouizerat, B. E. (Nov/Dec 2004). Aortic Aneurysms. Journal of Cardiovascular Nursing. Lippincott Williams & Wilkins, Inc.:19(6):409-416, 34(2).
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