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
Basic Respiratory/Airway
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
Basic Respiratory/Airway
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 FiO
2
Nasal 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
Physiology of Ventilation
Ventilation
Movement of air in and out of the lungs
Occurs in two phases
Inspiration (Active)
Expiration (Passive)
13
Physiology of Ventilation
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 Matching
18
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 CO
2
Pulse oximetry reflects
oxygenation, End Tidal CO
2
reflects 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
Asthma
Acute 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
25
Asthma
Management
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
ENA, CEN Review Manual, 2001
29
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
ENA, CEN Review Manual, 2001
31
Acute Bronchitis
Assessment
Recent URI
Dry, hacky, cough
Nonproductive initially
Normal RR
Use of accessory muscles
Prolonged expiratory phase
Rhonchi, wet lung bases
Normal CXR
32
Acute Bronchitis
Management
Rest
Humidification of air or supplemental
O
2
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, 2002
37
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 Medicine
42
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
ENA, CEN Review Manual, 2001
44
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
Croup
Management
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
Croup
Laryngotracheobronchitis
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
50
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
Tachycardia
53
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
PaO
2
< 65mmHg, SaO
2
< 92%,
PaCO
2
> 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 O
2
saturations 92%. Based on your assessment, you
suspect the patient has:
A. Pericarditis
B. Acute coronary syndrome
C. Pulmonary embolus
D. Viral pneumonia
56
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 S
2
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 PaO
2
, SaO
2
,
and SvO
2
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, 1998
62
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 2
nd
heart sound
Right ventricular
failure
Distended neck veins
Right ventricular 3
rd
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
ENA, CEN Review Manual, 2001
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
1
st
rib fractures seen with injuries to
subclavian artery and aortic rupture
Lower rib fractures associated with
spleen or liver injuries
75
Rib/Sternal Fractures
Assessment
Chest wall pain
Aggravated with deep breathing &
coughing
Point tenderness
Subcutaneous emphysema
Hypoventilation
Shallow respirations
76
Rib/Sternal Fractures
Management
Monitor respiratory status
Analgesics
Cough & deep breathe
Incentive spirometry
Complications
Pneumothorax
Hemothorax
77
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 O
2
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 status
Holleran, 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
breath
Holleran, 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
Clinical Manifestations
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 fracture
89
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 O
2
,
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 11
th
edition
92
ARDS
Clinical Manifestations
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 Therapy
94
ABGs
Condition pH PCO
2
HCO
3
Respiratory
Acidosis
normal
Respiratory
Alkalosis
normal
Metabolic Acidosis normal
Metabolic Alkalosis normal
95
ABGs
Normal Values
Variable Normal Value
pH 7.35-7.45
PaO
2
80-100
PaCO
2
35-45
HCO
3
22-26
BE
+
2
-
2
96
ABG Interpretation
pH 7.35 (< acidosis) 7.45 (> alkalosis)
CO2 35 (< alkalosis) 45 (> acidosis)
HCO3 22 (<acidosis) 26 (> 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
pCO
2
< 40mmHg alkalosis is
respiratory origin
pCO
2
> 40mmHg or normal, alkalosis is
metabolic origin, go to step 4
98
Steps to Determine
Step Threewhen the pH is decreased
pCO
2
> 40mmHg, acidosis is
respiratory
pCO
2
< 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; PO
2
125mmHg; PCO
2
42mmHg; HCO
3
10mEq/liter.
The correct interpretation of these ABGs is:
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
100
Question????
A patient has been in cardiopulmonary arrest for
approximately 15 minutes with ongoing resuscitative
efforts. His ABGs reveal:
pH 7.15; PO
2
, 50mmHg; PCO
2
, 68mmHg;
HCO
3
, 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 acidosis
101
Question????
Interpret the following ABGs:
pH 7.60; PO
2
, 140mmHg; PCO
2
, 15mmHg;
HCO
3
, 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 acidosis
ENA, 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
107
References
Buttaro, T. M., Trybulski, J., Bailey, P. P.,
& Sandberg-Cook, J. (2008). Primary
care a collaborative approach (3
rd
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 (2
nd
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 (2
nd
ed.). Boston: Jones and Bartlett.
Edmunds, M. W. & Mayhew, M. S.
(2004). Pharmacology for the
primary care provider (2
nd
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 (18
th
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 (3
rd
ed.). St. Louis: Elsevier
Mosby.
Pagana, K. D. & Pagana, T. J. (2009).
Diagnostic and laboratory test reference
(9
th
ed.). St. Louis: Mosby.
Ralston, Mark. (2006). Pediatric advanced
life support. Dallas: American Heart
Association.
112