Slide 1 I Found the Vital Sign: Now What? Demystifying What All Those Numbers Mean for Complex Patient Management J. Dyson, Orlando Health, Orlando, FL K. Levenhagen, Saint Louis University, Saint Louis, MO T. Norris, Barnes-Jewish Hospital, Saint Louis, MO K. Swanick, Florida Gulf Coast University, Fort Meyers, FL J. Tompkins, Mayo Clinic, Phoenix, AZ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 2 Objectives • By the end of the presentation, the learner will: • Recognize the importance of determining vital signs prior to initiating an examination/intervention. • Describe the clinical considerations related to abnormal physiological and hemodynamic indicators. • Classify vital signs that are pertinent to physical therapy professionals and their implications on the movement system. • Utilize the various invasive and noninvasive measures to appropriately dose intervention and identify absolute parameters for therapeutic participation. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Slide 3 What are vital signs? • Merriam Webster: important body functions (such as breathing and heartbeat) that are measured to see if someone is alive or healthy • Clinical decision making • Body temperature • Heart rate • Breathing rate • Blood pressure • Pulse oximetry • Pain • Walking speed ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________
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Slide 1
I Found the Vital Sign: Now What? Demystifying What All Those Numbers
Mean for Complex Patient ManagementJ. Dyson, Orlando Health, Orlando, FL
K. Levenhagen, Saint Louis University, Saint Louis, MO
T. Norris, Barnes-Jewish Hospital, Saint Louis, MO
K. Swanick, Florida Gulf Coast University, Fort Meyers, FL
J. Tompkins, Mayo Clinic, Phoenix, AZ
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Slide 2 Objectives
• By the end of the presentation, the learner will:• Recognize the importance of determining vital signs prior to initiating an
examination/intervention.
• Describe the clinical considerations related to abnormal physiological and hemodynamic indicators.
• Classify vital signs that are pertinent to physical therapy professionals and their implications on the movement system.
• Utilize the various invasive and noninvasive measures to appropriately dose intervention and identify absolute parameters for therapeutic participation.
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Slide 3 What are vital signs?
• Merriam Webster: important body functions (such as breathing and heartbeat) that are measured to see if someone is alive or healthy• Clinical decision making
• Body temperature
• Heart rate
• Breathing rate
• Blood pressure
• Pulse oximetry
• Pain
• Walking speed
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Slide 4 So why are we not taking vitals?
Thistle et al (2016)
Vitals % of Outpatient PTs
BP 41%
HR 35.3%
RR 17.6%
Pulse Oximetry 29.4%
Temp 5.9%
Frese et al (2002)
Facility HR/BP Never or < half the time
HR/BP Always or > half the time
Acute Care 76.8%/83.9% 23.2%/16.1%
Rehabilitation 70.9%/69.1% 29.1%/30.9%
Extended Care Facility 53.8%/61.5% 46.2%/38.5%
Home Health 11.1%/22.2% 88.9%/77.8%
Outpatient 91.5%/92.1% 8.5%/7.9%
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Slide 5 So why are we not taking vitals?
• Patient young in age
• Previously documented by health care professional
• No documented history of cardiovascular comorbidities
• Taking blood pressure medication
• Time constraints
• Implementation
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Slide 6 Why should you take vital signs?
• 62% of OP PT orthopedic patients have secondary cardiovascular disease Billek-Sawhney, 1998
• Interpreting cardiovascular response is multifactorial• Risk factors/PMH• Type and dosage level of cardiac meds• Vitals signs (before, during, and after)• Patient report• Your observations
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Slide 7 Movement System (APTA 2017)
• PTs provide a unique perspective on purposeful, precise, and efficient movement across the lifespan based upon the synthesis of their distinctive knowledge of the movement system and expertise in mobility and locomotion.
• PTs examine and evaluate the movement system (including diagnosis and prognosis) to provide a customized and integrated plan of care to achieve the individual's goal-directed outcomes.
• PTs maximize an individual's ability to engage with and respond to his or her environment using movement-related interventions to optimize functional capacity and performance.
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Slide 8 Systemic Blood Flow at Rest and Exercise Healthy Young Individual
OrganResting(mL/min)
Mild exercise(mL/min)
Maximal exercise(mL/min)
Skeletal muscle 1200 4500 12,500
Heart 250 350 750
Brain 750 750 750
Integument 500 1500 1900
Kidney 1100 900 600
Gastrointestinal 1400 1100 600
Others (i.e., liver, spleen)
600 400 400
Total 5800 9500 17,500
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Slide 9
DigestiveAbsorbs nutrients and water; delivers nutrients to liver for processing by hepatic portal vein; provides nutrients essential for hematopoiesis and building hemoglobin
EndocrineDelivers hormones: atrial natriuretic hormone (peptide) secreted by the heart atrial cells to help regulate blood volumes and pressures.
IntegumentCarries clotting factors, platelets, and white blood cells for homeostasis, fighting infection and repairing damage; regulates temperature by controlling blood flow to the surface.
LymphaticTransports white blood cells and antibodies throughout the body to maintain health; carries excess tissue fluid not reabsorbed by the vascular capillaries.
Muscular Removes lactic acid and distributes heat generated by contraction; muscular pumps aid in venous return; exercise contributes to cardiovascular health.
Interplay of Systems Affecting Vitals
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Slide 10
NervousProduces cerebrospinal fluid (CSF); cardiac and vasomotor centers regulate cardiac output and blood flow through vessels via autonomic system
RespiratoryProvides blood for critical exchange of gases to carry oxygen needed for metabolic reactions and CO2 generated as byproducts of these processes
SkeletalProvides calcium, phosphate and minerals critical for bone matrix; transports hormones regulating buildup and absorption of matrix including erythropoietin stimulates myeloid cell hematopoiesis.
Urinary
Delivers 20% of resting circulation to kidneys for filtering, reabsorption and secretion of excess; regulates blood volume and pressure by regulating fluid loss in the form of urine and by releasing the enzyme renin, essential in the renin-angiotensin-aldosterone mechanism
Interplay of Systems Affecting Vitals
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Slide 11
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Slide 12
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Slide 13
Pulse Rate
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Slide 14 Pulse
• Stretch and recoil of the arterial wall during a cardiac cycle• Rate
• Number of beats per minute
• Rhythm• Interval between beats
• Volume – amount of blood pushed through the artery• Strength = ventricular contraction/cardiac output
• ↑ strength = ↑ systolic pressure• Bounding/full
• ↓ strength = ↓ systolic pressure• Weak/ thready
• Quality
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Slide 15 Variations in Pulse Wave• Pulsus alterans
• Alteration of weak and strong pulse beats not related to cycle length• Pericardial effusion
• Left ventricular failure
• Asthma
• Bigeminal pulse• Two beats close together with a pause following each pair
• Hypertrophic obstructive cadiomyopathy
• Hypothyroidism
• Electrolyte imbalance
• Paradoxical pulse• Exaggerated fall in systolic blood pressure with inspiration
• COPD
• Cardiac tamponade
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Slide 16 Pulse Assessment
Grade Pulse Description
0 Absent No perceptible pulse
1+ Thready Barely perceptible, easily obliterated with slight pressure
2+ Weak Difficult to palpate, slightly stronger than thready, can be obliterated with light pressure
3+ Normal Easy to palpate; requires moderate pressure to obliterate
4+ Bounding Very strong , hyperactive
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Slide 17 Factors Affecting Pulse
• Age• Infant = 100 - 130 bpm
• Child (1-7 yrs old) = 80 - 120 bpm
• Adult = 60 – 100 bpm
• Gender
• Emotional status
• Systemic or local heat
• Body size
• Exercise
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Slide 18 Effects of Aging
• Resting HR may be lower
• HR response is blunted• Rely more on Borg or BP response
• Heart Rate Reserve or Karvonen to determine target HR (closely approximates HR and VO2Max)• HRR=[((220-age)- Rest HR) X ____%] + Rest HR
• Beta Blockers
Borg RPE % of HRR % of 220-age
12-13 40-59% 55-69%
14-16 60-84% 70-89%
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Slide 19
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Slide 20
Blood Pressure
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Slide 21 Definitions
• Arterial Blood Pressure• Reflects the combined effects of arterial blood flow per minute
(cardiac output) and the resistance to that flow (peripheral vasculature)
• Systolic• Estimate of the work of the heart and the force of the blood against the
arterial walls during ventricular systole
• Diastolic• Heart’s relaxation phase
• Indicates peripheral resistance
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Slide 22 Classification of Hypertension (2017 Hypertension Guideline)
Classification Systolic blood Pressure (mm Hg)
Diastolic Blood Pressure (mm Hg)
Normal <120 <80
Prehypertension/Elevated
120-129 <80
Stage 1 hypertension
130-139 80-89
Stage 2 hypertension
> 140 >90
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Slide 23 Components of Arterial Blood Pressure (mm Hg)
• Position cuff 1” above elbow crease and bladder centered over brachial artery
• Antecubital fossa at heart level resting comfortably with no muscle tension
• Patient should not talk or cross legs
• Increase pressure to 30 mm Hg above the level radial pulse extinguished
• Deflation rate at 2 mm Hg per beat
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Slide 39
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Slide 40 Recommended Technique (Chobanian 2003)
• Read the systolic level ( first sound of clear tapping, Phase I Kortkoff) and the diastolic level (the point at which the sound disappears, phase V Korotkoff)• If Korotkoff sounds persist to 0 mm Hg then use Phase IV
• Record BB to nearest 2 mm Hg on manometer and 1 mm Hg on electronic
• To avoid venous congestion should wait at least 1 minute between cuff readings
• Should be taken in both arms on the first visit to determine if one arm is consistently higher
• Document HR, BP, Position, arm used, Heart rhythm
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Slide 41
Respiratory Rate
Supply the body with oxygen for metabolic activity and to remove carbon dioxide
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Slide 42 Why should you take respiratory rate?
• Retrospective study: abnormal RR increased the odds of critical admission (OR = 1.66, 95% CI = 1.05-2.06) when compared to controls (Smith 2011)
• RR and HR are independent predictors of adverse events after discharge from ICU (Chaboyer 2008)• RR <10 or >25 (OR 4.23, 95% CI 2.12-8.45)
• Significant correlation (r = 0.84) between manual RR and continuous electronic monitoring (Smith 2011)
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Slide 43 The Respiratory System
• Inspiration• Contraction of the diaphragm and intercostal muscles
• Increases the intrathoracic space for lungs to expand
• Expiration• Passive during recoil of the lungs
• Pons and medulla serve as the respiratory cents• Control rate and depth of breathing in response to metabolic
needs
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Slide 44 Afferent Inputs• Chemoreceptors
• Central is in the respiratory center
• Sensitive to carbon dioxide and hydrogen ion levels
• Peripheral in the carotid bifurcation and arch of aorta• Sensitive to partial pressure of
oxygen
• Mechanoreceptors• Motor cortex
• Muscles and joint receptors
• Stretch receptors in the lung tissue and bronchioles
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Slide 45 Respiratory Assessment
Rate• Tachypnea >24 bpm
• Bradypnea < 10 bpm
Depth• Volume of air exchanged with each breath
Rhythm• Regularity of inspirations and expirations
Character• Deviation from normal quiet effortless breathing
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Slide 46 Patterns of Respiration
Type Description
Eupnea Normal respirations, with equal rate and depth, 12-20 breaths/min
Kussmaul’s Respirations Gasping, labored pattern
Biot’s Respirations Alternating periods of apnea and hyperapnea
Cheyne-StokesRespirations
Gradual increase in rate and depth, followed by gradual decrease
Apnea Absence of respiration
Paradoxical respirations Lung inflation during expiration, deflation during inspiration
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Slide 47 Factors Influencing Respiration
• Age• Newborns 30 - 50 bpm• Adults 12 – 18 bpm
• Body size
• Stature
• Exercise
• Body position
• Environment
• Emotion and Stress
• Drugs
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Slide 48 Peripheral Pulse Oximetry
Estimation of arterial oxyhemoglobin saturation (SaO2) by utilizing selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin (SpO2)
• Indirect measure
• Appropriate for continuous and prolonged monitoring• Smoking can provide a false increased reading
• Nail polish, dark skin or poor circulation can affect reading
The probe should be cleaned between patient applications according to manufacturer recommendations.
Documentation of results, therapeutic intervention (or lack of), and/or clinical decisions based on the SpO2 measurement should be noted in the medical record.
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Slide 49
Body Temperature
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Slide 50 Body Temperature
• Balance between the heat produced or acquired by the body and lost
• Maintain relatively constant internal body temperature
• Monitors to maintain optimal normal cellular and vital organ function
• Thermoreceptors• Provide input peripherally or centrally to the hypothalamus
Symptoms based approach! Collaboration with the healthcare team!
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Slide 60 Joint Commission as the 5th Vital Sign
• Information from the patient history• Pain characteristics
• Location and distribution
• Duration and periodicity
• Quality
• Associated signs and symptoms
• Management strategies
• Relevant medical history
• Relevant family history
• Psychosocial history
• Impact on daily life• Patient’s goals
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Slide 61 Joint Commission as the 5th Vital Sign
Unidimensional Pain Assessment Tools
• Numeric rating scale
• Visual analog scale
• Face pain scale
Multidimensional Pain Assessment Tools
• Brief Pain Inventory
• Initial Pain Assessment Inventory
• McGill Pain Questionnaire
• Memorial Pain Assessment Card
• Pain Drawing
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Slide 62 “Walking Speed: the Sixth Vital Sign”Fritz and Lusardi 2009
• 10 meter walk test • 5 m acceleration and 5 m deceleration
• Instructed to walk a comfortable pace
• Range for normal walking speed is 1.2-1.4 m/sec
• A change in .1 m/sec can be a predictor for improved health or a decline
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Slide 63 “Walking Speed: the Sixth Vital Sign”Fritz and Lusardi 2009
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Slide 64
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Slide 65 5 Meter Walk test
• Uses by STS (Society of Thoracic Surgeons) as predictor of Frailty
• Used with TAVR patient: pre and post op:
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Slide 66 Gait Speeds
• In acute care setting may be a better predictor of function and be considered as part of the discharge plan
• Gait speed rather that distance and FIM scores should be considered when determining safe discharge
• Should be utilized as part of the Physical Therapist Assessment in Acute Care
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Slide 67 Vital Signs are VITAL!
• Integrate into plan of care
• Look for trends
• Clinical decision-making
• Provides information on treatment presciption
• Accurate, documented vital signs are important
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Slide 68
Break
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Slide 69
Hemodynamic Monitoring and Invasive Lines
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Slide 70 Purpose
• Become more familiar with the hemodynamic monitoring devices
• Become more familiar with the numbers we see on the screen
• Plan– Explain 3 hemodynamic monitoring devices
• Arterial line
• Central venous line
• Swan line
– Explain the numbers seen on the monitor screen
– Determine safety to mobilize
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Slide 71 Safe?
“It is feasible and safe to provide progressive mobility activities in cardiovascular ICU patients with femoral catheters who meet the criteria for mobility interventions”
“provision of bedside physical therapy while patients underwent CRRT is feasible, and appears safe.”
“no significant contraindication to mobilize patients with femoral arterial/venous cannulation”
• Damluji, Abdulla, et al. "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." Journal of critical care 28.4 (2013): 535-e9.
• Dubb, Rolf, et al. "Barriers and strategies for early mobilization of patients in intensive care units." Annals of the American Thoracic Society13.5 (2016): 724-730.
• Gokalp, Orhan, et al. "Cannulation in extracorporeal membrane oxygenation." Critical Care 18.4 (2014): 443.• Perme, Christiane, et al. "Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a prospective
observational study." Cardiopulmonary physical therapy journal 24.2 (2013): 12.• Toonstra, Amy L., et al. "Feasibility and safety of physical therapy during continuous renal replacement therapy in the intensive care unit."
Annals of the American Thoracic Society 13.5 (2016): 699-704.• Wang, Yi Tian, et al. "Early mobilization on continuous renal replacement therapy is safe and may improve filter life." Critical Care 18.4
(2014): R161.
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Slide 72 Review A & P
• The heart
– anatomy
–Physiology• The plumbing
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Slide 73
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Slide 74
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Slide 75 Myocardial Conduction
• Sinoatrial Node (SA)– Pacemaker of the heart
– Cluster of cells ~ superior R atrium
• Atrioventricular Node (AV)– Slow conduction
• Bundle of His– Carry’s conductive signal from AV node to ventricles
• Purkinje Fibers– Carry signals into ventricles for contraction
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Slide 76
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Slide 77 Definitions of Heart Function
• Stoke Volume (L) ~70 ml– Volume of blood pumped by L ventricle in 1 beat
• Cardiac Output (L/min) ~ 5 L/m– Volume of blood pumped in 1 min
• Cardiac Index (CO/body weight)
• Ejection Fraction ****** Most important diagnostic measure of cardiac health
– % of volume ejected
– 60-67% Normal
– < 40% compromised cardiac dysfunction
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Slide 78
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Slide 79 Arterial line
• Where:
– Radial artery
– Femoral artery
– Brachial
– Axillary
– Dorsalis pedis
• Why?
– Arterial blood pressure (ABP)
– Oxygen saturation (SaO2)
– Source for serial blood gas draws• PaO2
• PaCO2
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Slide 80 Arterial Line
• Continuous arterial pressure monitoring
– Surgical procedures, CABG, other major surgeries or procedures
– All hemodynamic unstable patients
– Receiving potent vasopressor or vasodialator drugs
– IABP
– Need intracranial pressure monitoring
– Hypertensive crisis such as AAA, sepsis and stroke
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Slide 81 Arterial Line
• Serial blood gas measurements
– Respiratory failure
– Pt’s on or being weaned from mechanical support
– Acid/base abnormalities
– SaO2 more accurate reading than SpO2 saturation if peripherally compromised
Laboratory Values Interpretation Resource (updated January 2017)
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Slide 82 Mean Arterial Pressure
• MAP = [(2 x diastolic) + systolic] / 3 ...diastole counts twice as much because 2/3 of your cardiac cycle is in diastole
• A MAP of about 60mmHg is necessary to perfuse coronary arteries, brain, and kidneys.
• Arterial readings are higher than sphygmomanometer
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Slide 83 Considerations For Therapists
• Position of transducer to heart
– the transducer above the heart get a false low reading
– if below heart, have false high reading
• Enough slack
• Stopcock open to allow continuous flush
• Heparin bag needs to be pressurized
• If in femoral artery guarded activity in that leg (No ROM or flexion of hip)
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Slide 84 Arterial line
• Problems
– Ischemia or necrosis of the tissue
– Vascular insufficiency
– Infections
– Hemorrhagic disorders
– What are you going to do if you pull it out?
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Slide 85
110/70 mmHg
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Slide 86 Central Venous Pressure Line (CVP)
• Ie: Central line
• Where: tip located in superior and inferior vena cava
• How does it get there?– Subclavian
– R internal and external jugular
– Femoral
– Antecubital
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Slide 87
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Slide 88 CVP line Use
• Draw blood (serial draws)
• Provide fluids
• Invasive monitoring in the ICU/Critical Care or Surgery– Monitor central venous blood pressure
– Help determine right atrial (superior vena cava) pressure• Limited by respiratory variation and function
– Assess fluid volume status
– Administration potentially caustic medications
– Emergency route for pacemaker insertion
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Slide 89 Therapy Considerations
• Dysrhythmias with position changes
• Unstable patients may require supine position for accurate readings
• Maintain enough slack of lines
• Primarily a route for fluids, likely able to ambulate with CVP line
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Slide 90
6-12 mmHg
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Slide 91 Pulmonary Artery Catheter(Swan-Ganz)
• HJC Swan and Santa Monica Bay sailboats (NEJM 1970)
• Where: – Initiating @ external jugular
– Distal port in the pulmonary artery
– Proximal port in the right atrium
• How: place catheter into external jugular use balloon to float through heart and become wedged in pulmonary artery
Swan, H. J. C., et al. "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter." New England Journal of Medicine 283.9 (1970): 447-451.
• Holding their breath• Breathing is REQUIRED ! Not an
optional activity
• Valsalva• Decreased BP
• Decreased cardiac output
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Slide 145 Sepsis
• Accurate and timely assessment of vital signs can help with early diagnosis and treatment
• Vital signs and lab values are needed for complete assessment
• Putting all the pieces of the puzzle together
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Slide 146 Bringing Sepsy Back
• https://www.youtube.com/watch?v=58Y0OfOVzMo
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Slide 147 VITALS…. Are VITALLY Important
• Assessment of vital signs is a quality indicator
• EMR can be reviewed : random chart reviews
• Best Practice includes vital signs asessment
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Slide 148
How do we know we have proper perfusion?
The role of ICP, CPP, APP
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Slide 149
Cerebral Pressure and Perfusion
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Slide 150 Intracranial Components
• Brain parenchyma- 80%
• Cerebrospinal fluid (CSF) -10%
• Blood-10%
• Intracranial compartment is protected by the skull.
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Slide 151 CSF
• Clear liquid that surrounds the brain and spinal cord
• Essential for the protection and the brain
• Transporter of waste away from the brain and nutrients to the brain
• Brain’s 2nd circulation
• Produced in the ventricles
• We must have a balance of production and absorption for our brain to function normally
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Slide 152 Ventricles and CSF
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Slide 153 Ventricles and CSF
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Slide 154
Intracranial Pressure (ICP)
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Slide 155 Intracranial Components and ICP
• Volume is fixed in rigid skull
• An increase in any 1 of these components must be met with an equal decrease in another OR you have an increase in intracranial pressure (Monro-Kellie Doctrine)
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Slide 156 Intracranial Pressure (ICP)What is it?
• The pressure inside the skull and considered to be the result of the pressure in the brain tissue and the pressure that the cerebrospinal fluid (CSF) exerts in the ventricles and blood volume.• Total – Parenchyma (brain), blood and vessels, CSF)
• As intracranial blood volume goes up, so does the ICP
• Our body has a mechanism called autoregulation which can compensate for initial levels of increased ICP but has limited ability as these levels get higher.
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Slide 157 ICP
• Norms ~7–15 mmHg• Goal may be to keep it to >20 mmHg
• Intracranial Hypertension is diagnosed when ICP is at a sustained elevation ~37 mmHg
• Autoregulation can manage increased ICP up to 50 mmHg/day
• Increased intracranial pressure can lead to a medical emergency!
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Slide 158 Causes
• Due to a change in one of the components:
• CSF levels
• ↑ CSF production (meningitis, choroid plexus tumor, hemorrhage)
• Obstruction to CSF flow/absorption (Hydrocephalus)
• Volume of brain tissue
• Cerebral edema (brain injury, heart or liver failure)
• Edema volume added to the intracranial cavity
• Brain tumor, hematoma, abscesses)
• Changes in blood volume and flow
• Blood pooling or bleeding into part of brain
• Aneurysms, high blood pressure, stroke
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Slide 159 Signs and Symptoms
• Headache• Seizure• Nausea or Vomiting• Cranial nerve changes (blurred, double vision)• Changes in pupil appearance ((dilated, fixed, ipsilateral vs. bilateral)• Reflex changes• Changes in behavior• Problems with talking• Motor issues (weakness, paresis, posturing, hemiplegia)• Balance issues• Lack of energy or sleepiness
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Slide 160 Signs and Symptoms (continued)
• Posturing • Decerebrate: damage to midbrain and pons
• UE extension and external rotation; LE extension
• Decorticate: damage to the cerebral hemispheres • UE flexion (fist clenched) and internal rotation; LE extension
• External ventricular catheter or drain*• Gold standard
• Also known as a ventriculostomy
• Subarachnoid screw or bolt
• Intraparenchymal
• Epidural sensor
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Slide 164 External Ventricular Drain (EVD)
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Slide 165 External Ventricular Drains (EVD)
• What is it?• Catheter placed within the skull into the lateral ventricle which is connected
to a closed collecting device• A ventriculostomy is performed to create a hole within the ventricle for
drainage• If this drainage is temporary= EVD• If permanent drainage is in place= shunt
• Why is it used?• Allows drainage of CSF to relieve elevated intracranial pressure• Can be connected to a transducer that records ICP
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Slide 166 External Ventricular Drains
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Slide 167 External Ventricular Drains
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Slide 168 Treatment for Increased ICP
• Release of CSF through the external ventricular drain
• Positioning• Head of bed 30-45 degrees to increase cerebral venous drainage
• Environment (reduce stimuli)
• Blood pressure medication
• Sedation
• Osmotic diuretic (mannitol)
• Steroids
• Surgery (tumor excision, craniotomy)
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Slide 169
Cerebral Perfusion Pressure (CPP)
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Slide 170
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Slide 171 Cerebral Perfusion Pressure (CPP)- What is it?
• Blood flow to the brain!!• Pressure at which the brain is perfused
• About 15-20% of cardiac output
• Best indicator of brain perfusion
• Lack of blood flow= impaired oxygen and metabolic delivery and ultimately loss of brain tissue
• Impacted by mean arterial pressure and intracranial pressure
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Slide 172 Cerebral Perfusion Pressure (CPP)
•CPP= mean arterial pressure [MAP]- ICP
• CPP goals are 60-70 mmHg or ≥ 60 mmHg• 50 mmHg is critical level for occurrence of brain ischemia
• SAMPLE CALCULATION:• MAP of between 60 to 80 mmHg and an ICP about 10 mmHg
• CPP= (60-80) minus 10
= 50-70 mmHg
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Slide 173 Decreased Cerebral Perfusion Pressure
•How does the body react to
changes in CPP?
Body senses decreased CPP and ischemia
Senses decreased systemic blood
pressure
Dilates cerebral blood vessels
Increased cerebral blood
volume
This increases ICP
This leads to decreased CPP
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Slide 174 CPP- Implications
• Higher ICP from injury will require a higher CPP to maintain cerebral blood flow • Decreases in ICP can also positively impact cerebral perfusion HOWEVER in
most cases the MAP is adjusted to control CPP
• Blood pressure could be kept HIGHER to ensure adequate cerebral perfusion.
• Patients administered vasopressor agents to increase MAP• may lower ICP by improving perfusion
• allowing autoregulatory vasoconstriction as ischemia is relieved and ultimately decreasing intracranial blood volume
• Mortality increases approximately 20% for each 10 mmHg loss of CPP
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Slide 175 Considerations for Rehab Professionals
• Patients may be sedated to try and reduce ICP• Reduction of metabolic demand
• Be aware of ICU’s parameters for the ICP before starting PT • If patient has an ICP of ~20, you may want to hold PT due to impact of elevation of
ICP on CPP
• Report changes in ICP during session• Changes that last ≥ 5 minutes are more concerning than brief changes
• Be aware of the ICP value and waveform on the monitor. The waveform may change shape if cerebral hypoxia or ischemia occurs.
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Slide 176 Considerations (continued)
• EVDs must be clamped • before getting out of bed, changing body position
from supine, or adjusting angle of bed
• Keep slack in the lines
• Must bring EVD collection bag/lines with mobility—2nd set of hands needed
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Slide 177 Considerations (continued)
• Patients with elevated ICP are positioned with head of bed (HOB) elevated at 30◦ to maximize venous flow. • Lowering HOB may increase ICP.
• Lateral neck flexion and extreme hip flexion may increase ICP
• Changing patient position in bed (sliding down) could affect drainage system
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Slide 178 Considerations (continued)
• Patient may only tolerate short bouts of activity.
• Monitor for signs and symptoms of ICP changes • headache, confusion, dizziness
• Monitor Glasgow Coma Scale score changes especially if patient has a brain injury
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Slide 179 Considerations (continued)
• ICP Normal: ~7-15 mm Hg
• ICP >20 mmHg (GCS 13-15)• patient drowsy and confused
• ICP > 30 mm Hg (GCS <8) • severe brain swelling
• patient non-participatory
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Slide 180
Abdominal pressure and perfusion
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Slide 181 Abdomen and Abdominal Cavity
• Organs
• Blood vessels
• Peritoneum
• Muscles
• Fascia
• Skin
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Slide 182 Intra-abdominal Pressure (IAP)
• Our abdomen has a steady state pressure in our abdominal cavity.
• Pressure changes occur:• With postural changes• With movement of diaphragm• Physical activity• Coughing• Straining• Organ dysfunction• Fluid overload• Pregnancy
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Slide 183 Intra-abdominal Hypertension(IAH)
• When IAP is sustained ≥12 mm Hg the patient now has intra-abdominal hypertension
Types of Intra-abdominal Hypertension (IAH)
Definition Cause
Hyperacute Elevation of IAP lasting for seconds
From coughing, sneezing, straining, physical activity
Acute Elevation of IAP that lasts for hours
Result of trauma or intra-abdominal hemorrhage
Subacute Elevation of IAP that lasts for days
Common with medical patientsand can last for days
Chronic Elevation of IAP that develops over months or years
• Count the number of small boxes between two R waves and divide into 1500.
• Count the number of R waves in a six second strip and multiply by 10.
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Slide 217 Lets try it
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Slide 218
Sinus Rhythms
• Sinus Rhythm- 60-100 bpm
• Sinus Bradycardia- < 60 bpm
• Sinus Tachycardia- > 100 bpm
• These rhythms have normal P waves, PR int and QRS int
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Slide 219
Supraventricular Dysrhythmias
Atrial and Junctional Mechanisms
– Supraventricular tachycardia (SVT)
–Atrial tachycardia
–Atrial Flutter
–Atrial Fibrillation
– Junctional Rhythm
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Slide 220 SVT
Rate- 150-250- regular rhythm- no visible P waves- PR not measurable-QRS .12 or less
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Slide 221 Atrial Tachycardia
Rate 150-250- regular- 1 P per QRS- PR may be shorter, QRS .12 or less
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Slide 222 Atrial Flutter
Atrial rate 250-450- ventricular varies- Atrial is regular-ventricular can be irregular- P wave- saw tooth- PR not
measurable- QRS <.12.
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Slide 223
Atrial FibrillationRate can vary- Irregularly Irregular- P waves chaotic- PR not measured- QRS <.12.
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Slide 224 Junctional RhythmRate- 40-60- regular- P waves inverted-before or after QRS or absent- PR if
present <.12- QRS .12 or less.
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Slide 225 Ventricular Dysrhythmias
Premature Ventricular Contraction (PVC)
–Bigeminy
–Ventricular couplet
–Multifocal PVC (>1 ectopic focus)
Ventricular Tachycardia
Ventricular Fibrillation
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Slide 226 PVC
Rate varies- Can be regular or irregular- P wave will be absent-unmeasurable PRI- QRS >.12.
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Slide 227 Bigeminy
1 PVC every other beat- regular-irregular rhythm
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Slide 228 Ventricular Couplet
PVC occurs twice
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Slide 229 Multi-Focal PVC
Can be both positive and negative since there are different ectopic origins
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Slide 230 Ventricular Tachycardia
3 or more PVC with rate >100 bpm- patient can be asymptomatic-symptomatic or unconscious and pulseless.
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Slide 231 Ventricular Fibrillation
No organized rhythm- needs immediate defibrillation
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Slide 232
Atrioventricular Blocks
First Degree AV Block
Second Degree AV Block• Mobitz Type 1- Wenckebach
• Mobitz Type 2
Third Degree AV Block
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Slide 233 First Degree Heart Block
PR interval > .20s
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Slide 234 Mobitz Type 1
PR interval progressively get longer than QRS drops
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Slide 235 Mobitz Type 2
Regular dropped QRS every 2nd third or 4th P wave- consistent PR interval
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Slide 236 Third Degree Heart Block
No conduction between A and V- both will have regular rates- Ps can be hidden in QRS
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Slide 237 Story of the AV block Family
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Slide 238 Bundle Branch Blocks
• Right Bundle Branch Block RBBB
• Left Bundle Branch Block LBBB
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Slide 239 Left Bundle Branch Block
• Increased QRS >.10s
• Once a widened QRS > 0.10s is identified, we look at leads closest to the LV to identify a LBBB.Leads V5,V6, I, and aVL are in close proximity to the left ventricle, and as such, are the best location to identify a LBBB.
• Characterized by an RSR segment or notched QRS
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Slide 240
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Slide 241 Right Bundle Branch Block
Look at Right chest Leads V1 and V2
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Slide 242
Myocardial Infarction
• ST segment elevation
• ST segment depression
• Inverted T wave
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Slide 243
ST segment elevation
• Transmural MI
• Use precordial leads to localize
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Slide 244
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Slide 245
ST segment depression
• Myocardial ischemia- can be diagnostic during exercise
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Slide 246
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Slide 247
Inverted T wave
• Myocardial ischemia (can be old)
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Slide 248
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Slide 249
EKG Lab
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Slide 250 Case 1
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Slide 251 Case 2
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Slide 252 Case 3
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Slide 253 Case 4
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Slide 254 Case 5
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Slide 255 Case Studies
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Slide 256
Game Show Wrap Up
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Slide 257 References Academy of Acute Care Physical Therapy (2017). Laboratory Values Interpretation Resource. Retrieved from
http://www.acutept.org/?page=ResourceGuides American Physical Therapy Association. (2016). Guide to Physical Therapy Practice 3.0. Alexandria: American Physical
Therapy Association. Retrieved from www.apta.org: http://guidetoptpractice.apta.org/site/misc/terms.xhtml American Physical Therapy Association. (2016). Guide to Physical Therapy Practice 3.0. Alexandria: American Physical
Therapy Association. Retrieved from www.apta.org: http://guidetoptpractice.apta.org/site/misc/terms.xhtml American Physical Therapy Association. (2016, May). The Movement System Brings it All. PT in Motion, 8(4), 14-21. American Physical Therapy Association, Movement System. http://www.apta.org/MovementSystem/. Accessed
10/30/2017. Anatomy and Physiology: Homeostatic regulation of the Vascular System. http://philschatz.com/anatomy-
book/contents/m46603.html. Accessed 10/30/17. Arbour R. Intracranial Hypertension Monitoring and Nursing Assessment. Crit Care Nurse October 2004 vol. 24 (5): 19-
32. Askandar, S., Bob-Manuel, T., Singh, P., & Khouzam, R. N. (2017). Shorter Door-To-Balloon ST-Elevation Myocardial
Infarction Time: Should There Be a Minimum Limit?. Current Problems in Cardiology, 42(6), 175-187. Bartlo, P., Brooks, G., & Cohen, M. (2015). Toward entry-level competencies in cardiovascular and pulmonary physical
Phys Ther. 27, 57. Burlew Cn et al. Trauma. In: Brunicardi F, et al. (ed). Schwartz's Principles of Surgery, 10e New York, NY: McGraw-Hill;
2015.
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Slide 258 References Cahalin, L.P., Mathier, M.A., Semigran, M.J., Dec, G.W., Disalvo, T. G. (1996). the six-minute walk test predicts peak
oxygen uptake and survival in patients with advanced heart failure. Chest, 110(2), 325-32. Chaboyer, W., Thalib, L., Foster, M., Ball, C., Richards, B. (2008). Predictors of adverse events in patients after
discharge from the intensive care unit. Am J Crit Care, 17(3), 255-63. Daamen, M. A. M. J., Brunner-la Rocca, H. P., Tan, F. E. S., Hamers, J. P. H., & Schols, J. M. G. A. (2017). Clinical
diagnosis of heart failure in nursing home residents based on history, physical exam, BNP and ECG: Is it reliable?. European Geriatric Medicine, 8(1), 59-65.
Damluji, Abdulla, et al. "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." Journal of critical care 28.4 (2013): 535-e9.
Dubb, Rolf, et al. "Barriers and strategies for early mobilization of patients in intensive care units." Annals of the American Thoracic Society 13.5 (2016): 724-730.
Fields, C., Trotsky, A., Fernandez, N., & Smith, B. A. (2015). Mobility and Ambulation for Patients With Pulmonary Artery Catheters: A Retrospective Descriptive Study. Journal of Acute Care Physical Therapy, 6(2), 64-70. doi:10.1097/JAT.0000000000000012
Fritz, S., Lusardi, M. (2009). White: paper: “Walking speed: the sixth vital sign.” J Geriatr Phys Ther, 32(2), 46-9. Frownfelter, D., & Dean, E. (2012). Cardiovascular and Pulmonary Physical Therapy Evidence and Practice (5th ed.).
St Louis: Elsevier-Mosby. Gestring, M. Abdominal Compartment Syndrome in Adults. In: UpToDate, Sanfey H (Ed), UptoDate, Waltham, MA,
2017. Goodman, C. C., & Fuller, K. S. (2015). Pathology Implications for the physical therapist. St Louis: Elsevier Saunders. Gokalp, Orhan, et al. "Cannulation in extracorporeal membrane oxygenation." Critical Care 18.4 (2014): 443.
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Slide 259 References Haines KJ, et al. Association of postoperative pulmonary complications with delayed mobilization following major
abdominal surgery: an observational cohort study. Physiotherapy 99 (2013) 119-125. Hall, J. B., Schmidt, G. A., & Kress, J. P. (2015). Principles of Critical Care. New York: Mcgraw-Hill Education. Hedges JS. et al. Chapter 4 Early Rehabilitation Interventions. In: Robinson LR (ed). Trauma Rehabilitation: Wolters
Klumer Health, 2005. Hemphill, JC et al. Management of acute severe traumatic brain injury. In: UpToDate, Aminoff, MJ (Ed), UpToDate,
Waltham, MA, 2017.Hemphill JC et al. Neurologic Critical Care, Including Hypoxic-Ischemic Encephalopathy, and Subarachnoid Hemorrhage In: Kasper D et al.(ed). Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill Education; 2014.
Ho VP, Barie PS. Acute Abdominal Dysfunction. In: Oropello JM, et al.. eds. Critical Care New York, NY: McGraw-Hill; Joyner, M. J., Casey, Darren, D. P. (2015). Regulation of Increased Blood Flow (Hyoeremia) to Muscles During Exercise:
A Hierarchy of Competing Physiological Needs. Physiol Rev, 95(2): 549-601. Kasper DL, et al. eds. Increased Intracranial Pressure and Head Trauma. In: Harrison's Manual of Medicine, 19e New
York, NY: McGraw-Hill; Kerr M, Crago EA. Nursing management: acute intracranial problems. In: O'Brien PG, Giddens JF, Bucher L, eds.
Medical-Surgical Nursing: Assessment and Management of Clinical Problems. St Louis, Mo: CV Mosby Inc; 2004: 1491-1524.
Kirkman MA et al. Intracranial Pressure Monitoring, Cerebral Perfusion Pressure Estimation, and ICP/CPP-guided Therapy-A standard of care or optional extra after brain injury. Br J Anaesth. 2014;112(1):35-46.
Lundy-Ekman L C et al. Neuroscience Fundamentals for Rehabilitation. 4th ed, Saint Louis, Mo: Saunders; 2013.
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Slide 260 References Lyell, D., & Coiera, E. (2016). Automation bias and verification complexity: a systematic review. Journal of the American
Medical Informatics Association, 24(2), 423-431. Malone, D., Ridgeway, K., Norton-Craft, A., Moss, P., Schenkman, M., & Moss, M. (2015). Physical therapist practice in
the Intensive care Unit: results of a National Survey. Physical therapy, 95, 1335-1344. doi:10.2522/ptj.20140417 Malone DJ, Lindsay KLB. Physical therapy in acute care : a clinician's guide. Thorofare, NJ: Slack; 2006. Mariano GL, et al. Intracranial Pressure: Monitoring and Management. In: Hall JB, eds. Principles of Critical Care, 4e
New York, NY: McGraw-Hill; 2014. Martin, N. Management of the open abdomen in adult. In: UpToDate, Bulger EM (Ed), UpToDate, Waltham, MA, 2017. Matuskowitz, A. J., Carr, C. M., Jennings, L., Hall, G. A., & Saef, S. H. (2016). 107 How Good are Paramedics and
Emergency Physicians at Diagnosing a STEMI by EKG Compared to Cardiologists?. Annals of Emergency Medicine, 68(4), S43.
Mufti, T. S., Durkhanay W. (2016). Accuracy of Blood Pressure recording by Manual and Automated Digital Devices: A Clinical Guideline. J Rehman Med Inst, 2(2), 17-25.
Oropello JM, Mistry N, Ullman JS. Head Injury. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of Critical Care, 4e New York, NY: McGraw-Hill; 2014.
O’Sullivan, S., Schmitz, T., Fulk, G. (2014). Physical Rehabilitation. 6th ed. Parry, S. M., Granger, C. L., Berney, S., Jones, J., Beach, L., El-Ansary, D., . . . Denehy, L. (2015, Feb 5). Assessment of
impairment and activity limitations in the critically ill: a systematic review of measurement instruments and their clinimetric properties. doi:10.1007/s00134-015-3672-x
Paz J. Michelle West. Acute Care Handbook for Physical Therapist 4th edition St. Louis, Mo: Elsevier; 2014.
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Slide 261 References Paz J, West M. Acute care Handbook for Physical Therapists. 3rd ed. St. Louis: Saunders Elsevier; 2009 Perme, Christiane, et al. "Safety and efficacy of mobility interventions in patients with femoral catheters in the ICU: a
prospective observational study." Cardiopulmonary physical therapy journal 24.2 (2013): 12. Pescatello, L.S. (2014). American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription. 9th ed.
Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins Health. Pierson, F. M. (2007). Principles and Techniques of Patient Care 4th Ed. St. Louis: Saunders. Ristic A et al. Current neuromonitoring techniques in acute care. Journal of Neuroanaesthesiology and Critical Care;
2015: 2(2): 97-103. Rodgers WK et al. Intraabdominal Hypertension, Abdominal Compartment Syndrome, and the Open Abdomen.
Chest;2017 Aug: epub ahead of print. Schlichting A, Schmidt GA. Abdominal Compartment Syndrome. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of
Critical Care, 4e New York, NY: McGraw-Hill; 2014. Schmalz, T., Blumentritt, S., Jarasch, R. (2002). Energy expenditure and biomechanical characteristics of lower limb
amputee gait: the influence of prosthetic alignment and different prosthetic components. Gait Posture. Dec; 16(3), 255-63.
Silva YR et al. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Physiotherapy 99 (2013) 187-193.
Smith ES et al. Evaluation and management of elevated intracranial pressure in adults. In: UpToDate, Aminoff, MJ (Ed), UpToDate, Waltham, MA, 2017.
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Slide 262 References
Smith, I., Mackay, J., Fahrid, N., Krucheck, D. (2011). Respiratory rate measurement: a comparison of methods. British Journal of Healthcare Assistants. 5(1), 18-23.
Swan, H. J. C., et al. "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter." New England Journal of Medicine 283.9 (1970): 447-451.
The AVERT Trial Collaboration group. (2015). Effi cacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet, 386, 46–55.
Toonstra, Amy L., et al. "Feasibility and safety of physical therapy during continuous renal replacement therapy in the intensive care unit." Annals of the American Thoracic Society 13.5 (2016): 699-704.
Wang, Yi Tian, et al. "Early mobilization on continuous renal replacement therapy is safe and may improve filter life." Critical Care 18.4 (2014): R161.
Witcher, R., Stoerger, L., Dzierba, A. L., Silverstein, A., Rosengart, A., Brodie, D., & Berger, K. (2015). Effect of early mobilization on sedation practices in the neurosciences intensive care unit: A preimplementation and postimplementation evaluation. Journal of Critical Care, 30, 344-347. doi:10.1016/j.jcrc.2014.12.003
Wright DW, Merck LH. Head Trauma. In: Tintinalli JE, (et al.) eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016.