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CCRN - My Flashcards > Multisystem > Flashcards

Multisystem Flashcards

1
Q

Shock Definition

A
  • Shock is cellular disease due to inadequate perfusion OR the inability of cells to utilize the delivered oxygen
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2
Q

The 3 STAGES of shock

A

-Compensatory Stage: The blood pressure is MAINTAINED via the sympathetic nervous system and the RASS system

-Progressive Stage: HYPOtension occurs accompanied by tachycardia, tachypnea, oliguria, and changes to LOC

-Refractory Stage: Severe HYPOtension and multiple organ dysfunction syndrome. Vitals are not responsive to intervention. The patient may survive shock but die from organ failure (same as ARDS)

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3
Q

Compensatory Stage Specifics

A

-BP MAINTAINED
-Patient may complain of thirst
-Normal PaO2
-Skin is PALE
-Restlessness and anxiety

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4
Q

Progressive Stage Specifics

A

-HYPOTENSION
-Metabolic acidosis
-DECREASED PaO2
-Skin is CLAMMY and MOTTLED
-Mild changes in LOC
-Complaints of nausea

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5
Q

Refractory Stage Specifics

A

-Not responsive to interventions
-Severe Hypo-perfusion/hypotension
-Multiple organ dysfunction syndrome (usually the cause of death)

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6
Q

TYPES of shock

A

-Hypovolemic
-Septic
-Anaphylactic
-Cardiogenic
-Obstructive
-Neurogenic

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7
Q

Hypovolemic Shock (Most Common) - Definition and Presentation

A

-Reduction in the circulating intravascular volume leading to inadequate tissue perfusion

-Internal - 3rd spacing
-External - Hemorrhage, GI or renal loss, burns, excessive diaphoresis

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8
Q

Hypovolemic Shock Blood Pressure and Vitals

A

-Systolic BP decreases
Diastolic BP increases or stays the same
-NARROW pulse pressure

-ALL vitals Decrease (CVP, PAOP, Cardiac Output)
EXCEPT FOR SVR

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9
Q

Hypovolemic Shock Treatment Plan

A

-Replace volume
-2 large bore IV sites or central line
-ISOtonic solutions (NS or LR)
-If >2,000mL of fluid is given in 1 hour use a fluid warmer

-NS and LR effects last 40 minutes and then leaves vascular space

-Avoid vasopressors

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10
Q

Hemorrhagic Shock (A type of hypovolemic shock)

A

-A form of hypovolemic shock in which severe blood loss leads to inadequate oxygen delivery at the cellular level

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11
Q

Hemorrhagic Shock Classifications

A

Class I: Up to 750mL of loss
Class II: 750-1/500mL of loss
Class III: 1,500-2,000 mL of loss
Class IV: >2L of loss (2,000mL)

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12
Q

How to treat each class of hemorrhagic shock

A

Class I and Class II: Treat with crystalloids

Class III and Class IV: Treat with crystalloids AND blood

-WARM blood to prevent hypothermia

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13
Q

Hemorrhagic Shock Treatment (Generalized/Non-Specific to Classification)

A

-STOP THE BLEEDING
-Blood transfusion (Goal HgB is >7)

-HgB levels are not accurate during active bleeding

-PRBCs lack plasma and platelets so coagulation components may be require

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14
Q

Massive Blood Transfusion (MTP)

A

-10 units of blood in 24 hours OR 5 units of blood in less than 3 hours

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15
Q

Triad of Death

A

-Hypothermia
-Acidosis
-Coagulopathy

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16
Q

Sepsis and Septic Shock

A

-Sepsis: A life threatening organ dysfunction caused by an abnormal host response to an infection
- Sepsis = Infection + Organ dysfunction

-Septic Shock: Sepsis with the addition of vasopressor requirements and a serum lactate greater than 2mmol/L
- Vasopressors to keep MAP >65 when fluid resuscitation did not work

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17
Q

Sepsis Presentation

A

-Hypotension
-Acute hypoxemia
-Low urine output
-Lactate 2mmol/L or greater
Abrupt mental status change

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18
Q

qSOFA Scoring (quick Sepsis Related Organ Failure Assessment)

A

-Bedside evaluation that identifies organ dysfunction

Criteria: (1 point for each)
-Systolic BP < 90
-Respiratory Rate 22 or higher
-GCS < 15

-A score of 2 or 3 indicates high probability for organ dysfunction

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19
Q

EARLY signs of septic shock

A

-Tachycardia, bounding pulse
-BP responsive to vasopressors
-Confusion
-FEVER
-Lactate > 2

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20
Q

LATE signs of septic shock

A

-Tachycardia, weak thready pulse
-Hypotension not responsive to vasopressors
-HYPOTHERMIA
-Oliguria
-Lactate > 4

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21
Q

Is a fever ALWAYS present in septic shock

A

-NO

-Only with EARLY signs of septic shock

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22
Q

Septic Shock Treatment

A

-Start with a fluid challenge ASAP: 30mL/kg of crystalloid to raise MAP, increase urine output, decrease tachycardia

-If symptoms persist move on to vasopressors and inotropic therapy

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23
Q

Septic Shock Vasopressor Regimen

A

-Norepinephrine (Levo) is the vasopressor of choice (FIRST LINE)

-Epinephrine drip is the second vasopressor added to regimen

-Vasopressin drip (Non-titratable) can be added to enhance the effectiveness of the initial vasopressor

If BP does not respond to high dose vasopressor and fluid treatment the patient may have catecholamine refractory septic shock The alpha receptors in the arterial bed are not responsive to vasopressors

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24
Q

Inotropic Therapy for Septic Shock

A

-Dobutamine can be used alone or alongside vasopressors
-Stimulates heart muscle and improves blood flow by helping the heart pump better

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25
Q

Blood Cultures and Antibiotics for a Septic Patient

A

-Obtain 2 sets of blood cultures ASAP; draw from 2 sites simultaneously
-Obtain blood cultures PRIOR to antibiotic administration
-Antibiotics should be started within 3 hours of culture result

-Obtain a serum lactate ASAP
-Remeausure within 2-4 hours if > 2

26
Q

Septic Shock MAP/Lactate Interventions PRIOR to Vasopressors

A

-If MAP remains below 65 OR the serum lactate is 4 or greater…
Reassess fluid status Via Passive leg raise or fluid challenge

OR

-ECHO
-CVP measurement

27
Q

Anaphylactic Shock

A

-An allergic reaction with rapid onset

-Due to IgE-mediated hypersensitivity to protein substances
-Typically occurs AFTER first exposure

  • ** Anaphylactoid Response ** presents the same but caused by release of mast or basophils
    -No prior exposure is necessary
28
Q

Anaphylactic Treatment

A

-Removal of irritant/agent
-O2
- 0.3-0.5mg of 1:1,000 epinephrine IM
-Aggressive fluid resuscitation (1-4L)
-Antihistamine (Benadryl) 25-50mg IV
-Inhaled beta adrenergic agents
-Steroids IV

29
Q

Multiple Organ Dysfunction Syndrome (MODS)

A

-Progressive insufficiency of 2 or more organs so that homeostasis cannot be maintained without intervention
-The greater the number of organs involved, the higher the mortality rate

-qSOFA score or SOFA scoring

30
Q

Trauma! First and Second Line Assessment

FIRST LINE

A

-FIRST LINE ASSESSMENT:
(A, B, C, D ,E)

-Airway - Ensure patent airway
-Breathing - Give 100% O2
-Circulation - 2 large bore IVs with warm isotonic fluid
-Disability - Quick neuro assessment
-Expose/Environmental - Remove patient clothes. Provide warmth/cold as needed

31
Q

Trauma! First and Second Line Assessment

Second LINE

A

-SECOND LINE ASSESSMENT:
(F, G, H, I)

-Full set of vital signs
-Give comfort measures (pain management)
-History
-Inspect Posterior (Flip patient over)

32
Q

Sedation/Analgesia

A

-For agitation:
-Analgesia first before anxiolytics
(“Analgesia-first sedation”)

-Non-pharmacological interventions should be attempted first before using anxiolytics (Music, relaxation, ect.)

-Light levels of sedation are associated with better patient outcomes
-Daily interruptions of continuous sedation allows for neuro assessments

33
Q

Levels of Sedation and Assessment

A

-Minimal (Light)
-The patient responds normally to verbal commands

-Moderate
-The patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Patient able to maintain patent airway

-Deep
-The patient cannot be easily aroused but responds purposefully to repeated or painful stimulation
-Likely requires airway assistance

-Generel Anesthesia
-Loss of consciousness
-Not arousable even with stimulation

34
Q

Sedation Medications with Specifics
(Dexmedetomidine (Precedex)

A

Dexmedetomidine (Precedex)
-No loading dose recommended
-DO NOT Paralyze while on Precedex
-May not need mechanical ventilation

35
Q

Sedation Medications with Specifics
(Ketamine (Ketalar)

A

Ketamine (Ketalar)
-Give slowly via 1 minute IV push
-May cause increased BP, HR, salivation
-May cause psychosis (pre-treat with benzodiazepine)

36
Q

Sedation Medications with Specifics
(Lorazepam (Ativan)

A

Lorazepam (Ativan)
-Loading dose of 1-4mg q 30 minutes until goal RASS or CIWA is achieved
- Use a 0.22 micron filter for continuous infusions
-Daily sedation vacations with PRN Versed doses as needed. If Ativan drip is restarted, start at half previous dose

  • Doses > 20mg/hr are associated with metabolic acidosis and renal insufficiency
37
Q

Sedation Medications with Specifics
(Midazolam (Versed)

A

Midazolam (Versed)
-Loading dose 1-4mg q 5-15 minutes until goal RASS is met
-MAX PRN dosing is 10mg/hr
-Daily sedation vacation with PRN doses as needed. If versed drip is restarted, start at half the previous dose

38
Q

Sedation Medications with Specifics
(Propofol (Diprivan)

A

Propofol (Diprivan)
-Loading dose not recommended
-Titrate by 5mcg q 10 minutes until goal RASS is met
-Daily sedation vacation with PRN Versed doses as needed. If propofol drip is restarted, start at half the previous dose
-Only for ventilated patients
-DO NOT Paralyze while on propofol
-No analgesic properties
-Monitor triglycerides q 48 hours (lipid based sedative)
-Change tubing with every new bottle or q 12 hours

Rates up to 150mcg/kg/min may be used for STATUS EPILEPTICUS

39
Q

Benzodiazepine Reversal

Prefix Usually -zolam or -azepam

A

-Reverse using Flumazenil (Romazicon)
- Give 0.2mg over 15 seconds for moderate sedation
- Give 0.2mg over 30 seconds for overdose

-Repeat dose q 1 minute for maximum of 4 doses

-Reversal effects wear off faster than benzodiazepine effects Monitor for 2 hours for re-sedation

40
Q

Daily Sedation Withdrawal
AKA Spontaneous Awakening
AKA Sedation Vacation

A

-Daily neurological assessment to determine if sedation is needed
-Best done on same day as spontaneous breathing trial
-For propofol titrate down to prevent agitation

41
Q

Pain Assessment

A

-Number scoring (AOx4)
-Behavioral Pain Score (Ventilated)
-CPOT (Unable to self report; ventilated or not ventilated)

-Vital signs alone should not be used to assess pain. Vitals are a cue to assess further
-Consider asking family members whether behavior may indicate pain

42
Q

Pain Management

A

-IV Opioids are first line

-Prevent pain by using:
Preemptive analgesia prior to procedures
Non-pharmacological such as distraction

-With an agitated patient treat pain first, then sedate

43
Q

Opioid Reversal

(Fentanyl, Dilaudid, Morphine)

A
  • Reverse using Naloxone (Narcan)
    -Give 0.4 - 2mg every 2 minutes until maximum dose of 10mg
44
Q

Opioid Analgesics with Specifics
(Fentany (Sublimaze)

A

Fentany (Sublimaze)
-Loading dose of 25-100mcg q 10-15 minutes until pain score achieved

-Taper down gradually if on continuously for > 1 week
-Taper not needed if replace with equal strength analgesic via an alternate route
-Contact physician if > than 200mcg is needed

45
Q

Opioid Analgesics with Specifics
Hydromorphone (Dilaudid)

A

Hydromorphone (Dilaudid
-Loading dose of 0.2-0.5mg q 5-15 minutes until pain score achieved

-Taper down gradually if on continuously for > 1 week
-Taper not needed if replace with equal strength analgesic via an alternate route
-Contact physician if rate exceeds 3mg/hr

Lower doses for those with sleep apnea, elderly, and obese patients

46
Q

Opiod Analgesics with Specifics
(Morphine)

A

Morphine
-Loading dose of 2-4mg q 5-15 minutes until pain score is achieved

-Taper down gradually if on continuously for > 1 week
-Taper not needed if replace with equal strength analgesic via an alternate route
-Contact physician if rate exceeds 10mg/hr

Lower doses for those with sleep apnea, elderly, and obese patients
-In the elderly, active metabolite may accumulate resulting in renal insufficiency and increased sedation

47
Q

Targeted Temperature Management (TTM)

A

-Lowers patients core temperature to avoid neurological effects of an ischemic injury in the brain of survivors of sudden cardiac death

-Must have ROSC
-Unresponsive post cardiac arrest
-Witness with downtime < 60min

48
Q

Contraindications to Targeted Temperature Management

A

No TTM if
-Pregnant
-Active bleeding (specifically hemorrhage)
-GCS > 8
-Already hypothermic
- Age < 18 or > 85
-Drug intoxication

49
Q

The 3 Phases of TTM

A

Induction
-Lower core temperature to 32-36 degrees; begin ASAP (within 90 min)

Maintenance
-Keep patient at target temperature for 24 hours

Rewarming
-Slowly increase temperature to 36.5-37 degrees

50
Q

INDUCTION PHASE of TTM

A

-Set goal time to target temperature
-Monitor core temperature (continuous internal monitor)
-Initiate deep sedation
-Manage shivering with Demerol

-Goal systolic > 90
-Goal MAP > 70

51
Q

Hypothermia from TTM may cause:

A

-Hyperglycemia 2/2 insulin resistance from hypothermia
-Electrolyte an fluid shifts
-Pupil and corneal reflexes may be absent
-Alteration of coagulation
-Decreased cardiac output
-Increased risk for infection

52
Q

MAINTENANCE PHASE of TTM

A
  • 24 hours
    -Monitor core temperature (rectal, bladder, esophageal)
    -Monitor vitals hourly
    -Routine blood glucose monitoring
    -Train of 4 if paralyzed; goal of 1-2 twitches to prevent prolonged paralysis
53
Q

REWARMING PHASE of TTM

A
  • Rewarm to 36.5-37 degrees
    -Increase temperature by 1 degree per hour
    -Rebound hyperkalemia may occur. Stop potassium administration 8 hours prior to rewarming

-Pupil and corneal reflexes may remain absent

54
Q

Toxin/Drug Exposure

A
  • Initial Management: Assess Airway, Breathing, and Circulation

-If the patient is comatose, give D50% 50mL, thiamine 50-100mg, and Naloxone 2mg IV

-To prevent absorption give activated charcoal 1gm/kg via gastric lavage

-Give antidote if possible

-If it is a chemical exposure, remove the chemical
-If it a powder, brush it away
-If it is a liquid, flush with saline or water

-Cover with a sterile, damp dressing

-Do not rub

55
Q

Central Line associated Bloodstream Infections (CLABSI)

A

-Develops within 48 hours of a central line placement and is not related to an infection at other sites

-Ideal is subclavian - Avoid femoral and internal jugular if possible

56
Q

Central Line Maintenance

A

-Hand hygeine
-Head to toe CHG bath daily
-Scrub hubs for > 5 seconds when accessing
-No need to routinely replace lines UNLESS line placed emergently
-D/C if there are signs of infection
-Perform daily review of line necessity
-

57
Q

Catheter Associated Urinary Tract Infection (CAUTI)

A

-A UTI that presents after an indwelling catheter has been in place for 2+ days
-Avoid indwelling catheter use when possible
-Remove catheters ASAP

58
Q

Catheter Insertion and Maintenace

A

-Aseptic technique
-2-person activity (one watches for sterility)
-Hand hygiene
Routine cleanings
-Unobstructed urine flow (kinks, loops, bag below patient)
-Samples from urine port

59
Q

3 Outcomes of Poor Diagnosis
- Palliative Care

A

-Palliative care includes the prevention and treatment of the symptoms/side effects of serious illness
-Can be initiated at any time (early initiation has better outcomes)
-Shown to increase survival rates

-Shown to decrease cost and readmission rates

60
Q

3 Outcomes of Poor Diagnosis
-Hospice Care

A

-Hospice Care is specific to those with a terminal illness
-It includes palliative care but disease modifying treatments are discontinued
-Grief and bereavement services are included

61
Q

3 Outcomes of Poor Diagnosis
-End of Life Care

A

-End of life care avoids prolongation of the dying process
-End of life care provides support to the patients family

CCRN - My Flashcards (5 decks)

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