MULTISYSTEM Flashcards
shock is a CELLULAR DISEASE due to…
- inadequate perfusion (oxygen demand > oxygen delivered) or
- inability of cells to utilize the delivered oxygen (oxygen utilization, consumption)
during the compensatory phase of shock, the BP is maintained due to what 2 mechanisms?
- stimulation of the sympathetic nervous system –> vasoconstriction –> increased HR & contractility
- activation of renin-angiotensin-aldosterone system (RAAS) –> increased renin secretion —> angiotensin I –> angiotensin II –> vasoconstriction; aldosterone release –> Na & H2O retention
what are the S/S of compensatory phase of shock? (BP maintained)
tachycardia, tachypnea, respiratory alkalosis, normal PaO2, oliguria, cool/pale skin, restlessness, anxiety, thirsty, BP MAINTAINED
what are S/S of progressive phase of shock? (compensatory mechanisms failing)
HYPOTENSION, worsening tachycardia/tachypnea/oliguria, metabolic acidosis, decreased PaO2, clammy/mottled skin, change in LOC, nausea
what are S/S of refractory phase of shock?
not responsive to interventions, severe systemic hypoperfusion, MULTISYSTEM ORGAN DYSFUNCTION, may survive shock but die from failure of one or more organs
what are the 2 most common types of hypovolemic shock?
- internal - 3rd spacing, pooling in intravascular compartments
- external - hemorrhage, GI or renal losses, burns, excessive diaphoresis
what happens hemodynamically in hypovolemic shock?
- NARROW PULSE PRESSURE (SBP decreases, DBP maintains or elevates)
- decreased: BP, CVP (RA), CO, O2 delivery, PAOP (LA), SvO2
- increased systemic vascular resistance
how would you treat hypovolemic shock?
- identify cause and correct if possible
- volume! use fluid warmer if >2L/hr
- goal is to maintain O2 delivery and uptake into tissue and sustain aerobic metabolism
- use NS/LR
what is NS, how long do effects last, disadvantages, contraindications?
- isotonic crystalloid
- 40min, then leaves vascular space
- large volumes may lead to hyperchloremic acidosis
- don’t give to those with hypernatremia or renal failure
what is LR, how long do effects last, disadvantages, contraindications?
- isotonic crystalloid; best mimic extracellular fluid, minus proteins, recommended resuscitation fluid
- 40 min, then leaves vascular space
- has potential to correct lactic acidosis; yet in severe hypo perfusion may promote lactic acidosis duet lactate accumulation
- don’t give t those who shouldn’t receive K or lactate
should you give pressers for hypovolemic shock?
NO, SVR is already high r/t compensatory mechanisms
what is hemorrhagic shock class I? how to treat?
- blood loss < 750ml
- blood loss <15%
- HR <100
- BP normal
- pulse pressure normal or decreased
- capillary refill normal
- RR 14-20
- UO >30ml/hr
- slightly anxious
- treat with crystalloids
what is hemorrhagic shock class II?
- blood loss 750-1500ml
- blood loss 15-30%
- HR >100
- BP normal
- pulse pressure decreased
- capillary refill decreased
- RR 20-30
- UO 20-30ml/hr
- mildly anxious
- treat with crystalloids
what is hemorrhagic shock class III?
- blood loss 1.5-2L
- blood loss 30-40%
- HR >120
- BP normal
- pulse pressure decreased
- capillary refill decreased
- RR 30-40
- UO 5-15ml/hr
- anxious, confused
- treat with crystalloids + blood
what is hemorrhagic shock class IV?
- blood loss >2L
- blood loss >40%
- HR >140
- BP decreased
- pulse pressure decreased
- capillary refill decreased
- RR >35
- UO scant
- confused, lethargic
- treat with crystalloids + blood
why should blood products be warmed?
- to prevent hypothermia: impairment of red cell deformability, platelet dysfunction, increase in affinity of hgb to hold onto O2
how can blood transfusion cause hypocalcemia and hypomagnesemia?
citrate in transfused blood binds ionized Ca and Mg
banked blod doens’t have adequate 2,3-DPG. What is the consequence?
shifts oxyhemoglobin-dissociation curve to the LEFT, increases affinity of hemoglobin to hold onto O2
what are massive transfusion protocols?
provide rapid infusion of large quantities of blood products to restore oxygen delivery, oxygen utilization, and tissue perfusion
10 units of RBCs in 24hrs, or 5 units in <3hrs
when is a massive transfusion protocol indicated?
- traumatic injuries, ruptured abdominal aortic or thoracic aneurysm, liver transplant, OB emergencies
- prevent TRIAD OF DEATH: hypothermia, acidosis, coagulopathy
- > 50% mortality
what is systemic inflammatory response syndrome? (SIRS)
2 or more of the following:
- T >/= 38C or <36C
- HR >90
- RR >20 or PaCO2 <32mmHg
- WBC >12K or <4K or bands >10% (shift to left)
- MAY HAVE SIRS W/O SEPSIS
what is sepsis?
- systemic inflammatory response to a documented infection
- clinical manifestations would include 2 or more of the SIRS criteria plus a documented infection or suspected infection
what is a suspected infection?
presence of one or more of the following:
- cx results from blood, sputum, urine, etc
- receiving abx anti fungal, or other anti-infectives
- AMS in elderly
- possible PNA
- nursing home pt w/ foley
- presence of pressure ulcers
- acute ab
- infected wounds, esp w/ hx of DM
- immunosuppression
what is severe sepsis?
- sepsis plus markers of organ dysfunction
- EX: hypotension, acute hypoxemia, acute drop in UO, lactate >2mmol/kg, change in LOC, plt <100K, coagulopathy
what is septic shock?
severe sepsis plus one or both of the following:
- systemic MAP <65mmHg despite adequate fluids
- maintaining systemic MAP >65mmHg requires a PRESSOR
what organisms can cause severe sepsis/septic shock?
- gram +/- bacteria, fungi, viruses, Rickettsia, parasites
what are some S/S of early septic shock?
tachycardia, bounding pulse, BP normal/low, skin warm/flushed, RR deep/fast, irritability, confusion, mental changes, oliguria, fever
what are some S/S of progressive, later, septic shock?
hypotension, tachycardia, pulse weak/thready, skin cool/pale, RR fast/slow, lethargy, coma, anuria, hypothermia
what are the hemodynamics of septic shock?
increased: CO/CI, SvO2, O2 delivery
decreased: RA, PA, PAOP, SVR, O2 consumption
what are the hemodynamics of progressive, late, septic shock?
increased: RA, PA, PCWP,
decreased: CO/CI, O2 delivery, O2 consumption
variable: SVR, SVO2
what are the diagnostic test results for septic shock?
- mild resp alkalosis, combined respiratory alkalosis and metabolic acidosis
- increased: PT/PTT, bands, glucose, lactate, troponin
- decreased: PaO2, plt
WBC up/down
what are the diagnostic test results for progressive, late septic shock?
- metabolic acidosis
- very high: PT/PTT, bands
- increased: BUN, creatinine, liver enzymes, lactate, troponin
- very low: PaO2, plt
- decreased: WBC, glucose
what is the treatment for septic shock?
- fluid challenge: 30ml/kg of crystalloid in first 3 hrs
- pressers prn (NOREPI/LEVO, EPI, VASO)
- ABX asap after blood cx X2 from different sites
- inotropes (DOBUTAMINE) - for pts with cardiac dysfunction
- SpO2 >95%; SvO2>65% when CVP and MAP goals met or ScvO2 >70%
- if ScvO2 or SvO2 not achieved, consider further fluids, dobutamine infusion, or PRBC transfusion if hgb <7
what are the therapeutic endpoints for septic shock?
- CVP 8-12mmHg
- MAP >65mmHg
- UO >0.5ml/kg/hr
- ScvO2>70% or SvO2>65%
- normalization of HR
- warm extremities
- normal mental status
- decreased lactate/improved base deficit
what happens in anaphylactic shock?
- IgE MEDIATED immediate hypersensitivity reaction to PROTEIN substances
- usually occurs after previous exposure to substance
- hives, angioedema in 88%, respiratory tract involvement in 50%, shock in 30%
what is the pathophysiology of anaphylactic shock?
antigen antibody reaction–> histamine released–>increase capillary permeability, massive dilation, decreased CO, bronchospasm, laryngeal edema, urticaria–>hypotension
how is anaphylactic shock treated?
- removal of causative agent, if able
- O2
- epi IM to decrease dilation, bronchospasm
- fluids 1-4L for hypovolemia
- Benadryl 25-50mg IV to decrease allergic response
- inhaled B-adrenergic agents to decrease bronchospasm
- steroids (high dose) IV asap to decrease inflammatory response
what is multiple organ dysfunction syndrome (MODS)?
- progressive insufficiency of 2 or more organs in an acutely ill patient such that homeostasis can’t be maintained without intervention
- may be due to any type of shock
what is the trauma 1st and 2nd line assessment?
Airway - ensure patent/intubate
Breathing - 100% O2
Circulation - 2 large bore IVs with warm LR
Disability - neuro exam
Exposure/Environmental - remove clothes; warm/cool prn
Full set VS
Give comfort measures - pain
Hx
Inspect posterior
the patient who is agitated should first receive analgesia-first sedation or anxiolytic? light/moderate/heavy level?
analgesia-first sedation; light bc improved clinical outcomes
what should you know about Benzo reversal with Flumazenil (Romazicon)?
reversal effects of flumazenil may were off before effects of benzos; therefore, monitor for return of sedation, respiratory depression for at least 2 hrs and until the pt is stable and resedation is unlikely
what are some adverse effects of Diazepam (valium)?
respiratory depression, hypotension, phlebitis
what are some adverse effects of lorazepam (Ativan)?
respiratory depression, hypotension, propylene glycol-related acidosis/renal failure
what are some adverse effects of midazolam (versed)?
respiratory depression, hypotension
what are some adverse effects of propofol (diprivan?
pain on injection, respiratory depression, hypotension, hypertriglyceridemia, pancreatitis, allergic reactions, propofol-related infusion syndrome
*give loading dose if hypotension unlikely to occur
what are some adverse effects of dexmedetomidine (precedex)?
bradycardia, hypotension; hypertension with loading dose; loss of airway reflexes
*avoid loading dose of hemodynamically unstable
fentanyl (sublimaze) has more/less hypotension than morphine? accumulation with what organ impairment(s)?
less; hepatic
what should you give to patients tolerant to morphine/fentanyl? accumulation with what organ impairment(s)?
dilaudid; hepatic/renal
morphine has what kind of release? has the potential for what adverse effect? accumulation with what organ impairment(s)?
histamine; potential hypotension; hepatic/renal impairment
when should remifentanil (ultiva) be used?
use IBW if body weight > 130% IBW
no accumulation in hepatic/renal failure
What is Therapeutic hypothermia?
Treatment that lowers the patient’s core body temp in order to prevent neurological effects of ischemic injury to the brain of survivors of sudden cardiac death
What is the inclusion criteria for use of therapeutic hypothermia?
- cardiac arrest with ROSC
- unresponsive or not following commands after cardiac arrest
- witnessed arrest with downtime of <60min
What is the exclusion criteria for use of therapeutic hypothermia?
Pregnancy, core temp <35C, age <18 or >85, existing DNR or terminal, CKD, sustained refractory ventricular arrhythmias, active bleeding, shock, hemodynamic instability, drug intoxication
what is the induction phase?
- 33C; initiate w/i 90min of arrest, may go out to 6hrs of arrest
- goal SBP >90mmHg and MAP >70mmHg
- CBC, CMP, coags, Mg, Phos, ABG, glucose
- 12 lead ECG
- deep sedation
- paralytic for shivering
- monitor/manage systemic effects of hypothermia
what are systemic effects of hypothermia?
- insulin resistence –> hyperglycemia
- electrolyte and fluid shifts
- shivering
- skin breakdown
- decreased CO; up to 25%
- alteration in coagulation; plt dysfunction
- increased risk for infection - neutrophil and macrophage functions decrease at temps <35C
what is the maintenance phase (24hrs at 33C)?
- continuous temp
- monitor VS qhr
- bedside glucose; insulin gtt prn
- monitor train of 4 qhr if paralytic used with goal twitch 1-2 to prevent prolonged paralyzation
- labs q8h until rewarmed
what is the rewarming phase?
- passive rewarming to 36.5C
- increase target temp by 1C/hr
- stop all K administration 8 hrs prior to rewarming; rewarming causes rebound hyperkalemia
- d/c paralytics (if used) after pt is warmed to 36.5C
- repeat labs when pt rewarmed
- close neuro assessment
what should you do during toxic ingestion?
ABCs FOR INITIAL MANAGEMENT
- if comatose, give 50% dextrose 50mL, thiamine 50-100mg, narcan 2mg IV
- activated charcoal 1gm/kg via gastric lavage; contraindicated with hydrocarbon or corrosive ingestions, not necessary with iron, lithium, EtOH
- facilitate removal of drug - urine alkalization, HD
- monitor for arrhythmias
- monitor UO
