Midterm Flashcards
What parameters are going to be monitored with hemodynamic monitoring?
preload (CVP and PAWP)
afterload (PVR ad SVR)
CO/CI
Describe preload
Right atrial pressure
- CVP (central venous pressure): 2-8 mmHg
Left atrial pressure
- PAWP (pulmonary artery wedge pressure): 8-12 mmHg
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
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
What will be done if the afterload is high vs low?
high = give vasodilator
low = give vasopressor
What is the difference between vasopressors and vasodilators?
vasopressors increase BP
vasodilators decrease BP
What are examples of vasodilators?
nitroglycerin
nitroprusside
morphine
ca channel blockers
ace inhibitors
What are examples of vasopressor?
norepinephrine
dopamine
vasopressin
epinephrine
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
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)
What is the cause of cardiogenic shock?
- heart not pumping effectively (within the heart)
- MI
- HF
- cardiomyopathy
What is the cause of hypovolemic shock?
- loss of fluid
- dehydration
- hemorrhage
- burn
What are examples of distributive shock?
whole body
septic (#1 shock state)
neurogenic
anaphylactic
What is the cause of septic shock?
- infection
- sepsis (urosepsis)
What is the cause of neurogenic shock?
head trauma
spinal cord injury (T6 or higher)
What is the cause of anaphylactic shock?
allergy (drug, food, environmental)
What is the cause of obstructive shock?
heart not pumping effectively (outside the heart)
- pulmonary embolism
- tension pneumothorax
- aortic dissection
- cardiac tamponade
What are the signs of cardiac tamponade?
beck’s triad
- hypotension
- JVD
- muffled heart sounds
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)
