Acute Bleeding And Acute Abdomen And Peritonitis Flashcards
State some causes of acute bleeding
IATROGENIC
•TRAUMATIC/INJURIES – FRACTURES, OPEN/STAB WOUNDS, G.I/ PERFORATIONS (VISCOUS), VASC. RUPTURE, EXPLOSIONS, ETC
•HAEMATOLOGICAL – DIC, HAEMOPHILIA, SCD, EMBOLI, ETC
•GYNAECOLOGICAL/OBSTETRICS.
•NEOPLASTIC – BRAIN TUMOR, COLON/ LUNG/ BREAST CAs, ETC
•INTRACRANIAL - CVA, RUPTURED ANEURYSMS, OTHERS
•DRUGS.
•OTHERS.
Pathophysiology of bleeding depends on what?
THE MECHANISM OF INJURY TO THE VASCULATURES
•THE BODY’S RESPONSE TO THE INJURY - VIRCHOW’S TRIAD
•THE VOLUME OF BLOOD LOSS
the types of bleeding are based on what things?
THE VASCULAR –ARTERIAL, VENOUS AND CAPILLARY.
THE BODY LOCATION – INTERNALLY AND EXTERNALLY.
THE VOLUME OF BLOOD LOSS – MINOR AND MAJOR.
THE DURATION – ACUTE AND CHRONIC.
What is shock
Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization.
- Inadequate oxygen delivery to meet metabolic demands
- Usually results from global tissue hypoperfusion and results in metabolic acidosis
•Shock can occur with a normal blood pressure and hypotension can occur without shock
State the types of shock
What are the types of hypovolemic shock and give examples under each
Hypovolemic •Cardiogenic •Septic •Anaphylactic •Neurogenic •Obstructive
Hemorrhagic •Trauma •GI Bleed •Massive Hemoptysis •AAA rupture •Ectopic pregnancy or Post-partum bleeding •Non-hemorrhagic •Vomiting/Diarrhea (Gastroenteritis) •Small and Large Bowel obstruction •Pancreatitis •Burns •Environmental (Dehydration)
Cardiac output is equal to what?
Blood pressure is equal to what?
What is stroke volume?
Stroke volume is a function of what factors
Cardiac Output = SV X HR
Thus,
Blood Pressure = SV X HR X PVR
Blood Pressure = Stroke Volume X Heart Rate X Peripheral Vascular Resistance
Stroke Volume = Volume of blood pumped by the heart during 1 cardiac cycle
10
Stroke Volume is a function of what factors?
Myocardial contractility
Preload
Afterload
What is the pathophysiology of shock
What is the physiologic compensation in shock
Heart rate increases as a compensatory response to Shock
•Inadequate systemic oxygen delivery activates autonomic responses to maintain systemic oxygen delivery
–Sympathetic nervous system
•NE, epinephrine, dopamine, and cortisol release
–Causes vasoconstriction, increase in HR, and increase of cardiac contractility (cardiac output)
–Renin-angiotensin axis
•Water and sodium conservation and vasoconstriction
•Increase in blood volume and blood pressure
•Goal is to maintain cerebral and cardiac perfusion
–Vasoconstriction of splanchnic, musculoskeletal, and renal blood flow
What is multi organ dysfunction syndrome
What is the clinical presentation of someone with this?(history and physical exam)
Inability of O2 to meet metabolic demands despite attempts at physiological compensation leads to triad of lactic acidosis, cardiovascular insufficiency and increased metabolic demands
•Downward spiral continues with progression of physiologic effects:
–Cardiac depression
–Respiratory distress
–Renal failure
–Disseminated Intravascular Coagulation (DIC)
•Result is end organ failure and death
History –Recent illness/Trauma –Fever –Chest pain, SOB –Abdominal pain –Co-morbidities –Medications –Toxins/Ingestions –Recent hospitalization or surgery –Baseline mental status
Physical examination •Vital Signs •CNS – mental status •Skin – color, temp, rashes, sores •CV – JVD, heart sounds •Resp – lung sounds, RR, oxygen sat, ABG •GI – abd pain, rigidity, guarding, rebound •Renal – urine output
What are the diagnostic tools used in MODS
Diagnostic Tools •Physical exam •Clinical signs and symptoms vary depending on the severity of disease and early recognition is key to diagnosis and intervention •Basic Labs: •CBC •Chemistries •Lactate •Coagulation studies •ABG •Blood cultures (septic screen)
Additional Diagnostic Tools
•CT of head/sinuses for occult infections/abscesses
•Lumbar puncture for meningitis/encephalitis
•Wound cultures
•Acute abdominal series
•Abdominal/pelvic CT or US
•Fibrinogen, FDPs, D-dimer if suspicion for DIC is high
What’s the initial approach to shock?
ABCs •Cardiorespiratory monitoring •Pulse Oximetry •Supplemental oxygen •Large bore IV access x 2 •ABG, labs •Foley catheter •Vital signs including rectal temperature (core temparature)
How do you estimate blood pressure in a shock patient
How is hypovolemic shock classifies
Quick method of estimating the blood pressure in patients
•If you palpate a pulse in these regions, then you know the SBP is at least this number:
60 in the arms
80 in the groin
90 in the knees
CLASS I - IV
•BVL - < 15%, 15 - 30%, 30 - 40%, > 40%
•AMOUNT - 750 cc, 750 - 1500 cc, 1500 - 2000 cc, > 2000 cc
•PULSE – <100, >100, >120, >140
•BP
•RESP
•CNS
•Urine
•TX
REFER TO TABLE.
What is the hypovolemic shock threatment goals
ABCDE
•Airway: Assess airway patency and intervene in critically ill patients to decrease work of breathing and support airway control
•Intubation and mechanical ventilation can initially worsen hypotension
•Sedatives can lower blood pressure
•Positive pressure ventilation decreases preload
•May need aggressive volume resuscitation prior to intubation to prevent hemodynamic collapse
•Control work of Breathing: Respiratory rate increases with shock to compensate for metabolic acidosis
•Respiratory muscles consume a significant amount of oxygen
•Tachypnea can further exacerbate lactic acidosis
•Mechanical ventilation and sedation will decrease work of breathing and improve overall survival
•Optimize Circulation: Isotonic crystalloids (Normal Saline or Lactated Ringers) is optimal first-line fluid
•Titrate to:
•CVP 8-12 mm Hg if you have central venous access
•Maintain urine output 0.5 – 1.0 ml/kg/hr (30 ml/hr)
•Improve heart rate (Goal HR < 100)
•Often requires large amounts of fluids or blood products (>4-6 Liters)
•No survival or outcome benefit from colloids
•Adequate oxygen Delivery: Decrease oxygen demand for patients
–Provide analgesia and anxiolytics to relax muscles**
–Avoid shivering
•Maintain and increase arterial oxygen saturation
–Give supplemental oxygen
–Maintain hemoglobin > 7 g/dL
•Tissue oxygen extraction can be measured with serial lactate levels on an ABG or central venous oxygen saturations if equipment is available
•Monitor End points of resuscitation:
Use objective hemodynamic and physiologic parameters to guide specific therapy
–i.e. Check vital signs and physiologic markers frequently
•Directed parameters to follow
–Urine output > 0.5 mL/kg/hr (simplest measure)
–CVP 8-12 mmHg (if central venous access available)
–MAP 65 to 90 mmHg
–Central venous oxygen concentration > 70% (if central venous access available)
How is hypovolemic shock managed
ABCs, IV/O2/Monitor
•Establish 2 large bore IVs or a central line
•Crystalloids
•Normal Saline or Lactate Ringers
•Up to 3 liters in adults
•Pediatrics = 20 cc/kg boluses (may need multiple boluses)
•Blood Products (Whole Blood, PRBC’s/FFP/Platelets)
•O negative or cross matched if type specific is not available
•Control any sources of active bleeding
•Arrange definitive intervention for hemorrhagic shock (Operating Theatre)
Hypovolemic Shock
•Evaluate response to treatment
A. Rapid Response
B. Transient Response
C. No Response
Based on
•Vitals - return to normal, Transient improvement with return to previous, Remain Abnormal.
•Estimated Blood loss- 10-20%, 20-40% with ongoing likely, Severe >40%.
•Need for more Fluid - Low, High, High.
•Need for Blood - Type and cross, type specific, O-Neg.
•Need for surgery - Possible, likely, highly likely
What is peritonitis
Depending on the underlying cause, the result is
What are the classes of peritonitis and define them
Inflammation of the serosal membrane or the lining of the abdominal cavity and its content
Depending on the underlying cause, the result is
•Infectious
•sterile- chemical
Introduction of infection – into a sterile environment
•Irritantants- HCL, Bile, foreign bodies and blood
Primary- from haematoginous spread – young 1 to 10year in older persons – cirrhosis and ascites. Nephrotic syndrome
- Secondary – from inflammation of organs, perforations etc.
- Tertiary- persistent or recurrent infection after adequate initial therapy.
