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CardioPulm II > Hemodynamics and Shock > Flashcards

Hemodynamics and Shock Flashcards

1
Q

Hemodynamic instability

A

hypotension, change in mental status, and signs of shock

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2
Q

Hypotension

A

mean arterial pressure (MAP)

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3
Q

Mean Arterial Pressure

MAP

80 – 100 mmHg

A

MAP =DBP + 1/3 (SBP-DBP)***

Better mesured for t
Need at least 65 in order for your organs to have adequate organ perfusiotn

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4
Q

Cardiac Output

4 – 7 L/min

A

CO

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5
Q

Cardiac Index (CI)

2.8 – 3.6 L/min/M2

A

CO/body surface area

–>corrected CO for weight

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6
Q

Pulmonary Artery Occlusion Pressure
a.k.a. Pulmonary capillary wedge pressure

12-15 mmHg

A

Measure the pressure of L ventricle at the end of diastole. The heart is filled with the maximum volume of blood. Learn patients volume status.

  • indicates preload
  • pressure in left ventricle
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7
Q

Systemic Vascular Resistance

SVR

1300 – 2100 dynes-s/cm5

A

SVR- constriction/dilation of blood vessels

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8
Q

SHOCK

A

An acute, generalized state of inadequate perfusion of critical organs

  • Serious pathophysiological consequences, including death
  • USUALLY but not always associated with hypotension (SBP
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9
Q

o Signs of poor/reduced perfusion:

A 
Hypotension
• Increased HR and RR
• Cold extremities
• Mental status change or unconscious
• Reduced urine output (worsening renal function)-increase in ScR
• Lactic acidosis
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10
Q

Shock: hypovolemic

A

Low vascular volume

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11
Q

Shock: Distributive

A

Septic or anaphylactic: vasodilation

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12
Q

Shock: Cardiogenic

A

poor heart function

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13
Q

• Vasopressors (“vasoconstrictors”)

Route and titrating frequency?

A

Administered via continuous infusion

Frequent dosing adjustments may be necessary
(titration) every 5-15minutes

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14
Q

Can Vasopressors be used in Central line?

phentolamine (antidote)

A

YES or else

Tissue necrosis with extravastation:
o To avoid: administer through a central line

o Treat extravasation with intradermal administration of
10-15 ml of saline and** 5-10 mg of phentolamine**

 • Phentolamine: blocks alpha-adrenergic receptors
  causing vasodilation and minimizes necrosis
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15
Q

α1 - Vasoconstriction

α2- Vasoconstriction

β1 - inotropic (contractility) and chronotropic (HR)


β2- vaso-/Brocodilation

DA - Vasodialtion in the kidney, Heart, and GI
A

α1 - Vasoconstriction

α2- Vasoconstriction

β1 - inotropic (contractility) and chronotropic (HR)


β2- vaso-/Brocodilation

DA - Vasodialtion in the kidney, Heart, and GI
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16
Q

Dopamine

Central line line

A

DOC if low risk of arrhtymias
-Large DA and B1 activity

AE:
**Worst for Tachycardisa–>B1
peripheral vasoconstriction–>a1

Arrhythmias, tachycardia, peripheral and gut ischemia/ necrosis

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17
Q

Epinephrine
Catecholamines

Central line line

A

(Adrenaline®)

Large a1 and B activity (less B2)

AE:
hyperglycemia**
hypokalemia*

Agitation, tremor, headache, Arrhythmias, tachycardia hyperglycemia, peripheral and gut ischemia/ necrosis, “K+

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18
Q

Norepinephrine
Catecholamines
Central line line

A

(Levophed®)

often 1st line: a and b activity.

generally additive therapy to dopamine for septic shock

AE:
Hyperglycemia**

Agitation, headache, tremor–>B
peripheral/gut ischemia–>a

Hypokalemia**

19
Q

Phenylephrine

Noncatecholamines

Central line line

A

Neosynephrine

Only alpha- a

indicated if hypotensive with tachyarrhthmia (no B1 effects)

20
Q

Vasopression

A

Antidiuretic hormone

V1 Receptors – located in smooth muscle in blood vessels, hepatocytes, platelets, and on some cells in kidney

V2 Receptors: located in the renal collecting duct

Higher doses restricted in shock due to AEs

AE:

Decreased CO and circulation to skin and GI tract
peripheral ischemia
Hyponatremia**

May decrease CO and circulation to skin and GI tract (high doses > 0.04 units/min), decreased splanchnic circulation (high doses > 0.04 units/min), peripheral ischemia, hyponatremia

0.01-0.04 units/min (higher doses NOT recommended in shock–>Will cause auto amputee??? Vasopressors

21
Q

Inotropes

A

Dobutamine

Milrinone

22
Q

Dobutamine

A

2min half-life
hepatic metabolism
B and a1 activity
two isomers: (+) -> B-activity, (-) –>a

used in low CO states

  • -> CI Left Ventricular dysfunction
  • -> Shock

AE: Tachycardia, arrhythmias, hypotension (rarely), angina, premature ventricular beats

23
Q

Milrinone

A

Half-life: 1-2hours
Renal (need lower in renal dysfunction)

PDE-3 inhibitor to enhance contractility

AE: Hypotension, arrhythmias

24
Q

Hypovolemic Shock: Causes

A

Blood loss (shot wounds)

Fluid sequestered within a compartment of the body due to loss of oncotic pressure or increased capillary permeability

Fluid lost from urine, diarrhea/vomiting, skin (burns) o Hemodynamic effects

25
Q

Hypovolemic Shock: Hemodynamic effects

A

Decreased: MAP, CVP, PCWP, CO, SVR

Increased: SVR

26
Q

Hypovolemic Shock: Treatment

A

Plasma expanders - 1st line

  • -> NSS or Lactated ringer (isotonic crystalloid)
  • ->albumin (colloids)
  • ->Blood: if caused by blood loss

Vasopressor–Last line
–>vessel are already contracted to compensate for loss of BP

27
Q

Hypovolemic Shock: Monitoring

A

HR, BP, lactate, and Scr

28
Q

Distributive Shock: Septic Shock

Cause

A

Infection - Gram (+) most common

29
Q

Distributive Shock: Septic Shock

Risk factors

A

Elderly

Immunosuppressed states (AIDS, cancer, transplant,
chronic immunosuppressing medications)

Malnutrition

Alcoholism

Chronic organ failure

30
Q

Definition of Systemic inflammatory response syndrome (SIRS)

A

Patient must have two or more of the following:

WBC ≥ 12,000 or WBC ≤ 4,000 or bands > 10%

Hyperthermia (≥38°C or 100.4°F) or hypothermia (≤36°C or 96.8°F)

(PaCO2 ≤32 mmHg)

RR ≥20

Mechanical ventilation for an acute respiratory process

Heart rate ≥ 90 beats/min

31
Q

Sepsis

A

SIRS + infection

32
Q

Severe Sepsis

A

Sepsis + organ dysfunction

33
Q

Septic Shock

A

1 or 2 or 3 + Fluid refractory hypotension

34
Q

Distributive Shock: Septic Shock

Pathophysiology

A 
(1) Bacteria toxins cause-->Macrophages recognize the infection and (over)react and
release inflammatory mediators. 
--> TNF-α
--> IL-1
--> IL-6
  1. Vasodilation
  2. Vascular endothelial injury resulting in activation of the coagulation cascade
  3. o Fluid to leak out of vasculature and into tissues
35
Q

Distributive Shock: Septic Shock

Hemodynamic Effects

A

Decreased: MAP, CVP, PCWP, SVR

Increased: CO

36
Q

S/S

Early sepsis

A 
Fever or hypothermia
Rigors or chiles
Tachycardia
Tachypnea
Hypoxia
Hyperglycermia
Myalgias
37
Q

S/S

Late sepsis (evidence of organ failure

A

Increase Lactate*
Increase LFTs*
Pulmonary failure*

Decrease urine output/increase Scr
Hypotension
Thrombocytopenia
COMA

38
Q

Treatment (Surviving Sepsis Guidelines)

A

Prompt diagnosis and identification of pathogen causing infection

Early administration of antibiotics

Adequate organ perfusion (CVP > 8 and MAP > 65,
lactate

39
Q

Distributive Shock: Septic Shock

Antimicrobial therapy

A

Blood cultures should be sent before antimicrobial therapy is initiated as well as cultures from any other site that is suspected as causing the infection

–Blood must be sent immediately; start antimicrobial empirically within 1 hour*** (IV therapy)

40
Q

Distributive Shock: Septic Shock

(1) Fluids

A

Fluide challenge:
Administer 30 ml/kg of NNS or Lactated Ringers
–>Continue giving until goals met or signs of volume overload

Albumin - 2nd line

Blood due to loss

Monitoring: Sodium/chloride (crystalloids only), BP, HR, CVP, lactate, urine output, pulmonary edema, heart failure, edema

41
Q

(2)Vasopressors/inotropes

A

Noreperienpherine: 1st line for hypotension in septic shock

Dopamine: alternative if at low risk of arrhythmias–> low dose not useful. “Renal-dose dopamine” not useful (

42
Q

(2) Vasopressors/inotropes

Goals and Monitor

A

MAP>65

BP, HR, potassium, glucose,
peripheral/splanchnic vasoconstriction

43
Q

(3) Steroids

Adminstration (period) And Monitoring and Goals

A

Recommended to administer intravenous hydrocortisone in septic shock patients refractory to (1) fluids and (2) vasopressors
–> (Hydrocortisone 50mg IV)** every 6 hours or as continuous at 8 mg/hr

Goals: MAP > 65, avoid adverse effects, discontinuation of vasopressors

Monitoring: BP, glucose, mental status, fluid retention, infection, GI ulceration

44
Q

(4) Insulin

Goal and monitor

A

Glucose elevate by EPI–> (precaution)
Continuous infusion with short-acting insulin
(regular or lispro)

***Goal: blood glucose

CardioPulm II (11 decks)

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