PHYSIOLOGIC MONITORING
 
<ul><li>Hemodynamic Monitoring </li></ul><ul><li>- provides information as to the C-P status of the patient </li></ul><ul>...
<ul><li>A. Arterial Catheterization </li></ul><ul><li>1. Indications </li></ul><ul><li>a. Need for continuous blood  press...
<ul><li>Conditions that need continuous  and accurate BP monitoring: </li></ul><ul><li>i. shock states </li></ul><ul><li>i...
<ul><li>2. Contraindications </li></ul><ul><li>- no ABSOLUTE  contraindication  to arterial catheterization </li></ul><ul>...
<ul><li>3. Sites of Catheterization </li></ul><ul><li>a. radial artrery </li></ul><ul><li>- dual blood supply </li></ul><u...
<ul><li>b. axillary artery </li></ul><ul><li>- for long term monitoring </li></ul><ul><li>- large size </li></ul><ul><li>-...
<ul><li>c. femoral artery </li></ul><ul><li>- large size and superficial  location </li></ul><ul><li>- prone to atheroscle...
<ul><li>f. brachial artery </li></ul><ul><li>- for short term use only </li></ul><ul><li>- median nerve contracture  (Volk...
<ul><li>*Complications of arterial catheterization </li></ul><ul><li>1. failure to cannulate </li></ul><ul><li>2. hematoma...
<ul><li>B. Central Venous Catheterization </li></ul><ul><li>1. Indications </li></ul><ul><li>a. access for fluid therapy <...
 
<ul><li>*Central Venous Pressure Monitoring </li></ul><ul><li>1. useful in hypotensive patients </li></ul><ul><li>2. traci...
<ul><li>2. Sites of catheterization </li></ul><ul><li>a. subclavian vein </li></ul><ul><li>- easiest to cannulate </li></u...
<ul><li>*Complications </li></ul><ul><li>1. catheter malposition </li></ul><ul><li>2. dysrythmmias </li></ul><ul><li>3. em...
<ul><li>II. Respiratory Monitoring </li></ul><ul><li>- monitoring ventilation and gas exchange </li></ul><ul><li>* Indicat...
<ul><li>A. Ventilation monitoring </li></ul><ul><li>1. Tidal volume – volume of air moved in or  out of the lung an  a sin...
<ul><li>B. Gas Monitoring </li></ul><ul><li>- reported as directly measured partial pressures (PO2 and PCO2) </li></ul><ul...
<ul><ul><li>2. Capnography  </li></ul></ul><ul><ul><li>- graphic display of CO2 concentration in wave form  </li></ul></ul...
<ul><ul><li>3. Pulse oximetry </li></ul></ul><ul><ul><li>- reliable, real time estimation of the arterial </li></ul></ul><...
 
<ul><li>4. Gastric Tonometry </li></ul><ul><li>- relatvely non-invasive  monitor of  adequacy of aerobic metabolism in  or...
<ul><li>III. Renal Monitoring </li></ul><ul><li>-  the kidney is an excellent monitor of adequacy of perfusion </li></ul><...
<ul><li>A. Urine Output </li></ul><ul><li>- commonly monitored but may be misleading </li></ul><ul><li>- normal urine outp...
<ul><li>B. Glomerular Function Tests </li></ul><ul><li>1. Blood Urea Nitrogen (BUN) </li></ul><ul><li>a. affected by GFR a...
<ul><li>2. Plasma Creatinine </li></ul><ul><li>a. more accurate than BUN </li></ul><ul><li>b. directly proportional to cre...
<ul><li>3. Creatinine Clearance </li></ul><ul><li>a. used if values of plasma  creatinine are affected by muscle  disease ...
<ul><li>C. Tubular Function Tests </li></ul><ul><li>1. The most reliable test to distinguish  pre- renal azotemia from tub...
<ul><li>IV. Neurologic Monitoring </li></ul><ul><li>-  early recognition of cerebral dysfunction </li></ul><ul><li>-  faci...
<ul><li>B. Electrophysiologic Monitoring </li></ul><ul><li>- reflects spontaneous and on-going electrical activity in the ...
<ul><li>V. Metabolic Monitoring </li></ul><ul><li>A. Caloric Demands </li></ul><ul><li>B. Respiratory Quotient of Food </l...
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Principles Of Trauma Care (3)

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Principles Of Trauma Care (3)

  1. 1. PHYSIOLOGIC MONITORING
  2. 3. <ul><li>Hemodynamic Monitoring </li></ul><ul><li>- provides information as to the C-P status of the patient </li></ul><ul><li>- traditional clinical assessment are usually unreliable </li></ul><ul><li>- major changes in the cardiovascular status may not be clinically obvious </li></ul><ul><li>- invasive techniques must be utilized </li></ul>
  3. 4. <ul><li>A. Arterial Catheterization </li></ul><ul><li>1. Indications </li></ul><ul><li>a. Need for continuous blood pressure monitoring. </li></ul><ul><li>b. Need for frequent arterial blood sampling. </li></ul>
  4. 5. <ul><li>Conditions that need continuous and accurate BP monitoring: </li></ul><ul><li>i. shock states </li></ul><ul><li>ii. hypertensive crisis </li></ul><ul><li>iii. surgery in high risk patients </li></ul><ul><li>iv. use of potent vasoactive or inotropic drugs </li></ul><ul><li>v. controlled hypotensive anesthesia </li></ul><ul><li>vi. situations that may lead to rapid changes in cardiac function </li></ul>
  5. 6. <ul><li>2. Contraindications </li></ul><ul><li>- no ABSOLUTE contraindication to arterial catheterization </li></ul><ul><li>- RELATIVE contraindications are: </li></ul><ul><li>a. bleeding problems (hemophelia) </li></ul><ul><li>b. anticoagulant therapy </li></ul><ul><li>c. presence of a vascular prosthesis </li></ul><ul><li>d. local infection </li></ul>
  6. 7. <ul><li>3. Sites of Catheterization </li></ul><ul><li>a. radial artrery </li></ul><ul><li>- dual blood supply </li></ul><ul><li>- most commonly used site </li></ul><ul><li>- simple canulation </li></ul><ul><li>- low complication rate </li></ul><ul><li>- modified “Allen’s” test – assess ulnar artery </li></ul><ul><li>- Doppler technique, plethysmography, pulse oximetry </li></ul>
  7. 8. <ul><li>b. axillary artery </li></ul><ul><li>- for long term monitoring </li></ul><ul><li>- large size </li></ul><ul><li>- close proximity to the aorta </li></ul><ul><li>- deep location </li></ul><ul><li>- technical difficulty in insertion </li></ul><ul><li>- located near neurovascular structures </li></ul>
  8. 9. <ul><li>c. femoral artery </li></ul><ul><li>- large size and superficial location </li></ul><ul><li>- prone to atherosclerosis </li></ul><ul><li>- difficult to keep clean </li></ul><ul><li>d. dorsalis pedis </li></ul><ul><li>e. superficial temporal artery </li></ul><ul><li>- surgical exposure is required </li></ul><ul><li>- neurologic complications observed </li></ul>
  9. 10. <ul><li>f. brachial artery </li></ul><ul><li>- for short term use only </li></ul><ul><li>- median nerve contracture (Volkman’s contracture) </li></ul>
  10. 11. <ul><li>*Complications of arterial catheterization </li></ul><ul><li>1. failure to cannulate </li></ul><ul><li>2. hematoma </li></ul><ul><li>3. disconnection from monitoring system </li></ul><ul><li>4. infection </li></ul><ul><li>- catheters in place for more than 4 days </li></ul><ul><li>- surgical insertion </li></ul><ul><li>- local inflammation </li></ul><ul><li>5. retrograde cerebral embolization </li></ul><ul><li>6. A-V fistula / pseudoaneurysm </li></ul><ul><li>7. severe pain, distal necrosis </li></ul>
  11. 12. <ul><li>B. Central Venous Catheterization </li></ul><ul><li>1. Indications </li></ul><ul><li>a. access for fluid therapy </li></ul><ul><li>b. access for drug infusion </li></ul><ul><li>c. parenteral nutrition </li></ul><ul><li>d. CVP monitoring </li></ul><ul><li>e. other indications </li></ul><ul><li>- aspirate air embolism </li></ul><ul><li>- placement of cardiac pacemaker / vena cava filters </li></ul><ul><li>- hemodialysis access </li></ul>
  12. 14. <ul><li>*Central Venous Pressure Monitoring </li></ul><ul><li>1. useful in hypotensive patients </li></ul><ul><li>2. tracings for arrythmias </li></ul><ul><li>3. gives information about the relationship between intravascular volume and right ventricular function </li></ul><ul><li>4. use of a water manometer for pressure measurements </li></ul><ul><li>5. Normal CVP measurement – 5-10 mmH2O </li></ul>
  13. 15. <ul><li>2. Sites of catheterization </li></ul><ul><li>a. subclavian vein </li></ul><ul><li>- easiest to cannulate </li></ul><ul><li>- pneumothorax most common complication </li></ul><ul><li>- difficult to control bleeding </li></ul><ul><li>b. internal jugular vein </li></ul><ul><li>- lower risk of pneumothorax </li></ul><ul><li>- arterial puncture most common complication </li></ul><ul><li>c. external jugular vein </li></ul><ul><li>d. basilic vein </li></ul>
  14. 16. <ul><li>*Complications </li></ul><ul><li>1. catheter malposition </li></ul><ul><li>2. dysrythmmias </li></ul><ul><li>3. embolization </li></ul><ul><li>4. vascular injury </li></ul><ul><li>5. cardiac, pleural, mediastinal, neurologic injury </li></ul>
  15. 17. <ul><li>II. Respiratory Monitoring </li></ul><ul><li>- monitoring ventilation and gas exchange </li></ul><ul><li>* Indications </li></ul><ul><li>1. Decision making for the need of mechanical ventilation. </li></ul><ul><li>2. Assessment of response to therapy. </li></ul><ul><li>3. Optimize ventilatory management. </li></ul><ul><li>4. Decision to wean from ventilator. </li></ul>
  16. 18. <ul><li>A. Ventilation monitoring </li></ul><ul><li>1. Tidal volume – volume of air moved in or out of the lung an a single breath </li></ul><ul><li>2. Vital capacity – maximal volume at expiration after a maximal inspiration </li></ul><ul><li>3. Minute volume – total volume of air leaving the lung each minute </li></ul><ul><li>4. Phsiologic dead space – the portion of tidal volume that does not participate in in gas exchange </li></ul><ul><li>a. anatomic dead space </li></ul><ul><li>b. phsiologic dead space </li></ul>
  17. 19. <ul><li>B. Gas Monitoring </li></ul><ul><li>- reported as directly measured partial pressures (PO2 and PCO2) </li></ul><ul><li>- use of pulse oximeters for continuous measurements </li></ul><ul><li>1. Blood gas analysis – information about: </li></ul><ul><li>a. efficacy of gas exchange </li></ul><ul><li>b. adequacy of alveolar ventilation </li></ul><ul><li>c. acid – base status </li></ul>
  18. 20. <ul><ul><li>2. Capnography </li></ul></ul><ul><ul><li>- graphic display of CO2 concentration in wave form </li></ul></ul><ul><ul><li>- available systems </li></ul></ul><ul><ul><li>a. infrared analysis </li></ul></ul><ul><ul><li>b. mass spectrometry </li></ul></ul><ul><ul><li>c. Raman scattering </li></ul></ul><ul><ul><li>d. disposable colorimetric devices </li></ul></ul><ul><ul><li>e. semi-quantitive measurement on the end- tidal CO2 concentration </li></ul></ul>
  19. 21. <ul><ul><li>3. Pulse oximetry </li></ul></ul><ul><ul><li>- reliable, real time estimation of the arterial </li></ul></ul><ul><ul><li>Hgb saturation </li></ul></ul><ul><ul><li>- wide clinical acceptance </li></ul></ul>
  20. 23. <ul><li>4. Gastric Tonometry </li></ul><ul><li>- relatvely non-invasive monitor of adequacy of aerobic metabolism in organs whose superficial mucosal lining is extremely vulnerable to low flow changes and hypoxemia </li></ul>
  21. 24. <ul><li>III. Renal Monitoring </li></ul><ul><li>- the kidney is an excellent monitor of adequacy of perfusion </li></ul><ul><li>- prevention of renal failure </li></ul><ul><li>- predict drug clearance and proper dose adjustment </li></ul>
  22. 25. <ul><li>A. Urine Output </li></ul><ul><li>- commonly monitored but may be misleading </li></ul><ul><li>- normal urine output  0.5 ml/kg/hour </li></ul><ul><li>- correlates with glomerular filtration rate (GFR) </li></ul><ul><li>- high output may not accurately reflect GFR ex. Diabetes Insipidus </li></ul><ul><li>- may be affected by other factors </li></ul>
  23. 26. <ul><li>B. Glomerular Function Tests </li></ul><ul><li>1. Blood Urea Nitrogen (BUN) </li></ul><ul><li>a. affected by GFR and urea production </li></ul><ul><li>b. increased in TPN, GI bleeding, trauma, sepsis, steroid use </li></ul><ul><li>c. lowered in starvation, liver disease </li></ul><ul><li>d. not a reliable test </li></ul>
  24. 27. <ul><li>2. Plasma Creatinine </li></ul><ul><li>a. more accurate than BUN </li></ul><ul><li>b. directly proportional to creatinine production </li></ul><ul><li>c. inversely related to GFR </li></ul><ul><li>d. not affected by protein or nitrogen production or rate of fluid flow through tubules </li></ul><ul><li>e. related to muscle mass </li></ul>
  25. 28. <ul><li>3. Creatinine Clearance </li></ul><ul><li>a. used if values of plasma creatinine are affected by muscle disease </li></ul><ul><li>b. serial determination of urine is done and is currently the most reliable method of assessing GFR </li></ul>
  26. 29. <ul><li>C. Tubular Function Tests </li></ul><ul><li>1. The most reliable test to distinguish pre- renal azotemia from tubular necrosis </li></ul><ul><li>2. Requires simultaneous collected urine and blood samples </li></ul>
  27. 30. <ul><li>IV. Neurologic Monitoring </li></ul><ul><li>- early recognition of cerebral dysfunction </li></ul><ul><li>- facilitate prompt intervention and treatment </li></ul><ul><li>A. Intracranial Pressure Monitoring </li></ul><ul><li>1. Cerebral Perfusion Pressure - >70mmHg </li></ul><ul><li>2. Glasgow Coma Scale </li></ul>
  28. 31. <ul><li>B. Electrophysiologic Monitoring </li></ul><ul><li>- reflects spontaneous and on-going electrical activity in the brain </li></ul><ul><li>C. Transcranial Ultrasound </li></ul><ul><li>- monitors cerebral blood flow </li></ul><ul><li>- detects vasospasm </li></ul><ul><li>D. Jugular Venous Oximetry </li></ul><ul><li>- measures relationship of blood flow to O2 consumption </li></ul>
  29. 32. <ul><li>V. Metabolic Monitoring </li></ul><ul><li>A. Caloric Demands </li></ul><ul><li>B. Respiratory Quotient of Food </li></ul><ul><li>VI. Temperature Monitoring </li></ul><ul><li>A. Rectal </li></ul><ul><li>B. Middle Ear </li></ul><ul><li>C. Esophageal </li></ul>

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