Critical Care

Concepts
Archer Review Crash Course

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 Ventilators

Terminology
● Peak Inspiratory Pressure (PIP): The highest level of pressure in the lungs during
inhalation.
● Positive End Expiratory Pressure (PEEP): The amount of pressure in the alveoli at
the end of expiration.
● Fraction of inspired oxygen (FiO2): How much oxygen the patient is getting.
21-100%
● Tidal volume (TV): The amount of air that is inhaled during one respiratory cycle.
● End-Tidal Carbon Dioxide (ETCO2): The partial pressure of CO2 detected at the
end of exhalation.
● Room air: The atmospheric air we breathe under normal circumstances. It has an
FiO2 of 21%.
Ventilator Modes
Volume-controlled: There is a certain volume of air delivered to the patient with each
breath.
Pressure-controlled: The lungs are inflated to a certain pressure.
CPAP: Continuous Positive Airway Pressure. There is continuous positive airway
pressure, while the patient controls their respiratory rates and volumes.
BiPAP. Bilevel Positive Airway Pressure. There is positive airway pressure, set at
different pressures for inspiration and expiration.

Alarms
High Pressure Alarms Low Pressure Alarms
Pressure in the circuit is too high. Pressure in the circuit is too low.

Causes: Causes:
Patient coughing Tubing is disconnected
Gagging Loose connections
Bronchospasm Leak
Fighting the ventilator Extubation
ETT occlusion Cuffed ETT or trach is deflated
Kink in the tubing Poorly fitting CPAP/BiPAP mask
Increased secretions
Thick secretions
Water in ventilator circuit
 Hemodynamic Monitoring

Terminology
Preload Amount of blood returning to the right side of the
heart

Afterload Pressure against which the left ventricle must

pump to eject blood.

Compliance How easily the heart muscle expands when filled

with blood.

Contractility Strength of contraction of the heart muscle.

Stroke Volume Volume of blood pumped out of the ventricles with

each contraction.

Cardiac output The amount of blood pumped out

of the ventricles with each
contraction.
Cardiac Output
WHY is cardiac output SO important?!

● Tissue perfusion!
● End organ function
● Delivery of oxygen and nutrients to each and every cell in the body!
● Poor cardiac output??
○ Decreased LOC (not enough blood flow to the BRAIN)
○ Chest pain, weak peripheral pulses (not enough blood flow to the HEART)
○ SOB, crackles, rales (not enough blood flow to the LUNGS)
○ Cool, clammy, mottled extremities (not enough blood flow to the SKIN)
○ Decreased UOP (not enough blood flow to the KIDNEYS)

CO = SV X HR

↑ Preload → ↑ CO ↓ Preload → ↓ CO

↑ Afterload → ↓ CO ↓ Afterload → ↑ CO

↑ Compliance → ↑ CO ↓ Compliance → ↓ CO

↑ Contractility → ↑ CO ↓ Contractility → ↓ CO

↑ Stroke Volume → ↑ CO ↓ Stroke Volume → ↓ CO

Causes of DECREASED CO Causes of INCREASED CO
● Bradycardia
● Arrhythmias ● Increased blood
○ Pulseless v-tach volume...sometimes
○ V-fib ● Tachycardia...sometimes
○ Asystole ● Medications
○ SVT ○ ACE Inhibitors
● Hypotension ○ ARBS
● MI ○ Nitrates
● Cardiac muscle disease ● Inotropes

Normal hemodynamic Values

Swan-ganz catheter

Vasoactive Infusions
Common Indications
● Cardiac arrest
● Hypotension
● Shock refractory to fluid resuscitation
● Cardiac disease
○ Acquired
○ Congenital

Vasoactive infusions
Inotropes

● Act by increasing the force of myocardial contractility

Vasopressors

● Mimic sympathetic nervous system to cause vasoconstriction

Adrenergic Receptors

● Primarily found is ● Found in heart and ● Primarily found in

vascular smooth muscle intestinal smooth bronchial vasculature
● Peripheral muscle ● Bronchodilation
vasoconstriction ● Increase contractility ● Coronary artery
● Increased SVR ● Increase SV, HR, and CO vasodilation

Epinephrine
● Most often used in cold shock
● Low doses act on beta-1 receptors
○ Increase the cardiac output
● High doses act on alpha-1 receptors
○ Increase systemic vascular resistance → increase BP
Norepinephrine
● Most often used in warm shock
● Acts on alpha-1 receptors
● Causes peripheral vasoconstriction → increases BP
● Increases cardiac output

Dopamine
● Used in trauma patients and cold shock
● Low doses used in kidney failure to increase renal blood flow
○ ‘Renal dopa’
● Low doses increase contractility → Increase CO
● Higher doses cause vasoconstriction → Increase SVR → Increase BP
Phenylephrine
● Used for anesthesia-induced hypotension
● Second line agent in some shock patients
● Only acts on alpha-1 receptors
● Causes only vasoconstriction - no inotropy
● Vasoconstriction → Increased BP

Milrinone
● Used in patients with:
○ Cardiogenic shock
○ Decreased cardiac output
○ Congenital/acquired heart defects
● Causes systemic vasodilation, pulmonary vasodilation, decreased
afterload, & increased contractility.
● Doesn’t increase oxygen consumption
● How it works: phosphodiesterase inhibitor
○ Phosphodiesterase breaks down cAMP
■ cAMP - Cyclic adenosine monophosphate → a derivative of adenosine triphosphate (ATP) and
used for intracellular signal transduction. Basically… helps the cells of the heart muscle
contract!
○ By inhibiting the breakdown of phosphodiesterase, there is more cAMP, which means more
contractility.
 Vasopressin
● Antidiuretic hormone (ADH)
● ANTI-diuresis…. Less diuresis → more volume IN the vascular system.
○ More volume → more pressure!
○ Raises BP
● Second line in vasodilatory shock
● Third line in septic shock
○ 1st: Dopa or Norepi
○ 2nd: Epi or phenylephrine
○ 3rd: Vaso

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 Break!
Back at...

Drip
Calculations
 (Dose x weight x 60 minutes) ÷ concentration

Dose: How much medicine do you want to give the patient every minute? What is
the order?
Weight: MUST be in kg! If given to you in lb, convert to kg!

Minutes: If given to you in minutes, convert to hours. 1 hour = 60 minutes.

Concentration: How much (mg or mcg) per mL.

Step 1: (mcg x kg x 60 minutes) = mcg/hr

Step 2: mcg/hr ÷ mcg/mL = mL/hr

Hint: For a drip question, your final answer should be in mL’s per hour!! (How FAST
the medicine is going in)

NCLEX Question
While working in the PICU, you are checking the drip rates of your
vasoactive infusions. Your patient is ordered to have epinephrine
running at 0.03 mcg/kg/min. Their weight is 10kg. The concentration of
the epinephrine bag is 20 mcg to 1 mL. What rate should the pump be
set to?

a. 0.99 mL/hr
b. 0.9 mL/hr
c. 0.09 mL/hr
d. 9 mL/hr
Answer: A: 0.9 mL/hr
First multiply the dose (.03 mcg) by the weight (10 kg) by 60 (to
convert from minutes to hours):
(.03 mcg x 10 kg x 60 min) = 18 mcg/hr

Next divide this dose by the concentration (20mcg/1mL):

18mcg/20mcg = 0.9 mL/hr

NCLEX Question
While working in the ICU, you are initiating a vasopressin drip. The provider orders
1.5 U/kg/hr. Their weight is 144kg. The concentration of the vasopressin is 20 units
to 1 mL. What rate should the pump be set to?

____________________________ mL/hr
Answer: 10.8 mL/hr
For rate calculations use the formula (Dose x weight x 60 minutes) ÷ concentration

Dose: 1.5 U/kg/hr

Weight: 144 kg
Minues: **In this problem, they gave you an order in HOURS, so you don’t need to multiply by
minutes!! This step is only to convert minutes--> hrs for a drip rate, so if you already have
hours, don’t multiply!!**
Concentration: 20 U/1mL

Step one: 1.5 U x 144 kg = 216 U/hr

Step two: 216 U/hr ÷ 20 U/mL = 10.8 mL/hr

NCLEX Question
While working in the ICU, you are titrating a milrinone drip. The provider orders for the
drip to be increased to 0.5mcg/kg/min. Their weight is 27kg. The concentration of the
milrinone is 0.5 mg to 1 mL. What rate should the pump be set to?

____________________________ mL/hr
Answer: 1.62 mL/hr
For rate calculations use the formula (Dose x weight x 60 minutes) ÷ concentration

Dose: 0.5mcg/kg/min
Weight: 27 kg
Minues: **In this problem, they gave you an order in minutes, so you need to multiply by 60 to convert to hours**
Concentration: 0.5 mg/mL

Step one: 0.5 mcg x 27 kg x 60 minutes = 810 mcg/hr

Step two:
First you need to convert your concentration to mcg/mL so everything is in the same units. 0.5mg x 1,000 = 500
mcg/mL

810 mcg/hr ÷ 500 mcg/mL = 1.62 mL/hr

CPR
Unconscious patient
1. Try to wake the patient, yell and shake them.
a. Sternal rub
2. Check their pulse
a. Adult - carotid; infant - brachial
b. NO LONGER than 10 seconds
3. Press the code bell & yell for help

Patient has no pulse

1. Start chest compressions
a. 100-120 beats/min
b. Depth: 2 inches
c. Allow full chest recoil
2. Have someone get the crash cart
CPR Cycles
● 30 compressions: 2 breaths
● 2 minutes
● At 2 minute mark; check rhythm and pulse
● If patient still pulseles, switch compressors
and resume compression
● NEVER stop compressions for more than
10 seconds.

Shock
● Allow AED to analyze rhythm
● Follow prompts
● If ‘shock advised’, resume
compressions while device charge
● Clear patient when AED advises
● Ensure patient completely clear, and
deliver shock
● IMMEDIATELY resume compressions
Infant CPR
● 2 rescuers: compression to breath ratio is 15:2
● Use two fingers for compressions
● Compress to a depth of ⅓ the AP diameter

NCLEX Question
You arrive at the bedside of a 51 year old patient who was found unconscious,
CPR is in progress. Which of the following actions if observed would require
you to intervene? Select all that apply.

A. Providing 15 compressions for every 2 breaths

B. Providing compressions with two fingers
C. Allowing for full chest recoil.
D. Checking for a pulse for 10 seconds.
Answer: A & B
A is correct. In a 51 year old patient, it would not be appropriate to provide
compressions and breaths in a 15:2 ratio. This is the correct ratio for infant
CPR.

B is correct. Providing compressions with two fingers is not appropriate in an

adult patient. The nurse should use both hands to compress to a depth of 2
inches. The 2 finger technique is appropriate only in infant CPR.

C is incorrect. Allowing for full chest recoil is an appropriate action. No

intervention is needed.

D is incorrect. Checking for a pulse for 10 seconds is an appropriate action. No

intervention is needed.

ICU Devices/Equipment
Arterial Line

Central Venous Catheter (CVC)

CRRT

Cardiac Devices
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