Midterm Flashcards by Emily Herrera

What parameters are going to be monitored with hemodynamic monitoring?

preload (CVP and PAWP)
afterload (PVR ad SVR)
CO/CI

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Describe preload

Right atrial pressure
- CVP (central venous pressure): 2-8 mmHg

Left atrial pressure
- PAWP (pulmonary artery wedge pressure): 8-12 mmHg

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What will be done if the preload is high vs low?

high (CVP/PAWP) = pt in fluid volume overload, give diuretics and vasopressors

low = pt dehydrated - fluids (crystalloids/colloids) 1st if CVP is low, but if CVP is high give vasopressors

if CVP and PAWP is on the lower end of the normal range, it is still considered low

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Describe afterload

Right side of heart
- PVR (pulmonary vascular resistance): 100-250 dynes/sec/cm5

Left side of heart
- SVR (systemic vascular resistance): 800-1200 dynes/sec/cm5

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What will be done if the afterload is high vs low?

high = give vasodilator
low = give vasopressor

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What is the difference between vasopressors and vasodilators?

vasopressors increase BP
vasodilators decrease BP

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What are examples of vasodilators?

nitroglycerin
nitroprusside
morphine
ca channel blockers
ace inhibitors

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What are examples of vasopressor?

norepinephrine
dopamine
vasopressin
epinephrine

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Describe cardiac contractility

electrolytes and oxygen affect contractility
low CO/CI = ineffective contractility

cardiac output (CO)
- volume ejected each min
- 4-8 L/min

cardiac index (CI)
- dependent on height and weight of pt
- 2.5-4.3 L/min/m2

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What will be done if the cardiac contractility is high vs low?

high = negative inotropes (beta blockers and ca channel blockers)

low = give positive inotropes (dopamine, dobutamine, digoxin)

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What is the cause of cardiogenic shock?

heart not pumping effectively (within the heart)
MI
HF
cardiomyopathy

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What is the cause of hypovolemic shock?

loss of fluid
dehydration
hemorrhage
burn

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What are examples of distributive shock?

whole body

septic (#1 shock state)
neurogenic
anaphylactic

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What is the cause of septic shock?

infection
sepsis (urosepsis)

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What is the cause of neurogenic shock?

head trauma
spinal cord injury (T6 or higher)

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What is the cause of anaphylactic shock?

allergy (drug, food, environmental)

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What is the cause of obstructive shock?

heart not pumping effectively (outside the heart)

pulmonary embolism
tension pneumothorax
aortic dissection
cardiac tamponade

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What are the signs of cardiac tamponade?

beck’s triad
- hypotension
- JVD
- muffled heart sounds

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What are the signs of cardiogenic shock?

high HR , low BP
high CVP/PAWP, high SVR
low CO/CI
confused
SOB
tachypnea
crackles
low urine output

What is the treatment for cardiogenic shock?

inotropes (dopamine/digoxin)
diuretics
stent
valve replacement

What are the signs of hypovolemic shock?

high HR, low BP
low CVP/PAWP, high SVR
low CO/CI
altered LOC
low urine output
cold/clammy skin

What is the treatment for hypovolemic shock?

fluids (NS or LR), but vasopressors (norepi or dopamine if CVP high
lower HOB
if bleeding = packed RBCs
fluid replacement using 3:1 rule (3ml of fluids to every 1 ml of blood loss)

What is the difference between sepsis and septic shock?

sepsis: systemic inflammatory response

septic shock: sepsis w/ hypotension despite fluid resuscitation

What are the signs of early (warm) septic shock?

restlessness/confusion
low BP, high HR, high RR
warm, flushed skin
low CVP/PAWP, low SVR
high CO
high lactate, WBC

What are the signs of late (cold) septic shock?

lethargy/coma low BP, high HR, low RR cool, pale skin low CVP/PAWP, high SVR low CO high lactate, low WBC

What is the treatment for septic shock?

oxygen IV fluids antibiotics vasopressors maintain glucose levels <180 prevent stress ulcer (PPI)

What are the signs of neurogenic shock?

massive vasodilation bradycardia low BP temp dysregulation low preload, afterload, CO

What is the treatment for neurogenic shock?

fluids (NS, cautious bc it increases BP) vasopressors atropine corticosteroids (reduce inflammation)

What are the signs of anaphylactic shock?

massive vasodilation high HR, low BP decreased RR SOB, wheezing, stridor low preload, afterload, CO

What is the treatment for anaphylactic shock?

epinephrine (IM) fluids (if they don't work, give vasopressors) diphenhydramine corticosteroid airway mngmt

What are the signs of obstructive shock?

high CVP/PAWP, high SVR low CO/CI JVD high HR, low BP, high RR SOB, tracheal deviation, unilateral breath sounds

What is the treatment for obstructive shock?

needle decompression chest tube pericardiocentesis thrombolytic therapy laparotomy removal of mass

What are the stages of shock?

initial compensatory progressive irreversible

Describe the initial shock stage

- s/s absent - subtle changes

Describe the compensatory shock stage

- non progressive - low oxygen - tachycardia - tachypnea ex: neurogenic shock

Describe the progressive shock stage

- organ failure - lethargic - low BP ex: hypovolemic, anaphylactic

Describe the irreversible shock stage

death is imminent ex: cardiogenic

What diagnostic studies are done for the different types of shock?

hemodynamic monitoring 12 lead ECG echo CXR EGD lactate above 2 = bad

Describe SIRS

systemic inflammatory response syndrome manifested by 2 or more of following: - 36 C < Temp > 38 C - HR > 90 bpm - RR > 20 or PaCO2 < 32 - 4,000 < WBC > 12,000

How can a local infection progress?

local infection - systemic infection (shock) - SIRS - multiple organ system syndrome (MODS septic shock) - death

How does SIRS (organ failure) present?

- neuro: ALOC, fever, lethargy - resp: high RR, low O2 - cardio: tachycardia - GI: ulcer, bleed, electrolyte imbalance - GU: AKI, high BUN/creatinine - hematologic: DIC, bleeding, petechiae, high PTT/aPTT, INR > 1.5, low wbc

How is SIRS treated?

infection control maintain oxygen provide nutrition via enteral route support of failing organs: - ARDS: O2 therapy and mech vent - DIC: blood products - renal failure: CRRT or hemodialysis

What is DIC?

disseminated intravascular coagulation - not a disease, but a complication - proteins that control blood clotting become overactive, causing many blood clots to form all over the body

What causes DIC?

- infection/sepsis - trauma - shock - cancer - OB complication

What are the signs of DIC?

severe bleeding everywhere - petechiae, purpura, epistaxis (nosebleed), hematuria, melena (black tarry stools), hematomas thrombosis - brain= CVA (stroke) - heart= MI (heart attack) - lung= PE (pulmonary embolism) - leg= DVT (deep vein thrombosis)

What will the labs show for DIC?

prolonged PT, aPTT, INR low platelets low fibrinogen

What is the treatment for DIC?

treat underlying cause O2 therapy IV fluids blood transfusion - packed RBC (blood loss) - platelets - FFP - cryoprecipitate (replaces fibrinogen) - heparin (decrease clots)