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Practice Test 1 CCRN (Pass CCRN)
Terms in this set (104)
What is vasogenic cerebral edema?
Vasogenic cerebral edema is an increase in extracellular fluid caused by a breakdown of the blood-brain barrier with the resultant increase in vascular permeability. This cerebral edema begins locally and becomes more generalized. Common causes are trauma (including surgical trauma), tumors, hemorrhage, and abscesses
What ventilator parameter indicates fluid volume excess?
An A:a gradient greater than 10 mm Hg is a reflection of a diffusion defect. Note that the process of diffusion is between A (alveolus) and (a) arterial blood. An increase in intraalveolar fluid dilutes and inactivates surfactant, causing alveolar collapse (decreasing vital capacity) and decreases lung compliance. Peak inspiratory pressure increases reflect a decrease in lung compliance
What does autonomy refer to?
The patient's right to make decisions for themselves
What does beneficence mean?
Obligation to do good
What does nonmaleficence mean?
Obligation to do no harm
What does fidelity mean?
the obligation to abide by agreements and responsibilities
What does veracity mean?
The obligation to tell the truth
What are Diagnosis-Related groups?
DRGs constitute a prospective payment program for Medicare patients. Payment is based on primary and secondary diagnosis, primary and secondary procedures, age, and length of hospitalization
BNP is secreted in response to?
Ventricular wall stretch
What are omnious signs in a patient with status asthmaticus?
A normalization or increase in the PaCO2. This patient is still tachypneic, and if ventilation is normal, PaCO2 should be decreased. The other ominous sign in this patient would be absence of wheezing or rhonchi, because they would indicate that ventilation is insufficient to cause these noises.
What problems arise from losses from the GI tract?
Any loss results in hypokalemia. Vomiting results in loss of acidic contents, whereas losses below the pylorus result is alkalitic losses leading to metabolic acidosis. Fluid is sequestered in the intestine leading to hypovolemia, which could cause hypovolemic shock.
Actual problems are worse than potential problems!!
How can you differentiate the cause of jaundice?
An increase in direct bilirubin is associated with biliary obstruction because direct bilirubin is conjugated. An increase in indirect bilirubin is associated with hepatic disease or excessive hemolysis because indirect bilirubin is unconjugated
What antihypertensive meds work best in African american patients?
African-Americans do not respond well to angiotensin-converting enzyme inhibitors (e.g., captopril [Capoten]), but they do respond well to an angiotensin II blocker (valsartan [Diovan]). Of the beta-blockers, labetalol works best. Of the calcium channel blockers, diltiazem works best
What lab values define acute respiratory failure?
PaO2<50 and/or PaCO2>50
Hyperkalemia can cause what?
Diarrhea-increases gastric motility
Flaccid paralysis- partially depolarizes muscle cells, prevents further depolarization
Every 1 inch increase in abdominal girth equates to how much blood accumulation in the abdomen
What pacing method would be used in a patient in atrial fib?
VVI- you don't want to sense or pace the atria.
1st letter-paced chamber
2nd letter-chamber sensed
What is the difference between an anaphylactic and anaphylactoid reaction?
Anaphylactoid clinically indistinguishable but does not require previous exposure ,not IgE mediated, and direct activation and degranulation of mast cells triggered by complement . Anaphylactic :requires previous exposure ,IgE mediated
Mitral stenosis is associated with what?
Pinkish discoloration of the cheeks. It is a diastolic murmur
What murmur is associated with widened pulse pressure?
What murmur is associated with narrowed pulse pressure?
What lead changes are associated with left ventricle hyperthrophy?
Strain pattern in V5 and V6 (asymmetric T wave inversion)
When the depth of the S wave in lead V1 or V2 plus the height of the R wave in lead V5 or V6 is 35 mm or greater, this constitutes voltage
What lead changes are associated with right ventricle hypertrophy?
strain pattern in V1 and V2. Prominent R wave in V1 reverse progression of the R wave across the precordium.
What organ system is the most common to fail in severe sepsis?
Hematologic- coagulopathies are common in severe sepsis
What are the early signs of hypoglycemia?
The early signs of hypoglycemia are mediated by the sympathetic nervous system, which acts to mobilize glucose stores (tachycardia, tachypnea, diaphoresis). Later signs of hypoglycemia are related to low glucose levels in the brain (neuroglycopenia)
**Early signs can be masked in pts taking beta-blockers
What is the systolic BP at different locations if you are able to palpate a pulse?
If the radial artery can be palpated, the systolic BP is at least 80 mm Hg. If the brachial artery can be palpated, the systolic BP is at least 70 mm Hg. If only the carotid artery can be palpated, the systolic BP is approximately 60 mm Hg
What happens to SvO2 if oxygen delivery decreases for any reason
SvO2 is a reflection of oxygen reserve. If oxygen delivery is decreased, oxygen consumption continues, and oxygen reserve decreases. SvO2 decreases any time the delivery of oxygen decreases or the consumption of the tissues increases
A simple way to estimate CVP is to add 5 cm to the measured height that the jugular veins are distended above the sternal angle (angle of Louis) with the patient in a 45-degree angle
What is the most common cause of right ventricular failure?
Left ventricular failure- causes pulmonary congestion and pulmonary HTN which increases the workload for the right side of the heart
Other causes- primary pulmonary hypertension, RV infarction, pulmonic stenosis, PE, mitral stenosis
What findings would be consistent with a massive hemothorax?
Fluid, such as blood, will be dull to flat to percussion. The blood in the pleural space compresses normal lung tissue and causes diminished to absent breath sounds. A large volume of blood in the pleural space may cause the trachea to shift away from the affected side toward the unaffected side
How does positive pressure ventilation affect ICP
It increases intrathoracic pressure, leads to hi ICP
What is the difference between active and passive euthanasia?
Passive euthanasia is allowing a person to die without taking lifesaving measures. Hydration and nutrition is usually maintained. Active euthanasia is doing something that causes death
To minimize respiratory fluctuations on PAOP, you measure it
At the end of expiration
Lateral wall MI
Changes in V5, V6 and/or I and avL
Anterior wall MI
V2, V3, V4
Inferior wall MI
II, III, and aVF
Bleeding time is a reflection of what?
Platelet function. Clopidogrel and abciximab are specifically platelet aggregation inhibitors. Heparin is an indirect thrombin inhibitor, but it also inhibits platelet aggregation
What is the earliest sign of hepatic failure in MODS?
Hypoglycemia- liver helps form and breakdown glycogen. Ascites, increased serum bilirubin and increased ammonia levels take time to develop
Dobutamine is the drug of choice for cardiogenic shock
Beta-adrenergic stimulant, increases HR and contractility
What EKG changes occur with LBBB?
QRS complex greater than 0.12 second in duration and a QRS complex that is positive in leads V5 and V6 (consider these left ventricular leads) and negative in leads V1 and V2 (right ventricle leads)
RBBB- QRS upright in V1 V2, negative in V5 V6
SaO2 has the least impact on oxygen delivery. Hemoglobin and cardiac index are more important
Weakness, fatigue, muscle pain, and abdominal discomfort in a patient taking Metformin may indicate what?
Lactic acidosis and rhadomyolysis
How does Nifedipine (Procardia) work?
Nifedipine decreases myocardial oxygen consumption by dilating veins and arteries, thereby decreasing preload and afterload. Nifedipine also decreases vasospasm and potential for vasospasm. Unlike diltiazem and verapamil, nifedipine does not significantly decrease contractility
What are the components of the pulmonary artery waveform?
In a pulmonary artery waveform the three components of the waveform are systole, dicrotic notch, and diastole. Systole is the pressure generated by the right ventricle so that the pulmonic valve will be pushed open, the dicrotic notch is caused by the closure of the pulmonic valve, and diastole is the pressure in the pulmonary artery during ventricular diastole. The diastolic pressure is a reflection of the vascular tone in the pulmonary vascular bed. If the vessels are constricted or if there is back pressure from the left side of the heart, the diastolic pressure will be high
What is ankle-brachial index?
ABI is ankle-brachial index, or ankle artery pressure divided by brachial artery pressure. The pressure at the ankle normally is higher than the pressure at the brachial artery, and the normal ABI is 1 or greater. This measurement is more quantitative than the presence or absence of audible Doppler pulses. If an occlusion is developing, the ankle artery pressure (measured with a blood pressure cuff and a Doppler stethoscope) will decrease and the calculated ABI will decrease long before the pulses are no longer audible
How does hypoxemia affect pulmonary vascular pressures?
It causes the vasculature to constrict, which can lead to pulmonary hypertension
If you notice a sudden change in diastolic pulmonary artery pressures you should suspect what?
Proximal movement of the catheter. Recall that the systolic pressure of the pulmonary artery and the right ventricle are approximately the same. The diastolic pressure in the pulmonary artery is normally approximately 10 mm Hg, whereas the diastolic pressure of the right ventricle is normally close to 0. Any sudden decrease in the PA diastolic pressure should lead you to suspect that the catheter has flipped back into the right ventricle
What is DIC?
DIC is a consumptive coagulopathy. The clotting cascade is stimulated, causing clotting in the microcirculation. Platelet and clotting factors (including fibrinogen) are consumed and become depleted. Clotting studies are prolonged. The massive clotting stimulates the fibrinolytic system. FDPs are the result of this fibrinolysis, and they trigger more bleeding
Management of care for pt with DIC includes...
Avoidance of injections, replacement of fluids/blood/clotting factors, turning frequently and gently, and not using automated BP cuffs (risk of injury/trauma)
Drugs that may cause torsades de pointes
Amitriptyline (Elavil) causes QT interval prolongation and may cause torsades . Other drugs- Class IA antidysrhythmics (e.g., procainamide, quinidine, and disopyramide), Class III antidysrhythmics (e.g., sotalol and amiodarone), tricyclic antidepressants (e.g., imipramine [Tofranil]), and phenothiazines (e.g., chlorpromazine [Thorazine])
Advantages of an IABP vs pressors?
If you have a hypotensive patient with high afterload giving them pressors will increase SVR, work on the heart, and myocardial oxygen consumption. IABP increases coronary artery perfusion and myocardial oxygen without increasing afterload or decreasing BP
What are the determinants of oxygen diffusion
Surface area available for gas transfer
Thickness of the alveolar-capillary membrane
Diffusion coefficient of gas
What affects the driving pressure of oxygen?
Oxygen concentration (FiO2) and barometric pressure- so to increase SaO2 you either have to increase FiO2 or increase pressure (either by hyperbarics or PEEP/CPAP)
How do you manage fluid status in a patient with a subarachnoid hemorrhage?
You keep the patient hypervolemic with a PAOP (LV preload) greater than 12mmHg (normal is 8-12). Keeping them hypervolemic aids in the prevention and treatment of vasospam, which increases the morbidity
What is the goal of medical management of stable angina and how is that achieved?
The goal of medical management in angina is to decrease myocardial oxygen consumption and to prevent progression of the disease. Beta-blockers decrease myocardial oxygen consumption by decreasing heart rate and contractility. Nitrates decrease myocardial oxygen consumption by decreasing preload primarily and may decrease afterload also, depending on the dosage. Calcium channel blockers decrease myocardial oxygen consumption by decreasing preload and afterload. Aspirin is used for primary and secondary prevention of a myocardial infarction by inhibiting platelet aggregation
What do these hemodynamic parameters indicate and how to tx?
HR-112 BP-90/46 (60) RAP-16 PAP 26/10 PAOP- 5 CI-2
Right ventricular dysfunction- High RAP, normal PAP, PAOP low= decreased blood return to the left side of heart
Goal to improve LV filling to enhance CO. Achieve this by increasing RV filling pressure (RAP) to higher than normal to increase the passive flow of blood into LV. Discontinue venous vasodilators (nitroglycerin) and given fluid boluses. Don't give diuretics because they would decrease RAP and CO. Dobutamine is needed to improve RV contractility
How does Milrinone work?
Inotropic agent, has arterial and venous vasodilating qualities- decreases preload and lessens the filling of the left side of the heart. Is indicated for chronic LV failure.
Hyperthermia cause what change on the oxyhemoglobin dissociation curve?
It causes it to shift to the right, which decreases hemoglobin's affinity for oxygen (doesn't like it so it doesn't hold on to it). So your O2 sats would be lower than normal
ex: Pa02 of 60 normally gives you an SaO2 of 90%, but if your hyperthermic it would be closer to 86%
What activities increase myocardial ischemia?
Using the bedpan, having the bed changed, having painful procedures (such as the insertion of an intravenous catheter), and being weighed on an overbed scale increase myocardial oxygen consumption and may cause myocardial ischemia. Eating a meal also may shunt blood to the gastrointestinal tract and cause myocardial ischemia
What is the primary role of the case manager?
Advocate- informing and supporting in decision making, informing about available resources and negotiating access to resources
What are the current guidelines on providing oxygen to COPD patients
Maintain hypoxemia (lower than normal O2 in blood) but prevent hypoxia (low O2 to tissues). This is achieved by maintain SaO2/SpO2 around 90%. Therefore some patients may need more than 2L of oxygen.
What electrolytes may be involved in a patient with prolonged QT
Potassium, calcium, and magnesium. Low levels of any of these would result in prolonged repolarization, which would be seen as a prolonged QT segment
If the ventricles are depolarized before the atria in a junctional rhythm you would expect to find the P wave where?
After the QRS
A patient has CSF leaking from their nose after a transsphenoidal hypophysectomy, what do you do?
It is normal to have a CSF leak for 48 hrs after surgery. Cover with a sterile "moustache" 2x2 tapes under their nose to form a barrier.
If your dura is not intact that you would expect a leak, but it does increase your risk of infection
What is Wernicke's syndrome and what is it associated with?
Thiamine is necessary for use of glucose. Administration of glucose in patients with thiamine deficiency may cause Wernicke's syndrome (also called Wernicke's encephalopathy). The syndrome is characterized by diplopia, nystagmus, lack of coordination, and decreased metal function
Diastolic murmurs are always pathologic. Systolic murmurs can be pathologic (related to valve disease or septal defects) or they can be functional related to turbulence of blood flow
What causes a dampened pulmonary artery pressure and how do you correct it?
A damped pulmonary artery waveform may be caused by air or blood in the pressure monitoring system, a clot in the catheter, or the catheter being advanced distally enough that the catheter diameter occludes the pulmonary arteriole in which the catheter is located (referred to as a spontaneous wedge). First, make sure that air has not been left in the balloon inadvertently by making sure that the balloon lumen is open with the empty syringe attached. Next, search the system for air or blood. Then reposition the patient or ask the patient to cough. If there is no change in the waveform, try to aspirate a clot from the catheter. If there is still no change, have the patient assume a spontaneous wedge position, and the catheter should be repositioned (withdrawn slightly) by the physician as soon as possible to prevent a pulmonary infarction. If the catheter is fast-flushed and a clot is present, it will be embolized with 300 mm Hg pressure (the pressure bag is maintained at this pressure). If the catheter is in a wedge position and the catheter is fast-flushed, it may result in pulmonary arteriole rupture and potentially massive hemoptysis and even exsanguination
Pt with multiple traumas has a temp of 39, is restless/agitated, has warm/dry skin and his hemodynamics are as follows...
BP- 88/48 HR-124 CO-10.5 CI-5.35 RAP-4 PAOP-3 SVR-452 VSat-90
What does this represent and what med would treat it?
Distributive shock (septic shock- temp). Most specific characteristic of distributive shocks is low SVR (afterload). Goal is to restore afterload and perfusion gradient- which is done by the use of pressors (restore vascular tone caused by massive vasodilation)
What is Wolff-Parkinson-White syndrome and how is it treated?
There is an extra pathway between your hearts upper and lower chambers causing a rapid heartbeat. Lidocain and amiodarone may be used in treatment, as well as adenosine if experiencing SVT. DON't give verapamil because it slows conduction through the AV node which could lead to severe tachycardias
If you got a whole bunch of banked blood you also need to get platelets and plasma, why?
RBCs do not contain platelets; therefore patients receiving multiple transfusions also will need to receive platelets. Clotting abnormalities in these patients result from hypocalcemia, thrombocytopenia, and depletion of clotting factors. Fresh frozen plasma also is indicated to replace the clotting factors
What conditions would lead to a shift in the PMI from the midclavicular line to the anterior axillary line?
LV hypertrophy, right tension pneumo, right pleural effusion- think any pressure on the right side will shift things toward the left
Pericardial effusion- layer of fluid over the heart which will dampen the sounds but not cause a shift to the left
What does failure to capture indicate and how do you correct it?
failure to capture occurs when the electricity from the pacemaker does not cause depolarization of the ventricle (or atria if an atrial pacemaker). It would be logical to consider using more electricity (i.e., milliamperage). You can also try repositioning the pt on the side before they lost capture
What is failure to sense and what do you do for it?
Pacer spikes seen indiscriminately within pts own rhythm. Increase the sensitivity
What is oversensing on a pacemaker?
Oversensing occurs when the pacemaker senses an event besides what it is intended to sense and is inhibited by this event. Ex; The pacer senses the T wave or other inappropriate signals and is inhibited
How do you treat oversensing
Decrease the sensitivity if causing failure to fire
Why do heart failure patients take ACE inhibitors
hypoperfusion of the kidney causes stimulation of the RAA system, vasoconstriction and retention of sodium and water occur. If the hypoperfusion to the kidney was caused by HF, this worsens HF by increasing afterload and preload. ACE inhibitors inhibit this maladaptation (in heart failure)
Giving a malnourished patient adequate nutrition may result in what electrolyte disturbance?
Severe phosphate deficiency. This often is called refeeding syndrome. Nutritional support allows the cells to begin making more adenosine triphosphate (ATP), and phosphate supplies are depleted. The same thing happens in diabetic ketoacidosis with treatment when insulin allows glucose to move into the cell increasing production of ATP and depletion of phosphate.
What cardiac biomarker would you expect to be elevated within 3 hours of acute MI?
Myoglobin- effective for ruling out MI (sesitive for MI) but has a lot of false positives.
The least specific is likely to be the earliest
What are the stages in the ACE star model
Systematic review of the research related to a specific clinical question is an example of summary of the evidence. A clinical practice guideline is an example of translation of evidence. A pilot test would be an example of implementation of evidence
What are the purpose of chest PT?
increase mucociliary clearance of secretions which decreases airway resistance and decreases shunt
The reshaping that occurs with HF results in the heart taking on what shape?
More spherical shape- think the PMI gets displaced to the left
What are signs of oxygen toxicity?
Early indications of oxygen toxicity are substernal distress, paresthesias in extremities, and gastrointestinal symptoms (e.g., anorexia, nausea, vomiting, fatigue, malaise, dyspnea, and restlessness). Late indications are hypercapnia, cyanosis, decreasing compliance, increasing A:a gradient, and pulmonary edema
What is the best fluid for patients with DI?
D5W- Patients with diabetes insipidus lose more water than sodium, and they need to be treated with more water than sodium. Saline and lactated Ringer's solution would contribute to the hypernatremia. D10W could cause a hypertonic diuresis.
What do you need to consider when monitoring a patient who has received massive transfusion?
Hyperkalemia, hypocalcemia, hypothermia, and decreased tissue oxygen delivery caused by decreased levels of 2,3-diphosphoglycerate
Normal arterial oxygen saturation is ~100%, and normal venous oxygen saturation is ~75%. The tissues used 25%. The normal arterial oxygen content is ~20 mL/dL, and normal venous oxygen content is ~15 mL/dL. The tissues used 25%. The normal oxygen delivery (DO2) is ~1000 mL/min, and normal VO2 is ~250 mL/min. The tissues used 25%. The normal DO2I is ~600 mL/min/m2, so consider what is 25% of 600 mL/min/m2? The normal VO2I is ~150 mL/min/m2
100 out, 25 used, 75 reserved
Your pt has a pneumothorax. He complains of tingling around his mouth and fingertips and feeling light-headed. BP is normal, HR in 110s, RR is 36, temp normal. What is causing the tingling?
Decreased serum Ionized Ca. Hyperventilation causes hypocapnia and respiratory alkalosis. Alkalosis causes an increase in the binding between calcium and albumin. This reduces the serum ionized calcium level and causes of symptoms of hypocalcemia
Associate these symptoms with tetany and low Ca
What is volutrauma
Shearing of alveolar associated with high tidal volumes
A pneumothorax caused by the ventilator is what?
Result of barotrauma- the vent pushes air into the pleural space with each breath and because the parietal pleura is not open (like with a puncture) there is no where for the air to go- so you get a tension pneumothorax
What are the compensatory mechanisms of the SNS to the heart, and how are those affected by an MI
Alpha receptors of the SNS cause vasoconstriction and shift blood from nonessential (skin, bowel, kidney) to essential (heart and brain) organs. Beta1 receptors increase heart rate (positive chronotropic effect), increase contractility (positive inotropic effect), and increase conductivity (positive dromotropic effect). The dromotropic effect increases the propensity for ventricular ectopy. Beta2 receptors cause bronchodilation and vasodilation. In this case, the increase in heart rate and ectopy potential is caused by stimulation of the beta1 receptors. The increase in afterload is caused by stimulation of the alpha receptors. Contractility would have been increased by beta1 stimulation, but the patient's myocardium is unable to respond, and contractility remains decreased
What complications of COPD predispose the patient to developing PEs?
COPD causes pulmonary hypertension, right ventricular hypertrophy, and right atrial enlargement. The right atrial enlargement causes stretching of the atrial tissue and frequently results in atrial dysrhythmias. Atrial fibrillation is associated with mural thrombi and pulmonary and systemic emboli. The hypoxemia that results from COPD causes release of erythropoietin from the kidney, which stimulates release of red blood cells from the bone marrow and polycythemia. Polycythemia causes hypercoagulability. This hypercoagulability, especially coupled with inactivity, increases the risk of thrombosis and emboli
What is the first sign of uncal herniation?
ipsilateral pupil dilation with a sluggish reaction as a result of pressure on cranial nerve III. Motor weakness may occur but would be on the contralateral side
What electrolyte imbalances predispose you to digitalis toxicity?
Hypokalemia, hypercalcemia, and hypomagnesemia increase sensitivity to digitalis toxicity
K, Ca, and Mg affect the heart
Na is more important in extracellular and neuromuscular transmission
What are the steps of corrective discipline
Counseling is informal and first. Verbal warning is followed by written warning, if necessary. Suspension for a specified number of days occurs if the problem persists. Termination is, of course, the final step.
ACE-I can cause what electrolyte imbalance?
Hyperkalemia- Prevent angio 1 from converting to angio II. Angio II usually blocks aldosterone and cause vasoconstriction. Aldosterone usually holds on to Na and H2O in exchange for K (excretes it), but since you don't have it you get rid of Na and H20 and hold on to K
Pt post anterior MI gets PCI but develops signs of HF and cardiogenic shock. Started on dobutamine at 5mcg/kg/min. Hemodynamics are...
BP-80/60, RAP- 8, PAP-40/25, PAOP-22, SVR-2500, CI- 1.9, Venous sat-56%
Are these parameters ok/what do they show and what tx do you expect?
BP-low, RAP- slightly elevated (2-6), PAP-high, PAOP-high (8-12), SVRI-high (1970-2390) , CI-low (2.8-4.2), VSat-low (75)
Increasing the dobutamine will increase contractility to improve SV and CI. It also causes vasodilation to decrease preload (PAOP) and afterload (SVRI)
If the pts BP is not decreased because SVR is decreased than it is because CO is decreased, therefore treatment should be directed toward increasing CO rather than increasing SVR
When does the ballon inflate in a IABP on the arterial pressure waveform?
Diastole begins at the dicrotic notch, which represents closure of the aortic valve. The balloon is inflated at the initiation of diastole.
Sepsis causes a decrease in the body's ability to extract and use oxygen, therefore those patients will have decreased oxygen consumption
Pt on CVVH with chronic heart failure has an acute BP drop and there is a drop in plasma in the bag. What do you do?
Placing the filter below the level of the patient's heart allows the force of gravity to help move the ultrafiltrate. When the patient is hypotensive, the force that pushes the blood through the circuit is decreased, which decreases the amount of ultrafiltrate
What is a significant adverse affect of Plavix
A significant adverse effect of this platelet aggregation inhibitor is thrombocytopenia. Petechiae are an indication of decreased platelet number or function
What sign/symptom would you not expect to find with atelectasis?
Dullness on percussion- that indicates pneumonia (consolidation) rather than atelectasis. Hypoxemia, fever, and crackles are expected with atelectasis.
What treatment may be performed for rhado to prevent ATN?
To prevent damage to the tubules, forced diuresis with fluids and osmotic diuretics usually is initiated. Alkalinization of the urine through intravenous administration of sodium bicarbonate also may be initiated
Low dose dopamine is no longer recommended for increasing renal blood flow
What are the hallmarks of ARDS?
Intraalveolar fluid and damage to type II pneumocytes result in a decrease in the amount and effectiveness of surfactant. This causes alveolar collapse (decreased functional residual capacity), pulmonary edema, decrease in lung compliance, and massive intrapulmonary shunt. Intrapulmonary shunt causes severe hypoxemia that is refractory to oxygen therapy
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