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PCM IV Final > HYHO: Sepsis > Flashcards

HYHO: Sepsis Flashcards

1
Q

4 Types of Shock

A
    1. Cardiogenic shock
    1. Hypovolemic shock
    1. Distrubutive shock
    1. Obstructive shock
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2
Q

What is PCWP and CVP?

A
  • PCWP = pulmonary capillary wedge pressure (indirect measure of left atrial pressior and volume status of heart) is measured catheter in pulmonary artery
  • CVP = central venous pressure = marker for right atrial pressure
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3
Q

Cardiogenic Shock

  1. What is it?
  2. Cardiac output (CO)
  3. SVR?
  4. PCWP or CVP?
A
  1. <3 does not pump well or circulatory overload (Heart attack, end-stage heart conditions)
  2. CO = decrease
  3. SVR = increase
  4. PCWP/CVP = increase
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4
Q

Hypovolemic Shock

  • What is it?
  • Cardiac output (CO)
  • SVR?
  • PCWP or CVP?
A
  1. Poor fluid intake/ fluid or blood loss (sweating, diarrhea, vomitting, hemorrhage)
  2. CO = decrease
  3. SVR = increase
  4. PCWP/CVP = decrease
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5
Q

Septic/Anaphalctic (Distributive) Shock

  1. What is it?
  2. Cardiac output (CO)
  3. SVR?
  4. PCWP or CVP?
A
  1. Vasodilation, leading to low SVR
  2. CO = increase
  3. SVR = decrease
  4. PCWP/CVP = decrease
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6
Q

Neurogenic (Distributive) Shock

  1. What is it?
  2. Cardiac output (CO)
  3. SVR?
  4. PCWP or CVP?
A
  1. Vasodilation, leading to low SVR
  2. CO = decreased
  3. SVR = decreased
  4. PCWP/CVP = decreased
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7
Q

Obstructive Shock

  1. What is it?
  2. Cardiac output (CO)
  3. SVR?
  4. PCWP or CVP?
A
  1. Obstruuction of blood flow in major circuit (extracardiac causes of HF: PE, cardiac tamponade, tension pneumo, constrictive pericarditis)
  2. CO = decreased
  3. SVR = increase
  4. PCWP/CVP = variable
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8
Q

Sepsis

A

Life-threatening organ dysfunction caused by a dysregulated host response to an infection

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9
Q

Sepsis (organ dysfunction) is defined by a qSOFA score or SOFA score ____

A

≥ 2

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10
Q

what does qSOFA mean

A

quick Sequential Organ Failure Assessment

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11
Q

What is advantage between qSOFA vs SOFA?

A
  1. qSOFA = can be done at bedside with NO labs
  2. SOFA = needs labs
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12
Q

qSOFA Criteria

A
  1. RR > 22
  2. Systemic BP < 100 mmHg
  3. Altered mentation
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13
Q

What 6 systems are evaluated in SOFA?

A
  1. Respiration
  2. Coagulation
  3. Liver
  4. CV
  5. CNS
  6. Renal
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14
Q

Sepsis is associated with an inpatient mortality ____ %

A

≥ 10%

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15
Q

What is septic shock?

A

Subset of septic patients in which circulatory and cellular metabolism abnormalities are profound and substantially increase the risk of hospital mortality (>40%)

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16
Q

What is clinical standpoint of septic shock?

A

sepsis with persisting hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg + serum lactate > 2 mmol/L, despite adequate volume resuscitation

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17
Q

Sepsis Algorithm

A
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18
Q

Signs and symptoms of shock (all types)

A
  1. Tachycardia
  2. HypOtension
  3. AMS
  4. Oliguria
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19
Q

Signs and symptoms of sepsis

A
  1. Temperature ( > 38 °C or < 36°C)
  2. HR (> 90)
  3. Tachypnea (RR > 20)
  4. Leukocytosis (WBC > 12,000) or leukopenia (WBC < 4000)
  5. Signs of end-organ perfusion
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20
Q

What are signs of end-organ perfusion?

A
  1. Early sepsis: warm extremities d/t vasodilation (compared to cardiogenic shock, which has cool extremities)
  2. If Septic shock develops, extremities can become cool from redirection of blood to core organs
    1. Skin mottling
  3. CNS: AMS
  4. Kidney: Oliguria or anuria
  5. Bowel: No bowel sounds or ileus
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21
Q

What lab tests should you run to assess for DIC, a complication of sepsis?

A
  1. PT (INR)/PTT
  2. Fibrinogen
  3. D-dimer
  4. Peripheral blood smear
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22
Q

Why would you run a CMP in a patient with sepsis?

A
  1. Acute liver injury
  2. AKI
  3. Electrolytes
23
Q

Why would you run a CBC with differential in a patient with sepsis?

A
  1. Leukocytosis/leukopenia
  2. Anemia
  3. Thrombocytopenia
24
Q

Why would you run a ABG (arterial blood gas) in a patient with sepsis?

A

Assess for hypoxemia and ARDS (from PaO2:FiO2 ratio)

25
Q

Why would you run a check serum lactate in a patient with sepsis?

A

Check for signs of sepsis (poor organ perfusion)

26
Q

When are procalcitonin levels elevated in a patient with sepsis?

A

Bacterial infections and sepsis

Tool used to determine duration of ABX (particularly in CAP)

27
Q

Complications of sepsis

A
  1. DIC
  2. Acute kidney injury
  3. Acute hepatic injury
  4. ARDS (acutre respiratory distress syndrome)
28
Q

How should you manage a patient that you SUSPECT has sepsis?

A
  1. qSOFA >2?
    1. No => still suspect sepsis? If no, monitor and reval if needed. If see, proceed down.
    2. Yes = look for evidence of organ dysfunction and conduct SOFA
      1. SOFA <2 = monitor and reval if needed.
      2. SOFA > 2 = Sepsis is confimed
  2. Sepsis is confirmed. Now determine if the patient is in septic shock. To do so, ask:
    1. Despite adequate fluid resuscitation, does the patient need vasopressors to maintain MAP >65mmHg AND is their serum lactate >2mmol/L.
    2. ^If yes = septic shock!
29
Q

Labs for DIC

A
  1. Thrombocytopenia
  2. Elevated PT/PTT
  3. Elevated D-dimer and fibrin degradation products
  4. Decreased fibrinogen
  5. ABNL peripheral blood smear (schistocytes/helmet cells)
30
Q

DIC can cause what problems?

A
  1. AKI
  2. Acute hepatic injury
  3. Acute lung injury
  4. Neuro problems
  5. Adrenal failure (Waterhouse - Friederischen syndrome)
    6.
31
Q

What is ARDS?

A
  1. Acute and diffuse inflammatory injury to the lungs.
  2. Many causes: 85% of cases due to
    1. Pneumonia
    2. Aspiration of stomach contents
    3. Sepsis
32
Q

Diagnosis of ARDS

A
    1. Onset within 7 days of initial insult
    1. Bilateral opacities on CXR or Chest CT consistent with pulmonary edema,
    1. Low PaO2:FiO2 ratio (< 300 mmHg)
33
Q

Initially, how do you treat a patient with sepsis?

A

Stabilize the patient hemodynamically + determine the cause of sepsis

34
Q

To treat sepsis, you need good vascular access for hemodynamic monitoring.

What do you need?

A
  1. 2 large bore peripheral IVs
  2. Central line, typically in right internal jugular vein (to administeral vasopressor)
  3. Arterial line
  4. Urinary foley catheter
    • ​(To measure accurate urine output to monitor renal function; goal > 0.5 ml/kg/hour)
35
Q

What is the 1 hour bundle for treatment of sepsis?

A

Surviving Sepsis Campaign recommends you need all of the following within 1 hour of realizing pt has sepsis/septic shock. In order:

  1. Measure lactate level. If initially elevated (>2mmol/L), remeasure.
  2. Get blood cultures before giving ABX
  3. Administer broad spectrum ABX
  4. Begin rapid administration of 30 mL/ kg of IV fluids (crystalloid) for hypOtensive pts or lactate > 4mmol/L.
  5. Give vasopressors if hypotensive during or after fluid resusitation to keep MAP > 65mmHg.
    1. NE = preferred.
    2. If still need to meet goal, give Vasopressin or EPI.
    3. If nothing else works, add Dobutamine.
36
Q

70 kg male with hypotension and sepsis would get ____ ml of IVF bolus with

additional fluid as needed per hemodynamic status

A

2100

37
Q

What are crystalloid fluids?

A
  1. Lactated ringers
  2. Normal Saline
38
Q

______ is used as a marker of tissue hypoperfusion

A

Lactate

39
Q

Name Vasoperssin Receptors (5)

A
  1. a-1
  2. B-1
  3. B-2
  4. D1
  5. V1/2 (vasopressin-R)
40
Q

a-1 receptors

  1. Location
  2. Activation causes:
A
  1. Vascular smooth muscle
  2. Vasoconstriction
41
Q

B-1 receptors

  1. Location:
  2. Activation causes:
A
  1. Heart
  2. Increases HR (chronotropy) and contraction of heart (inotropy)
42
Q

B-2 receptors

  1. Location:
  2. Activation causes:
A
  1. Vascular and bronchial smooth muscles
  2. Vasodilation and bronchodilation
43
Q

Dopamine Receptors (D1)

  1. Location:
  2. Activation causes:
A
  1. Renal and splanchnic (mesenteric) vascular beds
  2. Vasodilation
44
Q

V-1 receptors

  1. Location:
  2. Activation causes:
A
  1. Vascular smooth muscle
  2. Vasoconstriction
45
Q

V-2 receptors

  1. Location:
  2. Activation causes:
A
  1. Renal collecting duct
  2. Anti-diuresis
46
Q

Bronchi Chapmans Points

A
  1. Anterior: ICS between the 2nd/3rd ribs at the sternocostal junction, bilateral
  2. Posterior: midway between the SP and the tip of the TP of T2, bilateral
47
Q

Upper Lung Chapman Points

A
  1. Anterior: ICS between the 3rd and 4th ribs at the sternocostal junction, bilateral
  2. Posterior: in between the TP of T3 and T4, midway between the SP and the tip of the TP, bilateral
    3.
48
Q

Lower Lung Chapmans Points

A
  • Anterior: ICS between the 4th and 5th ribs at the sternocostal junction, bilateral
  • Posterior: in between the TP of T4 and T5, midway between the SP and the tip of the TP, bilateral
49
Q

Liver and GB chapmans points

A
  • Anterior: right ICS between the 5th, 6th, and 7th ribs, from the mid-mammillary line to the sternum
  • Posterior: between the TP of T5, T6, and T7, midway between the tips of the SP and the TP, right side only
50
Q

Kidney Chapmans Points

A
  • Anterior: 1 inch above the BB, laterally on either side of the midline
  • Posterior: between the TP of T12 and L1, midway between the tips of the SP and the TP, bilateral
51
Q

ANS of Heart, Lungs, Liver and Kidney

A
  1. Heart: T1-T6, Parasympathetics Vagus Nerve (OA, AA)
  2. Lungs: T1-T7, Parasympathetics Vagus Nerve (OA, AA)
  3. Liver: T5-T9, Parasympathetics Vagus Nerve (OA, AA)
  4. Kidney: T10-T11, Parasympathetics Vagus Nerve (OA, AA)
52
Q

______ = is the most important action in the urgent setting in septic patient

A

Stabilizing patient

53
Q

5 factor model for septic patient

  1. Biomechanical
  2. Respiratory/Circulatory
  3. Neurologic
  4. Metabolic/Energetic/Immune
  5. Behavioral
A
  1. Biomechanical – OMT for SD
  2. Respiratory/Circulatory – Fluid status, vent settings, lymphatic OMT treatments
  3. Neurologic – PT/OT for any neurologic compromise, OMT to normalize sympathetics and parasympathetics
  4. Metabolic/Energetic/Immune – Assess ability for oral intake versus TPN, renal/hepatic dosing of meds, monitor ins and outs, daily weights
  5. Behavioral – Address factors leading to sepsis
54
Q
A

PCM IV Final (6 decks)

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