7 - Respiratory Emergencies and Thoracic Trauma.pdf

Respiratory

Emergencies

and Thoracic

Trauma

Michael D. Gooch

RN, MSN, ACNP, FNP, CFRN, CEN, EMT-P

1

Objectives

Discuss priorities of the primary and

secondary assessment of patients

presenting to the emergency

department.

Describe basic principles of disaster

management.

Analyze the effectiveness of patient or

family education in a clinical scenario.

Discuss the basic principles of safe

interfacility transfer.

2

Objectives

Describe anticipated assessment findings of patients with selected respiratory, medical, cardiovascular, neurologic, toxicological, gastrointestinal, and genitourinary emergencies,

Plan and prioritize interventions of patients with selected respiratory, medical, cardiovascular, neurologic, toxicological, orthopedic, psychiatric or gastrointestinal emergencies.

3

Objectives

Select appropriate triage

categories for patients in clinical

scenarios.

Differentiate cardiogenic,

hypovolemic, and distributive

shock with regards to

assessment and management.

4

Things to Review

ABG interpretation

Basic life support

COPD/Emphysema

ARDS

Childhood respiratory emergencies

Chest trauma

Indications/contraindications of

common drugs used in respiratory

conditions

5

Basic Respiratory/Airway

Concepts

Assessment of work of

breathing & adventitious breath

sounds

Laryngeal Mask Airway (LMA)

Used for blind intubation

Confirmation of ETT placement

Measurement for pediatric ETT

placement

6


Concepts

Rapid Sequence Intubation (RSI)

Pre-med (to prevent bradycardia, dry secretions, suppress cough reflex, decrease ICP & muscle fasciculations)

Anesthetize / Sedate

Paralyze

Sellick maneuver for intubation

Cric or needle cricothyroidomy (jet insufflation)

For emergency airway 7


Concepts

Continuous positive airway pressure

CPAP delivers pressurized air during inspiration & expiration via mask

Bi-level positive airway pressure

Bi-PAP alters pressure, increasing during inspiration

Positive End Expiratory Pressure (PEEP)

Increases alveolar gas exchange

May cause atelectasis

8

Basic Intervention

Aside from administration of oxygen, an essential item of equipment for preserving airway integrity once the airway is established is:

A. An accurate flow meter.

B. A suction catheter.

C. An ET tube.

D. A laryngoscope.

9

Device flow and concentrations

Device Gas Flow FiO2Nasal cannula 1 6 L/min 24 % - 44%

Simple face mask 8 10 L/min 40% 60%

Venturi mask Varies by dial 24%, 28%, 35%, 40%

Non re-breathing

mask

8 15 L/min 60% 100%

10

Basic Intervention

A mother comes into the ED carrying her 12-month-old child, who has stridor and is cyanotic. The mother states that the child was eating a hotdog before her symptoms began. Initial intervention would include:

A. Opening the airway and try to remove the food.

B. Delivering five back blows and five chest thrusts.

C. Grabbing the child by the legs and turning her upside down.

D. Performing a needle cricothyrotomy with a 14-gauge needle.

Holleran, 2001

11

Physiology of Ventilation

Control of Ventilation

Lung Volumes and Capacities

Compliance

Ventilation and Perfusion Ratios

Breath Sounds

12


Ventilation

Movement of air in and out of the lungs

Occurs in two phases

Inspiration (Active)

Expiration (Passive)

13


Controls of Ventilation

Voluntary

Involuntary

Medulla sets basic pattern of

breathing (brainstem)

Located in Brainstem

Rhythmic stimulation of

intercostal muscles & diaphragm

14

Lung Volumes and

Capacities

Tidal volume Normal is 5-8ml/kg

Residual volume

Minute volume Normal 5-7L/min

Vital capacity Normal 4500-5000ml

Functional residual capacity Normal 2200-2400ml

Alveolar ventilation Volume that reaches alveoli and participates in gas exchange

Anatomic dead space Volume remaining in conducting airways

15

Factors Affecting

Ventilation

Elasticity

Ability of the lungs to collapse and

recoil

Compliance

Ease with which the lungs expand

Surfactant

Reduces alveolar surface tension

16

Factors Affecting

Ventilation

Airway Resistance

Force that must be overcome for air to move in and out

Increased with Cystic Fibrosis, Asthma Attack

Work of Breathing

Amount of oxygen consumed to move air

Decreased compliance with Pulmonary Edema

Increased airway resistance, Increased RR

17

Physiology of Perfusion

Normal Gas Exchange

Depends on:

Adequate Ventilation

Adequate Perfusion

Adequate Diffusion

HIGHER concentration to LOWER

concentration

V/Q Matching18

Breath Sounds

19

Non-invasive Ventilation

Methods

Continuous positive airway pressure

CPAP delivers pressurized air during inspiration & expiration via mask

Bi-level positive airway pressure

Bi-PAP alters pressure, increasing during inspiration

Positive End Expiratory Pressure (PEEP)

Pressure continues through the end of the patients exhalation

Increases alveolar gas exchange

May cause atelectasis

20

End Tidal CO2

Pulse oximetry reflects

oxygenation, End Tidal CO2reflects ventilation.

21

Asthma

Chronic reversible, obstructive disorder Airway inflammation

Increased airway responsiveness

Multiple immunologic and non-immunologic triggers

Onset typically occurs before age 10 > 30% diagnosed in childhood will have it as an adult

> 4000 deaths each year

22

Pathophysiology

Immune system releases

various chemical mediators in

response to a

trigger/precipitating factor

Mediators cause smooth

muscle contraction,

vasodilation, mucosal edema,

and increased mucus secretion

23

AsthmaAcute Clinical Manifestations

Dyspnea at rest

Diffuse wheezing

Both insp. & exp.

Prolonged expiration phase

Diminished breath sounds

Cough

Reduced peak flow

Increased work of breathing

Tachycardia

Hyperresonance

Diaphoresis

Restlessness

Low Sats

Hypoxemia on ABGs

24

AsthmaManagement

Supplemental oxygen

Provide humidification

IV access and fluids

Bronchodilators

Corticosteroids

Heliox and/or

Magnessium

Secretion clearance

Anticipate

ventilatory support

Pt/family education

26

P.Z. a 44-year-old asthmatic measures her

peak flow rate. Peak expiratory flow rate

should be

A. greater than 80% of predicted or personal best

B. less than 50% of predicted or personal best

C. about 20-30%

D. half of predicted or personal best

Question????

Measurement of peak expiratory flow rate is a useful tool in

the management of asthma because:

A. Rising values can indicate and impending

exacerbation of asthma

B. It helps clear airway passages of mucus plugs

C. Measurement does not rely on patient effort

D. In can document reversibility of airway narrowing

ENA, CEN Review Manual, 2001 28

Question????

A patient experiencing an acute asthma exacerbation

states that his routine medication includes the use of a

cromolyn (Intal) inhaler. This medication is given to

A. Relieve acute bronchospasm on an as-

needed basis

B. Block the release of chemical mediators

from mast cells

C. Inhibit cough receptors in the bronchial

lining

D. Block the uptake of calcium in the bronchial

smooth muscle


Question????

When you are teaching an asthma patient how to avoid

potential triggers of the disease, which of the following

should you be sure to discuss?

A. Avoidance of spicy foods can help to reduce

asthma attacks

B. Exacerbation of asthma can be reduced by

decreasing physical activity

C. Chronic postnasal drip can contribute to

recurrent asthma attacks

D. Most triggers of asthma can be avoided

ENA, CEN Review Manual, 2001

30

Question????

A patient presents to the ED with a chief complaint

of sore throat, stuffy nose, and a nonproductive

cough that keeps him awake at night. A workup

has been complete and his CXR is negative. You

suspect that this patient has:

A. COPD

B. Asthma

C. Acute bronchitis

D. Pneumonia


Acute Bronchitis

Assessment

Recent URI

Dry, hacky, cough

Nonproductive initially

Normal RR

Use of accessory muscles

Prolonged expiratory phase

Rhonchi, wet lung bases

Normal CXR32

Acute Bronchitis

Management

Rest

Humidification of air or supplemental

O2

Remove irritants

Increase PO fluid intake

Bronchodilators

Cough medications

33

Bronchiolitis

Assessment

Profuse secretions

Low-grade fever

Rhinorrhea

Cough

Poor feeding

Tachypnea

Tachycardia

Decreased sats

Signs of respiratory distress

Lethargy

34

Bronchiolitis

Management

Maintain ABCs

Pay close attention to infants

RSV culture

Oxygen therapy

Nebulizers for wheezing

Ribavirin for RSV

35

Question????

A 5-yr-old girl is brought to the ED by her family.

Her parents state that she has been febrile,

lethargic, and unable to lie down and has been

drooling. During the initial assessment of this

patient, the emergency nurse should do all of the

following except:

A. Assess the childs level of consciousness

B. Look down the childs throat

C. Assess the childs respiratory status

D. Assess the childs circulatory status

Holleran, 2001

36

Question????

A 21-year-old woman comes to the ED with a

chief complaint of persistent sore throat, high

fever, and inability to swallow. She is positioned

in the tripod position and appears anxious. You

suspect:

A. Croup

B. Epiglottitis

C. A foreign body aspiration

D. Pneumothorax

JEN, 28:2, 200237

Epiglottis

The initial care for a child who is suffering respiratory

distress from acute epiglottitis would include:

A. Administration of chloramphenicol

B. Administration of racemic epinephrine

C. Obtaining x-ray films of the childs neck

D. Preparing the child for intubation

Holleran, 2001 38

Epiglottitis

Holleran, 2001

The most common cause of epiglottitis is:

A. Streptococcus

B. Haemophilus influenzae

C. Staphylococcus

D. Pneumococcus

39

Epiglottitis

Causes

H. Influenzae

Staph

Strep

Laryngospasm possible upon visualization of epiglottis

Potential life-threatening condition characterized by edema of the epiglottis and epiglottic folds not extending below the vocal cords

40

Clinical Findings

Drooling

Acute/severe sore throat

Tripod or sniffing position

Dysphagia, dysphonia or aphonia

Inspiratory stridor, expiratory snore

Substernal or supraclavicular

retractions

Tenderness on palpation of the

anterior neck and hyoid bone

41

Thumb

Sign

Knoop, Stack, 2002 Atlas of Emergency Medicine42

Management

Decrease stress

Cool humidified oxygen

Have emergency surgical airway

equipment in room with patient

Antibiotics

Delay any diagnostic procedures

except lateral neck x-ray until

epiglottitis is ruled out or airway is

secured

43

Question????

A 4-yr-old child presents to the ED with a

barky cough, stridor, retractions, and

hypoxia. This child is most likely to have

A. Asthma

B. Croup

C. Pneumonia

D. Epiglottitis


Croup????

Upon assessment, the nurse would expect to

note which early signs of hypoxemia in this

patient?

A. Use of accessory muscles

and development of a resonant cough

B. Expiratory stridor and cyanosis

C. Lethargy and tachypnea

D. Restlessness and a rapidly increasing

heart rate

Vonfrolio, 1998

45

CroupManagement

The nurse knows that management of a child with

croup is primarily directed toward:

A. Maintaining the patients airway and

adequate respiratory exchange

B. Maintaining acid-base balance

C. Increasing the humidification of inspired

air

D. Liquefying respiratory secretions

Vonfrolio, 1998 46

CroupLaryngotracheobronchitis

Affects children 6 months - 4

years

Viral illness with slow onset (few

days)

Barky cough stridor low fever

Aerosolized (racemic)

epinephrine steroids cool air

mist

Must rule out epiglottitis

47

Normal X-Ray Steeple Sign

48

Pertussis

(Whooping Cough)

Acute, highly contagious bacterial infection

Bordetella pertussis ( gram negative cocci)

Infants & children up to 4 years

Peak incidence late summer & fall

7-10 day incubation (up to 21 days)

Airbornespread by coughing & sneezing 49

Pertussis

(Whooping Cough)

Severe, paroxysmal explosive coughing

Catarrhal stage: URI symptoms

Paroxysmal stage (2 4 weeks)

Apnea may occur in infants

Convalescent stage

Isolation

Erythromycin & palliative treatment

Patient education

51

Pneumonia

Acute infection of lung parenchyma

Impairs gas exchange

Pathogens may be bacterial, viral,

fungal, protozoan or others

Majority are viral

Bacterial cause majority of deaths

52

Pneumonia

Assessment

Dyspnea

Productive cough

Pleuritic chest pain

Fever/chills

Tachypnea

Dullness on percussion

Coarse crackles

Bronchial breath sounds

over affected lobe

Tachycardia53

Pneumonia

Management CXR

Sputum gram stain & C&S

Blood cultures

Position to facilitate breathing

Humidified oxygen

Secretion removal

Administer abx

Prepare for ventilatory support

Monitor for dysrhythmias 54

Indications for

Hospitalization

PaO2 < 65mmHg, SaO2 < 92%,

PaCO2 > 40mmHg

Patients unable to take

adequate fluids

Patients in a debilitated state,

exhaustion

Significant effusion on CXR

Suspicion of PCP

55

Question????

An obese 36-yr-old female present to your ED with sudden

onset of left-sided chest pain and shortness of breath. She

is diaphoretic, pale and in acute respiratory distress. She

denies any trauma, fever, n/v. Past medical history is

unremarkable except that she was placed on BCP 6 months

ago. Initial vital signs are BP 100/60, HR 120, RR 36/min,

and O2 saturations 92%. Based on your assessment, you

suspect the patient has:

A. Pericarditis

B. Acute coronary syndrome

C. Pulmonary embolus

D. Viral pneumonia56

Pulmonary Embolus

Risk factors

Virchows triad Hypercoagulability

Vessel injury

Venous stasis

Immobilization

Smoker

Oral BCP

Lung Bone Fractures

57

Pulmonary Embolus

Manifestations

Tachypnea

Tachycardia

Dyspnea

Anxiety

Chest pain

Cough

Right sided S2

Hemodynamic

instability

Hypotension

Shock

Signs of Rt

ventricular

failure

58

Hypoxic vasoconstriction

Decreased surfactant

Release of neurohumural mediators

Pulmonary edema

Atelectasis

Venous Stasis

Vessel Injury

Hypercoagulability

Thrombus Formation

Dislodgement of portion of thrombus

Tachypnea, Dyspnea, Hypoxemia,

Dead space, V/Q imbalances, Shock

Occlusion of part of pulmonary circulation

59

Pulmonary Embolus

Dx and Management

ABGs

Decreased PaO2, SaO2,

and SvO2

Respiratory alkalosis

D-dimers

Atrial dysrhythmias

New RBBB

CXRleast beneficial

V/Q scan

Angiography

Prevent embolus formation

ABCs

High-flow oxygen

Cardiopulmonary support

Baseline clotting profiles

Thrombolytic therapy

Heparin

LMWH

Oral anticoagulation

60

Pulmonary Embolus

When the nurse dorsiflexes the patients foot, the

patient complains of calf pain. The nurse correctly

interprets this response as an indication of a positive:

A. Trousseaus sign

B. Homans sign

C. Kehrs sign

D. Babinskis reflex

Vonfrolio, 1998

61

Atelectasis

When assessing breath sounds in a patient with

atelectasis, the nurse would expect to hear bronchial

breath sounds over the:

A. Carina

B. Middle of the right lung lobe

C. Right main-stem bronchus

D. Left main-stem bronchus

Vonfrolio, 199862

Pleural Effusion

Physical examination of a patient diagnosed

with a pleural effusion will reveal:

a) Increased tactile fremitus

b) Resonance upon percussion

c) Tracheal deviation toward the affected

side

d) Decreased or absent breath sounds

(JEN, 31:3, 2005)

63

Pleural Effusion

Fluid collection in the pleural space

Blood - hemothorax

Chyle - chylothorax

Serous serous effusion

Purulent empyema

64

S/S

Cough

Dyspnea

Use of accessory muscles

Fever

Increased fremitus above effusion, absent fremitus over effusion

Dullness to percussion

Lethargy/malaise

Treatment

Thorocentesis

Chest tube

Oxygen

Possible antibiotics

65

Cor Pulmonale

Alteration in the structure and

function of the right ventricle due to

a primary disorder of the respiratory

system

Pulmonary vasoconstriction

Primary lung disorders that

compromise the pulmonary

vascular bed (i.e. emphysema,

pulmonary embolism)

Idiopathic primary pulmonary

hypertension 66

Clinical Manifestations

Split 2nd heart sound

Right ventricular

failure

Distended neck veins

Right ventricular 3rd

heart sound

Peripheral edema

Treatment

Treat underlying

disorder

Avoid Fluid loading

Vasopressors

Oxygen

Vasodilators

67

Question????

A 52-yr-old male presents to the ED with complaints of

shortness of breath. He is unable to speak in complete

sentences. He reports a chronic cough with thick sputum.

He has smoked 1 packs of cigarettes for over 25 years.

On physical exam, he has scattered rhonchi and expiratory

wheezes, peripheral edema, and distended neck veins. The

history and clinical findings are consistent with a diagnosis

of:

A. Pneumonia C. Chronic bronchitis

B. Pulmonary edema D. Asthma

68

Emphysema

Disorder of impeded expiration

caused by:

Permanent over-distention of

alveoli

Loss of elastic recoil of the lungs

(compliance)

Increased dead space and

decreased functional lung tissue

69

Chronic Bronchitis

Inflammation of bronchi

Increased mucus production

Chronic cough

Chronic irritation

Loss of cilia

Peripheral mucus plugging

Airway collapse with air trapping

Chronic hypoxemia with hypercapnia

70

Clinical Presentation

Dyspnea on exertion progressing to

dyspnea at rest

Crackles, rhonchi, expiratory wheezes

Inability to speak in complete sentences

Pulsus paradoxus

Hypoxemia and hypercarbia on ABGs

Barrel chest appearance

Labs polycythemia, increased WBC,

eosinophilia, decreased alpha-antitrypsin

enzyme is indicative of emphysema

71

Chronic Bronchitis Management

72

Discharge Teaching

Exercise

Cough and deep breathing

Adequate hydration

Medication education

Pursed lip breathing or

diaphragmatic breathing

Immunizations

73

Emphysema

Patient teaching for a patient with emphysema should

include:

A. The importance of being vaccinated each year

against pneumococcal disease.

B. the need for prophylactic antibiotic therapy

when a family member is ill.

C. The need for adequate hydration to reduce

mucus tenacity

D. The importance of smoking cessation to

reverse structural damage caused by the

disease


74

Rib/Sternal Fractures

Associated with blunt trauma

Results in decreased minute

ventilation

splinting from pain

pulmonary shunting from atelectasis

and hypoxia

Must consider concomitant injuries

1st rib fractures seen with injuries to

subclavian artery and aortic rupture

Lower rib fractures associated with

spleen or liver injuries75


Assessment

Chest wall pain

Aggravated with deep breathing &

coughing

Point tenderness

Subcutaneous emphysema

Hypoventilation

Shallow respirations

76


Management

Monitor respiratory status

Analgesics

Cough & deep breathe

Incentive spirometry

Complications

Pneumothorax

Hemothorax77

Flail Chest

Fracture of two or more ribs in two

or more places

Costochondral separation

Sternal fracture

Results in free-floating segment

and paradoxical chest wall

movement

78

Flail Chest Assessment

Rapid labored breathing

Hyperventilation (early)

Paradoxical chest wall movement

Crepitus of chest wall

Diaphoresis

Pain

Dyspnea

Hypoxia

Diminished breath sounds

Respiratory failure

79

Flail Chest Management

ABCs

May require intubation

High flow O2 Stabilize chest wall

Turn on affected side

IV access/fluid resuscitation

Pain management

Monitor ABGs

Anticipate need for thorcostomy

Continuous monitoring of respiratory status 80

Pneumothorax

A 30-yr-old man has attempted suicide by shooting

himself in the left upper chest. On arrival to the ED,

the patient is alert, complaining of shortness of

breath, and is pale and diaphoretic. His vital signs

are BP 80/palpation, HR 140, RR 32/min. The

emergency nurse needs to assess quickly for the

presence of:

A. Breath sounds

B. Peripheral edema

C. Capillary refill

D. Altered mental statusHolleran, 2001 81

Pneumothorax Accumulation of air in pleural space

creating loss or collapse of the lung

Loss of intrapulmonary/intrapleural

subatmospheric pressure

Elastic recoil leads to collapse

Decreased area for

ventilation/perfusion

Hypoxemia

82

Pneumothorax

Results from blunt or penetrating trauma May be spontaneous

May be closed, open and can become tension ptx

Clinical manifestations Dyspnea, tachypnea, tachycardia,

Decreased or absent breath sounds on affected side

Subcutaneous emphysema +/-

Management Chest Tube

83

Pneumothorax

No breath sounds are auscultated on the left side.

The patients respiratory distress increases and he

becomes agitated. Until a physician is available, a

critical intervention the emergency nurse may

perform is

A. Obtain central line access

B. Perform a needle thorocotomy

C. Place the patient on a pulse oximeter

D. Obtain an emergent chest radiograph

Holleran, 2001

84

Question????

The correct location to perform a needle

thoracentesis is:

A. Unaffected side, third intercostal space at

the midclavicular line

B. Affected side, fifth intercostal space, at

the anterior axillary line

C. Unaffected side, second intercostal

space, midclavicular line

D. Affected side, second intercostal space,

midclavicular line 85

Pneumothorax

After the emergency nurse performs the needle

thorocostomy, evaluation of the effectiveness of this

procedure would include all of the following except:

A. A rush of air after insertion of the needle

B. Improvement in the patients blood pressure

C. A dramatic increase in the patients

shortness of breath

D. Decrease in the patients shortness of

breathHolleran, 2001 86

Chest Tube Management

A chest tube is inserted into the patients chest by the emergency

physician. The tube is connected to a water-seal bottle that has

a moderate air and fluid leak seen on expiration. When the

patient is taken to the radiology department, the bottle is

accidentally broken. Which nursing action should be taken?

A. Remove the chest tube immediately to prevent

aspiration of glass particles

B. Apply a clamp to the chest tube near the insertion site

and instruct the patient to exhale deeply

C. Pinch the chest tube, place the end of the tube in a

bottle of sterile saline or water and encourage

the patient to cough and breathe deeply

D. Use the phone in radiology to order a new bottle an

and do not manipulate the chest tube 87

Hemothorax


Dyspnea, chest pain

Dullness on percussion

Decreased or absent BS

Hypoxia

Respiratory distress

Signs of shock

Management

Chest tube insertion

Autotransfusion

Thoracotomy

Fluid resuscitation

Blood product transfusion

88

Question????

An unrestrained female driver is brought to the ED by

EMS. Paramedics report she was driving an old car

without airbags and that the steering wheel was bent. The

patient is awake and alert. She is pale and anxious with

labored respirations. She states that another driver cut

her off at an intersection. You note paradoxical chest wall

movement and suspect a flail chest. Which of the

following would be your primary concern for this patient?

A. Pulmonary contusion

B. Deep vein thrombosis

C. Facial lacerations

D. Concurrent thoracic vertebral fracture89

Pulmonary Contusion

Bruising to the lung parenchyma

resulting in hemorrhage into eh alveoli

and small airways

Airway collapse, loss of ventilation

and pulmonary shunting

Classic symptom is progressive

dyspnea and hypoxemia

Treat with supplemental O2,

supportive ventilatory management,

and pain management for frequently

associated rib fractures 90

Question????

A victim of a stab wound to the epigastric area

presents to the ED. Upon evaluation, he suddenly

develops shortness of breath, chest pain and

decreased breath sounds. You suspect:

A. Diaphragmatic tear

B. Myocardial contusion

C. Flail chest

D. Rib fractures

ENA, CEN Review manual, 2001

91

Pathophysiology of ARDS

Smeltzer, Bare, Hinkle & Cheever. 2008. Brunner & Suddarths Textbook of Medical-Surgical Nursing 11th edition

92

ARDS


Rapid shallow breathing

Dyspnea

Respiratory alkalosis

Decreased lung compliance

Refractory hypoxemia

Progressive metabolic acidosis

Diffuse alveolar infiltrates on CXR 93

Management

Ventilatory support

Mechanical ventilation

PEEP

Increases FRC and decreases dead space (recruits alveoli)

Sedation

Careful Fluid Management

Proning/Rotation Therapy94

ABGs

Condition pH PCO2 HCO3

Respiratory

Acidosis

normal

Respiratory

Alkalosis

normal

Metabolic Acidosis normal

Metabolic Alkalosis normal

95

ABGs Normal Values

Variable Normal Value

pH 7.35-7.45

PaO2 80-100

PaCO2 35-45

HCO3 22-26

BE + 2 -2

96

ABG Interpretation

pH 7.35 (< acidosis) 7.45 (> alkalosis)

CO2 35 (< alkalosis) 45 (> acidosis)

HCO3 22 ( alkalosis)

Compensation is based on the pH:

If the pH is 7.35-7.45 and the other

values are abnormal, then the patient is

considered compensated

97

Steps to Determine

Step One: Look at the pH

If the pH is > 7.45 go to step 2 (pt is

alkaloid)

If the pH is < 7.35 go to step 3 (pt is

acidosis)

Step Twowhen the pH is elevated

pCO2 < 40mmHg alkalosis is

respiratory origin

pCO2 > 40mmHg or normal, alkalosis is

metabolic origin, go to step 4

98

Steps to Determine

Step Threewhen the pH is decreased

pCO2 > 40mmHg, acidosis is

respiratory

pCO2 < 40mmHg or normal, acidosis is

metabolic, go to step 4

Step Four

pH and bicarbonate are both

decreased= metabolic acidosis

pH and bicarbonate are both elevated=

metabolic alkalosis

99

Question????

A 78-yr-old male is brought to the ED from home with

complaints of fever, tachycardia and tachypnea.

His ABGs reveal pH 7.01; PO2 125mmHg; PCO242mmHg; HCO3 10mEq/liter.

The correct interpretation of these ABGs is:

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis100

Question????

A patient has been in cardiopulmonary arrest for

approximately 15 minutes with ongoing resuscitative

efforts. His ABGs reveal:

pH 7.15; PO2, 50mmHg; PCO2, 68mmHg;

HCO3, 18mEq/liter

You interpret this as:

A. Fully compensated respiratory acidosis

B. Fully compensated metabolic acidosis

C. Partially compensated respiratory alkalosis

D. Mixed metabolic and respiratory acidosis101

Question????

Interpret the following ABGs:

pH 7.60; PO2 , 140mmHg; PCO2, 15mmHg;

HCO3, 22mEq/liter

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis

102

Question????

An anxious, panic-stricken patient arrives in the ED

with a chief complaint of dyspnea, rapid respiration and

periorbital edema. All serious causes for this breathing

pattern are eliminated and the patient is diagnosed with

hyperventilation. Which of the following findings do you

anticipate?

A. Respiratory Alkalosis

B. Dehydration

C. Stroke

D. Metabolic acidosisENA, CEN Review Manual, 2001

103

Question????

Factors that may limit the usefulness of a pulse

oximeter include:

A. Limited ambient light

B. Carbon monoxide poisoning

C. Normovolemia

D. Limited patient movement

104

Question????

Respiratory syncytial virus (RSV) not transmitted

by:

A. Large droplet aerosols

B. Sneezing

C. Visitors

D. Hand washing

105

Question????

A 67-yr-old female is brought to the ED in respiratory

distress. She is given supplemental oxygen via NRB.

Her vital signs are BP 158/84, HR 108, RR 28 and

labored. A stat CXR is performed and the physician

orders nitroglycerin and lasix. The goal of this therapy

is to:

A. Increase preload and increase afterload

B. Decrease preload and increase afterload

C. Increase preload and decrease afterload

D. Decrease preload and decrease afterload

106

References

Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J. (2008). Primary care a collaborative approach (3rd ed.). St. Louis: Mosby Elsevier.

Crain, E. F., & Gershel, J. C. (2003). Clinical manual of emergency pediatrics(4th ed.). New York: McGraw-Hill.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2003). Advanced health assessment and clinical diagnosis (2nd ed.). St. Louis: Mosby.

Danis, D. M. , Blansfield, J. S., & Gervasini, A. A. (2007). Handbook of clinical trauma care: the first hour (4th ed.). St. Louis: Mosby Elsevier.

108

References Diaz, S. E. (2006). The little black book of emergency medicine (2nd

ed.). Boston: Jones and Bartlett.

Edmunds, M. W. & Mayhew, M. S. (2004). Pharmacology for the primary care provider (2nd ed.). St Louis: Elsevier Mosby.

Field, J. M. (2006). Advanced cardiac life support. Dallas: American Heart Association.

Guyton, A. C. & Hall, J. E. (2000). Textbook of medical physiology(10th ed.). Philadelphia: W. B. Saunders. 109

References

Hawkins, H. S. (2004). Emergency nursing

pediatric course (3rd ed.). Des Plaines, IL:

Emergency Nursing Association.

Hay, W. W., Levin, M. J., Sondheimer, J. M.,

& Deterding, R. R. (2003). Current diagnosis

and treatment in pediatrics (18th ed.). New

York: McGraw Hill.

Hazinski, M. F. (2006). Basic life support for

healthcare provider. Dallas: American Heart

Association.

Holleran, R. S. (2005). Emergency and

transport nursing examination review (4th

ed.). St. Louis: Elsevier Mosby.110

References

Howard, P. K. & Steinman, R. A. (2010). Sheehys Emergency Nursing Principles and Practice (6th ed.). St. Louis: Mosby.

Hoyt, K. S. & Selfridge-Thomas, J. (2007). Emergency nursing core curriculum (6th ed.). St. Louis: Saunders Elsevier.

Karch, A. M. (2003). Nursing drug guide. Philadelphia: Lippincott.

Ma, O. J., Cline, D. M., Tintinalli, J. E., Kelen, G. D., & Stapczynski, J. S. (2004). Emergency medicine manual (6th ed.). New York: McGraw-Hill.

111

References

McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis for disease in adults and children (5th ed.). St. Louis: Mosby.

Trott, A. T. (2005). Wounds and lacerations (3rd ed.). St. Louis: Elsevier Mosby.

Pagana, K. D. & Pagana, T. J. (2009). Diagnostic and laboratory test reference (9th ed.). St. Louis: Mosby.

Ralston, Mark. (2006). Pediatric advanced life support. Dallas: American Heart Association.

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