mechanical ventilator

Neuro Pharmacology: Remember!!!

Anticonvulsants

  • Barbiturates INDUCE lipid soluble drugs metabolism, meaning, its effect last less than normal. Example of lipid soluble drugs: Oral Contraceptives (OCP), warfarin, phenytoin, carbamazepine.
  • OCP DECREASES BZD metabolism.
  • Anticonvulsants DECREASES OCP efficacy, bc of Cyt p450 induction, eg: Phenytoin, Carbamazepine, Phenobarbital.
  • Women & Anticonvulsants: if pt wants to get pregnant, change to Phenobarbital (safest bc >protein bound); if pt don’t wanna get pregnant and is taking OCP, change to Valproic Acid (bc is a Cyt p450 inhibitor!)
  • Avoid abrupt withdrawal of Anticonvulsants bc it can precipitate seizures and increases risk of status epilepticus!!!
  • Carbamazepine SE: increased ADH secretion & Steven Johnson Sd.
  • Phenytoin SE:

  • Valproic Acid SE:

  • Valproic Acid & Ethosuximide: abscense seizures.

Anesthetics

  • Atracurium, Mivacurium: drugs used in anesthesia as muscle relaxants, Nicotinic Antagonists, non depolarizing competitive drugs.
  • Laudanosine is a metabolite of Atracurium (spontaneous inactivation) crosses BBB and can cause seizures.
  • Halothene SE: malignant hyperthermia, hepatitis, <3 arrythmias
  • Ketamine: dissociative anesthesia (pt is aware of pain, but gives zero fucks about it) stimulates CV function (good for elders with <3 problems)
  • Ketamine SE: vivid nightmares, increase ICP 

  • Succynilcholine SE: Malginant hyperthermia, hyperkalemia, atypical pseudocholinesterase.
  • Dantrolene: tx for malignant hyperthermia, Neuroleptic Malignant Sd (NMS)

Opioids

  • Opioid Acute Toxicity Classic Triad: CPR, Coma, Pinpoint pupils, Respiratory Depression 
  • Meperidine: is also antimuscarinic, pt won’t have miosis!!!!! (pt will also be tachycardic, no GI, GU gallblader spasm) Metabolized to Normeperidine (serotonin reuptake inhibitor, caution with Serotonin sd)
  • NEVER GIVE O2 WHEN GIVING OPIATES -UNLESS YOUR PT IS MECHANICALLY VENTILATED- BC YOU TAKE AWAY THE HYPOXIC DRIVE (that thing that tells the body: “hey dude, you gotta breathe more cause your O2 is falling”) AND SINCE PTS TAKING OPIATES HAVE A DECREASE RESPONSE TO ↑PCO2, YOU’LL LEAVE PT WITH NOTHING

  • When giving opiates as a long-term tx, it can cuase norepinephrine levels to decrease. As a response, the body makes more alpha1 & beta1 receptors. When long-term tx is stopped, a massive sympathetic response can happen, so, to prevent that, give clonidine (alpha2 agonist) that will decrease NE and cancel the sympathetic response.
  • Methylnaltrexone: for opioid induced contispation (cancer pts)

Parkinson Disease Drugs

  • Amantadine SE: livedo reticularis

Typical Antipsychotics: 

  • Thioridazine: cardiotoxicity (torsades), retinitis pigmentosa, ↓↓↓EPS

  • Droperidol: NMS, Tardive Dyskinesia
  • Fluphenazine: long acting injection (given e/ 2-3w), EPS.
  • Haloperidol: NMS, Tardive Dyskinesia, torsades
  • Chlorpromazine: NMS, corneal pigmentation, EPS

  • Loxapine: last to be given, antagonist D1 to D2
  • Tx for NMS: Bromocriptine, Dantrolene, Pergolide

Atypical Antipsychotics: 

  • Clozapine: AGRANULOCYTOSIS (weekly WBC), increased salivation (wet pillow syndrome)
  • Quetiapine: QT prolongation, drug monitoring
  • Ziprasidone: elders w/ dementia increased mortality, IM
  • Risperidone: Insomnia, PRL↑
  • Aripiprazole: partial agonist D2 & 5HT1, antagonist 5HT-2, adjunct tx for depression, akathisia

Antidepressants

  • MAO inhibitors SE: tx w/ Phentolamine (alpha1 antagonist) or Chlorpromazine (antipsychotic)
  • SSRI SE: anorgasmia :(, bruxism, weight loss 
  • Bupropion: DA reuptake inhibitor, associated w/ seizures, mimics drug addiction chemestry, bc increases DA in mesolimbic system.
  • Varenidine: partial Nicotinic receptor agonist (Mnemonic: “Vane & Nadine are trying to quit smoking”)
  • Both drugs are used in smoking cessation

    oh dear God! you are awful but I miss you so much 

  • SNRI: Venlafaxine (no ANS side effects, bc is a nonselective 5HT, NE reuptake blocker), Desvenlafaxine, Duloxetine.

Bipolar Disorder

  • Lithium: prevents recycling of inositol (decrease PIP2) and decrease cAMP; SE.. 

    Tx NDI with amiloride, triamterene (don’t give thiazides, it decreases Li clearance)
  • Never give Lithium to a pregnant women!!!!! If BD, change to Gabapentin & Clonazepam

ADHD

  • Methylphenidate: amphetamine-like
  • Atomoxetine: NE reuptake inhibitor
  • Do not stop this drugs abruptly! Withdrawal causes severe depression & suicide ideas

Dear people, dear fellow witches,religious people,

This is my new cousin, he’s a month old. Some weeks ago he caught a cold, it got worse and now it’s pneumonia.

For those that don’t know, pneumonia can be fatal for a kid. But this is worse, he’s a new born.

Last night his mother told us he now needs a mechanical ventilator aid. He’s literally plugged in.

I ask you for your blessings, any little ritual or prayer you believe on for this little guy to get better. He could really die.

If you can’t do this or don’t want to do it, please reblog, signal boost.

Thank you.

Sure thing! 

So a patient gets put on a ventilator when:

  • They have significant damage to the muscles that control respiration
  • They are paralyzed from a drug that prevents those muscles from working (like during surgery)
  • Their lungs are so damaged/full of fluid that the muscles aren’t strong enough (or have become too exhausted) to pull air in/keep fluid from building up further (this can be for many reasons, the most common being severe burns, pneumonia, bronchiolitis in children, cancer, and poorly controlled right-sided heart failure).

Scenarios where this might be applicable in fanfiction:

  • Character receives a gunshot/stab wound to the upper abdomen, where the diaphragm is pierced or otherwise badly damaged.
  • Character is envenomated by a blue-ring octopus or some other paralyzing neurotoxic venom.
  • Bow-and-Arrow-themed superhero ironically receives a typically lethal dose of curare (a personal fav).
  • Character sustains injuries involving multiple broken ribs, rendering breathing excessively difficult/painful.
  • Character sustains severe burns with suspected inhalation injuries (burns in the lung) and their lungs are swelling/filling with fluid.

I’m going to talk about ventilators for a second before getting into the meat of your question. There are two distinct types of mechanical ventilation. Positive Pressure (PP) Ventilation and Negative Pressure (NP) Ventilation

PP Ventilation is what most people think of when they think of a ventilator. This type of ventilator consists of a tube that either goes down a patient’s throat or through a hole in their windpipe called a tracheostomy. The tube is connected to a computerized and mechanized reservoir of air that pushes a set quantity of air through the tube into the patient’s lungs. Patients then (usually) breathe out passively. These can be set to “breathe” either a certain number of times per minute or to detect the beginning of a patient’s breath and only “assist” with the breath instead. 

Here is a video that demonstrates breathing and shows how this machine typically works. These machines look like this:

In NP ventilation there is no tube going into the patient’s lungs. This machine works by changing the air pressure around the patient’s body, causing the chest to expand and take in air. One familiar example of this is the iron lung. While these are not typically used today, one of their descendants, called the biphasic cuirass ventilator (BCV), is (link is to a video). This is like a wearable mini iron lung and looks like a turtle shell: 

It is possible for people to be on both types of ventilators while awake.

Trauma patients usually need to be on PP ventilation, and will be at least partially sedated during their time on a vent, on painkillers, and anti-anxiety drugs. This means they usually aren’t particularly “with it” during this time. The sedatives and anti-anxiety drugs are used with PP ventilation because the experience can be very scary and uncomfortable for patients (think of not being able to move while your brain is telling you you’re suffocating, even though you aren’t, combined with pain from other injuries, unfamiliar surroundings/noises from the machine/hospital in general). Most people wouldn’t want to experience/remember that.  Painkillers would be less for the ventilation itself and more for other injuries, but could still have a significant impact on consciousness.

That being said, the moment in a fanfic where a character wakes up on a PP vent and is told “Don’t fight it!” can be accurate in limited circumstances. In this situation, if the patient is fighting the ventilator, it may be time to change the vent setting to one where the patient initiates the breaths (see above). If the character’s breathing still needs to be entirely mechanically controlled for another reason, doses of sedative medication may need to be changed. Irl, it would be unacceptable to simply leave a patient in a condition where they were constantly fighting the ventilator. Even if the patient was calm and trying really, really hard not to fight it, it would likely still be a mentally and physically exhausting and uncomfortable experience for them. 

People who are more used to being on a ventilator (long term patients) may need fewer interventions/drugs to stay comfortable. It is possible to “get used to it” over time. Those who are conscious/calm enough to communicate typically can do so through writing or a book/board with pictures they can point to that help express their needs/answer questions. These patients can answer questions like “What is your name and birthday?” “What year is it?” and “Point to the picture of a dog” In order to determine mental status.

Measuring mental status with sedated patients is done through observational scales like this one: 

Patients on NP ventilation have no need for paralytic or sedative drugs to initiate or continue ventilation. They can talk and even eat normally while wearing a BCV, and movement is only slightly restricted. However, it is much less likely that a BCV would be used in a trauma situation because it requires an intact chest cavity to work, and because it does squeeze and pull at the chest, it could cause more pain and damage to injured bones and muscles..

Hope this answered your question!

PS, if you haven’t read this SGA fic, you may love it.

Pneumothorax

Imagine your lungs. Now, imagine one of your lungs collapsing. Serious, right? So what happens when you’re on the floor and a patient’s lung collapses?

First of all:  how will you know it occurred? Assessment

  • absent breath sounds on affected side
  • decreased chest expansion unilaterally
  • sharp chest pain
  • tachypnea
  • tracheal deviation to the unaffected side (tension pneumothorax) [occurring when there’s a buildup of air from INSIDE; i.e. defect in mechanical ventilation]

Second:  how will you intervene? Intervention

  1. Priority:  apply a nonporous dressing over an open chest wound
  2. Administer oxygen as prescribed
  3. Place patient in Fowler’s position (as with any patient with a respiratory problem to allow for increased lung expansion)
  4. Prepare patient for chest tube

Um, what’s a “chest tube” and what do you look for once it’s in place?

A chest tube drainage system facilitates the return of negative pressure to the intrapleural space in order to expand the lungs.

A chest tube drainage system (aka Pleur-Evac) will consist of a (1) water seal chamber and (2) suction control chamber

Water seal chamber

  • With the chest tube submerged in water, this chamber allows fluid and air OUT, but NOT in.
  • This chamber should move up and down as the patient inhales and exhales, respectively
  • Excessive bubbling indicates an air leak

Suction control chamber

  • This chamber, with the appropriate amount of water, provides the suction to facilitate negative pressure to the chest and prevents lung tissue from being sucked in (which is obviously not desirable)
  • Gentle bubbling is expected and indicative of proper suctioning

Assessing the Pleur-Evac and Interventions

  • Report bright red drainage to HCP
  • Report continuous bubbling in water seal chamber to HCP
  • Maintain an occlusive sterile dressing over chest tube insertion site
  • Assess respiratory status frequently
  • Keep the Pleur-Evac below the patient’s chest and free of kinks
  • Encourage deep breathing and coughing
  • IF the Pleur-Evac cracks or breaks, place the chest tube in water to prevent air from entering lung
  • IF the chest tube is pulled out of the chest, immediately apply a sterile, occlusive dressing over the area and notify the HCP

CO2, but from where?

Geologists have many records that tell the story of the last glacial maximum, the time between about 20,000 and 15,000 years ago when the glaciers of the last ice age reached their peak size and started to retreat. Ice cores, sediment cores, records of plants, soil, wind-blown loess deposits, ice-rafted debris in the ocean, etc. One story told over and over is that CO2 in the atmosphere went up significantly, from about 180 ppm to 280 ppm (for comparison, we’re currently very close to 400 ppm). That CO2 pulse into the atmosphere warmed the planet and created a runaway process that melted the glaciers.

One big question has always remained though; where did this CO2 come from? We know where the CO2 pulse today is coming from; fossil fuels, but 15,000 years ago there were no coal plants.

Keep reading

Things Change Pt.12

Part 11

I accept all your love/depression. It’s reasonable. People react that way. Trust the long, painful, somewhat rewarding journey.

Enjoy!

The five stages of grief: denial, anger, bargaining, depression, acceptance. He couldn’t tell if he was still at denial, or had reached to anger.

Everything moved in slow motion as they walked through the foreign hospital. Doctors, nurses, patients, gurneys, they all whished past Owen slowly, ignoring him as if he didn’t even exist. He was lost in a daze as the police officers led them to a waiting room before leaving.

Keep reading

2

Polio and the Iron Lung,

From the early 1900’s up to the 1960’s polio ravaged Europe and North America, crippling hundreds of thousands of people.  A dangerous virus that causes severe fever,  in about 1% of cases the disease will cause damage to the motor neurons of the central nervous system (brain, spinal chord).  This causes muscular disorders and paralysis for victims who face such a symptoms.  Thousands of children and adults lost the ability to walk in the early 20th century, even future US President Franklin D. Roosevelt.

For others the consequences were even more dire. Many lost the ability to breathe as the disease paralyzed the diaphragm, which is the primary muscle of respiration. When a person breathes , the diaphragm contracts,  causing the lungs to expand as well as the chest and ribs.  This expansion causes the pressure within the lungs to be lower than the outside air.  As a result air rushes into the lungs leading to inhalation.  When the diaphragm relaxes, pressure within the lungs increases resulting in air rushing out of the lungs, or exhalation.  A person suffering from paralysis above the diaphragm may have severe problems with respiration, or may not be able to breathe at all as the diaphragm is unable to contract.  Often such people may need mechanical assistance with breathing.

In the late 1920’s and 1930’s the first negative pressure ventilators were introduced to aid people who had breathing problems due to paralysis, most notably victims of polio.  Colloquially known as the “iron lung”, the negative pressure ventilator worked by creating pressure changes which aided a dysfunctional diaphragm.  The iron lung consisted of a large airtight tank in which the patient laid in, with his or her head sticking out. The pressures within the tank would rise and fall, simulating the changing pressures within the lungs. Unfortunately the patient was completely confined to and dependent of the iron lung throughout treatment.  However most patients would be rehabilitated as nervous system and diaphragm regained motor control.  Most patients would only spend a few weeks within the lung.  Many however, would be forced to spend months, years, or even a lifetime in the machines.  

The use of the iron lung skyrocketed in the 1940’s and 1950’s as the polio epidemic peaked.  The number of people paralyzed by polio made demand so high, that they were put to use mere hours after production.  Many city hospitals had entire wards and floors which had nothing but rows and rows of iron lung machines.  The prevalence of iron lung machines decrease in the 1960’s after massive government sponsored vaccination programs nearly eradicated the disease in developed nations.  In addition, more portable and efficient negative pressure ventilators were developed which replaced the iron lung, forefathers of mechanical ventilators today.  By 2008, the number of people dependent on iron lung machines in the US numbered only 30.  An Australian woman named June Middleton is credited for living the longest in an iron lung, spending 50 of her 83 years within the machine.  Today, Polio is all but eradicated within developed nations as most of the population is immune to virus.  In poorer nations polio continues to be a scourge that maims thousands.

Da Vinci's Resume

I posted this before when I started job hunting but I’m going to post this again now that I am getting job interview requests and will probably start interviewing next week. One other job hunter in history was Leonardo Da Vinci, who in 1488 sent this letter to the Duke of Milan requesting the position of his personal engineer.

Most Illustrious Lord, Having now sufficiently considered the specimens of all those who proclaim themselves skilled contrivers of instruments of war, and that the invention and operation of the said instruments are nothing different from those in common use: I shall endeavor, without prejudice to any one else, to explain myself to your Excellency, showing your Lordship my secret, and then offering them to your best pleasure and approbation to work with effect at opportune moments on all those things which, in part, shall be briefly noted below.

1. I have a sort of extremely light and strong bridges, adapted to be most easily carried, and with them you may pursue, and at any time flee from the enemy; and others, secure and indestructible by fire and battle, easy and convenient to lift and place. Also methods of burning and destroying those of the enemy.

2. I know how, when a place is besieged, to take the water out of the trenches, and make endless variety of bridges, and covered ways and ladders, and other machines pertaining to such expeditions.

3. If, by reason of the height of the banks, or the strength of the place and its position, it is impossible, when besieging a place, to avail oneself of the plan of bombardment, I have methods for destroying every rock or other fortress, even if it were founded on a rock, etc.

4. Again, I have kinds of mortars; most convenient and easy to carry; and with these I can fling small stones almost resembling a storm; and with the smoke of these cause great terror to the enemy, to his great detriment and confusion.

5. And if the fight should be at sea I have kinds of many machines most efficient for offense and defense; and vessels which will resist the attack of the largest guns and powder and fumes.

6. I have means by secret and tortuous mines and ways, made without noise, to reach a designated spot, even if it were needed to pass under a trench or a river.

7. I will make covered chariots, safe and unattackable, which, entering among the enemy with their artillery, there is no body of men so great but they would break them. And behind these, infantry could follow quite unhurt and without any hindrance.

8. In case of need I will make big guns, mortars, and light ordnance of fine and useful forms, out of the common type.

9. Where the operation of bombardment might fail, I would contrive catapults, mangonels, trabocchi, and other machines of marvellous efficacy and not in common use. And in short, according to the variety of cases, I can contrive various and endless means of offense and defense.

10. In times of peace I believe I can give perfect satisfaction and to the equal of any other in architecture and the composition of buildings public and private; and in guiding water from one place to another.

11. I can carry out sculpture in marble, bronze, or clay, and also I can do in painting whatever may be done, as well as any other, be he who he may.

Again, the bronze horse may be taken in hand, which is to be to the immortal glory and eternal honor of the prince your father of happy memory, and of the illustrious house of Sforza.

And if any of the above-named things seem to anyone to be impossible or not feasible, I am most ready to make the experiment in your park, or in whatever place may please your Excellency - to whom I comment myself with the utmost humility, etc.

 


I purposely patterned my own resume after Da Vinci’s.  I know there are certain formats that are used (chronological, functional, etc.) but I threw that out the window.  Instead, I started by listing in bullet points in fine detail my skills, what I have experience doing, and what I can do.  It is the very first thing the employer looks at, and I wrote it in a first person style that is very bold and in your face, just like Da Vinci.  I didn’t lie nor was I deceptive, but I made it an emphasis to show the employer, “hey, this is what I can do for you!”. After that I then listed my clinical experience, job history, education, certifications, awards, etc. We are all standing on the shoulders of giants, it’s a good idea to follow the examples of the masters, and Da Vinci was the maestro.  BTW, Da Vinci got the job.  I just wish I knew how he handled job interviews.

-I have a year and a half of hands on experience in the Emergency Department, ICU, and General Floors.

-I have treated a wide variety of patients such as patients with chronic illnesses, traumatic injury, cardiac arrest, pulmonary embolism, pulmonary edema/congestive heart failure, severe burns,  alcohol intoxication, drug overdose, and various other illnesses and medical conditions.

-I have experience setting up and managing mechanical ventilators, both invasive and non-invasive, using a variety of modes and settings.

-I make it a point to answer all emergency codes and rapid responses. Thus I have performed or assisted in many emergency and acute care interventions such as advanced cardiac life support procedures, intubation, endoscopic examination and suctioning, resuscitation, and chest tube insertion.

-I have performed a wide variety of floor therapies such as oxygen administration, hyperinflation therapy, MDI/DPI administration, nebulizer treatments, patient education, and bronchopulmonary hygiene.

-I have performed many diagnostic tests and procedures including bedside spirometry, electrocardiography, the drawing of blood gasses, and the analysis of blood gasses.

- I am willing to learn new therapies, techniques, and become cross trained in other fields. I always try to be a part of the larger healthcare team by helping out other therapists, nurses, and hospital professionals.

- I have some experience is specialty fields such a neo-natal care, pulmonary rehabilitation, and pulmonary function testing.

-I believe that all patients should be treated with respect and dignity.

I used calculus for the first time in med school today.

And it was like…accidental calculus as I was trying to understand mechanical ventilator management.

This Word

Rory said, pointing to the little piece of parchment she was reading about Blast Lung Injuries. The part she was stuck on said,  If ventilatory failure is imminent or occurs, patients should be intubated; however, caution should be used in the decision to intubate patients, as mechanical ventilation and positive end pressure may increase the risk of alveolar rupture and air embolism. “What is… in..tubat…ed?”

As a respiratory therapist I would make an excellent Jedi to go up against Darth Vader because I would know which buttons to flip with the force on his portable mechanical ventilator.

Mechanical Ventilators used so far in Peashooter’s career as a respiratory therapist.

Newport HT-50 Transport Ventilator

Respironics Esprit V200

Puritan Bennett 840

Drager V500

AVEA

Sidious Medical Systems Imperial Puffs 990

On the 12th day of Christmas my true love gave to me...

12++++ breathing treatments

11 EKG’s

10  People with cough who shouldn’t have come to the damn ER and are wasting our time.

9 Acute Chest Pains

8 Arterial Blood Gasses

7 Fall Victims

6 COPD exacerbations

5 Congestive Heart Failures

4 Alcohol Poisonings

3 Narcotic Overdoses

2 Pneumothoraxes

And a guy found unresponsive who went in cardiac arrest and respiratory failure and needed to have CPR, be intubated, and placed on mechanical ventilation… in a tree!!!!