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CARING FOR CRITICALLY ILL PATIENT

Role of a Critical Care Nurse


Provide care direct to the patient.
Involve family members in patients care.
Facilitate communication among healthcare
provider, patient, and family.
Provide appropriate intervention & actions.
Formulate patient care goals.
Ensure patient safety:
Identify patient correctly
Improve communication among staffs.
Use medication safely.
Prevent infection.
Identify patient safety risks
Prevent mistakes in surgery.

ETHICAL & LEGAL ISSUES

Autonomy
Freedom to make decision without others
interference.
Critical care nurse act as patient advocate
before patient and family make decision:
Provide information
Clarify points
Reinforce information
Provide support

Beneficence
Promote wellbeing by considering harms and
benefits, leading to positive outcome.

Non-maleficence
Prevent harm and correct harmful situation.

Veracity
Truth telling in information given.
Important in requesting informed consent
because patient need to be aware about the
risks and benefits.

Fidelity
Requires loyalty, fairness, truthfulness,
advocacy, and dedication

Justice
Refers to an equal and fair distribution of
resources, based on analysis of benefits and
burdens of decision.

Elements in Code of Ethics
The professional code of ethics
Values and relationship among members of the
profession and society.
The purpose of the profession
The need of profession to provide certain
duties formed between nursing and society
The standards of practice of the professional
Describe specifics of practice in variety of
settings and subspecialties.

Steps in ethical decision making
- Identify the health problem
- Define the ethical issue
- Gather additional information
- Outline the decision maker
- Examine ethical & moral principles
- Explore alternative options
- Implement decisions
- Evaluate & modify actions
Legal Relationships Nurses duty
Nurse-employer Competent & able to
follow policies and
procedures.
Nurse-patient Give reasonable and
careful care
Nurse-law Provide safe and
competent practice as
defined by the standard

Patient Care Issues
Consent must be voluntary and informed
Person giving consent must be:
Legally competent
Adult
Mentally stable
Have capacity (reasoning)
Patient can refuse treatment.
If patient is not for resuscitation, DNR order
should be documented by doctor.
The doctor should explain everything to the
patient about diagnosis and treatment.

PATIENT & FAMILY EDUCATION

Nurses responsibility
Assess patient & family learning needs.
Education must be ongoing, interactive, and
consistent with the education level.
Reduce stress, anxiety, and fear first.
Focus on orientation of environment &
equipment, procedure explanation, and
immediate plan of care.
Ensure patient is emotionally stable.

Learning Needs
Orientation of various care providers &
services available.
Orientation on environment (eg: call bell)
Orientation on unit rutines and care plan
(visiting hour, monitoring, daily weight)
Explanation on equipments, monitors &
associates alarms (eg: ventilator)
Explanation on procedures & expected
outcomes.
Information on medication (name, indication,
side effects) and reporting to nurse.
Immediate plan of care
Transition to next level of care: transferring,
staffs, environment
Discharge plan (medication, diet, activity)

Successful Education
- Attention
The information must be important to know.
- Simple
Use everyday language & avoid medical terms
- Time
Be present when teaching.
- Reinforce
Provide positive rewards to patient.

Special Consideration for:
1. Older adult
2. Sedated or unconscious patient
3. Illiterate patient
4. Noncompliant patient
MYOCARDIAL INFARCTION (MI)

Definition:
Irreversible myocardial necrosis due to sudden
decrease or total stop of coronary blood flow to a
specific area of myocardium.

Pathophysiology


Clinical Manifestation
Chest pain squeezing in nature radiating to
left arm, jaw or upper back
Shortness of breath Nausea & vomiting
Heartburn Sweating
General malaise STEMI/ NSTEMI

Risk Factors
Hyperlipidemia Diabetes
Smoking Male
Family history Obesity

Types of MI



Cholesterol deposited on
artery wall forming plagues
and causes it to harden and
narrows the lumen.
The plagues may rupture and
blood clot form on the surface of
the plague.
The clot blocks the blood
flow and causes MI.
Oxygen delivery is affected and cause
due to the thrombosis or spasm close
to the rupture plague
Anterior MI
Occlusion of proximal left anterior
descending artery
ST-elevation in lead V1-V4
Most dangerous MI
Left Lateral MI
Occlusion of circumflex coronary artery
New Q waves & ST-elevation in leads I, aVL.
V5, V6
Inferior MI
Occlusion of right coronary artery
Distiurb blood supply to SA & AV nodes,
and Bundle of His (proximal part)
High mortality if Rt ventricle affected.
Right Ventricular MI
Occlusion of the proximal part of Rt
coronary artery
Can affect right ventricle and inferior wall
Posterior MI
Occlusion in Rt coronary artery or
circumflex artery
Tall R waves can be seen in leads V1, V2
Diagnostic Test
I. 12-lead ECG
ST-segment (elevated/ not elevated)
If NSTEMI, necrosis is not full thickness
Q wave present
II. Cardiac enzyme or biomarkers
CK-MB (rise 3-12 hrs, peak at 24 hrs,
remain elevated for 2-3 days)
Trop-I (rise 3-12 hrs, peak at 24 hrs, remain
elevated for 2-3 days)
Trop-T (rise 3-12 hrs, peak at 12-48 hrs,
remain elevated 5-14 days)
III. Chest X-ray

Treatment
a) Reopening of the coronary artery
-Fibrinolytic therapy
-Percutaneous Catheter Intervention (PCI)
b) Anticoagulation
-IV Heparin bolus with fibrinolytic therapy
c) Pain control
-SL Nitroglycerin 1 tab (0.04mg) every 5 mins
-IV Morphine 2-4mg
-Non-coated Aspirin 162-325mg
-Oxygen therapy maintain >90%
d) Dysrhythmias prevention
-IV Amiodarone
-Beta blocker reduce heart rate
e) Glucose control
f) Prevention of ventricular remodelling
-ACE inhibitor/ ARB reduce risk of heart failure

Complications of MI
^ Related to electrical dysfunction
New murmur
Bradycardia
Bundle branch block
Heart block
^ Related to contractility
Heart failure
Pulmonary edema
Cardiogenic shock

Nursing Management
Preventing complication
-Manage and alleviate chest pain
-Assess and reduce anxiety
-Monitor lab result (esp. K and Mg to prevent
arrhythmia)
-Monitor ST-segment continuously
-Monitor signs of arrhythmia
-Monitor arterial oxygen saturation
-Create plan for patients physical activity
-Assess signs of heart failure (pedal edema)
-Assess heart sound for new murmur.
-Monitor patient for drug compliance
-Give stool softener to prevent straining.
Patient education
-Eat variety of fruit and veggies, limit amount
of fat & reduce salt intake.
-Stop smoking
-Do simple, regular exercise 20-30 mins a day
-Explain the medication
-Reduce anxiety by deep breathing.
-Avoid sex for a few weeks. Consult the doctor.
Cardiac rehabilitation
Phase I (admission till discharge)-inapatient
Self care, exercise, diet, smoking
Phase II (After discharge and last for 4-8 weeks)
Level of activity, psychological, modify risk
factors, and return to work.
Phase III (Maintenance)- Follow-up.
CORONARY ARTERY DISEASE (CAD)

Definition:
Hardening of the coronary arteries, this may
cause angina pectoris and lead to myocardial
infarction.

Clinical manifestation
Chest pain/discomfort at arms, jaw, neck
Shortness of breath Lightheaded
Sweating Nausea and vomiting

Risk Factors
Middle to old age Male
Family history Hyperlipidemia
Obesity Hypertension
Smoking Diabetes
Chronic Kidney disease Post-menopause


Types of angina
Stable Angina Unstable Angina
Cause by the same
precipitating
factors each time
(eg: exercise)
Pain reduce by rest
and taking S/L GTN


Due to 75 blockage
of coronary artery.

Cause by change in
pattern of stable
angina

Pain need more
than rest & GTN. A
medical
emergency
Due to plague
instability & can
cause MI


Management:
g Accurate assessment of chest pain to
differentiate unstable & stable angina.
g Recognize myocardial ischemia by intensity of
pain, vital signs, 12-lead ECG, and immediate
fibrinolytic & heparin administered or PCI are
performed to detect obstruction.
g Relieve chest pain by giving oxygen,
nitroglycerin, analgesics, and aspirin.
g Maintain calm environment to reduce anxiety
g Patient education:
-Alert nurse for any chest pain or discomfort
-Avoid straining
-Risk factor modification
-Identify signs & symptoms of angina
-Importance of medication
-When to call doctors/seek treatment
-Emotion & stress management

HEART FAILURE

Definition:
A condition in which the heart cannot pump
blood at a volume required to meet the bodys
needs.

Classification (based on symptoms & pts effort)
Class I Normal daily activity does not
initiate symptoms.
Class II Normal daily activity initiate
symptoms, bit subside with rest.
Class III Minimal activity initiate symptoms.
No symptoms at rest.
Class IV Any activity initiates symptoms
and also present at rest.
Types of Heart Failure

Management:
Medical
Pulmonary Artery Catheter (PAC) to monitor
left ventricle function
Administer diuretics & fluid restriction to
prevent fluid overload.
Serve Morphine to reduce anxiety &
facilitate peripheral dilatation
Serve vasodilator (nitroglycerin) to reduce
preload & dilate coronary arteries.
Intra-aortic Balloon Pump (IABP) to support
inadequate CO and blood pressure.
Administer inotropic (dopamine) to increase
contractility.
Administer ACEi to inhibit ventricular
remodelling slows ventricular dilation.
Administer Beta blocker (carvedilol) to
reduce heart rate
Serve Digoxin to control Atrial Fibrillation
Permanent pacemaker

Nursing
Optimizing cardiopulmonary function
-Assess ECG for dysrhythmia due to Digoxin
toxicity and electrolyte imbalance.
-Assess respiration pattern & rate for
pulmonary congestion
-Give oxygen if dyspnea
-Administer diuretic or vasodilator to reduce
preload and afterload
-Serve Morphine to decrease anxiety
-Assist in intubation & mechanical
Ventilation
-Daily weight in fluid management.

Left Ventricular Failure (LVF)
Disturbance of contractility of left ventricle
Results in low CO, increase afterload &
vascular resistance, and pulmonary edema
Symptoms: Tachypnea, tachycardia, cough
Right Ventricular Failure (RVF)
Disturbance of contractility of right
ventricle
Due to acute condition like pulmonary
embolus and right ventricle infarction.
Symptoms: Peripheral edema, high CVP,
weakness, jugular venous distention
Systolic Heart Failure
Abnormality of heart muscle that decrease
contractility during systolic & reduse
quantity of blood that can be pumped out.
Symptoms: Dysnea, fluid overload,
exercise intolerance.
Diastolic Heart Failure
Abnormality in heart muscle making it
unable to rest, stretch or fill during
diastolic.
Ejection fraction may be normal or low.
Congestive Heart Failure
Determined by rapidity of syndrome
develops, presents of compensatory
mechanism & presence of fluid
accumulation.
In acute, it is sudden onset with no
compensatory mechanism.
In chronic HF, symptoms may be tolerable
with medication, diet & activity level.
Promote comfort and emotional support
-Restrict activity and assist ADL during SOB
-Put patient on bed rest
-Prop up the bed for maximal lung expansion
-Document signs of activity intolerance such
as dysnea, fatigue & tachycardia.
Monitor effects of pharmacological therapy
-Know the action, side effect & toxic level
-Monitor hemodynamic status closely
-Document correctly intake & output
Provide adequate nutritional intake
-Monitor closely for nausea & low appetite
-Encourage small, frequent meal
-Advice family members to provide tasty food
from home which compatible with condition.
Provide patient education
-Assess understanding of the disease & risk
factors of heart failure.
-Educate the importance of diet restriction
-Educate importance of daily weight, fluid
restriction & medication to control symptom
-Educate importance of lifestyle changes like
smoking, weight loss & exercise
-Inform when to call or seek treatment

VALVULAR HEART DISEASE

Definition:
Several disorders and diseases of the heart
valves, which are the tissue flaps that regulate
the flow of blood through the chambers of the
heart.

Mitral Valve Stenosis

Definition:
Narrowing of mitral valve orifice (<2cm
2
). The
thickened, calcified valve cannot open or close
passively, obstructing flow of blood from left
atrium to left ventricle.

Clinical Manifestation
Dyspnea Fatigue
Chest pain Atrial Fibrillation

Diagnostic test:
I. Chest X-ray: Pulmonary congestion,
enlargement of main arteries & Lt atrium.
II. ECG: Atrial fibrillation
III. ECHO: Valve leaflet thickening & restricted
opening
IV. Cardiac catheterization

Treatment:
Diuretics & sodium restriction
Anti-arrhythmia to treat atrial fibrillation
Anticoagulant to prevent thromboembolism
Beta blockers/CCB/digoxin to control HR
Antibiotic for prophylaxis of rheumatic fever
Percutaneous Balloon Vulvotomy
Mitral commissurotomy
Mitral valve replacement

Mitral Valve Regurgitation

Definition:
Backflow of blood in left atrium with each
ventricular contraction due to rupture of chordae
tendinae/ papillary muscle (emergency) or
dilatation of left atrium to maintain CO.
Clinical Manifestation:
Dyspnea Fatigue
Palpitation Orthopnea
Paroxysmal nocturnal
dyspnea
Pulmonary venous
hypertension

Diagnostic test:
I. Chest X-ray: Left atrial enlargement and
cardiomegaly
II. ECHO

Treatment
Acute Chronic
IV Nitropruside to
reduce afterload
IV Nitroglycerin to
reduce pulmonary
pressures
IABP to stabilize
vital signs
Mitral valve repair/
replacement
Medication to delay
surgery or
preventing left
ventricular
dysfunction
Assess ventricular
size, function &
severity every 6-12
month by ECHO.

Aortic Valve Stenosis

Definition:
Narrowing of aortic valve orifice which impedes
the blood flow from heart to body.

Diagnostic test:
I. ECG: Abnormal pattern reflecting thickening
of heart muscle
II. Chest X-ray: Dilation of aorta above the valve
III. ECHO: Diagnose & evaluate the severity

Treatment:
- Restriction from activity
- 6-12 month evaluation by ECHO to indicate
aortic valve replacement.
- Antibiotic prophylaxis given to avoid
endocarditis.
- Diuretics

Aortic Valve Regurgitation

Definition:
Backflow of blood into the left ventricle during
ventricular diastole.

Treatment:
Aortic valve replacement

Tricuspid Valve Stenosis

Definition:
Narrowing of the tricuspid valve orifice results in
increase pressure in right ventricle.

Diagnostic test:
I. ECG: Tall P wave in sinus rhythm
II. ECHO: To identify the presence & severity.

Treatment:
Sodium restriction
Diuretics
Tricuspid Valve Replacement


Tricuspid Valve Regurgitation

Definition:
Backflow of blood from right ventricle into right
atrium during systole.

Diagnostic test:
I. ECG: Incomplete right BBB
II. Chest X-ray: Cardiomegaly
III. ECHO: Identify the presence & severity

Treatment:
Tricuspid valve annuloplasty
Tricuspid valve replacement.

Pulmonic Valve Disease

Definition:
Stenosis- Narrowing of the pulmonic valve orifice
Regurgitation- Backflow of blood from pulmonary
artery into the right ventricle

Diagnostic test:
I. ECG: Incomplete right BBB
II. Chest X-ray: Prominent pulmonary artery
III. ECHO: Identify right ventricular hypertrophy
IV. Catheterization: Comfirm the diagnosis

CARDIOMYOPATHY

Definition:
A disease of heart muscle & associated with
ventricular dysfunction.

Hypertropic Obstructive Cardiomyopathy

Definition:
Excessive myocardial hypertrophy which the
heart able to contract but unable to relax and
remain stiff in diastole.

Clinical manifestation:
Supraventricular
tachycardia (SVT)
Ventricular
Tachycardia (VT)
Syncope Shortness of breath
Fatigue Atrial Fibrillation

Diagnostic test:
1. Physical examination
2. Chest X-ray
3. ECHO
4. Genetic testing

Treatment:
Beta blockers to reduce heart rate
Anti-arrhythmia
Anti-coagulant
Activity restriction to reduce sudden death
Implantable cardioverter defibrillator
Myectomy to improve blood flow from heart.

Dilated Cardiomyopathy

Definition:
Characterized as dilation of both ventricles
without muscle hypertrophy.

Types:
Ischemic Repeated MI/ myocardial injury
Familial Idiopathic /genetic



Clinical Manifestation:
Low cardiac output Dyspnea
Fatigue Orthopnea
Liver enlargement Syncope

Restrictive Cardiomyopathy

Definition:
Characterized as ventricular wall rigidity due to
myocardium scarring.

Clinical manifestation:
Shortness of Breath Edema
Palpitation Disrhythmia

Diagnostic test:
+ Physical examination
+ ECG
+ ECHO
+ MRI

Treatment:
Diuretics
ACE inhibitor
Exercise restriction

SHOCK

Definition:
A serious, life threatening medical condition
where there is insufficient blood flow to meet
tissues demand.

Stages of shock

Monitoring:
Non invasive Invasive
Consciousness level
Vital signs
Oxygenation
Infection signs
Urine output
Skin turgor
Peripheral perfusion
CO- Arterial line/ CVP
Ventilator
Urine output
Arterial Blood Gases
Blood results
ECHO/ TOE

Treatment:
Restoring blood volume and ensure
oxygenation and blood pressure adequate.
-Normal Saline
-Hartmann Solution Crystalloids
-Dextrose solution
-Albumin
-Polygeline
-Gelatin
-Hetastarch
-Blood products
Airway managed & initiate oxygen therapy
Vasopressant to induce vasoconstriction
Use anti-shock trousers to concentrate blood
in vital organs (lungs, brain, heart)
Keep patient warm
Antibiotics to prevent sepsis
Adrenaline to stimulate cardiac performance
Corticosteroid to reduce inflammation
Trendelenburg position to shunt blood back
to bodys core
Chest tube to treat pneumo/hemothorax
Thrombolysis to reduce size of clot.
Pericardiocentesis to treat tamponade

CARDIAC TAMPONADE

Definition:
Sudden accumulation of blood, fluid, clots, pus or
gas in pericardial space resulting in compression
of heart muscle & interfere systole & diastole.

Clinical Manifestation:
Tachycardia Difficulty in breathing
Hypotension Jugular vein distension
Shock Oliguria
Restlessness Dyspnea

Risk Factors:
Blunt/ penetrating cardiac trauma
Post cardiac catheterization
Anticoagulant therapy
Myocardial Infarction
Acute pericarditis

Management:
Pericardiocentesis
-Aspirate fluid from pericardial by needle
Subxiphoid pericardiostomy
-Drain pericardial sac
Emergency thoracotomy
-Pericardial sac evacuation
Fluid resuscitation
-Blood products, colloids, crystalloids
Inotropic agent
-Increase myocardial contractility and CO
Airway
-Oxygen, intubation, mechanical ventilation
ELECTROCARDIOGRAM (ECG)

12 lead ECG consist of:
a) 6 limb leads (I, II, III, aVR, aVL, aVF)
b) 6 chest leads (V1-V6)
c) Standard speed of 25mm/second
d) Small box = 0.04 sec = 1 mm
e) Large box = 0.20 sec = 5 mm



P wave Atrial contraction 0.08-0.10 sec
QRS
complex
Ventricular
contraction
0.06-0.10 sec
T wave Ventricular relax -
PR
interval
AV node function 0.12-0.20 sec

ST segment
+ Measured from end of QRS complex to
beginning of T wave.
+ Evaluate base on shape & location
+ Normally flat/isoelectric level

1 mm above Myocardial ischemia
2 mm above Myocardial infarction/
pericarditis
1 mm below Myocardial ischemia

QT interval
+ Indicates total time from onset of contraction
to relaxation.
+ Shorten with fast HR, lengthen in slow HR
+ Normal: <46 sec (women), <0.45 sec (male)
+ Prolong indicates torsades de pointes,
electrolyte imbalance, dysrhythmic treatment

Reading ECG
1. P wave presence and have relation with QRS.
2. PR interval duration
3. QRS complex shape, width & duration
4. QT segment length
5. ST segment elevation.

Methods in calculating heart rate
i. No. of R-R intervals in 6 sec times 10
(Irregular rhythm)
ii. No. of large boxes between QRS complex
divided into 300
iii. No. of small boxes between QRS complex
divided into 1500

*If HR>200 bpm or <30 bpm, emergency
measures are taken.
Initial
Hyperperfusion causes hypoxia.
Cellsperform anaerobic respiration leading
to lactate & pyruvate build up causing
metabolic acidosis.
Compensatory
Hyerventilate to clear CO
2
and improve pH.
Baroreceptors detect hypotension due to
vasodilatation
Adrenaline is released to increase BP.
Renin-angitensin axis is activated and
vasopresssin released to conserve fluid via
kidneys reducing urine output.
Vessels in other organ also constrict to
divert blood to heart, lungs & kidneys.
Progressive (decompensating)
Vessel constriction causes blood remain in
capillaries.
Hydrostatic pressure increase and
histamine released cause leakage of fluid
and protein into surrounding tissue.
Blood concentration increase causing
sludging of microcirculation.
Vital organ compromised due to reduced
perfusion.
Refractory
Vital organ failed and brain death occured.
Death will occur imminently.
Colloids
HEMODYNAMIC MONITORING

Definition:
Is the bedside measurement of the ever-changing
pressure of blood flow through the cardiac,
pulmonary & systemic vasculature via invasive
catheters.

Benefits:
Improve patient outcome
Lower mortality rates
Better quality of life after critical illness

Measurement:
Direct Indirect (calculation)
CVP
Rt Ventricle Pressure
Pulmonary Artery P.
Cardiac output
Cardiac Index
Lt Ventricular
Ejection Fraction
Lt Atrial Pressure
Capillary Wedge P.

Tools:
Intra-Arterial
Catheters (IAC)
Purpose
Measure MAP correctly
Draw blood for ABG
Monitor Arterial BP

Insertion site
* Radial artery
* Femoral artery
* Dorsalis pedis
* Brachial artery
* Axillary artery
Central Venous
Access

Insertion site
* Subclavian vein
* Brachial vein
Jugular vein
Purpose
When peripheral site
nor accessible
For fluid resuscitation
CVP monitoring
Access for PAC
Monitor blood
circulation
Pulmonary Artery
Catheter (PAC)

Insertion site
* Subclavian vein
* Jugular vein
* Femoral vein
* Brachial vein

Purpose
Measure pressure in
both side of heart &
pulmonary artery
Measure CO
Blood for mixed venous
Fluid infusion

Nursing intervention
Tranducer at 4
th
ICS
Zero transducer b4
read
Supine/ Semi-fowlers
Intra-aortic
Balloon Pump
(IABP)

Insertion site
* Femoral artery
Purpose
Support in low CO & BP
Post CABG

Signs of complications
^ Peripheral pulses
^ Urine output
^ Balloon migration
^ temperature/ WBC
^ Hematocrit (bleed)

Weaning:
O Hemodynamic stable
O No chest pain
O Adequate urine output
ACUTE LUNG INJURY (ALI)

Definition:
A systemic process of pulmonary manifestation
which cause multiple organ dysfunction
syndromes. Severe ALI is known as Acute
Respiratory Distress Syndrome (ARDS).

Clinical Manifestation:
Exudative phase Fibroproliferative
phase
* Tachypnea
* Restlessness
* Anxiety
* Use accessory
muscles
* Agitation
* Dyspnea
* Fatigue
* Use accessory
muscle excessively
* Fine crackles

Risk factors:
Direct Indirect
Aspiration
Drowning
Toxic inhalation
Pulmonary
contusion
Pneumonia
Oxygen toxicity
Sepsis
Trauma
Hypertransfusion
CABG
Severe pancreatitis
Embolism
Shock

Pathophysiology


Diagnostic test:
I. Arterial Blood Gases (ABG)
- PaCO2: Despite high oxygen demand
- PaCO2: Hyperventilation, fatigue
- pH: Respiratory acidosis
II. Chest X-ray

Management:
Medical Nursing
Mecha. Ventilation
Low tidal volume
(6ml/kg)- prevent
Barotrauma
Pemissive
hypercapnia
Increase CO2
slowly
Oxygen therapy
Tissue perfusion
Adequate CO
contractility
Restrict fluid
Diuretics
Optimizing
oxygenation &
ventilation
Preventing
desaturation
Promote
secretion
clearance
Positioning
Provide comfort &
emotional support
Prevent
complications

PNEUMONIA

Definition:
Acute inflammation of the lung parenchyma

Community Acquired
Pneumonia (CAP)
Hospital Acquired
Penumonia (HAP)
Pathogens
-Strep. Pneumoniae
-Legionella sp.
-H. Influenzae
-Staph. Aureus
-Mycoplasma pneu.
-Clamydia pneu.
-Pseudomonas
Pathogens
-Staph. Aureus
-Strep. Pneumoniae
-Pseudomonas
-Aceno. Baumannii
-Klesiella sp.
-Proteus sp.
-Serratia sp.
Risk factors
Alcoholism
COPD
Diabetes
Malignancy
Coronary disease
Risk factors
Elderly
COPD
Chronic illness
Mecha. ventilation
Smoking

Clinical manifestation:
Dyspnea Uremia
Fever Thrombocytopenia
Cough Hypoxemia
Coarse crackles Tachypnea

Diagnostic test
a. Chest X-ray
b. Sputum culture
c. Bronchoscopy
d. Full Blood Count
e. Arterial Blood Gases

Nursing management:
i. Optimize oxygenation & ventilation
-Oxygen therapy
-Positioning
-Secretion clearance
-Bronchodilators
ii. Prevent infection spreading
-Proper hand washing
-Administer antibiotic
iii. Provide comfort & emotional support
-Adequate rest
-Perform procedures as needed
-Explanation on procedures
iv. Prevent complications
-Close monitoring
-Aseptic technique

PULMONARY EMBOLISM

Definition:
Occurs when thrombotic embolus (clots) or non-
embolus (fat, air, foreign bodies) stuck into the
pulmonary arterial system, disrupting blood flow
to the lungs.

Pathophysiology



After direct/ indirect injury, inflammatory-
immune system is stimulated
Inflammatory mediators released from the
site
Causes neutrophils, macrophages & platelet
accumulate in pulmonary artery.
Initiate humoral mediators that damage
alveolar-capillary mambrane.
Alveolar collapse and cause increase work of
breathing
Hypoxemia
When occluded, alveolar dead space
work of breathing
Hypercapnia & hypoxia causes
bronchoconstriction
pulmonary vascular resistance
right ventricular workload
Clinical manifestation:
Tachycardia Hemoptysis
Tachypnea Cough
Dyspnea Crackles
Anxiety Fever

Risk factors:
Venous stasis (AF, CO, immobility)
Injury to vessels (infection, incision)
Polycythemia
Cardivascular disease (HF, cardiomyopathy)
Cancer
Trauma
Pregnancy

Diagnostic test:
- Arterial Blood Gases ( PaCO2, PaO2, pH)
- ECG (sinus tachycardia, BBB, AF)
- Chest X-ray (cardiomegaly, pleural effusion)
- Pulmonary angiogram
- DVT studies

Management:
Medical Nursing
~ Fibrinolytic agents
(streptokinase)
~ Embolectomy
~ Anticoagulant
(heparin or warfarin)
~ Inotropes
~ Fluid
~ Optimize ventilation
& oxygenation
~ Monitor bleeding
~ Provide comfort
~ Prevent
complications
~ Health education

PNEUMOTHORAX

Definition:
Accumulation of air between the parietal &
visceral pleura with lung collapse.

Types:


Management:
1. Oxygen therapy
2. Analgesics
3. Thoracocentesis
4. Chest tube
5. Thoracotomy- prevent recurrent
BASIC AIRWAY MANAGEMENT

Oxygen administration:
Types Amount/percentage
Nasal cannula 2-6 Lpm/25-50%
Face mask 6-10 Lpm/ 35-60%
Partial rebreather >10 Lpm/ >60%
Non rebreather >10Lpm/ 60-95%
Demand valve 100 Lpm/ 100%
Venturi mask
(15 Lpm)
With reservoir 50%
No reservoir >95%

Intubation
Techniques
Head tilt, chin lift: Tongue may obstruct
Jaw thrust: For spinal injury patient
Body position
Lateral position allow fluid drain out
Used when no spinal injury
If so, patient secured on a board first.
Airway adjunct
Oropharyngeal:
-For unconscious patient
-Measure from mouth to angle of
mandible
Nasopharygeal:
-For conscious patient
-When oropharungeal airway not
accessible
-Measure from tip of nose to end of
earlobe
Laryngeal mask:
-For unconscious patient
-Not suitable if esophagus is injured
-Must be remove after patient conscious
-Does not prevent aspiration
Tracheostomy:
-For prolong ventilation
-When patient fail to be intubated
-Done in OT

Complications of intubation:
Laceration of gum, lip, vocal cord, pharynx
Broken teeth
Vocal cord paralysis
Pneumothorax
Esophageal intubation
ETT dislodgement

Suctioning:
O Hyperventilate patient or apply high-
concentration of oxygen before suction
O Use sterile apparatus
O Maximum of 10 sec on each suction
O Be gentle
O Rotate the catheter when withdrawing it.
O Apply aseptic technique
O Use soft, flexible catheters
O Monitor for arrhythmia
O Attach oxygen after suction


MECHANICAL VENTILATION

Definition:
A mode of assisted or controlled ventilation using
mechanical devices that cycle automatically to
generate airway pressure.

Types:
i. Volume-cycled: Preset tidal volume
ii. Pressure-cycled: Preset pressure limit
iii. Flow-cycled: Preset flow rate
iv. Time-cycled: Preset time factor

Modes:



Spontaneous
A closed pneumothorax (no leak)
Causes: Rupture of visceral layer due to
infection (primary), disease complication
(secondary)
Symptoms happen during rest
Traumatic
Can be opened (opening in chest wall) or
closed
Causes: Penetrating injury (biopsy,
thoracocentesis), fracture, PEEP, CPR
Tension
Air enter pleura space when inhale and
cannot escape because of flap-valve effect.
Life- threatening ( CO)
Causes: Trauma, infection, mechanical
ventilation
Control Ventilation (CV)
Deliver preset volume/pressure despite own
inspiratory effort
Used for apneic patient
Assist-Control Ventilation (ACV)
Deliver breath in response to own effort &
when fail to breathe.
Used in spontaneous breathing with weaken
respiratory muscle
Synchronize Intermitten Mandatory
Ventilation (SIMV)
Ventilator breath are synchronize with own
effort
Used in weaning from ventilation
Pressure Support Ventilation (PSV)
Preset pressure that augment own
inspiratory effort & decrease work of
breathing
Used in weaning with SIMV mode
Positive End Expiratory Pressure (PEEP)
Used with CV, AC & SIMV to improve
oxygenation by opening collapse alveoli.
Constant Positive Airway Pressure (CPAP)
Similar to PEEP but used only with
spontaneously breathing patient.
Maintain constant +ve pressure in airways.
Independent Lung Ventilation (ILV)
Ventilate each lung separately. Requires 2
ventilator and sedation.
Used in unilateral lung disease/ different
disease process in each lung
High Frequency Ventilation (HFV)
Deliver small gas amount at rapid rate (60-
100 bpm). Require sedation
Used in hemodynamic instability, in short-
term procedure or risk of pneumothorax.
Inverse Ratio Ventilation (IRV)
I:E ratio reversed to allow longer inspiration.
Require sedation.
Improve oxygenation in hypoxic patient with
PEEP. Keeps alveoli from collapse.
Settings:
Ventilator
Modes
Modes used in delivering
positive pressure.
Respiratory
Rate
Number of breath ventilator
delivers per minute
(10-12/min)
Tidal
Volume
Volume delivered to patient
during normal ventilator
breath (7-10 ml/kg). Volume
>10 ml/kg cause volutrauma.
Inspiratory
flow
A measure of preset
respiratory volume: the more
quantity of a flow, the more
quickly ventilator will submit
mandatory respiratory volume
(45-60 L/min)
I:E ratio Ratio comparing time
delivering O2 and time to
exhale (1:2).
PEEP Positive pressure applied at
end of expiration (3-5 cm H2O)
FiO2 Select delivery of O2 (21-
100%). Should be the lowest
level to prevent oxygen
toxicity.
Inspiratory
trigger
A control that adjust ventilator
response to patient
respiratory.

Criteria for starting mechanical ventilation:
i. Respiratory rate >35 or <5 breaths/minute
ii. Hypoxia: central cyanosis
iii. Hypercapnia
iv. Decreasing conscious level
v. Significant chest trauma
vi. Tidal volume <5ml/kg
vii. Control ICP in head injury
viii. Following cardiac arrest
ix. Prolong major surgery

Definition of weaning:
Gradual withdrawal of the mechanical ventilator
& reestablishment of spontaneous breathing

Criteria for weaning:
a. Respiratory rate <25 per min
b. Tidal volume 3-5 ml/kg
c. pH >7.35
d. PaO2 >80 mmHg with FiO2 <0.5
e. PaCO2 35-45 mmHg

Factors to consider before weaning
-Resolution of underlying pathologic condition
-Chest X-ray show good lung expansion
-Acceptable ABG with ventilator support
-Sepsis under control
-Awake with intact respiratory drive
-Minimal inotropic support
-Good hydration with normal serum electrolyte
-Adequate nutrition & energy
-Intact gag & cough reflex before extubation

Complications:
Mechanical- Equipment malfunction
a) Ventilator
Fail to cycle, Power failure
b) Circuit
Disconnection, Infection
c) Humidifier
Inadequate humidification, overheating
Physiological
A. Respiratory
-Barotrauma
-Atelectasis
-Infection (VAP)
B. Cardiovascular
-Decrease venous return and CO
C. Gastrointestinal
-Gastric ulceration
-Microaspiration
D. Renal/ hepatic
-Decrease urine output
-Sodium & water retention
-Decrease portal blood flow
E. Central Nervous System
-Decrease cerebral perfusion following
excessive PEEP

Drugs used in managing ventilated patient:
a) Sedative/ analgesics
-Midazolam
-Morphine
-Propofol
b) Neuromuscular Blocking Agent (NMBA)
-Suxamethonium
-Vecuronium
-Atracurium

Care of Patient on Mechanical Ventilator
Check ventilator settings according to doctors
order every shift
Make sure alarm are set
Empty ventilator tubing when moisture collects.
Never empty the fluid back into the cascade
Ensure temperature of delivered air maintained
at body temperature
If on PEEP, observe peak airway pressure to
determine the proper level
Assess patients respiratory status every shift:
Take vital signs 4 hourly
Check cuff pressure everyday to ensure tidal
volume
Provide mouth care every 2-4 hours
Observe the need for suction every 2 hours
Provide tracheostomy care every shift.
Change tube tape as needed
Check mouth for pressure sores.
Move the tube to opposite side of mouth every
24 hour to prevent ulcers
Maintain accurate intake & output records
Position patient every 2 hours to prevent
complication of immobility
Plan nursing care to provide rest
Include patient & family members in care
Provide materials for communication
Observe for gastrointestinal distress
Administer medication as appropriate
Initiate relaxation technique
Monitor for complication (barotraumas, CO)
Monitor readiness to wean.
NON INVASIVE VENTILATION

Definition:
Delivery of mechanical ventilation with a nasal or
face mask.

Advantages:
O Prevent intubation
O Enhance alveolar ventilation
O work of breathing
O Improve gaseous exchange
O nosocomial infection
O Enhance patient comfort
O length of stay
O cost

Indication
g AECOPD & respiratory failure
g Respiratory failure with hypercapnia
g Respiratory failure with acute hypoxemia
g Asthma

Methods:
1. Continuous Positive Airway Pressure (CPAP)
o Air delivered via mask fit to patients face
o Pump provide positive pressure
o Increase amount of air breathed in
o Not increase work of breathing
o Patient breathe spontaneously
o Usual range 5-15 cmH20
2. Bilevel Positive Airway Pressure (BiPAP)
o Provide higher positive pressure for
inspiration
o Enhance oxygenation & ventilation
o Higher pressure is for inhalation (IPAP),
lower pressure for expiration (EPAP)
o When inhale, air flow in high pressure to
support inhalation.
o Increase delivery of air with less breathing
workload.

Nursing management
Claustrophobia Assess for comfort
Serve anxiolytic
Pressure on
face
Place hydrocolloid dressing
Mucosal
dryness
Apply lip balm or nasal
spray
Stomach
distension
Insert nasogastric tube
Aspiration Check for nausea, abdo
girth
Serve antiemetic
Corneal
irritation
Ensure mask fit well
Apply eye drop
Hypoventilate Ensure mask fit well


ARTERIAL BLOOD GASES (ABG)

Interpreting ABG
1. Partial pressure of Oxygen (PaO2)
2. pH level
3. Partial pressure of Carbon Dioxide (PaCO2)
4. Bicarbonate (HCO3)



Disorder pH PaCO2
mmHg
HCO3
mEq/L
Respiratory acidosis
Uncompensated
Partially
Compensated
< 7.35
< 7.35
normal
> 45
> 45
> 45
normal
> 26
> 26
Respiratory alkalosis
Uncompensated
Partially
Compensated
> 7.45
> 7.45
normal
< 35
< 35
< 35
normal
< 22
< 22
Metabolic acidosis
Uncompensated
Partially
Compensated
< 7.35
< 7.35
normal
normal
< 35
< 35
< 22
< 22
< 22
Metabolic alkalosis
Uncompensated
Partially
Compensated
> 7.45
> 7.45
normal
normal
> 45
> 45
> 26
> 26
> 26
Mixed
Alkalosis
Acidosis
< 7.35
> 7.45
> 45
< 35
< 22
> 26

Causes:
Respiratory
alkalosis
~ Fever
~ Trauma
~ CNS infection
~ High altitude
~ Pneumothorax
~ Pregnancy
Respiratory
acidosis
~ Airway obstruction
~ Pulmonary edema
~ Pneumonia
~ CNS depression
~ Neuromuscular impairment
Metabolic
alkalosis
~ Volume depletion
~ Bicarb administration
~ Diuretics
Metabolic
acidosis
~ Diarrhea
~ Renal insufficiency
~ Rapid saline administration
~ Starvation
~ DKA
~ Lactic acidosis

BURNS

Definition:
Tissue damage caused by such agents as heat,
chemicals, electricity, UV light or nuclear
radiation. Leading cause of death is infection.

Types Causes
Thermal Hot water, flammable liquid,
explosion, fire
Electrical Massive electrical current
Chemical Strong acid/ alkali, mustard gas
Radiation Exposure to UV light

Classification of burn
Major 25% of TBSA
10% of TBSA full-thickness burn
Deep burn (head, perineum)
Inhalational injury
Chemical/high voltage burn
Moderate 15-25% of TBSA
Superficial partial thickness burn
(head, perineum, limbs)
Suspected child abuse
Concomitant trauma
Minor 15% of TBSA
Estimation of burn size
I. Rule of nine
Divides body part into 9% of TBSA each
II. Lund & Browder chart
Surface area is based on age
III. Palmar method
Use patient own hand, representing 11% of
TBSA

Degree of burns
1
st
degree -Superficial burn
-Causes pain, redness, swelling
-Heal within 3-5 days
2
nd
degree -Partial thickness burn
-Causes pain, swelling, blister
-Heal within 10-14 days
3
rd
degree -Full thickness burn
-Causes black,char skin, numb
-Heal within 30 days-months

Diagnosis test:
- Arterial Blood Gases
- Carboxy Hb level
- Coagulation studies
- Group Cross Match (GXM)
- Urine analysis

Management:
a) Resuscitative phase
-Adult (> 15%), children (>10%)
-Fluid resuscitation (Ringers Lactate):
Parklands Formula
(4 x BSA involved x body weight)
-50% given in 1
st
8 hours, 50% nest 16 hours
b) Acute phase
-Wound care
-Open dressing: Apply topical agent with gauze
-Close dressing: Use gauze to cover after apply
topical agents
-Apply topical antimicrobial (Silver nitrate)
c) Rehabilitation phase
-Physiotherapy
-Psychiatry
-Social worker

Nursing care:
+ Strict intake & output chart
+ Vital signs monitoring
+ Pain assessment, administer analgesics
+ Nutrition (high protein, enteral feeding)


DIABETIC KETOACIDOSIS (DKA)

Definition:
A metabolic state resulting from a profound lack
of insulin, usually found in type I DM. Inability to
inhibit glucose production from the liver results
in hyperglycemia, which can be extreme and lead
to severe dehydration.

Pathophysiology


Clinical Manifestations:
Hyperglycemia Coma
ketone level Shortness of breath
Polydipsia Weakness
Polyuria Weight loss
Polyphagia Abdominal pain
Nausea & vomiting Dehydration

Complication:
1) Cerebral edema
-Brain swell due to water accumulation
2) Acute kidney failure
-Caused by severe dehydration
3) Acute Respiratory Distress Syndrome
-Lungs filled with fluid causing SOB
4) Hypoglycemia
-Insulin enter into cells and glucose level
5) Hypokalemia
-Due to fluid & insulin used in treating DKA

HYPERGLYCEMIA HYPEROSMOLAR NON-
KETOACIDOSIS SYNDROME (HHNS)

Definition:
Hyperosmolarity & severe hyperglycemia
predominate with change of mental status due to
insulin resistance. Occurs in type II DM.

Pathophysiology


Hyperglycemia (absolute deficit in
insulin)
Inability of glucose to move into cells,
increasing its level
Fat from adipose tissue converted into
free fatty acids (FFA)
FFA converted to
glucose by liver
Liver also convert
glycogen into glucose
Worsen the
hyperglycemia
Deficit in insulin prevent glucose enter cells
Glucose level & blood become
hyperosmolar
Fluid drawn from the cell into vascular bed
Body try to eliminate excessive glucose by
urinating
If patient do not consume enough water, it
may results in severe dehydration
Clinical manifestations:
Hyperglycemia Polyuria
Dehydration Weakness
Excessive thirst Weight loss
Confusion Fatigue

Risk factors:
A. Poor DM control
B. Non compliant to DM treatment
C. Drink inadequate water
D. Intravenous feeding- glucose
E. Peritoneal dialysis
F. Diuretics

Complication:
1) Shock
2) Coma
3) Acute tubular necrosis
4) Vascular thrombosis
5) Death

Management for DKA and HHNS:
Medical Nursing
* Fluid resuscitation
* Administer insulin
* Restore electrolyte
* Patent airway
* Enough ventilation
& oxygenation
* Close monitoring
* Administer fluid,
insulin, electrolyte
* Monitor compliant
to therapy
* Prevent
complications
* Patient education

Patient education for DKA & HHNS:
a. Control blood sugar
b. Consult doctor for blood sugar level target
c. Drink a lot of water
d. Take medication as ordered
e. Watch for signs & symptoms- Ketone in urine

Comparison between DKA & HHNS
DKA HHNS
In type I DM In type II DM
Sudden onset Slow onset
ketone level Normal level
Serum sodium low Serum sodium high
Low bicarb level Normal level
Urine ketone present No urine ketone

POLYTRAUMA

Definition:
Consecutive systemic reactions which may lead
to dysfunction or failure of remote organs and
vital systems.

Trauma death: Second death peak occurs within
minutes to several hours after injury. This period
is called Golden Hour characterized by:
-Rapid transportation
-Rapid assessment& stabilization
-Rapid definitive care

Conditions & its management:
Head injury * Airway, breathing,
circulation
* Neurological assessment;
GCS
Obtain CT brain if comatose,
unequal pupils, GCS <13/15


Brain
herniation
* Hyperventilate
* Mannitol
* Immediate CT brain
* Contact neurosurgeon
Thoracic
trauma
* Adequate pain control
* Adequate oxygenation
* Chest wall stabilization
* Treat complication
Pneumothorax * Chest tube insertion
* Needle thoracostomy
* High flow oxygen
* Asherman chest seal
Massive
hemothorax
* Tube thoracostomy
drainage
* Thoracotomy
* Adequate fluid volume
Cardiac
temponade
* Pericardiocentesis
Aortic rupture * Maintain adequate volume
* Angiogram
* Emergency endovascular
stent graph
Renal injury * CRIB
* Sedation
* Observation (abd, girth)
* IV fluid (major injury)
* Antibiotic
* Full laparotomy
GI injury * Debride devitalized tissue
* Anastomoses if required
* NGT suction
* IV fluids
Pancreatic
injury
* External drainage
* Control hemorrhage
Liver injury * Close monitoring
* Blood transfusion
* Laparotomy
Spleen injury * Close monitoring
* Assess for bleeding
* Splenectomy
Vertical Shear * Apply compression belt/
external fixator
* Peritoneal aspiration
* Urine catheterization
* Suprapubic cystotomy
* Bed rest
Acetabular
fracture
* Traction
* Reduce dislocation
* Operative reduction (if fail)
Pelvic fracture * Massive fluid replacement
* Immobilization
* Bleeding control
Fat embolism * Adequate oxygenation
* Stabilizing hemodynamic
* DVT prophylaxis
* Early immobilization
* Use corticosteroid &
heparin reduce APO
Hypothermia * Cover with warm blanket
* Warm IV fluid before infuse
Shock * Oxygenation
* Arrest bleeding
* Pneumatic antishock
garment
* Monitor vital signs, I/O,
CVP, acid-base balance
* Blood tranfusion


TRAUMA CARE IN EMERGENCY

Triaging
O Categorising the patient according to
treatment priority.
O A 24 hour basis by well trained Triage
Officers.
O Triage criteria:
Non-critical Walk-in & stable
Semi-critical Hemodynamically stable
but unable to walk
Critical Critically ill, require
immediate treatment.

Zone & facilities:
Resuscitation
zone
Resuscitation bays
-Emergency treatment
golden hour
-Activation of trauma team
Critical care bays
-Observation & monitoring
Immediate
Care zone
Immediate bays
-Active bays for incoming
semicritical
Observation bays
-Observation for semi-
critical cases
-Duration stay <12 hours
Green zone Consultation room
-Minor treatment prior to be
discharge
-Eg: injection, dressing
Asthma bay No waiting time
Emergency treatment
One Stop
Crisis Centre
(OSCC)
Victims of domestic violence,
rape, child abuse
Registration done in the
room by emergency staff

Stabilization & transport of critically ill patient:
Indication Contraindication
Diagnostic purpose
Therapeutic
purpose (surgery)
Specialized care
(ED to ICU)
Increase potential
risk
Unstable/potential
patient

Potential mishap:
Accidental extubation
Ventilator disconnect
ECG disconnect
Monitor power failure
Vaso-active drug interruption
IV infiltration or disconnection

Elements:
i. Communication
- Reason for transport
-Patients condition
-Equipment needed
-Notify receiving department before transfer


ii. Equipments
-Small size, light
-Compatible
-Safe to staff and patient
Monitors -Know how to operate
-Monitors ECG, ABP, ICP,
SpO2, capnograph
Ventilators -Different modes
-High & low pressure alarms
-Electrically powered
-Have humidification system
-Oxygen supply, backup
Medication
& infusion
-List of drugs to be used
-Aware of drug effects
-Use plastic infusion bag
-Test IV drip before infuse
iii. Monitoring
-Pulse, SpO2, BP, RR
iv. Handling over (documentation)
-Indication for transport
-Patient status during transport
(Vital signs, level of consciousness)

COMMON DRUGS IN ICU

Sedation
Indication Relieve pain
Reduce anxiety &
agitation
Provide amnesia
Reduce patient-ventilator
dysynchrony
Reduce respiratory
muscle oxygen
consumption
Common drugs
BDZ
* Diazepam
* Lorazepam
* Midazolam
+ No analgesic properties
+ Lipid soluble
+ Interact with propranolol
Propofol + Respiratory & CVS
depression
+ Only in ventilated patient
Butyrophenones
* Haloperidol
+ Anti-psychotic tranquilizer
+ In agitated, delirious
&psychotic patient
+ Patient can develop EPS

Analgesics
Indication Relieve pain
Common drugs
Opiods
* Morphine
* Fentanyl

+ Morphine- hypotension
+ Fentanyl- expensive
Non-opiods
* Ketamine
* Ketorolac

+ Ketamine can cause
nightmares, hallucination
& bronchodilate
+ Ketorolac side effects
increase in critically ill &
can cause renal failure.


Muscle relaxant/paralytics
Indication For intubation
In mechanical
ventilation
Prevent increase in ICP
Reduce lactic acidosis
Common drugs
Depolarizing
agents
Eg: Succinylcholine
Non-
depolarizing
Eg: Pancuronium,
Vecuronium, Atracurium

Vasopressors
Indication Increase contraction (1)
Vasodilate vessels (2)
Bronchodilate (2)
Vasoconstrict ()
Common drugs
Dopamine + Increase mesenteric blood
flow
+ Risk of tachyarrhythmias
Dobutamine + Primarily 1
+ SVR may decrease
+ Useful in Rt heart failure
+ Risk of tachyarrhythmias
Isoproteronol + Positive chronotrope
+ Increase HR & myocardial
oxygen consumption
+ May worse ischemia
PDE inhibitor
* Milrinone
* Amrinone

+ Positive inotrope &
vasodilator
+ Little effect in HR
+ Used in CHF
+ Risk of tachyarrhythmia
Adrenaline + Very potent agent
+ Effect on metabolic rate
+ Useful in anaphylaxis
+ Risk of coronary ischemia,
renal vasoconstriction
Noradrenaline + Potent agent
+ Tend to spare brain & heart
+ Good in increasing SVR
+ Can cause reflex
bradycardia
Phenylephrine + Pure agent
+ Cause minimal increase in
HR or contractility
+ Does not spare brain &
heart
Ephedrine + Release tissue stores of
adrenaline
+ Last longer & less potent
than adrenaline
Vasopressin + Useful in septic shock
+ To parallel HRT
Nitroglycerine + Venodilator at low dose
+ Arteriodilation at high dose
+ Short duration, rapid onset
+ Risk of ICP, headache
Nitroprusside + Balanced vasodilator
+ Rapid onset
+ Used in HPT emergency,
severe CHF, aortic
dissection
+ Risk of CN poisoning, ICP
Labetolol + 1 & blocker
+ Does not ICP
+ Used in HPT emergency,
aortic dissection