you now my name is rich Bassett and the flight paramedic Swilley high-value medevac and today we’re going to be talking about hemodynamic monitoring specifically to the transport environment just review the objectives that we hope to cover today are preparing for the vase of lying monitoring system indications and utilization for an arterial line indications and utilization for CVP line indications utilizations for a swan-ganz or allied knows a pulmonary artery catheter line potential complications on baselines relative to the transport environment and also discussed a four classifications of cardiac related shock for vasive line preparation I was basically starting from scratch you need before you even get started you’ll need to gather all your supplies for your monitoring system so it would be a 500 bag of normal saline pressure and fusion bag disposable transducer pack and which will include both the pressure tubing and the transducer Saleh caps replaced Yelton caps on the stopcocks usually the sala cops will be included in the transpac or the the transducer ket cables to conduct the transducer to the martyr which if I don’t know IV pump bag here at motor back and means to secure the transducer to be leather with the scuba static access to start with and hopeful outlet video to go along with this off a youtube or something along those lines will place the IV saline bag in a pressure and freezer bag attached to pressure tubing closed most proximal clamp to the IV bag inflate the pressure in freezer bag to the Green Zone which would actually be about 250 or 300 millimeters of mercury on the gauge it’s on the bag and depends a little bit on the brand of the bag and this will deliver approximately three more layers now or through line is connected to whenever things opened up for smaller pediatric patients are infants consider the use of an IV syringe pump in place of this setup in other words in place of the pressure bag Prime the pressure monitor tubing please make sure all that there is no error in the line or the stopcocks we move as much air as possible from the IV bag this is especially important in the transport environment this can be done a couple of different ways can be done by opening a roller clamp by this by the spiking on spiking the bag prior to inflation in voting your tubing the bag one specialized and then opening the clamp to purge it out or use component kneel to vent up there after pressurizing from the bag itself before opening a bowl or clamp replace all the hollow stopcocks with solid caps be sure all the tiny air bubbles are removed by forming a meniscus of food that will open under the stopcock before replacing each cat so before we actually put the new cap back on when they shows that meniscus of fluid on top says no little air bubbles um thus all caps are extremely important in our environment um it’s very easy for a stopcock to be bumped into the wrong position and that could result it specially I can often arterial line an unrecognized blood loss and a well packaged patient in other words we money and see where that stop is gets rolled we’re bowling applying a big puddle of blood if we’re not careful and then if we want to attach our modern cable to a transducer from the transducer to the monitor and then place a transducer at the flutist attic access as pictured on the following slide in the transport

environment securing the transducer a patient’s arm is usually the most desirable to maintain the same position relative to the patient’s right atrium now the hospital you normally won’t see that they normally have like a leveling stick or maybe even a laser to line it up perfectly boffin IV yupo to the Philebus attic access and our varmint especially the helicopter that’s just not possible more practical even than the inlets just as a reference that’s where the flutist attic access is considered as mid-axillary line road intersects with the fourth intercostal space when a zero line open assistant to air by turn the lever the stopcock closest to transducer towards the patient and just something to keep in mind with stopcock so you can be confusing whether you know we’re using them for bogo lines for transducing pressure lines whatever just remember the shut-off lever whichever way the level is playing is where its shut off so when it’s shut off towards the patient that means there won’t be any blood backing up into your line once you have a shot off towards the patient then you can remove the cap from the port press 20 button on the monitor to correspond to zero through the line you are zeroing at morrow display a message that is 0 and after a couple seconds then you flush align to form a meniscus again on the open end of the stopcock closes system there then put the cap on it should be a solid capped especially at that point is over Mara for appropriate waveform for the type of line being monitored so there are different types of appearances are the waveforms you expect Motorola and look one way you expect to see is CVP line and look another arterial line and indications and how they’re used was two main purposes and one is the first one is a constantly monitor your blood pressure systolic and diastolic pressure usually suck as well as a mean arterial pressure so some of the costs would be keeping an eye on and these are grateful when your titrating like your vasoactive medications where they’re trying to raise the blood pressure lower the blood pressure but if you’re given carding and you want by moment see how far you’re dropping the pressures are not dropping it too low so you can titrate it maybe your tight trading on the opposite and some Levophed and it gives you almost immediate response to your arterial line it’s also special for the in-hospital folks it’s the verbal source for a be for a bee gees and even more even other blood work you know can be drawn off of that in the hospital may not see so much in our VAR but here at Lehigh they usually have a safe set on there so they can draw off like 10 cc’s of blood then draw off the live sample then we inject that blood and that way there is not this really cumulating blood loss it’s also a lot safer for the provider who’s drawing the look drawn the blood off the line they’re not constantly have to waste it it’s a close nice closed system there are two main reasons for CBP and for the sake of this discussion will also refer to as a CVP even has a non monitor triple lumen catheter for here on the triple lumen catheter is capable delivered multiple medications and fluids and blood products for different ports in the same line in addition to be I’ll deliver all these different medications at the same time it can be a safer way so a lot of people before to be giving like Levophed for example through like a central line through a triple lumen or maybe even potassium might be more comfortable for the patient if it’s given through a triple lumen if that’s available so there’s a distal media proximal port to the triple lumens and something you need to keep in mind now it looks like a big fancy line but if you really need to give fluids or blood fast and it’s a choice between hanging it on a triple lumen law and one of those ports there let’s say a short 16 or 14 gauge IV that IV even though it looks a lot simpler is actually going to function a lot faster and better for those cases when you need to push in the fluids fast or the bread fast something to keep in mind a triple lumen catheter second reason to have one that can also Mars central venous pressure or CVP some people refer to as a CV pressure as in ra or right atrial pressure so if you hear those

terms it’s all kind of the same where the atrial pressure CVP central venous pressure the CVP pressure is given didja provider an indication of the preload going in the right side of the heart may be may be useful and determine a patient’s fluid status but it’s not the end of diagnostic tool you have to correlate it with other things you know what’s the patient’s blood pressure has their urine output that type of thing what’s their whole clinical picture do they look dry so normally if it is going to be used for monitoring purposes a triple lumen catheter will be sorted through the incertitude Intel jugular vein or subclavian vein so it can be used with CVP monitoring can actually be transduced and there’s a little discussion out there we often see when we pick up every foreign hospitals a triple lumen serve it through a femoral vein and a lot of sources question whether we can really use that for CVP readings might be okay maybe the trend it’s certainly okay to be giving y’all blood fluids different medications and all that type of stuff to administer things but it might not be the best place to try to get CVP readings it’s just too far away most people feel normal values these are somewhat variable also normal values can be two to six millimeters of mercury or four to eight depending on which resource you’re going to use for the mechanically ventilated patient we’d won our readings to be about four millimeters higher than their other value so if you think that your normal value for the CVP line should be four to eight that would be like your desired value if your patients mechanically ventilated you would hope that value would be eight to twelve for example you’re just a ploy is typically used for invasive monitoring to get your CVP reading and it’s often the case where all the ports will be used for fluids and medications but you’ll just occasionally check your CVP it’s actually kind of hard to get a constant CVP reading to expect to get a constant one like an a-line especially in the transport environment oh so you might need the momentary turn off medications or fluids that are going into your distal part go ahead and transduce the line he’ll open it up to that and then obtain your reading see where you’re at on the left there is just a picture of a triple lumen line with three ports an example of how to use it to determine a fluid status just a more classic moment because maybe a septic patient that has a low reading has a little blood pressure anilos CVP reading with coral and clinical data such as well you’re an output it might give you an idea while the patient probably needs some more flu at that now if the same patient let’s see where a few more hours down the law and they’ve gotten a bunch of floor let’s say they got four liters they kind of got this data folder is a fluid for your septic patient and they still have a low BP but their CVP CVP reading is elevated well maybe instead of giving more fluid maybe you want to start a presser at that point maybe you know why people say maybe start some level get some llevo going so just looking at the CVP reading by itself isn’t really the end all I’m Diagnostics but you kind of you know equate it to your whole picture miss swan-ganz on otherwise known as a pulmonary artery catheter can be used for different reasons in some ways similar to a CVP line but with increased compatibility for monitoring and less use for multiple medications medications really always can be infused through the proximal part a port that is also used for right atrial or CVP pressures our medications can never ever be infused through the distal port they also known as a pulmonary artery port imagine if you could just imagine what the consequences of infusing a pressor directly into Pablo are especially something like Levophed if you injected that directly into the pulmonary artery think that what that’s going to do for your pulmonary circulation if the introducer catheter often known as a cordis is left in place with your small

ganz allein this is a port that you can easily use for fluid or blood product confusion and actually might be your best bet for rapid infusion it’s a very wide diameter catheter it’s in a French sighs um you can give a lot through that that’s just a picture there on the left shows the introducer or the quartus and that’s actually what the Swan gets fed through oh the subclavian an internal jugular actually be cannula with that first and after the right of the introducer there you can see your extra port that maybe you could hang some fluids or blood products with on the right there is the actual small against catheter showing all its different ports all sides the civilians there one of the main reasons this one gang castle would be uses to measure the pressure in the pulmonary artery if it’s properly placed the capital the tip of the catheter be in the right pulmonary artery actually inside the pulmonary artery and a pulmonary artery pressure is updating through there and it gives an idea of the right ventricular function and pulmonary vascular resistance and left atrial filling pressures as measured when the balloon is deflated oh when the balloon is inflated is referred to as a pulmonary capillary wedge pressure or simply as a wedge pressure here people talk about a wedge pressure that means they got that pressure when the balloon was inflated and it’s very important to know especially in our environment and your wedge pressures reflect on the preload to the left side of the heart my blood pressure was performed by inflating 1.5 CC zar from a specifically designed syringe for that the loan you don’t want to have a 3 cc syringe hooked up to that it looks like one but it’s not only goes back to one and a half CCS you don’t want to live like that balloon and pop it and then as soon as you get your reading that you need you need to remove all the air from the boon and this is very important this is something we’ve probably on a rare occasion where Odysseus one line might not be something we need during transport especially during especially transport and maybe that could be done in before the patient’s move maybe you have the ICU staff chances are we’re not going to be picking up the swamp a similar with a swan-ganz line I have an emergency room unless I mean it’s impossible but chances are we’re picking up it’s a pretty sick patient from somebody else’s ICU if they have a small in it so maybe that’s something that can be done why things are very controlled you can even get some of your other numbers maybe that might be helpful before you’re hooked up to a monitor you can get off there’s like you know a direct cardiac output or cardiac getting back that type of thing these are just an example of some of the pressure waveforms that we would expect to see sorry right atrial pressure which is also your cv cv be pressure and your pulmonary artery watch pressure your what pressure those rate forms look kind of the same the values are a little different values in the wedge pressure or actually you know maybe a little bit more than North Uruk than a writer to the pressure or cvv pressure but if you want to remember when you’re modeling or pulmonary artery your swan line you should be seen your pulmonary artery pressure on waveform which looks not all that different from a from a standard arterial line pressure the waveform itself the values are a lot different or a lot less but looks pretty similar there’s a diachronic notch has a pretty nice waveform but if you see that go to that looks like yours better CVP reading to look like or a pulmonary wedge pressure would look like that’s like a true emergency at that point and say it’s not exactly the same that wedge pressure as a CVP reading but if all of a sudden it looks like that that means that your catheter money introvert Lee wedge it’s very important that you recognize that even if you don’t recognize the the exact values without looking at the reference some other indications for swung against one it can get a cardiac output which is just simply the stroke volume times to heart rate and you’ll hear people talk about cardiac index that’s just the patients are patient size corrected

stroke volume indirectly the swan-ganz catheter can also measure sista systemic vascular resistance but the following formula and also can get pulmonary vascular resistance so I get your system in vascular resistance it’s just just a form of that involves your mean arterial pressure in your cv p divided by your cardiac output to get your your pulmonary vascular resistance that’s what we actually have to get a wedge pressure to be able to do the math for that so that’s something I’m going to keep in mind and that’s how it needs to be calculated out now why is that important probably not terribly important in our environment most of the time is pushing for how often we’re taking swan-ganz lines but for somebody already taken on the certification test for fed nursing flight paramedic I would probably know some of this if it means saving their copy of this slide on your computer if it means taking a picture of this slide with your phone there’s a good chance some of this is going to be on some of those exams either in some type of scenario or just a outward question but you know some of your now let some of it you know that you would expect your CVP to be the cardiac index to be your systemic vascular resistance or pen or vascular resistance to be like for example you’re right door fail your left heart failure a tamponade hypovolemia cardiogenic shock sepsis so yeah we talked a little about the sepsis you would expect a low c vp if they went through all the trouble to have a swallow mine Monta septic patient then you will also expect to see a pulmonary capillary wedge pressure we’re just simply a low wedge pressure will also expect to see a low cardiac index or cardiac output pretty much interchangeable terms I also allows system advise go resistance which means their basal dilated out now with the difference between that and maybe a cardiogenic shock you have septic shock and Corey Jay they’ll have a lot of systemic vascular resistance it will have a high c vp they’ll have a high wedge pressure but the cardiac input or cardiac index or cardiac output will still be crap so just kind of know some of the concepts between the different types of shock and know how they’re going to reflect on your invasive line marks you might need men men adamite me this memorized to so and so I for every day you come to work but have it as a reference and especially know it going into one of those tests I already made mention so many baise avoiding complications than transport environment but generally speaking disconnection lines resulting in blood loss or embolism so if it’s like a Venus on you might actually you could in theory get an air embolism all there’s an increased risk of infection risk of thrombus around us especially if the flow is not maintained so we need to make sure it’s maintained all the time and then here’s the biggie that can kill the patient in a few minutes invert and wedging of the pulmonary artery catheter I may mention one of those are what wedge pressure taken we need to be very careful before we take the patient and then or care during the transport that the catheters not get wet you know syringe for their does not go in this can happen and the worst obviously if it goes unrecognized this can happen maybe the catheter advances itself too far into the pulmonary artery or two narrowing of the pulmonary artery and it can also happen from the bruin become going to vote until inflate it or not properly deeply as I just mentioned most monitored you must monitor pulmonary artery pressures if you’re transporting some labor the Swan is not ever ever ever ever acceptable to take a swan line and not monitor it if the patient ends up with an invert and wedge and it’s not recognized the patient will probably die they’ll start put some 52 sputum their blood pressures will chances are we’ll go through the Toyota infarct the big part of their loan so they’ll never get talking to or from a referring facility to say I’ll we’re just going to cap it just go get the patient out of here it’s probably because they’re maxed out on

press is already a priority gave some epi or good whatever to for the patient’s I’ll have a heart rate they’re probably trying to get the patient out before they die in all honesty don’t ever ever ever take a capped pulmonary artery line or a swan line it’s got to be monitored if if I glancing at it your waveform does change from the nice crisp waveform of the dicrotic notch now looks like there’s just that little barely bumpy little waveform that looks similar to a CVP reading you know you have a problem so most people say try to be you got to work through the problem quickly and our bar makes perceive if they’re all packaging the aircraft that might be difficult first I’m going to try to do is maybe move the patient around a little bit have them turn their head to the side I’m turn their head to the left side my work haven’t turned her head to the right try to deflate the balloon make sure Samaritan getting it inadvertently the last ditch effort maybe you have to withdraw the catheter you know see where it’s at the beginning of your transport see if that catheter position change at all meant to begin your transport where it’s at but you might need to actually which all the catheter you want to withdraw it so it’s past the right ventricle so if you only withdraw it like an inch or two now you see what looks like a V tach on your monitor that means the end of the catheter is whipping around in the right atrium excuse me the right ventricle and can cause north mia and we need to be pulled past that you want to make sure there’s stuff flow going through it but it needs to be put y’all pulled back at least a few inches I know that may not be right not be might not be real comfortable with that purpose of tourists between that and and you know maintaining an invert and wedge which will care the patient probably pulling back you know maybe try to call in right away as soon as you do it but you know might be a life-saving maneuver my we talked about if the tip of the Swan gas becomes dislodged out of the primary and lip surrounding the ventricle look similar on the tracing and possibly even on the EKG to a v-tach it’s not really in gothic anybody here scope to try to float it back into the pulmonary artery catheter I’m sure we have some staff here that I’ve seen that done and I’ve seen these put in you know much more worse than I am on this but I think that’s worth no scope to try to you know reinforce the balloon and float one back I of course there is the possibility of a thrombus or even air embolus if the balloon ruptures there’s probably not a whole lot we can do about that but it’s just simply just throwing that out there is one of the possible complications we talked to a big mention of the shock box these are kind of the four different types of cardiac type shop we might see and we actually consolidated us off one of the other ones that we used one of our other powerpoint presentation of me and tom rothrock put together from somebody else’s powerpoint presentation we consolidated and the one page and just goes through the fur different classifications and so for your type 1 you’ll just have like maybe a normal cardiac index but maybe you’re starting to see a load of a normal wedge pressure she’s popping out whole are going to do about that you’re going to monitor the patient some oxygen some pain medications may be a little bit of fluid some sedation you’re too would be a load of normal on ledge might be volume depleted some very to kar diya and this is where more like your Whiteside heart feather so we some oxygen some fluids some things to make a contractility better maybe decrease your after load sometimes you might see for balloon pump you type 3 is like a normal cardiac index and a high wedge pressure it was like a volume all over all over kind of if you can picture your typical CHF patient especially before they go into cardiogenic shock so this would be like you know your diuretics you know your oxygen you know enhanced your contractor Eddie you know maybe get to heart rate

down some and then your your class 4 is going to be your all out corny genetic shock so they’re gonna have the frothy sputum we’re going to have a low blood pressure so you’re going to a actually decrease to preload decreased or after a while on pluggin eatable um I’m if they can fix the problem and so here’s just basically your to go along with the shock box kind of added this in your clinical presentation that kind of later Olympic teach one step for your your class one cardiac jock type patient will be most haunted pulmonary congestion yet who are class to be more your rails in the basis might hear an extra hearts out the atom nestor e your class trees up your acute pulmonary edema like your CHF patient and then your class for is your cardiogenic shock that’s when the rover liberal fluids and their blood pressure is low and then when we talk about some your children modalities it’s part of this whole shock box thing when you’re increasing your preload and you give us some fluid may be some vasopressin decreasing your preload giving diuretics restrict their fluids Venus dilators to increase their contractility your dobutamine dopamine me maybe calcium village leave out epi and then the decrease your contractility would be your beta blocker nor calcium channel blockers so when you go back and it says you know increase your contractility or decrease it being kind of over here just have an idea he said you might not need to memorize all this especially those four different types but if you just kind of remember the concept you know what you would do for these types of patients and definitely going into one of those certification type test yeah maybe have this memorized up a little bit better so pretty much in closing completing a mission by ground oil with a patient that has an invasive wanted some that does not a call that asking for for all of us and then we’re managing these patients it’s one of those rarely performed high-risk skills you hear that of term or a similar term falling around for stuff you don’t do too often and then it’s high-risk on top of it just makes the whole operation a little bit more risky I just want to remind by those invasive line training equipment at each air base which can be utilized by the crew to stay proficient with at least two mechanics is setting up your monitoring equipment also regular view of this type of material not justice but other material invasive wines as higher suggested for the four other crew members too we just don’t see it enough to be proficient with it every day he grew over in cardiac ICU or purse or even a regular icti medical circles you we’re dealing with the stuff all the time yes we get there on our clinical time and I beg all you know take advantage of it during your clinical time that that we have but just taking it’s hose out play with a little bit helps too and that’s all i have for invasive lauren monitoring in the new transport environment thank you other you

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