Chapter 1- Resuscitation Flashcards
What is shock?
State of impaired perfusion leading to inadequate O2 delivery and nutrients and clearance of metabolites with consequent reversible and eventual irreversible cellular injury
How is Hypotension and shock related?
state of low BP but hypotension can happen without the presence of shock and vici versa.
What is the pathophysio in shock?
Reduced delivery of O2, proportionally increased O2 extraction ratio to a point where there is supply-dependent O2 consumption and a oxygen deficit.
What are the mechanisms of shocks?
1) Preload decreased-Cardiogenic, hypovolemic and hemorrhagic
2) Pump failure- Obstructive
3) Reduced afterload- Septic, neurogenic and anaphylactic
what is the aim of rx in shock
Restore oxygen delivery to tissues and the end point of resus is complete repayment of oxygen debt
what are the classical signs of a hypoperfused state?
pallor, cool skin, tachycardia, diaphoresis, AMS, tachypnoea, reduced urine output
Which group of patients do not exhibit tachycardia in shock?
pts on B Blockers, athletes, neurogenic shock
What initial mgmnt caveats are there in shock?
1) Begin fluid resus only when cardiogenic shock is ruled out
2) Be prepared to intubate the patient on grounds of clinical deterioration
Basic investigations to order in Shock?
1) FBC-Hb and HCt to look for hemoconcentration and anemia. Neutrophil count not very suggestive
2) U/E/Cr- look for AKI and elevated urea suggestive of GI bleeding
3) ABG- get from both arterial and venous blood gas to look for widening gap
4) Lactate-for anaerobic resp
5) Trop T and cardiac enzymes and ECG-secondary MI
6) CXR-if indicated
7) GXM
8) CBG-in DM patients and peds patients
9) Blood cultures and septic work up(Urine culture,CRP) if indicated
10) UPT-if female and unexplained shock
What is the rx of hypovolemic shock?
- Aggressive fluid resus with 1 to 2L crystalloids
- once there is adequate fluid resus, can start inotropic support with Dopamine and Noradrenaline
What is the Rx of hemorrhagic shock?
Problem is inadequate vol and O2 carrying capacity
Hence, Rx is:
1) Control all external hemorrhage and involve the relevant surgical disciplines
2) -Prior to definitive surgical hemorrhagic control, low fluid resus strategy to prevent dislodgement of clot
-If severely hypotensive, GXM and transfuse 6 units of blood early
What is the rx of Obstructive shock?
Depends on the suspected etiology:
1) if tension pneumothorax is suspected then immediate relief with needle thoracotomy and definitive tube thoracostomy should be performed
2) If cardiac tamponade then FAST U/S exam followed by CTVS consult and prepare for pericardiocentesis.
3) If PE suspected, consider noradrenaline, adrenaline or dopamine
What is the rx of Cardiogenic shock?
1) Systolic BP
What is the rx of neurogenic shock?
1) IV fluids
2) Inotropic support
3) Atropine
4) Vasopressors
5) Urgent neuro or ortho consult
What is SIRS?
Systemic Inflammatory Response Syndrome(SIRS) is 2 out of the 4 of:
1) Fever>38 or 90bpm
3) WBC count>12 000
4) RR> 20 breaths/min or PaCO2
What is septic shock?
Hypotension (systolic40mmHg from baseline) due to sepsis despite adequate fluid resus along with presence of perfusion abnormalities(lactate>=4.0, oliguria)
Which groups exhibit an atypical response in sepsis?
Elderly-may present as tachycardia, tachypnoea, AMS
Young
Immunocompromised
What are RFs of Gram-negative Bacteremia?
1) DM
2) Lymphoproliferative disease
3) Chemotherapy
4) Burns
5) Cirrhosis
What is the mgmnt of septic shock?
1) Blood investigations as per routine shock
2) Maintain airway and consider intubation if needed
3) Aggressive fluid resus
4) Inotropic support with noradrenaline 1ug/kg/min
5) Antibiotic therapy:
- For meningitis, UTI, Biliary tract infection, immunocompetent with no obvious source: IV ceftriaxone
- For Intra-abdo infections: IV Metronidazole and IV ceftriaxone
- For CAP: IV augmentin, IV ceftazidime and IV Azithromycin
What is resp failure and the different types?
It is the failure of the lungs to oxygenate and/or remove CO2
Type I: Arterial Pa02
What are some hypercapnia?
1) Decreased central resp drive-Head injury, Drugs, CNS lesions, loss of hypoxic drive in chronic type 2 treated with O2
2) Airway obstruction-Asthma and COPD
3) Thoracic cage abnormalities-Rib fractures, kyphoscoliosis and morbid obesity
4) Neuromuscular abnormalities-MG, GBS, cervical/high thoracic injury
What are some mgmnt caveats in resp failure?
- Do not give bicarbonate to reduce the resp acidosis and correct the pH as it will exacerbate it instead
- Always give as much O2 as necessary to correct hypoxia in COPD patients as hypoxia kills before hypercapnia
How do you manage resp failure?
1) ECG, Vitals and Pulse Oximetry
2) Secure Airway via either invasive or non-invasive ventilation
3) Give Supp O2(devices dependant on the situation)
4) Perform early ABG to detect the type of resp failure and find cause asap
What is Non-Invasive Ventilation?(NIV)
NIV is the application of positive pressure vent to a patient in the absence of definitive airway such as ETT/tracheostomy. 2 types: Continuous postive airway pressure (CPAP) and Bi-level Positive airway pressure(BiPAP)
What are the indications of NIV?
1)Clinical Inclusion Criteria: Signs and symp of acute resp distress Moderate-sev hypoxia Abdominal paradox and accessory muscle use RR>24 2) Blood Gas findings -Resp Acidosis pH7.10 -PaCO2>45 3) Dx pneumonia COPD APO
What are some CI of NIV?
- Cardiac/resp arrest
- Trauma causing inability to use mask
- Excessive secretions
- Risk of aspirations
- Hemodynamic instability
- AMS/ agitation
Cx of NIV?
- Pneumothorax
- Patient-Ventilator dysynchrony
- Hypotension to PEEP causing reduced preload
