ABCDE circualtion Flashcards
Assessment ABCDE circualtion
Vitals:
- HR
- BP
Look:
- JVP
- Fluid status (mucous membranes, oedema) and balance (charts/catheter bag)
Feel:
CRT central and peripheral
Skin turgor
Temperature of peripheries
Pulse
Listen:
Heart sounds for pericardial rub, third heart sound, new murmur
Investigations circulation ABCDE
IV access
Bloods: FBC, U&E, LFT,
Sepsis: CRP, lactate, blood cultures
Haemorrhage/surgical emergency: coagulation and cross-match
ACS: troponin
Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
PE: d-dimer if wells score
Overdose: toxicology
Anaphylaxis: consider serial mast cell tryptase levels
ECG
Bladder scan
Urine pregnancy test
Other cultures/swabs
Catheter if need to monitor urine output
Interventions circualtion ABCDE
Fluid challenge/resuscitation
Blood transfusion
Consider continuous cardiac monitoring
what conditions are you looking for in C?
Shock
–> hypovolemic (haem/non-haem)
–> distributive SEPSIS, ANAPHYLAXIS, ADDISONIAN CRISIS
–> obstructive
PE, TAMPONADE
–> cardiogenic
MI, ARRYTHMIA,
Fluid overload
Bleeding
if someone is bleeding, what do you do? ABCDE circualtion
If hemodynamically unstable = major haemorrhage = major haemorrhage protocol
If hemodynamically stable = check Hb to guide transfusion
define shock
Shock is defined as a global tissue hypoperfusion state, leading to cellular hypoxia and dysfunction.
causes of non-haemorrhagic hypovolemic shock
GI losses: any diarrhoea or vomiting…
Renal losses: Diuretic therapy, osmotic diuresis from hyperglycemia (DKA, HHS, poorly controlled diabetes)
Skin: loss of skin barrier eg burns
causes of distributive shock?
Sepsis
SIRS
Anaphylaxis
Neurogenic
Endocrine eg addisonian crisis and myxedema
what is neurogenic shock?
It is a type of distributive shock
Neurogenic shock results from damage to the spinal cord above the level of the 6th thoracic vertebra
Neurogenic shock - loss of sympathetic tone and thus unopposed parasympathetic response driven by the vagus nerve. Consequently, patients suffer from instability in blood pressure, heart rate, and temperature regulation.
It can occur after damage to the central nervous system, such as spinal cord injury and traumatic brain injury.
bradycardia; hypotension; poikilothermy, hypothermia, or both, causing a flushed appearance; warm, dry skin (from vasodilation); and flaccid paralysis below the spinal injury level.
need ICU
causes of cardiogenic shock
cardiomyopathies
arrhythmia
severe valve insufficiency
Causes of obstructive shock?
Pulmonary vascular - due to impaired blood flow from the right heart to the left heart. Examples include hemodynamically significant pulmonary embolism, severe pulmonary hypertension.
Mechanical - impaired filling of right heart or due to decreased venous return to the right heart due to extrinsic compression. Examples include tension pneumothorax, pericardial tamponade, restrictive cardiomyopathy, constrictive pericarditis.
If a fluid challenge doesn’t work, what should you consider as the cause of shock?
cardiogenic shock – don’t give any more fluids – as this will likely only fluid overload the patient.
If BP is high, then heart failure is likely, and give furosemide 20mg and wait for response – make sure you have catheterised to measure urine output first
what is sepsis?
life-threatening organ dysfunction caused by a dysregulated host response to an infection
what is septic shock, how should it be treated?
a more severe form sepsis, technically defined as ‘in which circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone
Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion. This leads to a rise in blood lactate as the organs begin anaerobic respiration. This can be measured as either:
Systolic blood pressure less than 90 despite fluid resuscitation
Hyperlactaemia (lactate > 4 mmol/L)
This should be treated aggressively with IV fluids to improve the blood pressure and the tissue perfusion. If IV fluid boluses don’t improve the blood pressure and lactate level then they should be escalated to high dependency or intensive care where they can use medication called inotropes (such as noradrenalin) that help stimulate the cardiovascular system and improve blood pressure and tissue perfusion.
what score can be used outside ICU to assess a patients risk of mortality from sepsis if there is a ?infection
qSOFA
Respiratory rate > 22/min
Altered mentation (GCS)
Systolic blood pressure < 100 mm Hg
qSOFA Scores 2-3 are associated with a 3- to 14-fold increase in in-hospital mortality. Assess for evidence of organ dysfunction with blood testing including serum lactate and calculation of the full SOFA Score.
Patients meeting these qSOFA criteria should have infection considered even if it was previously not.
red flags for sepsis ?
A
B
- RR >25
C
- systolic bp <90 or drop of >40 from normal
- heart rate >130
- not passed urine in last 18hr/ UO < 0.5ml/kg/hr
- lactate > 2
D
- responds only to voice or pain/unresponsive
- acute confusional state
E
- non blanching rash, mottled, ashen, cyanotic
MHx
- recent chemo
when should the sepsis 6 be started?
when there are any red flags/ there is a suspicion of sepsis
what are the sepsis 6?
- Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
- Take blood cultures
- Give broad-spectrum antibiotics
- Give intravenous fluid challenges
NICE recommend a bolus of 500ml crystalloid over less than 15 minutes - Measure serum lactate
- Measure accurate hourly urine output
what is the SOFA score
used in ICU for patients ?sepsis
A SOFA score of 2 or more reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection.
amber flags for sepsis
A
B
- rr 21–24
C
- systolic bp 91-100
- heart rate 91-130 or new dysrhythmia
- not passed urine in last 12-18 hours
D
- relatives concerned about mental status
E
- clinical signs of wound, device or skin infection
- temp <36
MHx
- acute deterioration in functional ability
- immunosuppressed
- trauma/surgery/procedure in last 6 weeks
risk factors for sepsis
extremes of age; people who are frail, immunocompromised or immunosuppressed; people who have had recent trauma or surgery; people with a breach in skin integrity; and women who are pregnant, are post-partum, or have had a recent termination of pregnancy or miscarriage.
what are the sepsis 7 and 8
- Transfer to critical care may be needed to assess the need for central venous access and initiation of inotropes (increase cardiac output by increasing cardiac contractility) or vasopressors (increase blood pressure by increasing peripheral vascular resistance), to maintain perfusion pressure.
- Finding a source:
FBC: WCC may be high or low, thrombocytopaenia may indicate DIC
CRP - infection or inflamamtion
Creatinine, urea and electrolytes - dehydration, aki
LFTs - increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction.
Clotting screen — if abnormal may indicate coagulopathy/DIC.
Urine analysis and culture, chest X-ray, CT for intra-abdo infection or abscess, LP for meningitis/encephalitis
additional investigations depending on the person’s clinical presentation — this may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery.
what is neutropenic sepsis
It is sepsis in a patient with a low neutrophil count of less than 1 x 109/L.
Low neutrophil counts are usually the consequence of anti-cancer or immunosuppressant treatment.
drugs that can cause neutropenia
Anti-cancer chemotherapy
Clozapine (schizophrenia)
Hydroxychloroquine (rheumatoid arthritis)
Methotrexate (rheumatoid arthritis)
Sulfasalazine (rheumatoid arthritis)
Carbimazole (hyperthyroidism)
Quinine (malaria)
Infliximab (monoclonal antibody use for immunosuppression)
Rituximab (monoclonal antibody use for immunosuppression)
recognition and management of neutropenic sepsis ?
Have a low threshold for suspecting netropenic sepsis in patients taking immunosuppressants or medications that can cause neutropenia
Treat any temperature above 38C as neutropenic sepsis in these patients until proven otherwise.
Treatment is with immediate broad spectrum antibiotics such as piperacillin with tazobactam (tazocin).
The other aspects of management are essentially the same as for sepsis however extra precaution needs to be taken. Time is precious so don’t delay antibiotics while waiting for investigation results.
Abx of choice for neutropenic sepsis
Tazocin
