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33 Cards in this Set
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Endotracheal Tube with subglottic suctioning
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Clinical studies have shown that elimination of subglottic secretions decreases the risk of VAP (Ventilator Associated Pneumonia). The new ETT Suction features an integrated suction line for easy removal of this secretion to reduce the incidence of VAP.
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Oropharynx
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The Oropharynx (oral part of the pharynx) reaches from the Uvula to the level of the hyoid bone.
It opens anteriorly, through the isthmus faucium, into the mouth, while in its lateral wall, between the two palatine arches, is the palatine tonsil. |
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Importance of cuff pressure
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Establishing a secure airway via endotracheal intubation is a critical clinical skill and lifesaving technique commonly used in the prehospital setting. The procedure, however, can cause complications even long after the endotracheal tube (ETT) is placed past the vocal cords and secured. Tracheal necrosis,1 rupture,2, 3 stenosis,4 laryngeal nerve palsy5,6 and tracheo-esophageal fistula7 are all potential risks when the pressure in ETT cuffs is excessively high.
It has long been believed, without any evidence-based data, that trained clinicians are capable of determining proper ETT cuff pressures. More specifically, it is presumed that clinicians can detect appropriate inflation pressure and overinflated ETT cuffs by palpation of ETT pilot balloons. In this study, we sought to evaluate newly trained paramedics' ability to inflate ETT cuffs to a safe pressure, as well as to detect overinflated ETT cuffs by palpating the pilot balloon. The phenomenon merits study because overinflation of an ETT cuff may be prevented by using a manometer to directly measure inflation pressure.1,8 |
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When the pressure in an ETT cuff exceeds the capillary perfusion pressure of the tracheal mucosa, mucosal blood flow becomes obstructed. The precise pressure at which capillary perfusion is impaired certainly will vary from patient to patient, but reports suggest that 25 cm H2O is a "safe" pressure.9 The precise pressure at which any individual will experience impaired or obstructed tracheal mucosal blood flow will be dependent upon numerous factors, most importantly their blood pressure. Severe overinflation of the ETT cuff may result in severe, even fatal injury.3,11 Less severe, but significant, adverse effects are tracheal pain or stridor.12, 13
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This study demonstrates that recent paramedic graduates were unable to inflate an ETT cuff to a safe pressure. These study participants were also unable to differentiate overinflated ETT cuffs from appropriately inflated ETT cuffs by palpation of the pilot balloon.
Although these graduating paramedic students grossly overestimated a safe inflation pressure, comparison to a similar study examining the ability of emergency medicine physicians and another study of practicing paramedics showed that these students' abilities were similar to those of the more highly trained or experienced groups.14,15 This implies that this skill is not acquired over time with increased training or experience. |
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It has been suggested that using standardized instrumentation to measure cuff pressure would help to decrease the possibility of injury resulting from endotracheal intubation.1,8,16 Whether this is practical for paramedics to do in the field is unknown. Use of such instruments might interfere with the top priority of securing an airway or rapidly transporting the patient to a hospital environment. Additionally, since there are little data available on short-term complications, it is unclear what difference in outcome would result from measuring inflation pressures in the field relative to measuring such pressures in the hospital. This may be an area for future studies.
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Prehospital professionals should consider the available information suggesting that clinicians cannot detect overinflation of ETT cuffs by palpation of the pilot balloon. Emergency department staff should consider taking it upon themselves to measure cuff pressures after endotracheal intubations, whether performed in the field or in the ED, as it is a certain method of detecting overinflated ETT cuffs. Many patients who remain intubated eventually have their ETT cuff pressure checked by respiratory therapists or intensive care unit staff. However, since overinflation of ETT cuffs is recognized as potentially injurious, prehospital personnel and emergency medicine clinicians should consider screening for overinflation of ETT cuffs.
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The inability of clinicians to determine endotracheal tube cuff pressure by the traditional standard method of palpation of the pilot balloon has been addressed by other investigators. Anesthesiologists,17 as well as critical care unit staff,1,18 have demonstrated a prevalent inability to accurately determine intracuff pressure of the ETT cuff by palpation of the pilot balloon.
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The risk of injury resulting from an overinflated ETT cuff warrants evaluation of currently employed endotracheal intubation practices. The practice of inflating ETT cuffs without precisely measuring such pressure, in particular, should be closely scrutinized.
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Tracheal Tube Cuff Management
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Tracheal tube cuffs are used in children (> 5-6 years old) and adults to 'seal-off' the lower airway. This seal allows application of positive pressure ventilation to the lungs without extensive gas leaks. The seal provided by the cuff also can help prevent or minimize aspiration of oropharyngeal or supraglottic secretions into the lungs.
Unfortunately, the pressure used to inflate tracheal tube cuffs can cause damage to the surrounding tissues. If the cuff pressure is high enough to blocks off capillary blood flow (ischemia), tissue ulceration and necrosis will occur. Since capillary perfusion pressure range between 20-25 mm Hg, the goal is to keep tracheal tube cuff pressures below these levels whenever possible. |
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Respiratory minute volume
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(or minute ventilation) is the volume of gas inhaled (inhaled minute volume) or exhaled (exhaled minute volume) from a person's lungs in one minute. It is an important parameter in respiratory medicine due to its relationship with blood carbon dioxide levels. It can be measured with devices such as a Wright respirometer, or can be calculated from other known respiratory parameters. Note that although its name implies that it is a volume, minute volume is actually a flow (it represents a volume change over time).
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RAAS
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renin–angiotensin–aldosterone system
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renin–angiotensin–aldosterone system (RAAS) is a hormone system that regulates
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blood pressure and water (fluid) balance
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When blood volume is low, juxtaglomerular cells in the kidneys secrete __________ directly into circulation.
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renin
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Plasma renin then carries out the conversion of _____________ released by the ___________ to angiotensin I.
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angiotensinogen
liver |
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Angiotensin I is subsequently converted to __________ by the enzyme ________________ found in the lungs.
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angiotensin II
angiotensin converting enzyme |
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Angiotensin II is a potent ____-active peptide that causes blood vessels to __________, resulting in increased blood pressure.
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vaso
constrict |
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Angiotensin II also stimulates the secretion of the hormone _____________ from the adrenal cortex.
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aldosterone
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Aldosterone causes the tubules of the kidneys to ____________ the reabsorption of ________ and _____________ into the blood. This increases the volume of fluid in the body, which also increases blood pressure.
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increase
sodium water |
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f the renin–angiotensin–aldosterone system is abnormally active, blood pressure will be too ____. There are many drugs that interrupt different steps in this system to lower ______________. These drugs are one of the main ways to control high blood pressure (hypertension), heart failure, kidney failure, and harmful effects of ____________.
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high
blood pressure diabetes |
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fistula
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In medicine, a fistula (/ˈfɪstjʊlə/;[1][2] pl. fistulas (/ˈfɪstjʊləz/), or fistulae (/ˈfɪstjʊli/ or /ˈfɪstjʊlaɪ/)) is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect
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RAAS can be activated when there is a loss of blood ________ or a drop in blood pressure (such as in ___________).
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volume
hemorrhage |
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RAAS can be activated when there is a loss of blood volume or a drop in blood pressure (such as in hemorrhage). This loss of pressure is interpreted by baroreceptors in the _____________. In alternative fashion, a decrease in the filtrate _______ concentration and/or decreased filtrate flow rate will stimulate the ________________ to signal the juxtaglomerular cells to release renin.
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carotid sinus
NaCl macula densa |
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1.If the perfusion of the juxtaglomerular apparatus in the kidney's macula densa decreases, then the juxtaglomerular cells (granular cells, modified pericytes in the glomerular capillary) release the enzyme __________.
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renin
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2.Renin cleaves a zymogen, an inactive peptide, called angiotensinogen, converting it into _______________.
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angiotensin I.
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3.Angiotensin I is then converted to angiotensin II by ______________ which is thought to be found mainly in lung capillaries. One study in 1992 found ACE in all blood vessel endothelial cells.
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angiotensin-converting enzyme (ACE)
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4.Angiotensin II is the major bioactive product of the renin-angiotensin system, binding to receptors on intraglomerular __________ cells, causing these cells to contract along with the blood vessels surrounding them and causing the release of ____________ from the zona glomerulosa in the adrenal cortex. Angiotensin II acts as an endocrine, autocrine/paracrine, and intracrine hormone.
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mesangial
aldosterone |
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It is believed that angiotensin I may have some minor activity, but ______________ is the major bio-active product.
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angiotensin II
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Angiotensin II has a variety of effects on the body:
Throughout the body, it is a potent _________________ of arterioles. |
vasoconstrictor
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Angiotensin II has a variety of effects on the body:
In the kidneys, it __________ glomerular arterioles, having a greater effect on _________ arterioles than ________. As with most other capillary beds in the body, the constriction of afferent arterioles increases the arteriolar resistance, raising systemic arterial blood pressure and decreasing the blood flow. However, the kidneys must continue to filter enough blood despite this drop in blood flow, necessitating mechanisms to keep glomerular ______________ up. To do this, ______________ constricts efferent arterioles, which forces blood to build up in the glomerulus, increasing glomerular pressure. The glomerular filtration rate (GFR) is thus maintained, and blood filtration can continue despite lowered overall kidney blood flow. Because the filtration fraction has increased, there is less plasma fluid in the downstream peritubular capillaries. This in turn leads to a decreased hydrostatic pressure and increased oncotic pressure (due to unfiltered plasma proteins) in the peritubular capillaries. The effect of decreased hydrostatic pressure and increased oncotic pressure in the peritubular capillaries will facilitate increased reabsorption of tubular fluid. |
constricts
efferent afferent blood pressure angiotensin II |
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Angiotensin II has a variety of effects on the body:
In the kidneys, it constricts glomerular arterioles, having a greater effect on efferent arterioles than afferent. As with most other capillary beds in the body, the constriction of afferent arterioles increases the arteriolar resistance, raising systemic arterial blood pressure and decreasing the blood flow. However, the kidneys must continue to filter enough blood despite this drop in blood flow, necessitating mechanisms to keep glomerular blood pressure up. To do this, angiotensin II constricts efferent arterioles, which forces blood to build up in the glomerulus, increasing glomerular pressure. The glomerular filtration rate (GFR) is thus maintained, and blood filtration can continue despite lowered overall kidney blood flow. Because the filtration fraction has increased, there is less plasma fluid in the downstream peritubular capillaries. This in turn leads to a __________ hydrostatic pressure and increased ________ pressure (due to unfiltered plasma proteins) in the peritubular capillaries. The effect of decreased hydrostatic pressure and increased oncotic pressure in the peritubular capillaries will facilitate ________________ reabsorption of tubular fluid. |
decreased
oncotic increased |
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Angiotensin II has a variety of effects on the body:
Angiotensin II decreases medullary blood flow through the __________. This decreases the washout of NaCl and urea in the kidney medullary space. Thus, higher concentrations of NaCl and urea in the __________ facilitate increased absorption of tubular fluid. Furthermore, increased reabsorption of fluid into the medulla will increase passive reabsorption of sodium along the thick ascending limb of the loop of Henle. |
vasa recta
medulla |
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Angiotensin II has a variety of effects on the body:
Angiotensin II stimulates _____ exchangers located on the apical membranes (faces the tubular lumen) of cells in the proximal tubule and thick ascending limb of the loop of Henle in addition to Na+ channels in the collecting ducts. This will ultimately lead to increased sodium reabsorption |
Na+/H+
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Angiotensin II has a variety of effects on the body:
Angiotensin II stimulates the hypertrophy of renal tubule cells, leading to further __________ reabsorption. |
sodium
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Angiotensin II has a variety of effects on the body:
In the adrenal cortex, it acts to cause the release of ___________. _______________ acts on the tubules (e.g., the distal convoluted tubules and the cortical collecting ducts) in the kidneys, causing them to reabsorb more sodium and __________ from the urine. This ___________ blood volume and, therefore, increases blood pressure. In exchange for the reabsorbing of sodium to blood, potassium is secreted into the tubules, becomes part of urine and is excreted. |
aldosterone
Aldosterone water increases |
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Angiotensin II has a variety of effects on the body:
Release of anti-diuretic hormone (ADH), also called vasopressin – ADH is made in the ________ and released from the posterior pituitary gland. As its name suggests, it also exhibits vaso-_____________ properties, but its main course of action is to stimulate ________________ of water in the kidneys. ADH also acts on the central nervous system to increase an individual's appetite for ______, and to stimulate the sensation of thirst. |
hypothalamus
constrictive reabsorption salt |
