N124

Neck

Prof. MGAP Batalla

7/5/12

Carotid Arteries

Assessment of the Critically-Ill Patient

NHH - Gordons
o Signage if patient is unable to talk
(written, etc.)
o Its okay to note if health pattern is
unable to be retrieved from SO
o Katz Index of ADL
o IADL
PE
o
o
o

o
o

Focused assessment of cardiac,

respiratory, renal
LOC: confusion, delirium,
obtundation, coma, stupor
Glasgow Coma Scale
Severe: < 8
Moderate: 9-13
Minor: 13 and above
Visual Analog Scale/ Wongs for
pain
Cyanosis vs. Pallor
Cyanosis increased
deoxygenated blood
Pallor decreased circulating
RBC/oxyhemoglobin
Eyes
Unilateral
dilated pupil
Bilateral d
Irregular pupil
Conjugate
gaze deviation
Small pinpoint

Palpable
Pulse

RUQ
pressure
Position
change

Not affected

III nerve
compression
Midbrain injury
Orbital trauma

(+) dolls eye normal

Rule out for cervical
injury patients
Caloric test
Cold sterile water
Rule out tympanic
membrane injury first

Brisk, vigorous
Not easily
eliminated by
pressure
Not affected by
volume
No change

Jugular
Veins
Rarely
palpable
Soft
Eliminated
by light
pressure
Affected by
inspiration
Increased
prominence
Increased
in
recumbent
position

Jugular venous pressure

Normally 3-4 cm H2O
Increase in JVP results from
increase in blood volume
Respiratory
Breathing patterns
Cheyne-Stokes low,
high, low, apnea
Biot shallow, clustered
breathing followed by
apnea
Kussmaul rapid, deep
inspirations
Apneustic and Ataxic
Injury to brainstem
Ataxic irregular
patterns of rapid
breathing, apnea
Apneustic in hale,
break, exhale
Heart sounds
S1, S2, S3, S4
Murmurs location, quality
(blowing, harsh, raspy,
rumbling, vibrating, machinelike), pitch (low, medium,
high), time in cardiac cycle,
intensity
Systolic lush-dub,
between S1 and S2
Diastolic lub-dush,
between S2 and the
next S1
Conditions associated with
murmurs

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Abdomen

Extremities
Edema
Peripheral pulses
Pulse sites

Gangerene, proximal arterial

Elevation of limb venous
Irregular shaped, bony
prominences, dependent parts
venous
Regularly shaped arterial

HW: Differentiate the ff. arterial pulse

abnormalities:
1. Pulsus alterans
2. P. Bigeminus
3. P. Paradoxus
4. Water Hammer Pulse
5. Bounding pulse
6. Weak pulse

BEDSIDE MONITORING
Strength of LV contraction carotid upstroke
Reflects stroke volume, ejection velocity, and
systemic vascular resistance pulse pressure (30-40
mmHg)
Increased velocity
Increased resistance
Loss of ventricular compliance S3 (ventricular
gallop)
Elasticity of arterial walls DBP
Monitoring devices
Non invasive
o Pulse oximeter
o Cardiac monitor
o Capnography
Invasive
o Arterial pressure
o CVP
o PAP
o ICP monitoring
Dysrrhythmias
- Disorders of the formation and conduction or
both of the electrical impulse within the heart

Named accdg. to site of origin, mechanism

of formation or conduction involved

Sites of Origin
1. SA node
2. Atria
3. AV node
4. Ventricles
Mechanism
1. Bradycardia
2. Tachycardia
3. Fibrillation
4. Flutter
5. Premature complexes
6. Conduction
Atrial Dysrrhytmias
Caused by:
- Hypoxia
- Acidosis
- Digoxin toxicity
- CAD
- MI
Supraventricular tachycardia
o Inadequate pumping of blood (no
time for diastole)
o Do: carotid massage, amiodarone
Premature Atrial Contraction
o Every other wave bigeminy, every
third wave trigeminy
o Nonconducted no QRS
Atrial flutter
o Saw-toothed waves, no pwaves/flutter waves
o 220-430 bpm (A), <300 bpm (V)
o 4:1 for every P wave, 1 QR S
complex conduction
Atrial fibrillation
o Slow below 60
o Controlled 60-100
o Rapid above 100
AV block
o First degree
Prolonged PR interval (more
than 0.2 sec)

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Second degree
Type I
Progressively longer
PR interval
Type II
Do not know when it
will prolong
Different
interval length

* dropped beat P without QRS

Type III
No relationship
between P and RS

Ventricular Dysrhythmias
Caused by
- MI
- Hypoxia
- Heart failure
PVC (Premature Ventricular Contraction)
o Wide QRS, no P wave
o Caused by irritability
o Unifocal (one origin)
o Multifocal (multiple origins)
o Couplets/ Triplets
o PVC in salvos (more than 4)
o Refer 6 or more
Ventricular Tachycardia
o Wide QRS, pedia and adult
Torsade de pointes
o Can be cured with magnesium sulfate
o Chaotic QRS
V-fibrillation
o Small amplitudes
V- asystole
o Epinephrine and CPR
~ See ECG Notes and Interpretation and
Management Guide for dysrhythmias ~

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