Mean for Complex Patient Management K. Levenhagen, Saint ......Demystifying What All Those Numbers Mean for Complex Patient Management J. Dyson, Orlando Health, Orlando, FL ... Rhythm

Slide 1

I Found the Vital Sign: Now What? Demystifying What All Those Numbers

Mean for Complex Patient ManagementJ. Dyson, Orlando Health, Orlando, FL

K. Levenhagen, Saint Louis University, Saint Louis, MO

T. Norris, Barnes-Jewish Hospital, Saint Louis, MO

K. Swanick, Florida Gulf Coast University, Fort Meyers, FL

J. Tompkins, Mayo Clinic, Phoenix, AZ

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 2 Objectives

• By the end of the presentation, the learner will:• Recognize the importance of determining vital signs prior to initiating an

examination/intervention.

• Describe the clinical considerations related to abnormal physiological and hemodynamic indicators.

• Classify vital signs that are pertinent to physical therapy professionals and their implications on the movement system.

• Utilize the various invasive and noninvasive measures to appropriately dose intervention and identify absolute parameters for therapeutic participation.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 3 What are vital signs?

• Merriam Webster: important body functions (such as breathing and heartbeat) that are measured to see if someone is alive or healthy• Clinical decision making

• Body temperature

• Heart rate

• Breathing rate

• Blood pressure

• Pulse oximetry

• Pain

• Walking speed

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 4 So why are we not taking vitals?

Thistle et al (2016)

Vitals % of Outpatient PTs

BP 41%

HR 35.3%

RR 17.6%

Pulse Oximetry 29.4%

Temp 5.9%

Frese et al (2002)

Facility HR/BP Never or < half the time

HR/BP Always or > half the time

Acute Care 76.8%/83.9% 23.2%/16.1%

Rehabilitation 70.9%/69.1% 29.1%/30.9%

Extended Care Facility 53.8%/61.5% 46.2%/38.5%

Home Health 11.1%/22.2% 88.9%/77.8%

Outpatient 91.5%/92.1% 8.5%/7.9%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 5 So why are we not taking vitals?

• Patient young in age

• Previously documented by health care professional

• No documented history of cardiovascular comorbidities

• Taking blood pressure medication

• Time constraints

• Implementation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 6 Why should you take vital signs?

• 62% of OP PT orthopedic patients have secondary cardiovascular disease Billek-Sawhney, 1998

• Increased energy expenditure Schmalz, 2002• 20-40% transtibial amputee ambulation• 50-80% transfemoral amputee ambulation• 300% bilateral transfemoral

• Interpreting cardiovascular response is multifactorial• Risk factors/PMH• Type and dosage level of cardiac meds• Vitals signs (before, during, and after)• Patient report• Your observations

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 7 Movement System (APTA 2017)

• PTs provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based upon the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.

• PTs examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.

• PTs maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 8 Systemic Blood Flow at Rest and Exercise Healthy Young Individual

OrganResting(mL/min)

Mild exercise(mL/min)

Maximal exercise(mL/min)

Skeletal muscle 1200 4500 12,500

Heart 250 350 750

Brain 750 750 750

Integument 500 1500 1900

Kidney 1100 900 600

Gastrointestinal 1400 1100 600

Others (i.e., liver, spleen)

600 400 400

Total 5800 9500 17,500

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 9

DigestiveAbsorbs nutrients and water; delivers nutrients to liver for processing by hepatic portal vein; provides nutrients essential for hematopoiesis and building hemoglobin

EndocrineDelivers hormones: atrial natriuretic hormone (peptide) secreted by the heart atrial cells to help regulate blood volumes and pressures.

IntegumentCarries clotting factors, platelets, and white blood cells for homeostasis, fighting infection and repairing damage; regulates temperature by controlling blood flow to the surface.

LymphaticTransports white blood cells and antibodies throughout the body to maintain health; carries excess tissue fluid not reabsorbed by the vascular capillaries.

Muscular Removes lactic acid and distributes heat generated by contraction; muscular pumps aid in venous return; exercise contributes to cardiovascular health.

Interplay of Systems Affecting Vitals

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 10

NervousProduces cerebrospinal fluid (CSF); cardiac and vasomotor centers regulate cardiac output and blood flow through vessels via autonomic system

RespiratoryProvides blood for critical exchange of gases to carry oxygen needed for metabolic reactions and CO2 generated as byproducts of these processes

SkeletalProvides calcium, phosphate and minerals critical for bone matrix; transports hormones regulating buildup and absorption of matrix including erythropoietin stimulates myeloid cell hematopoiesis.

Urinary

Delivers 20% of resting circulation to kidneys for filtering, reabsorption and secretion of excess; regulates blood volume and pressure by regulating fluid loss in the form of urine and by releasing the enzyme renin, essential in the renin-angiotensin-aldosterone mechanism

Interplay of Systems Affecting Vitals

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 11

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 12

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 13

Pulse Rate

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 14 Pulse

• Stretch and recoil of the arterial wall during a cardiac cycle• Rate

• Number of beats per minute

• Rhythm• Interval between beats

• Volume – amount of blood pushed through the artery• Strength = ventricular contraction/cardiac output

• ↑ strength = ↑ systolic pressure• Bounding/full

• ↓ strength = ↓ systolic pressure• Weak/ thready

• Quality

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 15 Variations in Pulse Wave• Pulsus alterans

• Alteration of weak and strong pulse beats not related to cycle length• Pericardial effusion

• Left ventricular failure

• Asthma

• Bigeminal pulse• Two beats close together with a pause following each pair

• Hypertrophic obstructive cadiomyopathy

• Hypothyroidism

• Electrolyte imbalance

• Paradoxical pulse• Exaggerated fall in systolic blood pressure with inspiration

• COPD

• Cardiac tamponade

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 16 Pulse Assessment

Grade Pulse Description

0 Absent No perceptible pulse

1+ Thready Barely perceptible, easily obliterated with slight pressure

2+ Weak Difficult to palpate, slightly stronger than thready, can be obliterated with light pressure

3+ Normal Easy to palpate; requires moderate pressure to obliterate

4+ Bounding Very strong , hyperactive

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 17 Factors Affecting Pulse

• Age• Infant = 100 - 130 bpm

• Child (1-7 yrs old) = 80 - 120 bpm

• Adult = 60 – 100 bpm

• Gender

• Emotional status

• Systemic or local heat

• Body size

• Exercise

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 18 Effects of Aging

• Resting HR may be lower

• HR response is blunted• Rely more on Borg or BP response

• Heart Rate Reserve or Karvonen to determine target HR (closely approximates HR and VO2Max)• HRR=[((220-age)- Rest HR) X ____%] + Rest HR

• Beta Blockers

Borg RPE % of HRR % of 220-age

12-13 40-59% 55-69%

14-16 60-84% 70-89%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 19

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 20

Blood Pressure

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 21 Definitions

• Arterial Blood Pressure• Reflects the combined effects of arterial blood flow per minute

(cardiac output) and the resistance to that flow (peripheral vasculature)

• Systolic• Estimate of the work of the heart and the force of the blood against the

arterial walls during ventricular systole

• Diastolic• Heart’s relaxation phase

• Indicates peripheral resistance

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 22 Classification of Hypertension (2017 Hypertension Guideline)

Classification Systolic blood Pressure (mm Hg)

Diastolic Blood Pressure (mm Hg)

Normal <120 <80

Prehypertension/Elevated

120-129 <80

Stage 1 hypertension

130-139 80-89

Stage 2 hypertension

> 140 >90

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 23 Components of Arterial Blood Pressure (mm Hg)

Systolic/diastolic pressures• Hydrostatic Pressure

• Pressure exerted by blood on the walls of the heart or blood vessels

• Systemic arterial blood pressure = Cardiac Output X Total Peripheral resistance

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Pulse pressure• Difference between systolic and diastolic pressure

• Normal = 25% of systolic pressure • Below (called low or narrow)

• CHF (low stroke volume)

• Aortic valve stenosis

• Blood loss

• Above (high or wide) • Healthy individuals normal due to strenuous exercise (temporary)

• Chronically high = resistance in the arteries

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Mean arterial pressure• Average pressure of the blood in

the arteries• Normal range 70-110 mmHg• < 60 can result in ischemia and

hypoxemia

MAP=Diastolic BP + [0.333 (Systolic-Diastolic BP)]

Example: Patient with 127/89

102 mm Hg = 89 + [0.333(127-89)]

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 26 Factors Affecting Arterial Blood Pressure

Cardiac Output• ↑ will cause an ↑ in BP

• Increased calcium ions, thyroid hormones, sympathetic stimulation, catecholamines

• ↓ will cause a ↓ in BP• Parasympathetic stimulation, elevated or decreased potassium ion levels,

decreased calcium levels, anoxia, acidosis

Compliance• Vascular disease causes “stiffening”

• Reducing compliance and increasing resistance to blood flow

• ↑ BP

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 27 Factors Affecting Arterial Blood Pressure

Volume of blood• Hypovolemia (BP ↓)

• Bleeding, dehydration, vomiting, severe burns, antihypertensive medications

• Hypervolemia (BP ↑)• Retention of water and sodium

• CHF, liver cirrhosis, kidney disease, some steroid treatments

Viscosity of the blood• As viscosity ↑, resistance ↑ and flow ↓

• Anemia, polycythemia, cirrhosis, alcohol and drug toxicities, hepatitis

Blood vessel length and diameter• Obesity

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 28 Physiological Variations in BP

Age• SBP and DBP gradually rise with age (after the age of 30)

• > in males

Circadian variation• Lowest during sleeps and highest in the mornings after waking up

Increases transiently during physical stress, anxiety, emotional excitement

When erect, BP in any vessel varies in relation to the vertical distance from heart level

• Orthostatic hypotension

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 29 Regulatory Mechanisms for Blood Pressure

Vasomotor• Pons and upper medulla

• Produces a slow, continuous firing in all vasoconstrictor nerve fibers

• Normal vasomotor tone

Afferent Input• Baroreceptor

• Sensitive to stretch of vessel wall

• Concentrated at internal carotid arteries and above bifurcation of the aortic arch

• Chemoreceptor• Sensitive to decreased arterial oxygen concentration, increase in carbon dioxide, increase

in H+ ion concentration

• Carotid artery and aortic arch

• CN IX and X

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 30

Homeostasis Restored

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 31

Homeostasis Restored

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 32

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 33

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 34

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 35 Vital Signs: Blood Pressure

• Indirect method

• Cuff size matters• Too small, falsely high reading• Too large, falsely low reading

• Bladder width >40% of mid arm circumference

• Bladder length 80-100% of arm circumference

• Other sources of error• Arm position, rest period before,

body position, time between repeated measures, inflation/deflation method

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 36 Automatic vs Manual Blood Pressure

• Determine if validated in patients with atrial fibrillation• Wide range of error in automatic

• 6.3 mmHg higher systolic BP in automatic

• Error with wrist cuffs• Positioning

• May lack sensitivity in patients with hypotension

• Finger devices not recommended

• Home blood pressure units have predictive value for morbidity and mortality

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 37 Automatic vs Manual Blood Pressure

• Automated Blood Pressure Equipment is effective at detecting hypertension

• Is not reliable in detecting Hypotension

• Automated equipment has sensor looking for pulse pressure which is diminished when patient is hypotensive

• In presence of severe hypotension: can change to pediatric setting: less sensitive to pulse pressure

• Do you know how to adjust your equipment ???

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 38 Recommended Technique(Chobanian, 2003; Whelton, 2017)

• Calibrate equipment

• Select appropriate cuff size

• Position cuff 1” above elbow crease and bladder centered over brachial artery

• Antecubital fossa at heart level resting comfortably with no muscle tension

• Patient should not talk or cross legs

• Increase pressure to 30 mm Hg above the level radial pulse extinguished

• Deflation rate at 2 mm Hg per beat

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 39

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 40 Recommended Technique (Chobanian 2003)

• Read the systolic level ( first sound of clear tapping, Phase I Kortkoff) and the diastolic level (the point at which the sound disappears, phase V Korotkoff)• If Korotkoff sounds persist to 0 mm Hg then use Phase IV

• Record BB to nearest 2 mm Hg on manometer and 1 mm Hg on electronic

• To avoid venous congestion should wait at least 1 minute between cuff readings

• Should be taken in both arms on the first visit to determine if one arm is consistently higher

• Document HR, BP, Position, arm used, Heart rhythm

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 41

Respiratory Rate

Supply the body with oxygen for metabolic activity and to remove carbon dioxide

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 42 Why should you take respiratory rate?

• Retrospective study: abnormal RR increased the odds of critical admission (OR = 1.66, 95% CI = 1.05-2.06) when compared to controls (Smith 2011)

• RR and HR are independent predictors of adverse events after discharge from ICU (Chaboyer 2008)• RR <10 or >25 (OR 4.23, 95% CI 2.12-8.45)

• Significant correlation (r = 0.84) between manual RR and continuous electronic monitoring (Smith 2011)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 43 The Respiratory System

• Inspiration• Contraction of the diaphragm and intercostal muscles

• Increases the intrathoracic space for lungs to expand

• Expiration• Passive during recoil of the lungs

• Pons and medulla serve as the respiratory cents• Control rate and depth of breathing in response to metabolic

needs

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 44 Afferent Inputs• Chemoreceptors

• Central is in the respiratory center

• Sensitive to carbon dioxide and hydrogen ion levels

• Peripheral in the carotid bifurcation and arch of aorta• Sensitive to partial pressure of

oxygen

• Mechanoreceptors• Motor cortex

• Muscles and joint receptors

• Stretch receptors in the lung tissue and bronchioles

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 45 Respiratory Assessment

Rate• Tachypnea >24 bpm

• Bradypnea < 10 bpm

Depth• Volume of air exchanged with each breath

Rhythm• Regularity of inspirations and expirations

Character• Deviation from normal quiet effortless breathing

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 46 Patterns of Respiration

Type Description

Eupnea Normal respirations, with equal rate and depth, 12-20 breaths/min

Kussmaul’s Respirations Gasping, labored pattern

Biot’s Respirations Alternating periods of apnea and hyperapnea

Cheyne-StokesRespirations

Gradual increase in rate and depth, followed by gradual decrease

Apnea Absence of respiration

Paradoxical respirations Lung inflation during expiration, deflation during inspiration

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 47 Factors Influencing Respiration

• Age• Newborns 30 - 50 bpm• Adults 12 – 18 bpm

• Body size

• Stature

• Exercise

• Body position

• Environment

• Emotion and Stress

• Drugs

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 48 Peripheral Pulse Oximetry

Estimation of arterial oxyhemoglobin saturation (SaO2) by utilizing selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin (SpO2)

• Indirect measure

• Appropriate for continuous and prolonged monitoring• Smoking can provide a false increased reading

• Nail polish, dark skin or poor circulation can affect reading

The probe should be cleaned between patient applications according to manufacturer recommendations.

Documentation of results, therapeutic intervention (or lack of), and/or clinical decisions based on the SpO2 measurement should be noted in the medical record.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 49

Body Temperature

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 50 Body Temperature

• Balance between the heat produced or acquired by the body and lost

• Maintain relatively constant internal body temperature

• Monitors to maintain optimal normal cellular and vital organ function

• Thermoreceptors• Provide input peripherally or centrally to the hypothalamus

• Regulating center• Coordination to maintain 37⁰C (98.6 + 1.8⁰ F)

• Effector organs• Include vascular, metabolic, skeletal muscle response

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 51 Conservation of Body Heat

Vasoconstriction

• Hypothalamus activates sympathetic nervous system

• Vasoconstriction of cutaneous vessels

Decreased sweat gland activity

• To reduce or prevent heat loss by evaporation

• Sweating is stopped if body temperature falls below 37⁰C (98.6⁰F)

Cutis Anserina

• Hair standing on end (piloerection)

• Traps a layer of insulating air near the skin

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 52 Production of Body Heat

Shivering

• Posterior hypothalamus

• Increased muscle tone

Hormonal Regulation

• Increase in norepinephrine and epinephrine

• Increase in thyroxin

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 53 Increased Body Temperature

Pyrexia• Elevation of normal body temperature• Malaise, increased HR and RR, shivering, flushed skin

Hyperpyrexia• Extremely high temperature• Disorientation, confusion, seizure

Types• Intermittent• Remittent• Relapsing• Constant

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 54

Hypothermia

• Lowered body temperature

• Decreased HR and RR. depression of mental and muscular responses, cyanosis, decreased cutaneous sensation

• Thermoregulatory center impaired at 34.4⁰C (94⁰F) and completely lost at 29.4⁰C (85⁰F)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 55 Factors Influencing Body Temperature

Time of Day

Age

Emotions

Exercise

External environment

Menstrual cycle

Pregnancy

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 56 Healthy Exercise VitalsACSM 9th ed, Goodman and Snyder 4thed

• SBP Increases• In a linear fashion, 10 mm for every MET level

• 20 mm or more with min to mod exercise

• 40-50 mm with intense exercise

• SBP returns to pre-ex level in 5-7 min Pierson 2007

• HR rises linearly 10 BPM for each MET level

• HR returns to pre-ex level in 3-5 min

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 57

Modify or Terminate

“Normals” with low number of Risk Factors

•SBP decreases 20•SBP >260•DBP >115•HR does not increase w/ ex•Angina, diaphoresis, pallor, nausea, confusion, ataxia, dizziness•Significant change in rhythm•RPE beyond target rangeACSM 9thed

Vitals Consideration with Exercise

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 58

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 59

Initiate when Do not initiate Modify or Terminate

Cardiac Pump Failure(EF defines degree of failure)Mild: 40-60%Moderate: 20-40%Severe: < 20%

Speaks without dyspneaWheezes < ½ lungsHR < 120Cahalin, 1996

‒ HR < 40, >130

‒ SBP > 180‒ DBP > 100‒ RR > 35O’Sullivan 4thed

‒ Dyspnea >3/10‒ RR >40‒ S3 Heart sounds appear‒ New/↑ wheezes‒ Pulse pressure < 10 ‒ HR or BP ↓ > 10-20‒ Increased Supraventricular and

ventricular ectopy‒ Angina, diaphoresis, pallor,

nausea, confusion, ataxia, dizziness

‒ SBP > 220‒ DBP > 115ACSM 9thed, O’Sullivan 4thed, Cahalin, 1996

Vitals Consideration with Exercise

Symptoms based approach! Collaboration with the healthcare team!

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 60 Joint Commission as the 5th Vital Sign

• Information from the patient history• Pain characteristics

• Location and distribution

• Duration and periodicity

• Quality

• Associated signs and symptoms

• Management strategies

• Relevant medical history

• Relevant family history

• Psychosocial history

• Impact on daily life• Patient’s goals

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 61 Joint Commission as the 5th Vital Sign

Unidimensional Pain Assessment Tools

• Numeric rating scale

• Visual analog scale

• Face pain scale

Multidimensional Pain Assessment Tools

• Brief Pain Inventory

• Initial Pain Assessment Inventory

• McGill Pain Questionnaire

• Memorial Pain Assessment Card

• Pain Drawing

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 62 “Walking Speed: the Sixth Vital Sign”Fritz and Lusardi 2009

• 10 meter walk test • 5 m acceleration and 5 m deceleration

• Instructed to walk a comfortable pace

• Range for normal walking speed is 1.2-1.4 m/sec

• A change in .1 m/sec can be a predictor for improved health or a decline

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 63 “Walking Speed: the Sixth Vital Sign”Fritz and Lusardi 2009

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 64

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 65 5 Meter Walk test

• Uses by STS (Society of Thoracic Surgeons) as predictor of Frailty

• Used with TAVR patient: pre and post op:

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 66 Gait Speeds

• In acute care setting may be a better predictor of function and be considered as part of the discharge plan

• Gait speed rather that distance and FIM scores should be considered when determining safe discharge

• Should be utilized as part of the Physical Therapist Assessment in Acute Care

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 67 Vital Signs are VITAL!

• Integrate into plan of care

• Look for trends

• Clinical decision-making

• Provides information on treatment presciption

• Accurate, documented vital signs are important

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 68

Break

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 69

Hemodynamic Monitoring and Invasive Lines

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 70 Purpose

• Become more familiar with the hemodynamic monitoring devices

• Become more familiar with the numbers we see on the screen

• Plan– Explain 3 hemodynamic monitoring devices

• Arterial line

• Central venous line

• Swan line

– Explain the numbers seen on the monitor screen

– Determine safety to mobilize

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 71 Safe?

“It is feasible and safe to provide progressive mobility activities in cardiovascular ICU patients with femoral catheters who meet the criteria for mobility interventions”

“provision of bedside physical therapy while patients underwent CRRT is feasible, and appears safe.”

“no significant contraindication to mobilize patients with femoral arterial/venous cannulation”

• Damluji, Abdulla, et al. "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." Journal of critical care 28.4 (2013): 535-e9.

• Dubb, Rolf, et al. "Barriers and strategies for early mobilization of patients in intensive care units." Annals of the American Thoracic Society13.5 (2016): 724-730.

• Gokalp, Orhan, et al. "Cannulation in extracorporeal membrane oxygenation." Critical Care 18.4 (2014): 443.• Perme, Christiane, et al. "Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a prospective

observational study." Cardiopulmonary physical therapy journal 24.2 (2013): 12.• Toonstra, Amy L., et al. "Feasibility and safety of physical therapy during continuous renal replacement therapy in the intensive care unit."

Annals of the American Thoracic Society 13.5 (2016): 699-704.• Wang, Yi Tian, et al. "Early mobilization on continuous renal replacement therapy is safe and may improve filter life." Critical Care 18.4

(2014): R161.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 72 Review A & P

• The heart

– anatomy

–Physiology• The plumbing

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 73

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 74

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 75 Myocardial Conduction

• Sinoatrial Node (SA)– Pacemaker of the heart

– Cluster of cells ~ superior R atrium

• Atrioventricular Node (AV)– Slow conduction

• Bundle of His– Carry’s conductive signal from AV node to ventricles

• Purkinje Fibers– Carry signals into ventricles for contraction

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 76

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 77 Definitions of Heart Function

• Stoke Volume (L) ~70 ml– Volume of blood pumped by L ventricle in 1 beat

• Cardiac Output (L/min) ~ 5 L/m– Volume of blood pumped in 1 min

• Cardiac Index (CO/body weight)

• Ejection Fraction ****** Most important diagnostic measure of cardiac health

– % of volume ejected

– 60-67% Normal

– < 40% compromised cardiac dysfunction

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 78

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 79 Arterial line

• Where:

– Radial artery

– Femoral artery

– Brachial

– Axillary

– Dorsalis pedis

• Why?

– Arterial blood pressure (ABP)

– Oxygen saturation (SaO2)

– Source for serial blood gas draws• PaO2

• PaCO2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 80 Arterial Line

• Continuous arterial pressure monitoring

– Surgical procedures, CABG, other major surgeries or procedures

– All hemodynamic unstable patients

– Receiving potent vasopressor or vasodialator drugs

– IABP

– Need intracranial pressure monitoring

– Hypertensive crisis such as AAA, sepsis and stroke

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 81 Arterial Line

• Serial blood gas measurements

– Respiratory failure

– Pt’s on or being weaned from mechanical support

– Acid/base abnormalities

– SaO2 more accurate reading than SpO2 saturation if peripherally compromised

Laboratory Values Interpretation Resource (updated January 2017)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 82 Mean Arterial Pressure

• MAP = [(2 x diastolic) + systolic] / 3 ...diastole counts twice as much because 2/3 of your cardiac cycle is in diastole

• A MAP of about 60mmHg is necessary to perfuse coronary arteries, brain, and kidneys.

• Arterial readings are higher than sphygmomanometer

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 83 Considerations For Therapists

• Position of transducer to heart

– the transducer above the heart get a false low reading

– if below heart, have false high reading

• Enough slack

• Stopcock open to allow continuous flush

• Heparin bag needs to be pressurized

• If in femoral artery guarded activity in that leg (No ROM or flexion of hip)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 84 Arterial line

• Problems

– Ischemia or necrosis of the tissue

– Vascular insufficiency

– Infections

– Hemorrhagic disorders

– What are you going to do if you pull it out?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 85

110/70 mmHg

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 86 Central Venous Pressure Line (CVP)

• Ie: Central line

• Where: tip located in superior and inferior vena cava

• How does it get there?– Subclavian

– R internal and external jugular

– Femoral

– Antecubital

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 87

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 88 CVP line Use

• Draw blood (serial draws)

• Provide fluids

• Invasive monitoring in the ICU/Critical Care or Surgery– Monitor central venous blood pressure

– Help determine right atrial (superior vena cava) pressure• Limited by respiratory variation and function

– Assess fluid volume status

– Administration potentially caustic medications

– Emergency route for pacemaker insertion

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 89 Therapy Considerations

• Dysrhythmias with position changes

• Unstable patients may require supine position for accurate readings

• Maintain enough slack of lines

• Primarily a route for fluids, likely able to ambulate with CVP line

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 90

6-12 mmHg

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 91 Pulmonary Artery Catheter(Swan-Ganz)

• HJC Swan and Santa Monica Bay sailboats (NEJM 1970)

• Where: – Initiating @ external jugular

– Distal port in the pulmonary artery

– Proximal port in the right atrium

• How: place catheter into external jugular use balloon to float through heart and become wedged in pulmonary artery

Swan, H. J. C., et al. "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter." New England Journal of Medicine 283.9 (1970): 447-451.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 92

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 93 Swan Line

• What is it’s purpose?

– Distal port in pulmonary artery

• Pulmonary artery pressure (PA)

• Pulmonary artery wedge pressure (PAWP)• i.e. Pulmonary Artery Occlusion pressure (PAOP)

• Mixed venous draws (SVO2)

• Continuous flush

– Proximal Port

• Right atrial pressures (same as CVP)

• administer fluids

– Proximal injection for fluids

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 94

–Thermistor for measurement:

• Stroke volume

•Central Venous Pressure (CVP)

•Cardiac output (CO)

•Cardiac index (CI)

–Measures by the temperature change and how long it take to get back to normal

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 95 • Assesses circulatory volume (fluids) for many complex conditions:

– Heart failure– Shock– Burns– Renal disease– Many other cardiac dysfunctions

• Assessment of cardiovascular function for – complicated MI, severe CHF, structural defect

• Assessment of pulmonary status– cardiogenic vs. non-cardiogenic pulmonary edema, – acute respiratory failure– pulmonary hypertension

• Pre-op and post-op monitoring for complicated surgeries– (Cardiac, Organ Transplant, VAD placement)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 96 • Allows monitoring of all aspects of the heart

– Pulmonary artery

– Left and Right ventricle function

• Utilized for differential diagnosis– Pulmonary hypertension

– Cardiac tamponade

– Restrictive cardiomyopathy

• Pulmonary wedge/occlusion pressure• reflects left ventricular end diastolic pressure

• Assess left heart dysfunction

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 97 Therapy Precautions

• Keep transducer at heart level

• Most accurate measurements are supine

• Each physician has differing comfort levels with mobilizing patients with Swan lines

• Maintain enough slack in line

• Watch for dysrhythmias

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 98

http://bubbasoft.org/clinical-radiology

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 99

12 vpm 5L 90-100%

35-45 mmHg

60 bpm

110/70 mmHg

15-25/6-12 mmHg

6-12 mmHg

HR should be similar

to confirm accuracy37oC

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 100

Pulmonary Function Testing

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 101

Tidal Volume (TV) The volume of air breathed in and out

without conscious effort

Inspiratory Reserve Volume (IRV) The additional volume of air that can be

inhaled with maximum effort after a

normal inspiration.

Expiratory Reserve Volume (ERV) The additional volume of air that can be

forcibly exhaled after normal exhalation.

Vital Capacity (VC) The total volume of air that can be

exhaled after a maximum inhalation:

VC=TV+IRV+ERV

Residual Volume (RV) The volume of air remaining in the lungs

after maximum exhalation. The lungs are

never completely emptied.

Total Lung Capacity (TLC) Vital Capacity+Residual Volume

Minute Ventilation The volume of air breathed in 1 minute

(TV) * breaths/minute

Pulmonary Function Testing

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 102

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 103 Pulmonary Function Testing

• Forced expiratory volume (FEV)

• Maximal airflow measured over 1 s (FEV1.0)

• Compare to predicted values (should be >80% of predicted)

• FEV1.0 /FVC ratio indicates pulmonary airflow capacity

• Reflects pulmonary expiratory power and overall resistance to air movement

• FEV1.0 /FVC = ~85% in healthy individuals

• FEV1.0 /FVC ≤70% = delineation point for airway obstruction (obstructive lung disease)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


How much air volume can be moved into and out of the lungs?

How fast the air in the lungs can be moved in and out?

How is the compliance of the lungs?

How do the lungs respond to chest physical therapy and medications?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Uses

Screening for presence of obstructive or restrictive diseases.

Evaluating a patient prior to surgery.

Evaluate the patient’s condition for weaning from a ventilator.

Documenting the progression of pulmonary disease

Documenting the effectiveness of interventions

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Age- As a person ages the natural elasticity of the lungs

decreases which means smaller and smaller lung volumes as one

age.

Gender- Lung volumes for males are larger than those of

females even if they are matched for height and weight.

Body height and size- A small man will have a smaller

PFT result than a man of the same age who is much larger

Race- Environmental Factors and Altitude may have an affect

on PFT results.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Terminology

• FVC- Forced Vital Capacity

• FEV1- Forced Expiratory Volume in 1 second

• FEV1/FVC- FEV1%- what percent of FVC is expelled in 1st second

• FEV3- Forced Expiratory Volume in 3 seconds

• FEV3/FVC- FEV3%- should be close to 100%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


FVC

• Obstructive lung disease- FVC will be decreased due to obstruction and airway collapse during forced exhalation.

• Restrictive lung disease FVC will be smaller due to the lungs being smaller to start with because of the disease.

• Bronchodilators will improve FVC 10-15% with obstructive lung disease.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 109 Pulmonary Function TestingSVC

Slow vital capacity (SVC) test- Have the patient

slowly and completely blow out all of the air from

their lungs. Eliminates the strong

bronchoconstriction that come with a forced

exhalation. The VC may be larger with a SVC test

leading to an obstructive diagnosis.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 110 Pulmonary Function TestingFEV1

• In healthy individuals it is common the exhale 75-80% of vital capacity in first second of FVC test.

• If FEV1 is low compared to predicted values the patient may have an obstructive or restrictive lung disease.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 111 Pulmonary Function TestingFEV1%

• Both FVC and FEV1 will be low in both obstructive and resistive lung disease.

• If FEV1% is low (<70%) it is consistent with an obstructive disease.

• If FEV1% is 85%-100% it is consistent with a restrictive disease.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 112 Examples of Pulmonary Function Tests in Normal Subjects and in Patients with Obstructive or Restrictive Lung Disease

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Lets Give It A Try

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Case 1

Predicted Values Measured Values % Predicted

FVC 6.00 liters 4.00 liters 67%

FEV1 5.00 liters 2.00 liters 40%

FEV1/FVC 83% 50% 60%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Case 1




FEV1/FVC 83% 50% 60%

Obstructed Lung Disease

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Case 2




FEV1/FVC 84% 79% 94%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Case 2




FEV1/FVC 84% 79% 94%

Restricted Lung Disease

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Case 3




FEV1/FVC 82% 77% 94%

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


Case 3




FEV1/FVC 82% 77% 94%

Normal

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 120 Obstructive Lung Disease

Emphysema- permanent enlargement of air-spaces distal to the terminal bronchiole with destruction of their walls.

Leading cause is SMOKING

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 121 Emphysema

Clinical Presentation

Dyspnea- with exertion

Accessory muscle breathing

Pursed Lip breathing

Forward Posture

Barreled Chest

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 122 EmphysemaClinical Presentation

Pink Puffers

Increased Respiratory Work

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 123

Pink Puffer

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 124 EmphysemaClinical Presentation

Reduced breath sounds in all lung fields

Wheezes

Increased Total Lung Capacity

Increased Residual Volumes

Increased dead Space

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 125 Emphysema

Clinical Presentation

Chest X-ray

Over inflated Lungs

FlattenedDiaphragm

Elongated Heart

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 126 Treatment

Non PT

Iv Fluids

Antibiotics

Low Flow O2

Bronchodilators

Corticosteriods

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 127 TreatmentNote

Hypercapnia commonly occurs in severe Emphysema Oxygen

given to patients with emphysema may reduce their ability to

breath, resulting in hypercapnia. This is why exact doses of

oxygen are usually figured out for those with emphysema so that

they receive neither too little nor too much oxygen. Note: if a

patient is actively short of breath, never withhold oxygen from

them.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 128

Chronic Bronchitis

Chronic swelling and inflammation of the bronchi

and bronchioles

Diagnosis is based on a report of a productive

cough for 3 months during 2 consecutive years.

Obstructive Lung Disease

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 129 Blue Bloater

Stocky

Appear blue

due to

hypoxemia

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 130 Chronic Bronchitis

Blue Bloater

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 131 Restrictive Lung DiseasePossible Causes

Pleural Effusion

Kyphoscoliosis

Obesity

Late Term Pregnancy

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 132 Restrictive Lung Disease

Pulmonary Fibrosis

Sarcoidosis

Rheumatoid arthritis

Systemic Lupus Erythematosus

Scleroderma

Tuberculosis

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 133 Restrictive Lung Disease

Decreased Vital Capacity

Decreased Inspiratory Capacity

Decreased Total Lung Capacity

Decreased lung compliance

Decreased diffusing capacity

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 134

Lunch

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 135

LIFE= VENTILATION + PERFUSION

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 136 Now that we take the vital signs…….

• What next ?

• How do we use this information for clinical decision making

• How do we interpret vital signs ?

• How does this impact the plan of care ?

• What other factors do we need to consider that can affect vital signs?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 137 Other Factors Affecting Vital Signs

• Lab Values• Hgb

• Hct

• Sodium

• Potassium

• Calcium

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


• Medications• Pressors

• Beta Blockers

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


• CO2 Levels• Respiratory Acidosis• Respiratory Alkalosis

• Metabolic Causes• Metabolic Acidosis• Metabolic Alkalosis

• Vagal Responses

• Sepsis

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 140

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 141

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 142

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 143

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 144 Vagal Episodes

• Vagal

• Holding their breath• Breathing is REQUIRED ! Not an

optional activity

• Valsalva• Decreased BP

• Decreased cardiac output

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 145 Sepsis

• Accurate and timely assessment of vital signs can help with early diagnosis and treatment

• Vital signs and lab values are needed for complete assessment

• Putting all the pieces of the puzzle together

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 146 Bringing Sepsy Back

• https://www.youtube.com/watch?v=58Y0OfOVzMo

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 147 VITALS…. Are VITALLY Important

• Assessment of vital signs is a quality indicator

• EMR can be reviewed : random chart reviews

• Best Practice includes vital signs asessment

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 148

How do we know we have proper perfusion?

The role of ICP, CPP, APP

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 149

Cerebral Pressure and Perfusion

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 150 Intracranial Components

• Brain parenchyma- 80%

• Cerebrospinal fluid (CSF) -10%

• Blood-10%

• Intracranial compartment is protected by the skull.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 151 CSF

• Clear liquid that surrounds the brain and spinal cord

• Essential for the protection and the brain

• Transporter of waste away from the brain and nutrients to the brain

• Brain’s 2nd circulation

• Produced in the ventricles

• We must have a balance of production and absorption for our brain to function normally

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 152 Ventricles and CSF

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 153 Ventricles and CSF

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 154

Intracranial Pressure (ICP)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 155 Intracranial Components and ICP

• Volume is fixed in rigid skull

• An increase in any 1 of these components must be met with an equal decrease in another OR you have an increase in intracranial pressure (Monro-Kellie Doctrine)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 156 Intracranial Pressure (ICP)What is it?

• The pressure inside the skull and considered to be the result of the pressure in the brain tissue and the pressure that the cerebrospinal fluid (CSF) exerts in the ventricles and blood volume.• Total – Parenchyma (brain), blood and vessels, CSF)

• As intracranial blood volume goes up, so does the ICP

• Our body has a mechanism called autoregulation which can compensate for initial levels of increased ICP but has limited ability as these levels get higher.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 157 ICP

• Norms ~7–15 mmHg• Goal may be to keep it to >20 mmHg

• Intracranial Hypertension is diagnosed when ICP is at a sustained elevation ~37 mmHg

• Autoregulation can manage increased ICP up to 50 mmHg/day

• Increased intracranial pressure can lead to a medical emergency!

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 158 Causes

• Due to a change in one of the components:

• CSF levels

• ↑ CSF production (meningitis, choroid plexus tumor, hemorrhage)

• Obstruction to CSF flow/absorption (Hydrocephalus)

• Volume of brain tissue

• Cerebral edema (brain injury, heart or liver failure)

• Edema volume added to the intracranial cavity

• Brain tumor, hematoma, abscesses)

• Changes in blood volume and flow

• Blood pooling or bleeding into part of brain

• Aneurysms, high blood pressure, stroke

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 159 Signs and Symptoms

• Headache• Seizure• Nausea or Vomiting• Cranial nerve changes (blurred, double vision)• Changes in pupil appearance ((dilated, fixed, ipsilateral vs. bilateral)• Reflex changes• Changes in behavior• Problems with talking• Motor issues (weakness, paresis, posturing, hemiplegia)• Balance issues• Lack of energy or sleepiness

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 160 Signs and Symptoms (continued)

• Posturing • Decerebrate: damage to midbrain and pons

• UE extension and external rotation; LE extension

• Decorticate: damage to the cerebral hemispheres • UE flexion (fist clenched) and internal rotation; LE extension

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 161 Signs and Symptoms (continued)

• Incontinence

• Changes in level of consciousness

• Problems with command following

• Vital sign changes—increased temperature• Cushing’s triad

↑Blood Pressure

↓

Heart rate

Cushing’s Triad

↓

Respiratory Rate

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 162

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 163 ICP-How to Monitor

• External ventricular catheter or drain*• Gold standard

• Also known as a ventriculostomy

• Subarachnoid screw or bolt

• Intraparenchymal

• Epidural sensor

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 164 External Ventricular Drain (EVD)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 165 External Ventricular Drains (EVD)

• What is it?• Catheter placed within the skull into the lateral ventricle which is connected

to a closed collecting device• A ventriculostomy is performed to create a hole within the ventricle for

drainage• If this drainage is temporary= EVD• If permanent drainage is in place= shunt

• Why is it used?• Allows drainage of CSF to relieve elevated intracranial pressure• Can be connected to a transducer that records ICP

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 166 External Ventricular Drains

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 167 External Ventricular Drains

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 168 Treatment for Increased ICP

• Release of CSF through the external ventricular drain

• Positioning• Head of bed 30-45 degrees to increase cerebral venous drainage

• Environment (reduce stimuli)

• Blood pressure medication

• Sedation

• Osmotic diuretic (mannitol)

• Steroids

• Surgery (tumor excision, craniotomy)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 169

Cerebral Perfusion Pressure (CPP)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 170

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 171 Cerebral Perfusion Pressure (CPP)- What is it?

• Blood flow to the brain!!• Pressure at which the brain is perfused

• About 15-20% of cardiac output

• Best indicator of brain perfusion

• Lack of blood flow= impaired oxygen and metabolic delivery and ultimately loss of brain tissue

• Impacted by mean arterial pressure and intracranial pressure

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 172 Cerebral Perfusion Pressure (CPP)

•CPP= mean arterial pressure [MAP]- ICP

• CPP goals are 60-70 mmHg or ≥ 60 mmHg• 50 mmHg is critical level for occurrence of brain ischemia

• SAMPLE CALCULATION:• MAP of between 60 to 80 mmHg and an ICP about 10 mmHg

• CPP= (60-80) minus 10

= 50-70 mmHg

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 173 Decreased Cerebral Perfusion Pressure

•How does the body react to

changes in CPP?

Body senses decreased CPP and ischemia

Senses decreased systemic blood

pressure

Dilates cerebral blood vessels

Increased cerebral blood

volume

This increases ICP

This leads to decreased CPP

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 174 CPP- Implications

• Higher ICP from injury will require a higher CPP to maintain cerebral blood flow • Decreases in ICP can also positively impact cerebral perfusion HOWEVER in

most cases the MAP is adjusted to control CPP

• Blood pressure could be kept HIGHER to ensure adequate cerebral perfusion.

• Patients administered vasopressor agents to increase MAP• may lower ICP by improving perfusion

• allowing autoregulatory vasoconstriction as ischemia is relieved and ultimately decreasing intracranial blood volume

• Mortality increases approximately 20% for each 10 mmHg loss of CPP

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 175 Considerations for Rehab Professionals

• Patients may be sedated to try and reduce ICP• Reduction of metabolic demand

• Be aware of ICU’s parameters for the ICP before starting PT • If patient has an ICP of ~20, you may want to hold PT due to impact of elevation of

ICP on CPP

• Report changes in ICP during session• Changes that last ≥ 5 minutes are more concerning than brief changes

• Be aware of the ICP value and waveform on the monitor. The waveform may change shape if cerebral hypoxia or ischemia occurs.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 176 Considerations (continued)

• EVDs must be clamped • before getting out of bed, changing body position

from supine, or adjusting angle of bed

• Keep slack in the lines

• Must bring EVD collection bag/lines with mobility—2nd set of hands needed

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


• Patients with elevated ICP are positioned with head of bed (HOB) elevated at 30◦ to maximize venous flow. • Lowering HOB may increase ICP.

• Lateral neck flexion and extreme hip flexion may increase ICP

• Changing patient position in bed (sliding down) could affect drainage system

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


• Patient may only tolerate short bouts of activity.

• Monitor for signs and symptoms of ICP changes • headache, confusion, dizziness

• Monitor Glasgow Coma Scale score changes especially if patient has a brain injury

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


• ICP Normal: ~7-15 mm Hg

• ICP >20 mmHg (GCS 13-15)• patient drowsy and confused

• ICP > 30 mm Hg (GCS <8) • severe brain swelling

• patient non-participatory

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 180

Abdominal pressure and perfusion

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 181 Abdomen and Abdominal Cavity

• Organs

• Blood vessels

• Peritoneum

• Muscles

• Fascia

• Skin

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 182 Intra-abdominal Pressure (IAP)

• Our abdomen has a steady state pressure in our abdominal cavity.

• Pressure changes occur:• With postural changes• With movement of diaphragm• Physical activity• Coughing• Straining• Organ dysfunction• Fluid overload• Pregnancy

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 183 Intra-abdominal Hypertension(IAH)

• When IAP is sustained ≥12 mm Hg the patient now has intra-abdominal hypertension

Types of Intra-abdominal Hypertension (IAH)

Definition Cause

Hyperacute Elevation of IAP lasting for seconds

From coughing, sneezing, straining, physical activity

Acute Elevation of IAP that lasts for hours

Result of trauma or intra-abdominal hemorrhage

Subacute Elevation of IAP that lasts for days

Common with medical patientsand can last for days

Chronic Elevation of IAP that develops over months or years

Pregnancy or morbid obesity

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 184 Intra-abdominal Hypertension-Systemic Effects

Central Nervous System

Pulmonary

Cardiovascular

Kidney

Gastrointestinal

System Effects

Central Nervous System Cardiac System Pulmonary System

↑ Intracranial pressure Hypovolemia ↑ Intrathoracic pressure

↓ Cerebral perfusion pressure ↓ Cardiac output ↑ Airway pressure

Renal Function ↓ Venous return ↑ Peak inspiratory pressure

↓ Urinary output ↑ SVR ↓ Compliance

↓ Renal blood flow and ↓ GFR ↑PCWP and CVP ↑ Ventilation/perfusion Mismatch

Hepatic Function GI Function ↓ Functional residual capacity

↓ Portal blood flow ↓ Mucosal, celiac and SMA blood flow

↑ PaCo2

↓ Lactate clearance ↓ Renal blood flow ↓ PaO2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 185 Symptoms

• Tensely distended abdomen—classic sign

• Patients are critically ill and may be unable to communicate• Complaints of weakness, shortness of breath, abdominal pain, abdominal

bloating.

• As levels get higher they may need ventilator support.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 186 Transition of IAP to Abdominal Compartment Syndrome

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 187 Abdominal Compartment Syndrome (ACS)

• What is it?• Organ dysfunction that is caused by intra-abdominal hypertension

• Etiology• Injury or disease in the abdominopelvic region (pancreatitis, abdominal trauma)

• Severe burns

• Liver transplantation

• Trauma patients in shock with aggressive fluid resuscitation

• Medicine patients needing fluid resuscitation

• Post-surgical patients who are given large volume resuscitation

• Retroperitoneal conditions (ruptured AAA, pelvic fracture with bleeding, pancreatitis)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 188 Treatment of ACS and IAH

• Supportive care• reduce intra-abdominal volume through avoidance of adding extra fluid

• evacuation of intra-abdominal space-occupying lesions (i.e. ascites, hematoma)

• evacuation of intraluminal bowel contents

• improve abdominal wall compliance (pain meds and sedation)

• nasogastric and rectal drainage for patients with bowel distension

• positioning in supine to avoid increases in IAP

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 189 Treatment (continued)

• Surgical care• Open abdominal decompression with temporary abdominal closure

• May have temporary closure for days/weeks

• Could have open abdomen with closed or open fascia

• May be on a suction device

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 190 How to monitor intra-abdominal pressure

• Bladder catheter*

• Inferior vena catheters

• Intragastric catheters

• Intracolonic catheters

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 191

Abdominal Perfusion Pressure (APP)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 192 Abdominal Perfusion Pressure (APP)- What is it?

• Blood flow to the abdominal viscera!!

• High IAP leads to a lack of blood flow= impaired oxygen and metabolic delivery and ultimately loss of tissue, organ failure, and death

• Impacted by mean arterial pressure and intra-abdominal pressure

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 193 Abdominal Perfusion Pressure (APP)

•APP= mean arterial pressure [MAP]- IAP

• APP norms are 60-70 mmHg

• A target APP of at least 60 mmHg is correlated with improved survival from IAH and ACS

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 194 Considerations for Rehab Professionals

• Be aware of the APP and IAP levels before seeing patient and monitor during the session

• Be aware of what was done for open abdominal closure procedure• Open abdomen with open fascia- will be the most restrictive (may allow ROM

only)

• Open abdomen with closed fascia- may allow mobility with binder in place

• Be aware that changes in bed position will impact IAP• Some patients will need to be on bed rest

• These patients may be on sedation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________


• Patients who are s/p open abdominal decompression are STILL at rest for elevated IAP and for development of IAH and ACS

• Watch for signs of ischemia• Claudication pain

• UMN signs in the lower extremities (spinal cord ischemia)• weakness (no muscle wasting)

• clonus

• ↑ tone (may start out flaccid but then changes)

• ↑ reflexes

• + Babinski

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 196

Break

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 197

EKGElectrocardiography

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 198

Cardiac Action Potential

• Phase 0- depolarization- Na+ channels open

• Phase 1-prolonged action potential due to slow and extended opening of Ca+ channels -repolarization begins.

• Phase 2-outward flow of K+ and prolonged opening of Ca lead to a plateau phase

• Phase 3- closure of Ca channels and opening of K channels completes repolarization.

• Phase 4- resting phase Na and Ca are pumper out K is pumped in.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 199

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 200

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 201

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 202

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 203

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 204

EKG

• 12 Lead (view) of the heart

• Six Leads record frontal plane

• Six Leads record transverse plane

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 205

Frontal Plane Leads

• 3 Bipolar limb leads I, II, III

– Single positive and single negative electrode

• 3 augmented unipolar limb leads

– aVR (right arm)

– aVL (left arm)

– aVF (left leg)

Have single positive lead derive negative from a combination of other electrodes.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 206

Einthoven’s Triangle

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 207

Bipolar Leads

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 208

Augmented Leads

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 209

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 210 Axis Deviation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 211 Axis Deviation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 212

Precordial (transverse plane) Leads

• V 1-6

• V1 and V2 look at R Ventricle

• V3 and V4 look at the intraventricular septum

• V5 and V6 look at L Ventricle

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 213

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 214

EKG Evaluation

• What is the rate and pattern (regularity) is R-R interval equal for each beat?

• Is the a P wave before each QRS? = atrial

• Is the a QRS after every P wave?= conduction of atria to the ventricles

• P-R interval? Normal= 0.12-0.2 seconds > 0.2 seconds= conduction delay or block

• QRS normal duration (0.1 sec) and shape?

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 215

Calculating Rate

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 216

Calculating Rate

• Count the number of small boxes between two R waves and divide into 1500.

• Count the number of R waves in a six second strip and multiply by 10.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 217 Lets try it

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 218

Sinus Rhythms

• Sinus Rhythm- 60-100 bpm

• Sinus Bradycardia- < 60 bpm

• Sinus Tachycardia- > 100 bpm

• These rhythms have normal P waves, PR int and QRS int

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 219

Supraventricular Dysrhythmias

Atrial and Junctional Mechanisms

– Supraventricular tachycardia (SVT)

–Atrial tachycardia

–Atrial Flutter

–Atrial Fibrillation

– Junctional Rhythm

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 220 SVT

Rate- 150-250- regular rhythm- no visible P waves- PR not measurable-QRS .12 or less

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 221 Atrial Tachycardia

Rate 150-250- regular- 1 P per QRS- PR may be shorter, QRS .12 or less

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 222 Atrial Flutter

Atrial rate 250-450- ventricular varies- Atrial is regular-ventricular can be irregular- P wave- saw tooth- PR not

measurable- QRS <.12.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 223

Atrial FibrillationRate can vary- Irregularly Irregular- P waves chaotic- PR not measured- QRS <.12.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 224 Junctional RhythmRate- 40-60- regular- P waves inverted-before or after QRS or absent- PR if

present <.12- QRS .12 or less.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 225 Ventricular Dysrhythmias

Premature Ventricular Contraction (PVC)

–Bigeminy

–Ventricular couplet

–Multifocal PVC (>1 ectopic focus)

Ventricular Tachycardia

Ventricular Fibrillation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 226 PVC

Rate varies- Can be regular or irregular- P wave will be absent-unmeasurable PRI- QRS >.12.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 227 Bigeminy

1 PVC every other beat- regular-irregular rhythm

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 228 Ventricular Couplet

PVC occurs twice

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 229 Multi-Focal PVC

Can be both positive and negative since there are different ectopic origins

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 230 Ventricular Tachycardia

3 or more PVC with rate >100 bpm- patient can be asymptomatic-symptomatic or unconscious and pulseless.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 231 Ventricular Fibrillation

No organized rhythm- needs immediate defibrillation

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 232

Atrioventricular Blocks

First Degree AV Block

Second Degree AV Block• Mobitz Type 1- Wenckebach

• Mobitz Type 2

Third Degree AV Block

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 233 First Degree Heart Block

PR interval > .20s

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 234 Mobitz Type 1

PR interval progressively get longer than QRS drops

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 235 Mobitz Type 2

Regular dropped QRS every 2nd third or 4th P wave- consistent PR interval

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 236 Third Degree Heart Block

No conduction between A and V- both will have regular rates- Ps can be hidden in QRS

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 237 Story of the AV block Family

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 238 Bundle Branch Blocks

• Right Bundle Branch Block RBBB

• Left Bundle Branch Block LBBB

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 239 Left Bundle Branch Block

• Increased QRS >.10s

• Once a widened QRS > 0.10s is identified, we look at leads closest to the LV to identify a LBBB.Leads V5,V6, I, and aVL are in close proximity to the left ventricle, and as such, are the best location to identify a LBBB.

• Characterized by an RSR segment or notched QRS

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 240

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 241 Right Bundle Branch Block

Look at Right chest Leads V1 and V2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 242

Myocardial Infarction

• ST segment elevation

• ST segment depression

• Inverted T wave

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 243

ST segment elevation

• Transmural MI

• Use precordial leads to localize

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 244

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 245

ST segment depression

• Myocardial ischemia- can be diagnostic during exercise

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 246

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 247

Inverted T wave

• Myocardial ischemia (can be old)

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 248

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 249

EKG Lab

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 250 Case 1

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 251 Case 2

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 252 Case 3

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 253 Case 4

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 254 Case 5

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 255 Case Studies

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 256

Game Show Wrap Up

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 257 References Academy of Acute Care Physical Therapy (2017). Laboratory Values Interpretation Resource. Retrieved from

http://www.acutept.org/?page=ResourceGuides American Physical Therapy Association. (2016). Guide to Physical Therapy Practice 3.0. Alexandria: American Physical

Therapy Association. Retrieved from www.apta.org: http://guidetoptpractice.apta.org/site/misc/terms.xhtml American Physical Therapy Association. (2016). Guide to Physical Therapy Practice 3.0. Alexandria: American Physical

Therapy Association. Retrieved from www.apta.org: http://guidetoptpractice.apta.org/site/misc/terms.xhtml American Physical Therapy Association. (2016, May). The Movement System Brings it All. PT in Motion, 8(4), 14-21. American Physical Therapy Association, Movement System. http://www.apta.org/MovementSystem/. Accessed

10/30/2017. Anatomy and Physiology: Homeostatic regulation of the Vascular System. http://philschatz.com/anatomy-

book/contents/m46603.html. Accessed 10/30/17. Arbour R. Intracranial Hypertension Monitoring and Nursing Assessment. Crit Care Nurse October 2004 vol. 24 (5): 19-

32. Askandar, S., Bob-Manuel, T., Singh, P., & Khouzam, R. N. (2017). Shorter Door-To-Balloon ST-Elevation Myocardial

Infarction Time: Should There Be a Minimum Limit?. Current Problems in Cardiology, 42(6), 175-187. Bartlo, P., Brooks, G., & Cohen, M. (2015). Toward entry-level competencies in cardiovascular and pulmonary physical

therapy. Cardiopulmonary Physical Therapy Journal, 26(4), 99-107. Billek-Sawhney, B., Sawhney, R. (1998). Cardiovascular considerations in outpatient physical therapy. J Orthop Sports

Phys Ther. 27, 57. Burlew Cn et al. Trauma. In: Brunicardi F, et al. (ed). Schwartz's Principles of Surgery, 10e New York, NY: McGraw-Hill;

2015.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 258 References Cahalin, L.P., Mathier, M.A., Semigran, M.J., Dec, G.W., Disalvo, T. G. (1996). the six-minute walk test predicts peak

oxygen uptake and survival in patients with advanced heart failure. Chest, 110(2), 325-32. Chaboyer, W., Thalib, L., Foster, M., Ball, C., Richards, B. (2008). Predictors of adverse events in patients after

discharge from the intensive care unit. Am J Crit Care, 17(3), 255-63. Daamen, M. A. M. J., Brunner-la Rocca, H. P., Tan, F. E. S., Hamers, J. P. H., & Schols, J. M. G. A. (2017). Clinical

diagnosis of heart failure in nursing home residents based on history, physical exam, BNP and ECG: Is it reliable?. European Geriatric Medicine, 8(1), 59-65.

Damluji, Abdulla, et al. "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." Journal of critical care 28.4 (2013): 535-e9.

Dubb, Rolf, et al. "Barriers and strategies for early mobilization of patients in intensive care units." Annals of the American Thoracic Society 13.5 (2016): 724-730.

Fields, C., Trotsky, A., Fernandez, N., & Smith, B. A. (2015). Mobility and Ambulation for Patients With Pulmonary Artery Catheters: A Retrospective Descriptive Study. Journal of Acute Care Physical Therapy, 6(2), 64-70. doi:10.1097/JAT.0000000000000012

Fritz, S., Lusardi, M. (2009). White: paper: “Walking speed: the sixth vital sign.” J Geriatr Phys Ther, 32(2), 46-9. Frownfelter, D., & Dean, E. (2012). Cardiovascular and Pulmonary Physical Therapy Evidence and Practice (5th ed.).

St Louis: Elsevier-Mosby. Gestring, M. Abdominal Compartment Syndrome in Adults. In: UpToDate, Sanfey H (Ed), UptoDate, Waltham, MA,

2017. Goodman, C. C., & Fuller, K. S. (2015). Pathology Implications for the physical therapist. St Louis: Elsevier Saunders. Gokalp, Orhan, et al. "Cannulation in extracorporeal membrane oxygenation." Critical Care 18.4 (2014): 443.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 259 References Haines KJ, et al. Association of postoperative pulmonary complications with delayed mobilization following major

abdominal surgery: an observational cohort study. Physiotherapy 99 (2013) 119-125. Hall, J. B., Schmidt, G. A., & Kress, J. P. (2015). Principles of Critical Care. New York: Mcgraw-Hill Education. Hedges JS. et al. Chapter 4 Early Rehabilitation Interventions. In: Robinson LR (ed). Trauma Rehabilitation: Wolters

Klumer Health, 2005. Hemphill, JC et al. Management of acute severe traumatic brain injury. In: UpToDate, Aminoff, MJ (Ed), UpToDate,

Waltham, MA, 2017.Hemphill JC et al. Neurologic Critical Care, Including Hypoxic-Ischemic Encephalopathy, and Subarachnoid Hemorrhage In: Kasper D et al.(ed). Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill Education; 2014.

Ho VP, Barie PS. Acute Abdominal Dysfunction. In: Oropello JM, et al.. eds. Critical Care New York, NY: McGraw-Hill; Joyner, M. J., Casey, Darren, D. P. (2015). Regulation of Increased Blood Flow (Hyoeremia) to Muscles During Exercise:

A Hierarchy of Competing Physiological Needs. Physiol Rev, 95(2): 549-601. Kasper DL, et al. eds. Increased Intracranial Pressure and Head Trauma. In: Harrison's Manual of Medicine, 19e New

York, NY: McGraw-Hill; Kerr M, Crago EA. Nursing management: acute intracranial problems. In: O'Brien PG, Giddens JF, Bucher L, eds.

Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St Louis, Mo: CV Mosby Inc; 2004: 1491-1524.

Kirkman MA et al. Intracranial Pressure Monitoring, Cerebral Perfusion Pressure Estimation, and ICP/CPP-guided Therapy-A standard of care or optional extra after brain injury. Br J Anaesth. 2014;112(1):35-46.

Lundy-Ekman L C et al. Neuroscience Fundamentals for Rehabilitation. 4th ed, Saint Louis, Mo: Saunders; 2013.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 260 References Lyell, D., & Coiera, E. (2016). Automation bias and verification complexity: a systematic review. Journal of the American

Medical Informatics Association, 24(2), 423-431. Malone, D., Ridgeway, K., Norton-Craft, A., Moss, P., Schenkman, M., & Moss, M. (2015). Physical therapist practice in

the Intensive care Unit: results of a National Survey. Physical therapy, 95, 1335-1344. doi:10.2522/ptj.20140417 Malone DJ, Lindsay KLB. Physical therapy in acute care : a clinician's guide. Thorofare, NJ: Slack; 2006. Mariano GL, et al. Intracranial Pressure: Monitoring and Management. In: Hall JB, eds. Principles of Critical Care, 4e

New York, NY: McGraw-Hill; 2014. Martin, N. Management of the open abdomen in adult. In: UpToDate, Bulger EM (Ed), UpToDate, Waltham, MA, 2017. Matuskowitz, A. J., Carr, C. M., Jennings, L., Hall, G. A., & Saef, S. H. (2016). 107 How Good are Paramedics and

Emergency Physicians at Diagnosing a STEMI by EKG Compared to Cardiologists?. Annals of Emergency Medicine, 68(4), S43.

Mufti, T. S., Durkhanay W. (2016). Accuracy of Blood Pressure recording by Manual and Automated Digital Devices: A Clinical Guideline. J Rehman Med Inst, 2(2), 17-25.

Oropello JM, Mistry N, Ullman JS. Head Injury. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of Critical Care, 4e New York, NY: McGraw-Hill; 2014.

O’Sullivan, S., Schmitz, T., Fulk, G. (2014). Physical Rehabilitation. 6th ed. Parry, S. M., Granger, C. L., Berney, S., Jones, J., Beach, L., El-Ansary, D., . . . Denehy, L. (2015, Feb 5). Assessment of

impairment and activity limitations in the critically ill: a systematic review of measurement instruments and their clinimetric properties. doi:10.1007/s00134-015-3672-x

Paz J. Michelle West. Acute Care Handbook for Physical Therapist 4th edition St. Louis, Mo: Elsevier; 2014.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 261 References Paz J, West M. Acute care Handbook for Physical Therapists. 3rd ed. St. Louis: Saunders Elsevier; 2009 Perme, Christiane, et al. "Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a

prospective observational study." Cardiopulmonary physical therapy journal 24.2 (2013): 12. Pescatello, L.S. (2014). American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription. 9th ed.

Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins Health. Pierson, F. M. (2007). Principles and Techniques of Patient Care 4th Ed. St. Louis: Saunders. Ristic A et al. Current neuromonitoring techniques in acute care. Journal of Neuroanaesthesiology and Critical Care;

2015: 2(2): 97-103. Rodgers WK et al. Intraabdominal Hypertension, Abdominal Compartment Syndrome, and the Open Abdomen.

Chest;2017 Aug: epub ahead of print. Schlichting A, Schmidt GA. Abdominal Compartment Syndrome. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of

Critical Care, 4e New York, NY: McGraw-Hill; 2014. Schmalz, T., Blumentritt, S., Jarasch, R. (2002). Energy expenditure and biomechanical characteristics of lower limb

amputee gait: the influence of prosthetic alignment and different prosthetic components. Gait Posture. Dec; 16(3), 255-63.

Silva YR et al. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Physiotherapy 99 (2013) 187-193.

Smith ES et al. Evaluation and management of elevated intracranial pressure in adults. In: UpToDate, Aminoff, MJ (Ed), UpToDate, Waltham, MA, 2017.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Slide 262 References

Smith, I., Mackay, J., Fahrid, N., Krucheck, D. (2011). Respiratory rate measurement: a comparison of methods. British Journal of Healthcare Assistants. 5(1), 18-23.

Swan, H. J. C., et al. "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter." New England Journal of Medicine 283.9 (1970): 447-451.

The AVERT Trial Collaboration group. (2015). Effi cacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet, 386, 46–55.

Toonstra, Amy L., et al. "Feasibility and safety of physical therapy during continuous renal replacement therapy in the intensive care unit." Annals of the American Thoracic Society 13.5 (2016): 699-704.

Wang, Yi Tian, et al. "Early mobilization on continuous renal replacement therapy is safe and may improve filter life." Critical Care 18.4 (2014): R161.

Witcher, R., Stoerger, L., Dzierba, A. L., Silverstein, A., Rosengart, A., Brodie, D., & Berger, K. (2015). Effect of early mobilization on sedation practices in the neurosciences intensive care unit: A preimplementation and postimplementation evaluation. Journal of Critical Care, 30, 344-347. doi:10.1016/j.jcrc.2014.12.003

Wright DW, Merck LH. Head Trauma. In: Tintinalli JE, (et al.) eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

___________________________________

Documents

Mean for Complex Patient Management K. Levenhagen, Saint ......Demystifying What All Those Numbers Mean for Complex Patient Management J. Dyson, Orlando Health, Orlando, FL ... Rhythm