Haemodynamics scenario

Question 1

Treatment for uncontrolled bleeding

Answer 1

If the patient has uncontrolled bleeding or;
-penetrating truncal trauma
-penetrating peripheral trauma that is uncontrolled
-leaking triple A
-Ectopic pregnancy
Try and stop bleeding.
If patient is severely shocked administer 500mls sodium chloride.
If patient remains severely shocked administer another 500mls of fluid.
-Call for ICP backup and consider heams Dr.

Question 2

sucking chest wound

Answer 2

• apply a dressing to it
• do not seal the would as this can lead to tension pnemothorax
• keep reassessing for signs of tension pnemothorax
• remove if tension pnemothorax

Question 3

Permissive Hypotension

Answer 3

Is maintaining a blood pressure that allows organ perfusion, without regaining normotension. This is as increased blood pressure can blow clots that have formed and dilute the blood and its clotting factors.

Question 4

Hypovalemia from other causes

Answer 4

blunt trauma, GI bleeding, fluid loss, controlled peripheral bleeding

• keep pt warm
• If pt has signs of poor perfusion or hypovalemia administer 1000mls of fluid, repeat as needed.
• If severely shocked ICP backup

Question 5

Hypovalemia from fluid loss

Answer 5

This category is for fluid loss which does not fit into other categories, eg. Diarrhea or vomiting.

• administer 1000mls fluid, repeat if nececaary
• ICP backup if severe shock

Question 6

Anaphylaxis

Answer 6

• If pt has systemic signs administer 0.5mg of IM adrenaline-repeat at 10 mins if necessary
• If stridor administer 5mg nebulised adrenaline
• if signs of poor perfusion or hypovalemia adminster 1000mls fluid
• If not responding to adrenaline ICP backup

Question 7

What is Anaphylaxis?

Answer 7

Anaphylaxis is a multi-system reaction to an allergen.
The allergen initiates a Type 1 hypersensitivity reaction which causes the Ige antibodies to be released. These cause cross linkages to form on mast cells which causes the degranulation of mast cells. This causes a release of inflammatory mediators.

Question 8

How does Adrenaline help anaphylaxis?

Answer 8

-Alpha one receptor - smooth muscle contraction, vasoconstriction of blood vessels
reducing swelling
-Beta 1 – increase in cardiac contractility , increased heart rate, increased electrical
conduction
Beta 2 – smooth muscle relaxation, skeletal muscle vasodilation, bronchodilation,
stabilisation of mast cells.

Question 9

Treatment of Septic Shock

Answer 9

• If showing signs of hypovalemia or poor perfusion gain IV access
• If more than 30 minutes from hospital administer caluvanic acid and gentamicin.
• Administer 1000mls of fluids, repeat as required.

Question 10

Pathophysiology of sepsis.

Answer 10

Is when a microorganism (usually bacteria, can be virus or parasite though) invades an area of the body initiating an immune response.
The immune response triggers the inflammatory cells to produce pro-inflammatory mediators. Excessive pro inflammatory mediators causes an imbalance with anti-inflammatory mediators.
This leads to widespread vasodilation and increased capillary permeability. Fluid becomes distributed inappropriately and causes decreased perfusion when compensatory mechanisms fail.
Leads to hypoxia, disruption of coagulation, and MODS, and ARF.

Question 11

clauvanic acid/ amoxicicillin

Answer 11

I-A clinical diagnosis of menigincocal septicaemia
-septic shock if the patient is more than 30 minutes away from hospital
-cellulitis- if pt is being referred to a Dr and there may be a delay in seeing DR given as single IV dose.
C-severe allergy
-clearly severe allergy to penicillin
-anaphylaxis to any beta-lactum antibiotic (penicllins cephalosporis
Cautions-none
A- Amoxicillin is abeta -lactum antibiotic. Acts against gram negative and positive bacteria, it inhibits production of cell wall causing bacteria to die
Clauvanic acid has no antibacterial properties, however it stops resistant bacteria from affecting amoxicillin.
R-IV or IM, no repeat.
D-1.2g dissolved in 2mls of sodium chloride. Final volume should be 2.4mls.
S-none
onset-30-60 mins

Question 12

gentamicin

Answer 12

`I-Pt with septic shock that is more than 30 mins from hospital and site of infection is UTI, abdomen or unknown, administered with Amoxicillin/clauvanic acid.
C-allergy, pregnacy
cautions-none
A-aminoglyside antibiotic- activity against gram positive and negative bacteria. Works by inhibiting bacterial cell production.
R- Via litre of 0.9% sodium chloride or 5% glucose or via syringe into running IV.
D- less than 60kg 240mg
60-80kgs 320mg
greater than 80kgs 400mg
S- renal impairment, ototoxicity.
30-60 min onset
80mg in 2mls

Question 13

Hypoglycaemia

Answer 13

For BGL less than 3.5mmol

• If can swallow glucose gel
• If not 100mls of 10% glucose IV
• If no IV access glucagon
• continue to take BGL every 10 minutes until above 3.5mmol
• Feed pt some complex carbohydrates

Question 14

Causes of Hypoglycaemia

Answer 14

• Insulin overdose
• Severe sepsis in young kids
• Deterioration of kidney function
• Liver failure

Question 15

T1 DM

Answer 15

Is the complete destruction of the pancreatic beta cells. Usually people are genetically susceptible to type 1 diabetes and undergo a triggering event, resulting in destruction of Beta cells.

• results in hyperglycaemia (in the blood) due to lack of insulin, lack of insulin effect, or both.
• may be in the form of a bad infection, or huge physiological stress causing auto-antibodies to be produced, which destroy beta cells, resulting in lack of insulin secretion

Question 16

DKA

Answer 16

• DKA occurs in type 1 diabetics BGL 20 +where there is no glucose available to the cells, as it is all in the blood and there is no insulin to make it go into cells.
• The cells dont have energy source.
• So uses breakdown of fats (lipolysis) instead, these fats must be converted into ketones to be used for energy, moving the body into a state of ketosis.
• Ketones have a fruity smell about them, patients in DKA will smell fruity.
• state of ketosis, acid is being produced, resulting in metabolic acidosis. In order to combat this, bicarbonate is used to buffer the acid:This causes to much CO2 so to remove the carbon dioxide, the body increases the respirations, resulting in ‘Kussmaul’ respirations – of increased rate and depth.

Question 17

HONK

Answer 17

HS or hyperglycaemia non-ketoacidosis (HONK) occurs in type 2 diabetics.

• When low levels of insulin, glucose remains in the vascular (blood) system.
• Glucose attracts water molecules from cells (hypermolarity)
• This causes dehydration and increased urination. -When water is pulled from the brain, the patient may also begin to suffer neurological symptoms (hemiparesis, seizures, coma).
• DKA does not occur as there is still a small amount of insulin in the body and insulin inhibits ketogenisis.

Question 18

Meningoccocal Septicemia

Answer 18

Type of bacteria that has entered the bloodstraem.
Have influenza like symptoms and petchiae (small sponts the size of a pen tip caused by bleeding in capillaries of skin)
-purpura (larger spots that look like small bruises, result of ischemia and bleeding)
Dont blanch when touched.
Can do stuff on road for them.

Question 19

Hyperglycaemia

Answer 19

For patients with BGL above 20mmol, suspected DKA or HONK

• administer 1000mls of fluid over an hour
• Can not be done fast as can result in cerebral oedema

Question 20

Severe Traumatic Brain Injury

Answer 20

If cannot obey commands or GCS below 10

• administer oxygen (simple mask at 6lpm should be sufficient)
• manage airway
• If systolic BP below 120, administer 1000mls fluid to maintain systolic 120.
• Backup, consider ICP with RSI

Question 21

Why is it important to keep systolic at 120 in TBI’s.

Answer 21

Cerebral blood flow is dependent on cerebral perfusion pressure.

• CPP is determined by MAP- ICP=CPP.
• ICP increases in TBI’s
• So a reduction in CPP leads to cerebral ischemia and worsened outcomes.

Question 22

Why is Hypertension bad in TBI.

Answer 22

Is bad as it increases inter-cranial pressure

Question 23

SIRS

Answer 23

systemic inflammatory response syndrome.
have 2 or more of this criteria.
HR >100
RR >20
Temp >38    <36
If under 36 in cold shock phase.

Question 24

How differentiate tension pnemothorax and haemothorax and

Answer 24

Tension Pnemothorax
-JVD
-hyperessonance on percussion
-rapidly progressing severe shock.
-decreased air entry
-late stage thracheal deviation
Haemothorax
-dull sounds on percussion
-reduced air entry

Question 25

pnemothorax patho

Answer 25

A pnemothorax occurs when air gets into the pleural cavity ( the space between lung and chest wall).
The puts pressure on the lungs and can cause areas to collapse impededing ventilation and oxygenation.
Tension pnemothorax occurs when the opening becomes one way, so air only goes into pleural space this causes the lung to be pushed through the medistitium and impede venous return to the heart.

Question 26

why is glucose better than glucagon

Answer 26

it does not rely on glycogen stores.

• the t may have depleted glycogen stores
• the administration will also deplete the patients glycogen stores and they may struggle for following months

Question 27

hypoglycaemia treatment

Answer 27

• If pt can swallow glucose gel and food
• BGL less than 3.5
• gain IV access
• 100mls glucose as a bolus.
• take BGL every 10 minutes
• If BGL does not go above 3.5 repeat glucose dose
• get patient to eat some complex carbs
• determine it wasn’t a insulin overdose.

Question 28

Drip rate calculation

Answer 28

volume(mls) diveded by time (mins)

divedied by drop factor