Multisystem (14%) Flashcards
Normal ABG values
pH: 7.35-7.45
PaCO2: 35-45
HCO3: 22-26
Compartment syndrome
When pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia and death of tissue
6 P’s – pain, poikliothermia, pallor, pulselessness, paresthesia, paralysis
Common areas – LOWER LEG, forearm, wrist, hand
A strong pulse does not rule out compartment syndrome
Treatment – OR for fasciotomy
Distributive shock (e.g., anaphylaxis, neurogenic, septic) (minus cardiac parameters and treatment)
- What is happening: massive vasodilation
- Pathophysiology: systemic event causes the loss of the normal response to vascular smooth muscle and vasoconstriction coupled with a direct vasodilation
- Common causes: septic shock, anaphylaxis, and neurogenic shock
Distributive shock cardiac parameters
- SBP: < 90
- CVP: ↓ (plenty of fluid but vessels are wide open so they seem empty)
- CO/CI: ↓ (fluid isn’t returning to heart because vessels are too wide)
- SVR: ↓ (vessels are wide open)
- SvO2: ↓ or ↑
Distributive shock treatment (per each cause)
- Septic: treat cause of infection
- Anaphylactic shock: volume replacement, epinephrine, glucocorticoids (IV or PO; extends life of Epi), antihistamine
- Neurogenic shock: volume replacement followed by alpha antagonists (ex: phenylephrine)
Hypovolemic shock
- What is happening: nothing to fill up the vessels
- Pathophysiology: most common form of shock in trauma; multiple organ failure d/t inadequate circulating volume leading to inadequate tissue perfusion
- Common causes: acute hemorrhage, severe hydration, severe burns
- Cardiac pressures: SBP < 90, ↓ CVP (nothing in vessels), ↓ CO/CI (no fluid to circulate), ↑ SVR (vasoconstriction to try and compensate). ↓ SvO2 (not enough fluid to circulate to oxygenate)
- Treatment: treat underlying cause; volume replacement; transfuse PRN
Cardiogenic shock
- What is happening: have enough fluid, but pump isn’t working
- Pathophysiology: inadequate tissue perfusion secondary to loss of contractile function; “pump failure”
- Common causes: acute MI, acute HF, dysrhythmia
- Cardiac pressures: SBP < 90, ↑ CVP (fluid backs up), ↓ CO/CI (pump isn’t working), ↑ SVR (not d/t vasoconstriction, rather fluid backing up putting pressure on vessels), ↓ SvO2 (can’t pump blood out to circulate)
- Treatment: treat underlying cause; support CO with inotropes; support oxygenation
Obstructive shock
- What is happening: something blocking the filling of vessels and ventricles
- Pathophysiology: obstructive filling leads to the inability to produce good CO
- Common causes: PE, tension pneumothorax, cardiac tamponade
- Cardiac pressures: SBP < 90, ↑ CVP (fluid is backed up), ↓ CO/CI (vessels and ventricles can’t fill so they can’t pump anything out), ↑ SVR (fluid backing up putting pressure on vessels), ↓ SvO2 (can’t fill so can’t put out oxygenated blood)
Sepsis
Pathophysiology: dysregulated response to infection resulting in severe vasodilation, tissue perfusion, and organ dysfunction
Initially will be in hyperdynamic shock/”warm shock” but as compensatory mechanisms fail, will progress to hypodynamic shock/”cold shock”
Treatment is based on the surviving sepsis management
Surviving sepsis management of septic shock
Within 3 hours of presentation: measure lactate, obtain blood cultures prior to antibiotics, administer broad spectrum antibiotics, administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4
Within 6 hours of presentation: apply vasopressors (levophed) (for hypotension that doesn’t respond to initial fluid resuscitation to maintain MAP ≥ 65; if persistent hypotension after initial fluid bolus or if lactate was ≥ 4 – reassess volume status, re-measure lactate if initial was elevated
Follow-up: repeat focused exam (after initial fluid resuscitation)
Overall goals of treatment: CVP 8-12, MAP ≥ 65, urine output ≥ 0.5 ml/kg/hr, and SvO2 > 70%
Hemodynamic parameters
CVP (2-6 mmHg): reflects the amount of blood returning to the heart
PCWP (8-12 mmHg): left ventricular pressure when mitral valve is open
SVR (900-1400): the resistance of the systemic vascular bed
CO (4.8-6.4): volume of blood pumped out of the heart in 1 minute
CI (2.5-4.2): amount of blood pumped by the heart in 1 minute based on BSA
SvO2 (70-75%): the amount of O2 in the blood that’s returning to the heart
Ventilator modes: assist control (AC)
Ventilator delivers a specific number of preset supported breaths
Additional patient breaths trigger a fully-assisted breath
May be pressure or volume targeted
Do not use in tachypnea (can lead to hyperinflation and respiratory alkalosis)
Ventilator modes: synchronized intermittent mandatory ventilation (SIMV)
Ventilator delivers a minimum number of breaths that are synchronized with patient’s efforts
Additional patient breaths are possible with a TV that’s determined by patient’s effort
May be pressure or volume targeted
Non-invasive positive pressure ventilation (NIPPV)
CPAP – constant pressure maintained throughout respiratory cycle with no additional inspiratory support
BiPAP – a set expiratory positive airway pressure and inspiratory positive airway pressure
Common causes of fever
Infectious – bacterial (most common cause in acute care setting), viral, fungal, rickettsial, parasitic
Non-infectious – autoimmune, inflammatory, drug reaction
Post-op causes of fever
Most commonly the result of volume contraction (dehydration) or atelectasis
Bacterial
Volume contraction (dehydration)
Atelectasis
Post-op causes of fever - bacterial
Common findings – fever, leukocytosis, surgical site drainage
Diagnostic workup – evaluate for point of invasion, cultures
Treatment – antibiotics only with signs of bacterial infection, remove offending items (foley, lines, et.c)
Post-op causes of fever - volume contraction
Common findings – azotemia, decreased skin turgor, decreased PO intake/inadequate IV hydration
Diagnostic workup – metabolic panel, determine estimated blood loss and replacement, evaluate I&Os, urine output is most reliable indicator of perfusion
Treatment – isotonic fluids, increase PO fluid intake
Post-op causes of fever - atelectasis
Common findings – atelectasis present on CXR, lack of incentive spirometer use, cough, SOB, decreased lung sounds
Diagnostic workup – evaluate use of incentive spirometer, diagnosis of exclusion
Treatment – encourage incentive spirometer, OOB to chair and ambulation, splinting, evaluate med use that decreases respiratory drive
Principles of HIV - dx and tx for the acute care provider
- Transmitted via sexual, parenteral, or vertical transmission
- Flu-like syndrome weeks after initial viral acquisition and infection – suggests period of high viral replication
- ELISA SCREENING: > 99.9% sensitivity (screening, cheaper)
- Western blot CONFIRMS to 99.8% specificity (for confirmation)
- CD4+ count indicates level of functional immunity – used to initiate therapy
- Viral load measures viral replication – used to titrate therapy
- Consider beginning antiretroviral therapy regardless of CD4 count OR if clinically immunocompromised
HIV - PrEP (pre-exposure prophylaxis)
- Used for individuals who don’t have HIV but are at high risk
- When to start – as soon as possible following a risk behavior assessment and lab testing confirms absence of HIV
- Duration – daily treatment should continue until risk becomes low d/t less risk exposure
HIV - PEP (post-exposure prophylaxis)
- Used after a single high-risk event to minimize possibility of HIV infection
- Given to those without HIV who is at a high risk of HIV acquisition through isolated exposure within the past 72 hours
- When to start – as soon as possible following the event and always within 72 hours of possible exposure
- Duration – 28 days
Active TB
- Manifestations – significant coughing ≥ 3 weeks, chest pain, hemoptysis or sputum production, weakness/fatigue, weight loss, night sweats, fever
- Diagnostics – positive skin test or serologic result, CXR consistent with TB, abnormal sputum
- Treatment – patient will take several drugs for 6-9 months; first-line agents that are the core of treatment are: isoniazid, rifampin, ethambutol, pyrazinamide, and direct observation therapy
Latent TB
- Manifestations – none
- Diagnostics – positive skin test or serologic result, normal CXR, normal sputum
- Treatment – isoniazid for 6-9 months; rifampin for 4 months; direct observation therapy
Primary trauma survey
- A – airway, alertness, and cervical spine stabilization (suction, airway adjuncts, definitive airway)
- B – breathing, ventilation, and oxygenation (skin color, breathing effectiveness, O2, assist ventilation, EtCO2 measurement)
- C – circulation, hemorrhage control, and volume replacement (heart sounds, central pulse assessment, control hemorrhage, establish 2 large bore IVs, warm crystalloid boluses, consider need for blood transfusion)
- D – disability (evaluate GCS, assess pupils, consider head CT, consider intubation if GCS < 8)
- E – exposure and environmental control (expose patient, ensure warming methods are applied, consider preserving evidence if crime-related)
- The only time the order of this changes is if the patient is acutely bleeding – stop bleeding first and then proceed with ABCDE
Secondary trauma survey
- F – full set of vitals and family presence
- G – get resuscitation adjuncts and labs
- H – history (MOI, info from field, medical hx, etc.)
- H – head-to-toe assessment (complete head-to-toe, identify additional injuries, re-evaluate previous interventions)
- I – inspection (inspect posterior surface, determine need for backboard removal)
Chronic pain management
- Step 1 (mild pain, non-opioids) – aspirin, acetaminophen, NSAIDs, ± adjuvants
- Step 2 (moderate pain, weak opioids) – codeine, hydrocodone, oxycodone, tramadol, ± NSAIDs, ± adjuvants
- Step 3 (severe pain, strong opioids) – morphine, hydromorphone, methadone, fentanyl, ± NSAIDs, ± adjuvants
- Step up if pain continues to be persistent or pain increases
- For acute pain, step 1 is acute score of 1-3, step 2 is acute score of 4-6, and step 3 is acute pain score of 7-10
Burn sources (mechanisms of injury)
- Thermal – caused by heat source such as a hot item, steam, smoke, etc.
- Chemical – caused by a chemical agent such as acid or alkali substance
- Electrical – caused by AC or DC current
- Radiation – caused by a form of radiation such as sun exposure or cancer treatments
Treatment of burns
- Safety – of patient and provider
- Stop the burning process – wipe chemical away, deactivate chemical, remove hot items (ex: jewelry)
- Pain control – typically with opioids, but dictated by extend, degree of burn, and other comorbidities
- Fluid replacement (use Parkland formula if > 15-20% of TBSA)
- Maintain urinary output of 0.5 ml/kg/hr
Parkland formula
- For burns > 15-20% of TBSA
- 24-hour fluid replacement = 4 ml/kg/% TBSA burn
- ½ of volume in 8 hours from TIME OF BURN and remaining ½ in the remaining 16 hours
Liver transplant rejection
- Common occurrence, 60%
- Slight elevation of transaminases
- Signs and symptoms of liver failure – fever, malaise, anorexia, abdominal pain, ascites
- Diagnosis typically made with biopsy after functional complications have been excluded
Heart transplant rejection
- 50-80% chance of rejection
- Typically asymptomatic
- Signs of left ventricular dysfunction – dyspnea, nocturnal dyspnea, orthopnea, syncope
- Tachydysrhythmias – atrial > ventricular
- Diagnosis usually established by routine surveillance
Pancreas transplant rejection
- 20-30% rejection
- Typically asymptomatic
- Fall in urinary amylase
- Hyperglycemia – late sign
- Diagnosis is made via allograft biopsy
Kidney transplant rejection
- 10% rejection rate
- Elevated serum creatinine from baseline (most common)
- Decreased urine output, edema, worsening HTN
- Evaluate for other causes – infection, surgical complications, obstructions
- Diagnosis is made via percutaneous renal biopsy
Lung transplant rejection
- Most common type of transplant rejection, most patients have 1 episode of rejection
- Vague, non-specific signs and symptoms – fever, dyspnea, non-productive cough
- CXR is non-diagnostic
- Diagnosis is made by fiberoptic bronchoscopy with lavage and biopsy
- Infection must be ruled out
Transplant rejection general treatment concepts
- Steroids
- IV fluid resuscitation
- Treat for shock state
- Consult/transfer to transplant surgery service – anti-rejection medication levels
- Loading doses of anti-rejection meds
Opioid overdose
- Manifestations – respiratory depression, change in mental status, pupil changes (miosis)
- Diagnostics – typically a subjective/manifestation-based diagnosis, UDS (little help), CXR (only if concerned for aspiration)
- ED-focused treatment: airway management, naloxone hydrochloride (Narcan) for respiratory depression
- Naloxone: 0.04-2 mg IV bolus, consider IV infusion when multiple doses are administered, may need up to 10 mg IV for methadone overdose, can be administered SQ/IM/SL
Acetaminophen overdose
- Manifestations – typically asymptomatic; n/v, abdominal pain
- Diagnostics – made based on hx of overdose (need timeframe); APAP/acetaminophen serum level (at least 4 hours after ingestion); liver enzyme testing (elevated transaminases); INR (suggestive of liver failure)
- ED-focused treatment – indicated by patients with a toxic overdose (150 mg/kg is toxic limit); administer N-acetylcysteine within 8 hours of ingestion; oral or IV routes
- Oral dosing: loading dose of 140 mg/kg, then 70 mg/kg every 4 hours for 17 doses
- IV dosing: 1st option (150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours); 2nd option (150 mg/kg over 1 hour, then 14 mg/kg for 20 hours)
