Shock Trauma

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If you're at death's door, we'll pull you through

If you have cirrhosis and take another hit, you are gonna die

Hook heliox into the air inlet of the vent, then set fio2 at 21% to get heliox mix.

Always use left-selective tube when using double lumen

Myoglobin>10,000 use cvvh

Fendolopam for urine output

Atropine is too drying to use for spinal bradycardia

To perform bal
Wedge in bronchus
Infuse 40-60 initially, set suction to 80 or manually withdraw 20 cc, infuse 20 cc more
Should see foam layer (surfactant)
Lab can check for alveolar macrophages to make sure it is a good sample

Spinal cord
Alpha agents increase lung water
Dopamine makes them pee which makes them negative, but vessels already wide, so they need to be positive
They need volume and dobutamine b/c of spinal cord induced heart dysfunction (probably present in brain injury as well)

The lungs of a copder are extremely compliant. This makes it very difficult to fix atelectasis as any increased pressure simply expands the compliant areas and does not go towards the atelectatic areas.

COPDers lungs are incredibly compliant, so atelectasis is near impossible to resolve b/c all the pressure you add goes to the non-collapsed areas.

Esophageal opening pressure is 15 so keep IPAP of NIV <15

How to wean
1. Bring to room air
2. Ventilations
3. Lower CPAP

Should not see any expiratory work of breathing c ideal CPAP
Should just see very slight insp zen belly breathing

It may take 30-40 minutes for hypoventilation after hypocarbia to resolve even after CO2 normalizes

Brain adjusts to low CO2s, so when you raise it, ICP rises. But a normal CO2 does not result in higher ICPs at baseline

Should not actually be a gradient between ETCO2 and PaCO2, we create that gap

Servo I Open Lung Recruitment

Phase I-Baseline

Put PEEP 10 PC 20 to achieve 10 cc/kg Rate 20, 100%, I:E 1:1

Phase II-Open Lungs

Increase PEEP to 20

Increase PC by 5, then increase by another 5, then by 5, then last 5

to reach empiric opening pressure of 50; keep it for 2 minutes

Reduce PC until prerecruitment Vt is again reached

Phase III-Find Closing PEEP

Reduce PEEP by 2 every 30 seconds until a plateau and then a reduction in compliance is seen

Use cursor to find maximum

PEEP 2 above this level is optimal PEEP

Phase IV-Reopen lung

Increase PEEP to 15 then 20

Increase PC to get plat of 50

Hold two minutes

reduce PEEP to level in phase III

reduce PC until desired tidal volume

remember overdistension also ruins compliance