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CCEMT-P scope of practice - governed by civil laws (statutes), rules & regulations in each state Appropriate Care: Duty, Breach, Damages, Proximate Cause When patient info can be released Continuation of care, law requires it, billing, subpoena Pertinent transfer info Reason for transfer, MD to MD contact required PTA, treatment of patient, treatment and orders within your scope of practice, report: CC, S/S, Assessment, H&P, Plan of Care EMTALA (Emergency Medical Treatment & Active Labor Act) Requirements: Medical Records, S/S, Diagnosis, Test Results, Written Consent, MD verification that risks of transport outweigh the benefits Review Case Law for Exam
-Ostomies-
Stoma opening in the abdominal wall where the end of the colon is brought to the skin surface Indications: o Bowel Injury/ Disease o Bladder Injury/ Disease o Decompression o Stool Diversion Most common ostomy - Colostomy Diversion of urine from the bladder Urostomy Ureterostomies located on the patients flank -Renal Assessment & Urinary Catheters-
Indications: o Incontinence o Sedated/ Paralyzed Patients o Inability to void o Collection of Specimen Nephrolithiasis (Kidney Stones) - Types: Calcium, Struvite, Uric Acid, Cystine Urinary Tract Infections More common in females, E. Coli in 80% of patients Normal Urine Output: 30+ ccs per hour Order of Assessment: Visualization, Auscultation, Palpation, Percussion -Nasogastric, Orogastric & Feeding Tubes-
Gastric Tube contraindications esophageal varices, head injury or facial trauma (NG Tube) NG/OG Indications: Eternal Feeding, Medication Administration, Gastric Lavage & Decompression Measure NG/ OG tube from tip of nose to earlobe to xiphoid process Percutaneous Endoscopic Gastrostomy/ Jejunostomy (PEG/ PEJ) tube Feeding Tube
X-Ray Interpretation
If you see upper rib fractures, always assume c-spine injury Diaphragm is dome-shaped with clear costophrenic angles (inferior bilaterally) Inferior Ventricular Width is approximately 1/3 to1/2 the chest width Air = Black Fresh blood & water = Opaque White Tissue = Dense White ET Tube - should be 2cm above the carina Consolidation Infection, fluid, inflammatory exudate Atelectasis No ventilation to the lobe beyond obstruction (leads to pneumonia) Order of Chest X-Ray assessment: o A Airway (midline?) o B Bone Structures (visible?) {asymmetry, fractures, lesions, curvature of spine } o C Cardiac (size?) o D Diaphragm (clear costophrenic angles?) o E Event (Chronic or Acute?) 5 Steps to X-Ray Interpretation: 1. Assess lung expansion 2. Assess pleura 3. Look for infiltrates 4. Look at the mediastinum 5. Assess the abdomen Infiltrate = Pneumonia Thumb print/ Thumb sign = epiglottitis Steeple Sign = Croup Increased prominence in pulmonary vasculature, cardiomegaly = heart failure Diaphragm Right side is always higher 'White out consolidation or fluid filled alveoli Fluffy Pneumonia or ARDS Cor = size of the heart
CT Scan assessment & findings: o The X Look for symmetry in the film o Black spots Infarct or old blood o White spots Acute blood o Ventriloquist Are the ventricles compressed or too large? o Breaks Are there any fractures? o Masses Are they new or old?
ARDS (Acute Respiratory Distress Syndrome) relative pulmonary failure, characterized by hypoxemia with shunting, dyspnea and onset of bilateral diffuse pulmonary infiltrates on x-ray Usually develops within 24 - 48 hours of the insult Etiology: MSOF Insult to the lung Pneumonia Chest Trauma Burns Near Drowning Pancreatitis Signs & Symptoms: Dyspnea, Rapid & Shallow Respirations Accessory muscle use Cyanotic or mottled skin, not improving with O2 Management High FiO2, ABGs, Ventilation, CPAP c PEEP, fluid administration End Result - Decreased compliance, decreased gas exchange, hypoxemia DIC (Disseminated Intravascular Coagulation) Causation Factor Any causes of disequilibria in the balance of clotting versus lysis History: Recent Pregnancy Multi-System Trauma Cancer Infection Signs & Symptoms: Bleeding from odd sites: o Gums, Nail Beds, Eyes, IV Puncture Sites Thrombocytopenia Decrease of clotting factors Acute Renal Failure Acute Hepatic Failure Management: Treat underlying cause Treat loss of blood & constituents Heparin Therapy as required
Shock
Definition: Cells become hypoxic because of inadequate perfusion of the tissues. 4 Categories of shock: 1. Hypovolemic (Loss of volume) Burns, Hemorrhage, Gastroenteritis, Spleen Rupture 2. Cardiogenic (Loss of pump) Acute/ Chronic Cardiac Patients, TB Patients, Trauma Patients 3. Distributive (Loss of competency of vasculature) Septic, Neurogenic, Anaphylactic 4. Obstructive (Loss of pathway) Airway Obstruction, Cardiac Tamponade, Tension Pneumothorax
Stages of shock: 1. Compensatory 2. Progressive 3. Irreversible Cellular Effects of Shock: o Decreased ATP production o Excess Lactic Acid Production o Mitochondrial Death o Cellular Edema o Deterioration of the sodium-potassium pump Crystalloids are administered @ a 3:1 ratio Blood products are administered @ a 1:1 ratio
Whole Blood o Complete blood, unadulterated except for anticoagulants. o Cross-Match Necessary o Indications: Hypovolemic shock Acute hemorrhage Exchange transfusion Surgery Obstetrics Packed Red Blood Cells (PRBCs) o Contains all characteristics of Whole Blood, minus plasma. o Indications: Anemia CHF Surgery Fresh Frozen Plasma (FFP) o Contains clotting factors o For low PT/ PTT o Must be infused within 24 hours of being thawed o Indications: Active bleeding Hemophilia Thrombocytopenia Type & Screen o Indications: Blood Loss Anemia Surgical Work-Up o Procedure: Phlebotomy Spin & Separate Test for antibodies
Cross Matching o Indications: Specific blood for specific patient (O) Universal donor (AB) Universal Recipient
Both
RH Factor o Rh Positive Possess D Antigen o Rh Negative Possess no D antigen Rh Negative patients may develop D Antigen Blood Administration o Equipment needed: Physicians order Blood Type & Matched Large Bore Venous Access Filtered Administration Set Isotonic NS Thermometer o Transfusion Procedure: 1. Flush tubing with NS 2. Inspect Blood 3. Cover administration with blood 4. Connect Blood Tubing 5. Piggyback IV line of NS 6. Slowly start transfusion 7. Monitor for adverse reactions 8. Have at least two IV Sites o Transfusion Rate Procedure: Initial Rate of 1 ml/min Evaluate for hemolytic reaction Monitor vitals every 15 minutes
After 30 minutes adjust flow rate Evaluate for hemolytic reaction Monitor vitals every 30 minutes Transfusion Reaction: Fever Hives, Itching or skin symptoms Swelling or soreness @ IV site Tachycardia Respiratory Distress Hypotension Anaphylaxis Nausea/ Vomiting Blood in Urine Treatment of Transfusion Reaction: 1. STOP the Transfusion! 2. Maintain IV access with Isotonic NS 3. Save the remaining blood product 4. Administer Oxygen PRN Treatments continued: o Medications: Benadryl Epinephrine Tylenol Lasix
Pediatrics
General Pediatric Assessment: o Identify baseline findings o Systems Assessment o Vital Signs o Toe to Head Assessment Pediatric History: o Activity Level o Feeding/ Fluid Pattern o Perinatal history if under 1 year old Transport Considerations: o Double check fluid rates and medications o Secure Lines & Tubes SBP is = (90) + (2X Age in years) Rewarm Children @ no more than 1 Degree Celsius/ Hour
Dialysis
Function of the Kidneys: o Control bodys Water Balance o Regulation of Blood Pressure (Renin-angiotensin) o Electrolyte Balance (Na+, Ca2+, K+, etc) o Excretion of Metabolic Wastes (Urea, creatinine) o Acid/ Base Balance o Regulation of Red Blood Cell Production (erythropoietin) o Production of Vitamin D
Indications for Dialysis: Traumatic renal Insufficiency, End-Stage Renal Disease Dialysis Transport Complications: o Bleeding o Infection o Infiltration o Abdominal Pain o Signs of electrolyte & chemical Imbalances Hyper/ Hypoglycemia Sodium/ Potassium imbalances Hemodialysis: Vascular Access through either a fistula or arteriovenous shunt Peritoneal Dialysis: Introduction of Dialysate solution into the abdominal cavity with a catheter Accessing an Arteriovenous shunt: Need to know these steps! 1. 2. 3. 4. 5. 6.
Proprioception: The ability to discern where you are in space. (Spinal cord patients lose that ability) Poikilothermia: Loss of thermal regulation, patient will assume ambient temperature Spinal Shock: Profound disruption of the spinal cord o Bradycardia o Hypotension o Flaccid paralysis o Sensory loss below the level of injury o Loss of bowel & bladder function o Loss of temperature control o Priapism Orthostatic Hypotension: Result in a loss of peripheral resistance Autonomic Dysreflexia: An exaggerated sympathetic response which results in uncontrolled hypertension o Serious Hypertensive Emergency o Patients with injury @ T-6 and above
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Places Herniation Occur: Cingulate Uncal Central (Transtentorial) External Tonsillar (Cerebellar)
Factors that will Increase ICP: o Positional Changes o Coughing (Valsalva Maneuvers) o Body Temperature o Drainage of Interventricular Cannula o Medications o Environmental Considerations Strategies for Decreasing ICP: o Fentanyl, Morphine (Analgesia) o Versed, Ativan (Benzodiazepine Sedation) o Propofol (Sedation) o Ventilation (Hyperventilation when herniated) o Diuretics (Draw off excess fluid [Osmotic or Loop]) o Paralytics (Eliminate Pain Response) o Fluids 3% NaCl (Pull off fluid excess) o Vasopressors (Maintain MAP) o Potassium ([Hypokalemic] Because of Loop Diuretics) o Insulin (Combat release of cortisol) o Methylprednisolone (Spinal Cord Injuries) Compliance Change in volume divided by the change in pressure CSF Drainage: o If IVC (Interventricular Cannula) in place, open & close Over-drainage = herniation Under-drainage = hydrocephalus o Level IVC @ the ear Intracranial Pressure Waveforms: o Normal ICP between 0 -15 mmHg o Severe rise in ICP caused by a small increase in volume, looks like: A Vertical inflection Point
Aeromedical Physiology
Boyles Law o At a constant temperature, the volume of gas varies inversely with the pressure o As you go up, air will expand o *** More than 15% Pneumothorax Put in a chest tube o Fill ETT with fluid Daltons Law o In a mixture of gases, the total pressure is equal to the sum of the partial pressures of each gas o O2 Availability decreases with altitude o Altitude increase, decreases barometric pressure o *** Patient will require increased oxygen delivery at higher altitudes
Place patient in LLR Trendelenburg (Durants Position) if suspected Air Embolus/ Bends Eight Stressors of Flight: 1. Hypoxia 2. Barometric Pressure 3. Temperature Changes 4. Decreased Humidity 5. Noise 6. Vibration 7. Fatigue 8. G-Forces Hypoxia: o Hypoxic Hypoxia Deficiency in alveolar O2 exchange o Hypemic Hypoxia Deficiency in the O2 carrying capability of blood Signs & Symptoms: Objective: o Dyspnea, Tachypnea o Tachycardia, Bradycardia, Arrhythmias o Hypertension, Hypotension o Slouching, Euphoria, Belligerence o Confusion, Restlessness, Unconsciousness Subjective: o Personality & Judgment Changes o Hot & Cold Flashes o Head Ache, Blurred Vision, Dizziness, Tunnel Vision o Nausea o Confusion, Stupor, Insomnia, Anger, Euphoria o Numbness o Inability to rationalize sight, taste, sound or pain Time of Useful Consciousness: o Below 18,000 ft. (30 minutes) o 25,000 ft. (3 5 minutes) o 30,000 ft. (90 seconds) o Greater than 40,000 ft. (< 15 seconds) Contributing Factors to Crew-Member Fatigue: o Drugs o Exhaustion o Alcohol o Tobacco o Hypoglycemia
Hemodynamic Monitoring
Types: o Arterial MAP (Mean Arterial Pressure) o Venous CVP (Central Venous Pressure) o Pulmonary PAP, PCWP (Pulmonary Artery Pressure, Pulmonary-Capillary Wedge Pressure) th Phlebostatic Axis 4 Intercostal Mid-Axillary To zero a hemodynamic monitor, open it to air
Waveforms Types: o o o o Atrial Waveforms Ventricular Waveforms Pulmonary Artery Waveforms Arterial Waveforms
Dicrotic Notch An increase in Aortic Pressure that signals the start of diastole Central Venous Monitoring Evaluates net volume and Right Atrial Pressure (RAP) o Normal CVP or RAP is 2 -6 cm H2O o Increased CVP = Hypervolemia o Decreased CVP = Hypovolemia Pulmonary Artery Catheter (Swan-Ganz Catheter) Measures: o Right Atrial Pressure (RAP) o Pulmonary Artery Pressure (PA) o Pulmonary Artery Capillary Wedge Pressure (PCWP)
Complications: o No waveform: Transducer is not open to the catheter o Dampened Waveform: Improper monitor calibration Clot or air bubble in catheter Aspirate, NEVER irrigate first Blood in the transducer o Continuous PCWP Wedge Waveform: /.Catheter Migration Have the patient cough o No PCWP Wedge Waveform: Incorrect position of the catheter Insufficient air in the balloon Balloon Rupture Swan-Ganz Catheter Diagram:
Platelet Count (Thrombocytes) o Cell important for coagulation and hemostasis o Normal Platelet Count is 150,000 400,000 mcl o Decreased Platelets: Leukemia, Splenic Injury, Bone Marrow Disease o Increased Platelets: Hemorrhage, Anemia (Iron Deficiency), Surgery, Splenectomy, Trauma Blood Chemistry o Looks for Electrolyte & Metabolic Balances/ Abnormalities o Basic Metabolic Panel (BMP) Glucose Chief source of energy in the blood Normal Glucose Value is 70 -110mg/dl Increase Glucose: DM, Cushings, Pancreatitis, Hyperthyroidism Decrease Glucose: Addisons, Hypothyroidism, Bacterial Sepsis
Blood Urea Nitrogen (BUN) Metabolic byproduct from the breakdown of blood, muscle and protein Normal BUN is 8 20 mg/dl Increase in BUN (Azotemia): Kidney Disease, CHF, Gastrointestinal Hemorrhage Decrease in BUN: Excessive Hydration/ Fluids, Pregnancy
Creatinine Waste product of protein metabolism found in urine Normal Creatinine is 0.5 1.2 mg/dl BUN/ Creatinine Ratio is normally 10:1 or less. Greater than 10:1 is an indicator of renal failure Sodium Electrolyte: Alkali Metal Normal Sodium is 135 145 mEq/l Decreased Sodium: Diarrhea, Vomiting, Diabetic Acidosis Increased Sodium: Cushings, Diabetes Insipidus Potassium Electrolyte: Alkali Element Normal Potassium is 3.5 5 mEq/l Decrease in Potassium (Hypokalemic): V-Fib Increase in Potassium (Hyperkalemic): Asystole Sine Wave --------------------------------------------------------Creatine Phosphokinase (CPK) Enzyme broken down in muscles Increased CPK: Rabdomyolysis, Hypokalemia, Hypothyroidism, Trauma, Damaged Cardiac Muscle, Cerebrovascular Disease, Electrical Burns Troponin I & T Requires myocardial necrosis for release Early Rise 4 12 hours Peak in 12 -24 hours B-Type Natriuretic Peptide (BNP) Release from the ventricles in response to stretch from extra volume Normal BNP is <100 100 -400: COPD, CHF, Renal Failure 400+ Renal Failure or CHF ***Test will not work if patient on dialysis Bilirubin Pigment produced as the liver processes waste products Cholesterol Normal cholesterol is 140 220 mg/dl Amylase Normal Amylase is 50 -190 u/L Decreased Amylase: Pancreatitis Increased Amylase: Pancreatitis, Alcohol Poisoning Lipase Normal Lipase is 4 -24 u/dl Increased Lipase: Pancreatitis, Cirrhosis, Renal Disease Magnesium Normal Magnesium is 1.3 2.11 mEq/L
Urinalysis
Normal Urine Output 30+ccs/hour PT Checks for Coumadin Level PTT Checks for Heparin D-Dimer Diagnose: Abruptio Placenta, DIC, DVT, PE
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Pacing Response Triggered: Fixed Rate, Predetermined Rate, Does not regard underlying activity Inhibited: fire only when needed, Demand Pacemaker, Inhibit stimulus when they sense a patients complex Ventricular Pacemakers Stimulate only the ventricles Most all pacemakers have this function Atrial Pacemakers Depolarize the Atria & the hearts own conduction system is relied upon to depolarize the ventricles Common Types of Pacemakers: Single-Chamber Pacemakers Ventricular Demand Pacemaker (VVI) o Most common o Paces only when needed Atrial Demand Pacemaker (AAI) o Maintains the sequence of Atrial & Ventricular Contraction Dual-Chamber Pacemakers: A V Synchronous Pacemaker (VDD) o Senses Atrial & Ventricular Activity, but only paces the Ventricles A V Sequential Pacemaker (DVI) o Senses only Ventricular Activity, but paces chambers sequentially Optimal Pacemaker (DDD) o Fully automatic o Senses Atrial & Ventricular Activity o Paces either Atria, Ventricles or both Electrical Impulse Sharp, superimposed spike on the patients rhythm Troubleshooting problems should always start with the patient!
Implanted Cardioverter Pacemakers o o o Stay away from an MRI! First Human Implant of an ICD (1980 @ John Hopkins University Hospital) ICD Weight 97 -116 Grams
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1985: FDA Approved First Generation ICD Devices Pectoral region - accounts for 98% of ICD placements Amiodarone results in increased defibrillation threshold 6 8 weeks after introduced Place AICD leads as far away as possible from pacing electrodes Magnets will either turn off or suspend therapy from the ICD
Burns
Skin & its Effects on Burns: o Epidermis Sheading Skin o Skin: Largest Organ on body o Hydrostatic Pressure: Due to Water volume in body o Oncotic Pressure: Exerted by plasma proteins First Degree Burn: o Sunburn, Heat, Hot Liquids Second Degree Burn (Partial Thickness): o Chemicals, Flash Burns, Hot Liquids, Deep Sunburn o Extremely Painful, Red, Blistered, Painful Third Degree Burn (Full Thickness): o Fire, Deep Scald, Electricity, Chemicals o Pale White, Charred, Leathery, Painless
Burn Management: 1. All patients need 100% O2 Therapy & SaO2 Monitoring 2. Early intubation in these patients: Obtunded/ Confined Space Tachypnea, Stridor, Labored Breathing Inhalation Injury Largest ETT Possible 3. Tetanus Status? 4. Fluid resuscitation for all burns > 20% BSA 2 Large Bore IVs st Lactated Ringers for 1 24 hours st Fluid Resuscitation for 1 24 hours Do Not delay transport to gain IV access 5. Foley Catheter to monitor hourly I/O 6. NG/OG tube 7. Prevent Hypothermia
5. 6.
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Order of Paralysis: 1. Eyes, face, Neck 2. Extremities 3. Abdomen 4. Intercostals, Glottis 5. Diaphragm Pass the Tube Proof of Placement Objective Visualization Spo2 CO2 Detector Subjective Negative Epigastric Sounds Mist in the tube Positive Lung Sounds Equal Chest Rises & Fall Post Intubation Care [Non-Depolarizing Agent] Vecuronium (Norcuron) for paralysis (0.1 mg/kg) Duration of 20 30 minutes [Non-Depolarizing Agent] Rocuronium (Zemuron) for paralysis (1 mg/kg) Duration of 20 75 minutes
Performing an ABG Procedure: o Perform Modified Allens Test o Cleanse the Area o Hyper-Extend the wrist o Palpate the Arterial Pulse o Line the needle up to 45 Degrees and puncture (Bevel Up) o Withdraw the needle, Hold pressure o Invert syringe several times
12-Lead Electrocardiogram -Lead Placement & AcquisitionIf you have a pulse and a problem You should be doing a 12-Lead. -Bob Pageo Limb Leads (Bipolar): Positive looks towards negative Einthovens Triangle--------------------------------------------------Precordial Leads (Unipolar): V1-V6 Placement based on Anatomical landmark Placement------------------
-12-Lead Analysis-
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Q/T Interval should be 1/3 the R/R Interval R Wave Progression-----------------------------------------------Axis Deviation:
-Determining Axis & Hemiblockso Normal Axis - downward & to the left
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Ventricles out of sync: RSR Prime-------------------------------------------------------------Incomplete BBB: QRS Duration between 110-119 ms
-The 15-Lead ECGo o o o o 12-Lead Misses 50% of AMIs 23 out of 100 MIs could be missed for not doing this 15-Lead ECG increases sensitivity by 23% V4R-----------------------------------------------------------------------Up to 50% of Inferior MIs have Right Ventricular Involvement
Leopolds Maneuver-------
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Clonus Test Shaking Foot Post Pedal Flexion o No Response - 0 o Less than normal - 1+ o Normal - 2+ o More than normal - 3+ o Brisk - 4+ o Sustained (Seizure) - 5+ Station--------------------------------------------------------------------------Effacement:
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-Emergencieso Emergency Childbirth: Rarely Needed in the field Support Perineum Keep baby lower than perineum
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Clamp, cut & tie cord Warm baby & APGAR Baby to Moms chest Record time & place Start Pitocin @ 250 ml/hr (40 Units/1000 ml NaCl)
Types of Breech Presentation:----------------------------------------Post-Partum Hemorrhage: 4 Ts: Tone 70% Inability to contract Uterus Leads in increased bleeding Trauma 20% Tearing away of placenta Ruptured Placenta Tissue 10% Expelled fetal product Can cause increased bleeding Thrombin 10% Bleeding disorder of Mom 3 Trimester Bleeding Irregular, No contractions Heavy Bleeding Prolapsed Cord Ruptured Membrane Presenting part occluding cord (Babies blood flow) PROM (Premature Rupture off Membranes) Rupture prior to 37 weeks gestation Pre Eclampsia Hypertension >140/90 Proteinuria 1+ or >300 mg/24 hours Generalized Edema Must have ALL 3 to have Pre Eclampsia Foley to measure I&O Eclampsia Seizures
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-Fetal Monitoring Rhythmso Deceleration: Early deceleration is GOOD! Late deceleration is BAD! Variability: V-Fib is good!
Compliance Resistance of the lungs to a positive pressure breath o Increased Compliance Lungs are more receptive to a ventilator o Decreased Compliance (Positive End Expiratory Pressure) PEEP Positive pressure allows alveoli to stay open Clinical Guidelines: (VT) 10-15 ml/kg (f) 10-20 breaths per minute FiO2 ABG (PO2) or SpO2 Flow Rate 30-60 lpm (I:E ratio) PIP <40 lpm (VE) ABG(PCO2/ PH) ETCO2 Sigh 1.5-2 times VT Sensitivity -2 cm (adjust as tolerated) High Pressure Limit 10-15 cm above PIP Low Pressure Limit 10-15 cm below PIP
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Balloon pump: o Inflates at the beginning of diastole (Perfuses Coronary Workload) o Shuts before systole (Decreases Workload) o Normal balloon inflation is 30cc (Helium) o Can monitor SVR o Can draw blood Counter-pulsation: o Increases oxygen supply & Decreases oxygen demand Trigger: o Onset of new cardiac cycle Timing: o Start & End of Balloon inflation/deflation Augmentation: o Amount of benefit from IABP o Systolic is increased o Diastolic is decreased Frequency: o How often balloon inflates: I.e.: (1:1), (1:2), (1:3) (1:3) Commonly used to wean patient off IABP Indications: o CHF o Left Ventricular Failure o Cardiac Surgery o Weaning off bypass machine o Unstable Angina Contraindications: o Aortic dissection or regurgitation Things to remember: o Constantly monitor pedal pulses o Constantly monitor left radial pulse Balloon could be too high o Blood in the tubing: Balloon has ruptured o Machine failure: Inflate and deflate Half of balloons volume Balloon pumps are mechanical Nitroprusside