Hemorrhagic Shock and Hemostatic Agents Flashcards
What is shock
A life threatening state of generalized, insufficient perfusion due to hemodynamic instability (lack of blood flow)
What happens at the cellular level when there is a hemorrhage
Depletion of cells (red and platelets), decreased platelet function, depletion of clotting factors and loss of activity,
What are corrective measures the body tries to make during a hemorrhage
Active coagulation cascade (procoagulant effects), lactic acidosis, vasoconstriction, endothelium and neutrophil activation, increased vascular permeability
T/F: Hemorrhagic shock causes a decrease in cardiac output, decrease in blood pressure, decrease in perfusion, and less oxygen for tissues
True
Why does urine output decrease in hemorrhagic stroke
There is hypoperfusion of the kidneys (most likely other organs as well)
T/F: Blood pressure decreases while heart rate increases in order to keep cardiac output the same
True
What are the 4 steps to managing massive hemorrhage
Control the bleeding/minimize blood loss
Aggressive resuscitation
Management of BP and acidosis
Treatment coagulopathy
What is the goal of aggresive resuscitation
Provide adequate oxygen delivery to meet demand and reverse any ongoing tissue hypoperfusion
What are the product options for resuscitation
Colloids and/or crystalloids
What is the best colloid to use, others
Blood, albumin Hetastarch
Where does blood come from
Donor and auto transfusion (not ideal but doesn’t require testing)
What are the components of blood from most to least
Plasma, RBCs, WBCs, platelets (whole blood)
When a patient is low on hemoglobin what blood product can be given, shelf life/ what is a low hemoglobin level
Packed RBCs, 42 days/ less than 13.5 g/dL (males) and less than 12 g/dL (females)
What blood product would be used to elevate blood pressure
Fresh Frozen Plasma
When would a patient get platelets
Platelet count is less than 10,000 (prevent spontaneous hemorrhage)
What are risk of blood administration
Compatability, fever, allergy, acute hemolytic anemia, transfusion related acute lung injury
T/F: Hetastarch can be given for the most critically ill
False: Hetastarch should not be used under any circumstances
What is the main job of albumin, can it be used in hemorrhagic shock
volume expansion, no
What are the two preferred crystalloid solutions for resuscitation
Ringer’s lactate and 0.9 NaCl (both isotonic and stay in the vasculature)
Which crystalloid is preferred in hemorrhagic shock and why
Lactated ringer: off set acidosis (converted to bicarbonate) and minimizes chloride load
How much crystalloid should be given
Less than 3L in the first 6 hours (warm not cold)
What should be monitored from improvement once given fluids
Urine output, CVP, blood pressure, heart rate
What is the absolute best way to reverse the acidosis caused by hemorrhagic stroke, other methods
Restore perfusion and oxygenation, sodium bicarbonate adminstration: serum bicarbonate 6mEq/L and pH is less than 7.1 (also aids in catecholamine response)
When a patient has hemorrhagic shock what are the vasopressors that should be used to maintain BP (order from most used to least used)
Phenylephrine, Vasopressin, norephinephrine, epinephrine, dopamine
What are the factor deficeint coagulopathies
Hemophilia A: deficiency of Factor 8
Hemophilia B: deficiency of Factor 9
Von Willebrand disease: Deficiency in vWf
What expensive concentrate of blood plasma would be good for hemorrhage caused by coagulopathy and low fibrinogen
Cryoprecipitate
What are the three indications for hemostatic agents
disease state coagulopathy, trauma, medication reversal
What are the drugs that can be given for Hemophilia A induced coagulopathy, MOA
Desmopressin:increases plasma Factor 8 activity and Antihemophilic Factor: Replaces missing Factor 8
What are the drugs that can be given for Hemophilia B induced coagulopathy, MOA
Coagulation Factor 9 recombinant: Replaces missing Factor 9
Factor 9 Complex: Contains Factor 9,2,7, 10
Recombinant Factor 7a: Complexed with TF activates 9a and 10a PLUS converts prothrombin to thrombin
For the hemophilia factors how are they all administered, what should be monitored, what are the severe ADEs
Administered IV, bleeding and thrombosis along with factor activity, anaphylaxis and thrombosis
What other disease states can cause coagulopathies
liver cirrhosis, malabsorption, cancer, bacterial infections, intense exercise
What agent can be used for coagulopathies caused by other,MOA
Aminocaproic acid (amicar): inhibits activation of plasminogen which decreases the conversion to plasminogen to plasmin
What is the trauma induced coagulopathy hemostatic agent
Recombinant Factor 7a
What medications that cause coagulopathies can be reversed with other agents
Warfarin, Heparin, LMWH (partially),” Xabans”,
What medications cant be reversed by other agents
Direct Thrombin inhibitors and Antiplatelets
What is the reversal agent heparin
Protamine
What is the reversal agent Wafarin
Vitamin K and Prothrombin Complex Concentrate
What does coagulation Factor Xa recombinant reverse and what is the Brand name
Rivaroxiban and apixiban, Andexxa
What is the monoclonal antibody used to reverse a direct thrombin inhibitor, which direct thrombin inhibitor, whats the brand name
Idarucizumab: Praxbind/ Dabigatran
How much blood loss is considered class 1 hemorrhagic
Less than 15%
How much blood loss is considered class 2 hemorrhagic, what is the usual heart rate
15-30%, 100-120
How much blood loss is considered class 3 hemorrhagic, what is the usual heart rate, what has happened to the systolic blood pressure
30-40%, 120-140, decreased
How much blood loss is considered class 4 hemorrhagic, what is the HR, RR CNS symptoms
Greater than 40%, Greater than 140, greater than 35, lethargic
What is the normal adult volume of blood
7% of total body weight
