EVALUATING HEMODYNAMICS WITHOUT FANCY EQUIPMENT

Transcription

1 EVALUATING HEMODYNAMICS WITHOUT FANCY EQUIPMENT JUDY BORISH, RN, MSN, CCRN, PCCN OBJECTIVES BY THE END OF THIS SESSION THE PARTICIPANT WILL BE ABLE TO: * IDENTIFY THE NORMAL MECHANISMS OF THE BODY TO MAINTAIN PERFUSION TO VITAL ORGANS * ASSESS THE HEMODYNAMIC STATUS OF SEVERAL PATIENTS UTILIZING PHYSICAL ASSESSMENT FINDINGS, VITAL SIGNS, AND ACID BASE STATUS. * DISCUSS EARLY EVIDENCE-BASED MANAGEMENT FOR EACH OF THE CONDITIONS DISCUSSED. 62 YEAR OLD FEMALE WAS ADMITTED WITH PNEUMONIA. SHE HAS A HISTORY OF TYPE II DM, AND HAD AN MI WITH A STENT TWO YEARS AGO. AT HOME SHE WAS ON METOPROLOL 25 MG DAILY, METFORMIN 1000 MG TWICE DAILY AND LIPITOR 40 MG DAILY. WHEN YOU GO IN TO DO YOUR MORNING ASSESSMENT YOU FIND: SHE IS PALE AND HER EXTREMITIES ARE COOL; HER ABDOMEN IS DISTENDED AND SHE HAS HYPOACTIVE BOWEL TONES; LUNGS SOUNDS ARE COARSE AND DIMINISHED IN THE RIGHT BASE (NO CHANGE SINCE YESTERDAY) 1

2 SvO2 SVR CI Your patient just doesn t look right. You don t have the equipment available in critical care. What can you tell? PCWP SVV CO Hemodynamically, what is happening? PPV Tissue perfusion is most important! ADEQUATE TISSUE PERFUSION A FINE BALANCE BETWEEN OXYGEN SUPPLY AND DEMAND Oxygen Supply Oxygen Demand HEMOGLOBIN OXYGEN SATURATION CARDIAC OUTPUT INCREASED CONSUMPTION DECREASED CONSUMPTION 2

3 SUPPLY SIDE: HEMOGLOBIN EACH HEMOGLOBIN MOLECULE CAN CARRY 4 OXYGEN MOLECULES CAN CARRY OTHER THINGS BESIDES O2 PH AFFECTS ABILITY OF O2 TO DISSOCIATE FROM HEMOGLOBIN SUPPLY SIDE: OXYGEN SATURATION O2 SATURATION CAN BE NORMAL BUT PATIENT HYPOXEMIC LOW HEMOGLOBIN SAO2 CAN LOOK OK UNTIL PAO2 IS 60 SAO2 IS NOT THE FIRST SIGN OF RESPIRATORY DISTRESS SUPPLY SIDE: CARDIAC OUTPUT CO = HR X SV CO HR SV PRELOAD CONTRACTILITY AFTERLOAD 3

4 AS HEART RATE INCREASES DECREASED DIASTOLIC FILLING TIME SMALLER VOLUME TO EJECT LESS EFFICIENCY OF EJECTION DECREASED TIME FOR CORONARY PERFUSION LEADS TO DECREASED CARDIAC OUTPUT AS HEART RATE DECREASES INCREASED DIASTOLIC FILLING TIME DOES NOT NECESSARILY INCREASE EJECTION VOLUME LEADS TO DECREASED CARDIAC OUTPUT STROKE VOLUME AMOUNT OF BLOOD PUMPED BY VENTRICLE WITH EACH BEAT CAN T MEASURE DIRECTLY 4

5 WHICH OF THE FOLLOWING IS A NORMAL STROKE VOLUME? A. 35 ML B. 45 ML C. 75 ML D. 125 ML PRELOAD Stretch on ventricular myocardial fibers at end of diastole SIGNS OF INCREASED RV PRELOAD INCLUDE ALL OF THE FOLLOWING EXCEPT A. JUGULAR VENOUS DISTENSION B. PITTING PERIPHERAL EDEMA C. INSPIRATORY CRACKLES D. ABDOMINOJUGULAR REFLUX 5

6 ASSESSING PRELOAD NONINVASIVELY INCREASING DAILY WEIGHTS INCREASED PRELOAD ON THE RIGHT SIDE OF HEART JVD, ABDOMINOJUGULAR REFLUX, PITTING EDEMA TWO MOST COMMON CAUSES OF JVD ARE FLUID OVERLOAD AND RHF JVD IS BEST SIGN OF FLUID OVERLOAD ONE WAY TO MEASURE JVD PATIENT AT DEGREES LOOK FOR VEIN DON T PALPATE MEASURE FINGER WIDTHS ABOVE CLAVICLE MEASURED 0 TO +4 ONE FINGER WIDTH IS +1 NORMAL IS 0 TO +1 ASSESSING PRELOAD NONINVASIVELY INCREASED PRELOAD ON THE LEFT SIDE OF THE HEART SOB INSPIRATORY CRACKLES DECREASED O2 SATURATION 6

7 ASSESSING PRELOAD NONINVASIVELY SIGNS OF DECREASED PRELOAD DECREASED BP DECREASED UO FLAT NECK VEINS A WAY TO VERIFY DECREASED PRELOAD AND NEED FOR FLUIDS CONTRACTILITY ABILITY OF THE VENTRICLE TO CONTRACT INDEPENDENT OF PRELOAD OR AFTERLOAD 7

8 FACTORS AFFECTING CONTRACTILITY VENTRICULAR MUSCLE MASS CATECHOLAMINES METABOLIC STATE OF BLOOD PERFUSING HEART DRUGS AFTERLOAD PRESSURE THE VENTRICLE MUST OVERCOME TO EJECT FACTORS AFFECTING AFTERLOAD SYSTEMIC VASCULAR RESISTANCE (SVR) DETERMINED MAINLY BY ARTERIOLES NON COMPLIANT VASCULAR WALLS ANATOMIC AND PHYSIOLOGIC CHANGES THAT IMPEDE EJECTION BLOOD VISCOSITY 8

9 ASSESSING AFTERLOAD NONINVASIVELY DIASTOLIC BP IS THE CLOSEST WE HAVE TO SVR. GENERALLY AS DIASTOLIC BP RISES SO DOES SVR DEMAND SIDE OF TISSUE PERFUSION OXYGEN SUPPLY OXYGEN DEMAND Hemoglobin Oxygen saturation Cardiac Output ^ Increased consumption Decreased consumption WHICH OF THE FOLLOWING IS NOT AN EXAMPLE OF INCREASED CONSUMPTION? A. PAIN B. SEIZURES C. HYPOTHERMIA D. SEPSIS 9

10 DEMAND SIDE INCREASED CONSUMPTION PAIN SEIZURES SEPSIS FEVER SHIVERING AGITATION BURNS HEAD INJURIES NURSING PROCEDURES DECREASED CONSUMPTION HYPOTHERMIA ANESTHESIA DRUG INDUCED PARALYSIS LESS WORK OF BREATHING CELLULAR DYSFUNCTION BLOOD PRESSURE BP = CO X SVR ASSESSING SVR NONINVASIVELY CAN LOOK AT DIASTOLIC BP IF DIASTOLIC BP, USUALLY SVR ; IF DIASTOLIC BP, USUALLY SVR 10

11 ASSESSING SVR NONINVASIVELY WITH PULSE PRESSURE NARROWED PULSE PRESSURE (PP) IF PP < 35 AND TACHYCARDIA= EARLY SIGN OF INADEQUATE BLOOD VOLUME AS CO, SVR TO MAINTAIN BP SEE VASOCONSTRICTION AND INCREASED DIASTOLIC BP (NARROWED PP) SITUATIONS WITH NARROWED PP DEHYDRATION BLEEDING CARDIAC TAMPONADE NARROWED PULSE PRESSURE AORTIC OR MITRAL STENOSIS, ACUTE AORTIC OR MITRAL REGURGITATION VOLUME, PP SHOULD WIDEN AND SYSTOLIC BP SHOULD RISE WIDENED PULSE PRESSURE WIDENED PULSE PRESSURE (PP) WIDENED PP MAY BE DUE TO AN SBP OR DBP AS CO, WALLS OF ARTERIAL VESSELS RELAX AND PP WIDENS VASODILATION 11

12 WIDE PULSE PRESSURE SITUATIONS WITH WIDE PULSE PRESSURE EXERCISE ATHEROSCLEROSIS AORTIC REGURGITATION ICP A LATE SIGN ( SYSTOLIC BP) AS CO INCREASES WALLS OF ARTERIAL VESSELS RELAX (VASODILATION) SVR FALLS AND PP WIDENS FLUID OVERLOAD FEBRILE DISORDERS EARLY SEPSIS SIGNS OF BODY COMPENSATING TO MAINTAIN TISSUE PERFUSION CHANGES IN HR AND DIASTOLIC BP AND PP JVD AS AN ESTIMATE OF INCREASING RV PRELOAD CHANGES IN RR AS AN EARLY SIGN OF HYPOXEMIA OTHER SIGNS NONINVASIVE SIGNS OF DECREASED CO CHANGES IN MENTATION BRAIN IS SENSITIVE TO HYPOXIA RESPIRATORY DISTRESS DECREASED EXERCISE CAPACITY TACHYCARDIA AND RATE OF ECTOPY DECREASED URINE OUTPUT SKIN IS COOL, DIAPHORETIC 12

13 BAD SIGNS MOTTLED KNEES CAN T GET PULSE OXIMETRY TO WORK RISING LACTATE LEVELS CAN T MAINTAIN TEMPERATURE BACK TO CASE STUDY #1 62 YEAR OLD FEMALE WAS ADMITTED WITH PNEUMONIA. SHE HAS A HISTORY OF TYPE II DM, AND HAD AN MI WITH A STENT TWO YEARS AGO. AT HOME SHE WAS ON METOPROLOL 25 MG DAILY, METFORMIN 1000 MG TWICE DAILY AND LIPITOR 40 MG DAILY. WHEN YOU GO IN TO DO YOUR MORNING ASSESSMENT YOU FIND: SHE IS PALE AND HER EXTREMITIES ARE COOL; HER ABDOMEN IS DISTENDED AND SHE HAS HYPOACTIVE BOWEL TONES; LUNGS SOUNDS ARE COARSE AND DIMINISHED IN THE RIGHT BASE (NO CHANGE SINCE YESTERDAY); VS: T 98.1, HR 88, BP 106/90, RR 24, SPO2 94 (ON 3 L O2). HER VS AT 4 AM WERE: T 98.0 HR 58, BP 120/64, RR 14, SPO2 98 (ON 3 L O2). 13

14 WHAT COULD BE HAPPENING TO HER? CASE STUDY #1 CONTINUED YOU CALL HER PHYSICIAN. THE MD COMES AND EXAMINES THE PATIENT. SHE IS WORRIED ABOUT HYPOVOLEMIA AND POSSIBILITY OF THE PATIENT GOING INTO HYPOVOLEMIC SHOCK, POSSIBLY SECONDARY TO GI BLEED. SHE ORDERS A FLUID BOLUS OF 1 LITER NS, FREQUENT VITAL SIGNS, BMP AND AN ABG. HEMODYNAMIC CHANGES IN HYPOVOLEMIC SHOCK CIRCULATING VOLUME VENOUS RETURN AND PRELOAD. PRELOAD CO AS CO -- BP [AND HR IN ATTEMPT TO COMPENSATE] SYMPATHETIC NERVOUS SYSTEM RESPONDS WITH SVR TO INCREASE BP RR RATE AND DEPTH 14

15 HOW CAN WE SEE THIS NONINVASIVELY? CASE STUDY #1 CONTINUED HER ABG S ARE: PH 7.3 PO2 80 PCO2 28 HCO3 24 HER POTASSIUM IS 3.2 AND THE REST ARE NORMAL. HER CARDIOLOGIST DROPS BY AND ORDERS ST SEGMENT MONITORING. WHY DIDN T THIS PATIENT HAVE A TACHYCARDIA? WHY DOES HER MD WANT ST SEGMENT MONITORING? SHE IMPROVES WITH CONTINUED FLUIDS. ENDOSCOPY SHOWED SITE OF BLEEDING AND IT IS CAUTERIZED. 15

16 CASE STUDY #2 46 YEAR OLD MAN WAS TRANSFERRED FROM ICU TO YOUR UNIT YESTERDAY. HE IS 2 DAYS POST-OP AFTER OPEN HEART SURGERY FOR VSD REPAIR AND MITRAL VALVE REPLACEMENT. HIS VITAL SIGNS HAVE BEEN STABLE SINCE TRANSFER. THE MONITOR TECH TELLS YOU THAT HE HAS LOST HIS P WAVES CASE STUDY #2 YOU NOTE THAT HE HAS GONE INTO THIS RHYTHM. AS YOU HEAD DONE THE HALL TO CHECK HIM, HE PUTS HIS CALL LIGHT ON. AS YOU ENTER THE ROOM, HE SAYS, I JUST STARTED FEELING DIZZY AND LIGHT HEADED. YOU CHECK HIS VITAL SIGNS AND FIND: BP 86/50, HR 68 AND REGULAR, RR 16, SPO2 96%. THIS RHYTHM IS A. JUNCTIONAL RHYTHM B. NORMAL SINUS RHYTHM C. ACCELERATED JUNCTIONAL RHYTHM D. SINUS BRADYCARDIA 16

17 CASE STUDY #2 WHY IS HE DIZZY AND HIS BP FALLING? IF HE CONTINUES IN THIS RHYTHM, WHAT SHOULD YOU DO? A. WAIT. HE SHOULD FEEL BETTER IN A COUPLE MINUTES. B. CALL A CODE BLUE. YOU NEED HELP RIGHT NOW C. CALL RAPID RESPONSE TEAM AND PREPARE FOR URGENT SYNCHRONIZED CARDIOVERSION D. CALL MD/RAPID RESPONSE TEAM. FIRST DRUG OF CHOICE WOULD BE ATROPINE CASE STUDY #2 CONTINUED BEFORE ANY DRUG THERAPY WAS GIVEN, YOUR PATIENT WENT BACK INTO SINUS RHYTHM AND HE STARTED FEELING MUCH BETTER. WHY DO YOU THINK HE MIGHT HAVE GONE INTO ACCELERATED JUNCTIONAL RHYTHM? OVER THE NEXT COUPLE DAYS HE CONTINUED TO HAVE BOUTS OF ACCELERATED JUNCTIONAL RHYTHM WITH SYMPTOMS, FOLLOWED BY A RETURN TO SINUS RHYTHM. HIS SURGEONS FINALLY DECIDED TO INSERT A DUAL CHAMBER PACEMAKER TO MAINTAIN AV SYNCHRONY. 17

18 CASE STUDY #3 78 YEAR OLD FEMALE IS ADMITTED WITH CELLULITIS IN HER LEFT LOWER LEG. SHE HIT HER LEG ON A PIECE OF FURNITURE TWO WEEKS AGO, BREAKING THE SKIN. SHE SELF TREATED IT AT HOME WITH SLOW HEALING. SHE CAME TO THE ER YESTERDAY FOR SWELLING AND PAIN IN THE LEFT LEG. SHE HAS A HISTORY OF TYPE II DM AND PERIPHERAL VASCULAR DISEASE. SHE IS NOW ON IV ANTIBIOTICS. HER VITAL SIGNS HAVE BEEN STABLE WITH BP RANGING /70-80, HR 80 S, RR 12-16, AFEBRILE. CASE STUDY #3 CONTINUED SHE IS CURRENTLY ON O2 PER NASAL CANNULA AT 2 L WITH A SPO2 OF 98%. YOU ARE WORKING NIGHTS. ON YOUR FIRST ASSESSMENT YOU NOTE HER SPO2 HAS DROPPED TO 92%, SHE IS COMPLAINING OF SOB AND IS ANXIOUS. HER LUNGS ARE CLEAR TO AUSCULTATION. HER VITAL SIGNS ARE: BP 112/50, T 98.4, HR 98, RR 19. YOU INCREASE OXYGEN TO 3 L AND HER SPO2 INCREASES TO 96%. AT 2 AM SHE IS ESSENTIALLY UNCHANGED. HER SPO2 IS 95% ON 3 L, RR 21, STILL A LITTLE SOB BUT STATES SHE IS DOING OK. CASE STUDY #3 CONTINUED AT 4:30 AM SHE GETS UP TO THE BATHROOM WITH ASSISTANCE, AND FEELS VERY WEAK AND IS DIAPHORETIC. AFTER BEING HELPED BACK TO BED HER VITAL SIGNS ARE: HR 110, RR 24, BP 96/27, SPO2 IS

19 CASE STUDY #3 CONTINUED WHAT COULD BE GOING ON? WHAT CAN YOU TELL FROM HER VITAL SIGNS? WHAT SHOULD YOU DO? OTHER DATA MIGHT BE HELPFUL TO CLARIFY THE PICTURE. WHICH OF THE FOLLOWING WOULD BE LEAST HELPFUL IMMEDIATELY? A. BLOOD CULTURES B. CBC C. LACTATE LEVELS D. TEMPERATURE SIRS SEPSIS SEVERE SEPSIS SEPTIC SHOCK MODS SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME) 19

20 WHICH OF THE FOLLOWING IS NOT A SIGN OF SIRS A. TEMP > 38.5 DEGREES C OR < 35 DEGREES C B. LACTATE LEVEL >4 C. HR > 90 D. RR > 20 OR PACO2 < 32 MM HG SEPSIS SEPSIS: 2 SIRS CRITERIA WITH VISIBLE INFECTION OR CULTURE- PROVEN INFECTION DOES YOUR PATIENT HAVE SEPSIS? SEVERE SEPSIS SEVERE SEPSIS: SEPSIS PLUS 1 OR MORE SIGNS OF HYPOPERFUSION: 20

21 SIGNS OF HYPOPERFUSION IN SEVERE SEPSIS AREAS OF MOTTLED SKIN CAPILLARY REFILL > 3 SECONDS UO < 0.5 ML/KG FOR AT LEAST 1 HOUR OR RENAL REPLACEMENT THERAPY CREATININE > 0.5 MG/DL ABOVE BASELINE LACTATE > 2 MMOL/L ABRUPT CHANGES IN MENTAL STATUS COAGULATION ABNORMALITIES (INCLUDING PLATELET COUNT, DIC) SIGNS OF HYPOPERFUSION (CONTINUED) CARDIAC DYSFUNCTION SYSTOLIC BLOOD < 90 MM HG OR MAP < 70 MM HG OR A SYSTOLIC BLOOD PRESSURE DECREASE OF 40 MM HG BLOOD GLUCOSE GREATER THAN 140 MG/DL IN PATIENTS WITHOUT DIABETES ACUTE LUNG INJURY OR ARDS ARTERIAL HYPOXEMIA SEPTIC SHOCK SEPTIC SHOCK: SEVERE SEPSIS PLUS HYPOTENSION MAP < 60 MM HG DESPITE RESUSITATION MAINTAINING MAP > 60 REQUIRES VASOPRESSORS DESPITE ADEQUATE FLUID RESUSITATION 21

22 MODS SEVERE END OF SEPSIS SPECTRUM MULTIPLE ORGAN FAILURE VERY POOR OUTCOMES EARLY IDENTIFICATION CRUCIAL PATIENTS AT RISK: AGES < 1 YEAR AND > 85 YEARS IMMUNOCOMPROMISED SEVERE COMMUNITY ACQUIRED PNEUMONIA INTRA-ABDOMINAL SURGERY MENINGITIS CHRONIC DISEASES SUCH AS CV, RENAL AND DIABETES CELLULITIS UTI CASE STUDY #3 CONTINUED A ONE LITER FLUID BOLUS WAS ORDERED, MORE LABS WERE DRAWN INCLUDING A LACTATE LEVEL, AND AN ABG WAS ORDERED. 22

23 EARLY MANAGEMENT ACCORDING TO SURVIVNG SEPSIS GUIDELINES RAPID FLUID RESUSCITATION (INITIAL MINIMUM OF 30 ML/KG) NORMAL SALINE OR LACTATED RINGERS MEASURE SERUM LACTATE TO DETECT OCCULT HYPOPERFUSION MAINTAIN MAP 65 MM HG. EARLY MANAGEMENT CONTINUED URINE OUTPUT 0.5 ML/KG/HOUR < ONE HOUR OF THE DIAGNOSIS, OBTAIN CULTURES THEN START BROAD SPECTRUM ANTIBIOTICS EMPIRICALLY MAINTAIN GLUCOSE LEVELS LESS THAN 150 MG/DL HAS BEEN SHOWN TO REDUCE MORBIDITY BUT NOT MORTALITY IN CRITICALLY ILL MEDICAL PATIENTS WITH SEPSIS. IF STILL HYPOTENSIVE AFTER INITIAL FLUID RESUSCITATION OR LACTATE >4, INSERT CVP AND KEEP >8, MEASURE SCVO2 AND KEEP >70% CASE STUDY #3 CONTINUED EVEN AFTER 2 LITERS OF FLUID BOLUSES OF NS, YOUR PATIENT S BP REMAINS 80 S/30 S. HER JUGULAR VEINS REMAIN FLAT, LUNGS ARE CLEAR, EXTREMITIES ARE PALE AND COOL AND YOU NOTE MOTTLING ON HER KNEES. CRITICAL CARE BEDS ARE FULL AND THEIR CHARGE NURSE IS TRYING TO ARRANGE A TRANSFER FOR A BED FOR YOUR PATIENT. 23

24 WHAT HEMODYNAMICALLY IS HAPPENING TO YOUR PATIENT? YOUR PATIENT IS TRANSFERRED TO ICU CASE STUDY #4 MS. M WAS ADMITTED TO YOUR FLOOR FOLLOWING A BOWEL RESECTION. SHE HAS A HISTORY OF ASTHMA AND MI 10 YEARS AGO. HER VITAL SIGNS ARE STABLE: T 37.2 DEGREES C; HR 86 (SINUS RHYTHM); RR18; BP 136/76. FIRST POSTOPERATIVE DAY SHE IS ASSISTED OUT OF BED. SHE EXPERIENCES A LOT OF PAIN. AFTER SHE RETURNS TO BED, SHE CONTINUES TO HAVE PAIN. SHE REFUSES TO GET UP IN THE EVENING. SECOND POSTOPERATIVE DAY, SHE CONTINUES TO USE THE PCA A LOT FOR INCISIONAL PAIN AND HAS CONTINUED NAUSEA. VITAL SIGNS REMAIN NORMAL EXCEPT FOR A LOW GRADE FEVER. SHE CONTINUES TO REFUSE TO AMBULATE STATING SHE HURTS TOO MUCH AND IS NAUSEATED. SHE DOES HAVE HYPOACTIVE BOWEL TONES 24

25 CASE STUDY #4 CONTINUED THAT EVENING THE CNA ASSISTS HER TO THE BSC AND THEN BACK TO BED. TWENTY MINUTES LATER HER CALL LIGHT IS ON AND SHE IS VERY ANXIOUS. SHE IS RESTLESS, SOB AND COMPLAINING OF CHEST PAIN WORSE WITH INSPIRATION. WHAT DO YOU THINK IS HAPPENING? LARGE PULMONARY EMBOLUS Disruption of blood supply to a portion of the lung when a clot or other matter lodges in the pulmonary arterial system Lower lobes most common sites 25

26 CASE STUDY #4 CONTINUED ON ASSESSMENT YOU FIND CRACKLES IN HER LEFT BASE, DIAPHORESIS, AND A WARM, ERYTHEMATOUS, TENDER LEFT CALF. VITAL SIGNS ARE: 37.9 DEGREES C, HR 128, RR 34, BP 150/88. SHE IS PLACED IN A SEMI FOWLERS POSITION AND IS PLACED ON 4 L/NC. THE MD ORDERS ABG, ECG, CTA OF THE CHEST, AND DOPPLER STUDIES HEMODYNAMIC EFFECTS OF PULMONARY EMBOLISM Development of Pulmonary Hypertension if >50% of vascular bed obstructed Mediators released at site of injury and hypoxia pulmonary vasoconstriction As PVR workload on right ventricle RVF decreased preload for left ventricle CO, BP shock WHAT NONINVASIVE SIGNS OF INCREASED RVF AND DECREASED CO MIGHT YOU SEE? 26

27 PULMONARY EMBOLUS: WATCH FOR dyspnea PaO2 Acute RHF Cardiovascular collapse Cardiac Arrest PEA or Asystole PICK ONE NONINVASIVE SIGN OF HEMODYNAMIC CHANGES THAT MIGHT INDICATE THE WORSENING PE. A. DECREASED BREATH SOUNDS B. HYPERTENSION C. PEDAL EDEMA D. JVD CASE STUDY # 4 CONTINUED MRS. M RECEIVED A BOLUS OF HEPARIN AND A HEPARIN DRIP WAS STARTED. SHE WAS TAKEN TO CT AND THEN TRANSFERRED TO ICU. 27

28 Thank you. You deserve a balloon ride to relax! 28