The Critically Ill Patient Trivia Quiz

Answer: level of consciousness ( LOC )

The bedside monitor looks like a TV screen but it displays various body functions. Several sensing devices/electrodes are placed on the patient's body. These are attached to wires and cables leading to the monitor which in turn displays the body functions. Continuous monitoring of vital signs (blood pressure, heart rate, respiration) allows for early detection of changes in a patient's condition which may become fatal if allowed to go unattended. The monitors have alarms which are set to activate when there's danger or impending danger.

To determine a patient's level of consciousness, a neurological assessment has to be done whereby one evaluates the patient's level of alertness, orientation to person, place and time, (for example ability to state name, where he/she is and current month), ability to follow simple commands, response to painful stimuli, etcetera. It's possible for a patient to have normal vital signs and be unconscious.

Answer: visualization of the stomach

There are several indications for a nasogastric tube. A patient who is comatosed, has altered mental status or is unable to swallow can be fed via a nasogastric tube. If it's determined that the patient will remain in this state for a long time, a PEG (Percutaneous Endoscopic Gastrostomy) tube can be placed directly into the stomach. Medications normally taken orally are prepared in a liquid form and administered via the nasogastric tube. Not all medications can or should be crushed so an alternative drug may be used.

One should always ensure proper placement of a nasogastric tube before using it to prevent aspiration of fluid into the lungs, which can occur if the tube is in the trachea instead of the esophagus. Aspiration of acidic fluid into the lungs can cause serious lung injury and may lead to aspiration pneumonia. Checking the amount of fluid present in the stomach intermittently helps us to know how well the patient is tolerating the amount of feed given and if adjustments have to be made. For patients who have recently ingested something harmful, a nasogastric tube may be used to empty the stomach contents and lavage/wash out the stomach.

Answer: No

Prolonged use of a nasogastric tube can result in erosion of the nares where the tube is taped, sinusitis, and can pose a higher risk of aspiration pneumonia. PEG tube placement is a simple procedure which can be done either at the bedside in an ICU under moderate sedation, or in an operating room. The procedure takes about 20 minutes. The tube is passed through the mouth and esophagus, into the stomach. It is then passed through a tiny opening placed in the anterior stomach and abdominal wall. It's anchored in the stomach by a retention dome or balloon.

Patients who may need a PEG tube include those with a stroke, severe cases of dementia, those in a vegetative state or persons who are unable to consume enough food orally to prevent malnutrition. When the patient is able to sustain nutrition orally again, the PEG site can be closed.

Answer: Arterial line ( A-line )

An arterial line is a thin catheter inserted into an artery, usually on the inner aspect of the wrist. It can also be inserted in an artery in the elbow, groin or foot. The A-line allows for real-time measurement of the blood pressure, which is reflected on a bedside monitor. This is very useful for patients on continuous blood pressure medication as it helps with titration and weaning off of those medications. In addition to blood pressure monitoring, A-lines can be used for obtaining blood samples for analysis. It saves the patient from painful needle sticks each time blood is needed (which can be pretty often in a Critical Care Unit). A-lines also allow for monitoring of arterial blood gases. This is very useful for patients on a ventilator as it helps manipulation of ventilatory support and facilitates weaning from the ventilator.

The other catheters are inserted into large central veins instead of arteries. Tunneled catheters are for long term use, for example for hemodialysis. They run under the skin and have a cuff which stimulates tissue growth which helps with stability of the catheter. PICC lines are inserted into a vein in the arm and extend to a large vein near the heart. These too are for long term use. Non-tunneled catheters are for short term use and are commonly seen in the ICU.

Answer: The wrist

A central venous line is a catheter inserted into one of the big veins in the body. These include the right or left femoral vein found in the groin area, the right or left subclavian vein in the upper chest and the right or left internal jugular vein in the neck. When inserted in the neck or upper chest, proper placement should be confirmed prior to use. A post procedure x-ray, in addition to determining placement confirmation, helps to detect if a lung has been inadvertently punctured during the procedure.

Central lines allow for administration of large volumes of fluid quickly, for example, in cases of shock. They're also used for administering medication, obtaining blood samples and for providing nutrition for those patients who are unable to have enteral nutrition.

A commonly asked question is "Why does a patient need both an arterial and a central line?" Art lines are in ARTERIES. They're NEVER used for infusion/transfusion. Central lines are placed in VEINS, they're needed for transfusion/infusion. Both lines can be used for blood draws. However, an arterial blood gas can only be done on arterial blood.

Answer: control of an aggressive patient.

An endotracheal (ET) tube allows for air to pass freely in and out of the lungs. The tube has a cuff near the tip which, when inflated, helps to keep it in position. It also forms a seal which prevents aspiration of acid stomach contents. Outside of the body, the proximal portion of the tube is secured to the face or neck using tape or other stabilization devices. When the tube has to be removed, the air is let out of the cuff. Self extubation should be avoided because there's a risk of damage caused by the inflated cuff. Also, if reintubation becomes necessary, it's likely to be difficult because of swelling of the tissue in the throat. Patients have been known to have emergency bedside tracheostomy for this reason. Therefore, some patients may be seen wearing soft wrist restraints for safety.

In a critical care setting, the ET tube is usually attached to a ventilator which helps with respiration. To enhance comfort, an intubated patient may be sedated with drugs such as propofol. Where possible, the propofol drip can be held temporarily to allow patients to interact with their loved ones.

Answer: At the front of the neck.

A tracheostomy is a surgical opening into the trachea. It allows for the insertion of a short tube called a tracheostomy tube which keeps the airway open. This procedure is usually performed in an operating room. However, in cases of emergency it can be done at the bedside.

When a patient no longer needs a trach, the site can be closed but it leaves a little scar.

Answer: A ventilator

The nasal cannula, venturi mask and nonrebreather mask are all devices used to provide oxygen, but what good is oxygen if the patient is unable to breathe it in? The ventilator does the actual work of breathing for the patient as well as providing oxygen. There are several questions to be considered when assisting a person with the work of breathing. For example, what volume of air do you want the patient to have with each breath? How much force is needed to keep the alveoli/air sacs open? How many breaths should the patient take per minute? How much oxygen is really needed? Which ventilator mode works best for the patient?

Once the patient's condition improves, they are gradually weaned off the ventilator.

Answer: They come in one standard size.

An Indwelling Foley catheter is a tube which is introduced into the urinary bladder via the urethra. Foley catheters are made in various sizes.

In the critical care setting, they're used to monitor urinary output hourly. A drop in urinary output below normal hourly values may mean that the patient needs more fluid or that the kidneys aren't producing urine as they should. Hence, monitoring output hourly helps to promote prompt detection of problems and early intervention. A disadvantage of the foley catheter is the increased incidence of urinary tract infection associated with indwelling catheters.

Answer: frequency of stools

Vasopressors are drugs which cause peripheral vaso constriction. Because the circulation to the periphery is reduced, the patient's fingers and toes may feel cold to touch and eventually, as they continue to be deprived of adequate circulation, finger tips and toes appear bluish or darkened. Blood supply is also reduced to the skin so these patients are more susceptible to development of bedsores.

Certain vasopressors cause the heart to beat too fast (Tachycardia). If the heart beats too fast it won't be able to empty properly, so the heart rate should me monitored and a switch of drug made where possible. Because of the side effects of vasopressors, blood pressure should be monitored frequently, preferably with an arterial line, and the drug weaned off as soon as possible.