Multisystem Part 1

Question 1

Stages of shock - Compensatory

Answer 1

3 stages of shock: compensatory, progressive, refractory

During the COMPENSATORY stage, the B/P IS MAINTAINED as a result of 2 mechanisms: stimulation of the sympathetic nervous system and activation of the renin-angiotensin-aldosterone system (RAAS).

decrease in CO and stroke volume or increased O2 utilization ->
sympathetic stimulation ->
vasoconstriction, increased HR, increased contractility ->
B/P maintained

decrease in CO and stroke volume or increased O2 utilization ->
RAAS activation ->
renin secretion -> vasoconstriction
AND
aldosterone -> Na and H2O retention
->
B/P maintained

Question 2

Stages of shock - Progressive

Answer 2

3 stages of shock: compensatory, progressive, refractory

The progressive stage of shock occurs when compensatory mechanisms fail.

s/s:
HYPOTENSION (remember the patient is unable to compensate),
worsening tachycardia, tachypnea, oliguria,
metabolic acidosis,
decreased PaO2,
clammy, mottled skin,
further changes in LOC,
possible nausea

Question 3

Stages of shock - Refractory

Answer 3

3 stages of shock: compensatory, progressive, refractory

The refractory stage occurs when the patient is not responsive to interventions. MODS occurs. The patient may survive shock, but die from failure of one or more organs.

s/s:
Severe systemic hypoperfusion,
MODS (multiple organ dysfunction syndrome): pulmonary (ARDS), Kidney (acute tubular necrosis), Heart (failure, ischemia), hematologic (DIC), neuro (encephalopathy, stroke), liver (failure)

Question 4

Shock

Answer 4

3 stages of shock: compensatory, progressive, refractory

Types of shock:
hypovolemia,
septic,
anaphylactic,
neurogenic,
cardiogenic,
obstructive (tension pneumothorax, massive PE, cardiac tamponade)

Question 5

hypovolemic shock

Answer 5

critical reduction in the circulating intravascular volume, leading to inadequate tissue perfusion

common causes include: internal (third-spacing or pooling) and external (hemorrhage, burns, diaphoresis)

What it looks like: NARROW PULSE PRESSURE (SBP decrease, DBP stays or increases)
decrease B/P, decrease pulse pressure, decrease Right atrial pressure (CVP), decrease CO and O2 delivery, INCREASE SVR
(everything decreases except SVR)

Treatment:
ID cause and treat if possible,
Replace volume (rapid and vigorous), fluid resuscitation goal is to maintain O2 delivery and O2 uptake and sustain aerobic metabolism, use isotonic fluid (NS or LR)

Resuscitation goals:
MAP >65, CVP-6, Urine OP 0.5mL/kg/hr, heart rate decreased, Hgb >7 and coag/platelets corrected

Question 6

Normal Saline vs Lactated Ringer’s

Answer 6

Both are isotonic crystalloids, effects last approximately 40 mins, then leave vascular space

NS:
disadvantage- large volumes may lead to hyperchloremic acidosis
* Do not give to those with hypernatremia or renal failure

LR: Best mimics extracellular fluid (ECF) minus proteins, recommended resuscitation fluid by ACS Committee on Trauma
Has potential to correct lactic acidosis; yet in severe hypoperfusion, it may promote lactic acidosis d/t lactate accumulation
Do not give through a blood product transfusion line or to those who should not receive K+ or lactate

Question 7

Hemorrhagic Shock

Answer 7

classified into 4 classes

Class I: blood loss up to 750mL, up to 15%; treat with crystalloids
Class II: blood loss 750-1500mL, 15-30%; treat with crystalloids
Class III: blood loss 1500-2000mL, 30-40%; treat with crystalloids and blood
Class IV: blood loss >2000mL, >40%; treat with crystalloids and blood

Treatment:
1. STOP the bleeding
2. Blood transfusion;
PRBC’s, unlike whole blood, do not have plasma or platelets; therefore, the patient will need a replacement of these with FFP, Platelets, cryoprecipitate

Question 8

Risks of blood product administration

Answer 8

hemolytic and nonhemolytic reactions

transfusion-mediated

immunomodulation

viral infection transmission

TRALI (transfusion-related acute lung injury)

hypothermia - WARM blood products to prevent this

coagulopathy

hypocalcemia, hypomagnesemia - citrate in transfused blood

banked blood shifts the oxyhemoglobin-dissociation curve LEFT (increases affinity of hemoglobin to O2)

Question 9

Massive Transfusion Protocols

Answer 9

Designed to provide rapid infusion of large quantities of blood products to restore oxygen delivery, oxygen utilization, and tissue perfusion

indications include traumatic injuries, ruptured abdominal aortic or thoracic aortic aneurysms, liver transplant, OB emergencies

definitions: 10 units of RBCs in 24 hours or 5 units < 3 hours

mortality > 50%

need to prevent the triad of death:
hypothermia
acidosis
coagulopathy

Question 10

Systemic Inflammatory Response Syndrome (SIRS)

Answer 10

a systemic inflammatory response to a wide variety of severe clinical insults, manifested by 2 or more of the following:
Temp > 39C or <36C
Heart Rate >90 bpm
Respiratory rate > 20 breaths/minute or PaCO2 < 32 mmHg
WBC >12,000 or <4000 or band >10%

A patient may have SIRS WITHOUT SEPSIS; not a good indicator of sepsis

Question 11

Sepsis

Answer 11

infection + organ dysfunction

A life-threatening organ dysfunction that is caused by an abnormal host response to an infection. The infection may be “suspected” rather than “proven”
suspected infection presentation:
positive culture, receiving antibiotics, antifungal, or anti-infective therapy, AMS in the elderly, infiltrates on chest radiograph (pneumonia), nursing home pt with indwelling catheter, pressure ulcer

organ dysfunction may be identified by assessing the patient’s qSOFA or SOFA score

organ dysfunction: hypotension, acute hypoxemia, drop in Urine OP, lactate high, AMS, platelets < 100, coagulopathy

Risk factors:
extremes of age, chronic health problems, invasive procedures and devices, surgical wounds, GI infections, prolonged hospitalizations, NPO, AIDS, use of cytotoxic and immunosuppressive agents,
alcoholism, malignant neoplasm, transplantation, hx of splenectomy

Question 12

Septic Shock

Answer 12

hypotension d/t an infection; includes markers of hypoperfusion, which persists despite adequate fluid resuscitation; requires the administration of pressors

Question 13

qSOFA

Answer 13

quick sepsis-related organ failure assessment

3 criteria, assigning 1 point for each of the following:
SBP <= 100
Respiratory Rate >= 22 bpm
GCS < 15 (AMS)

a score of 2 or 3 indicates a high probability of organ dysfunction

Question 14

Pathophysiology of Sepsis/Septic Shock

Answer 14

infecting organism -> Uncontrolled inflammatory response d/t release of mediators which includes:

vasodilators -> decreased SVR

increased capillary permeability and significant leak -> decreased vascular volume

impaired O2 extraction, utilization, and maldistribution of blood flow -> anaerobic metabolism (lactic acid)

accelerated coagulation and microemboli formation -> DIC

myocardial dysfunction -> decreased cardiac output (late)

pulmonary dysfunction -> ARDS

Question 15

Early vs Late Septic Shock

Answer 15

Early s/s:
tachycardia, bounding pulse
BP low, responsive to pressors
skin is warm, flushed
deep, somewhat fast respirations
lactate > 2 mmol/L
confusion (esp in elderly)
oliguria
fever

Late s/s:
BP low, may not respond to pressors
tachycardia, weak and thread pulse
lactate > 4 mmol/L
skin is cool, pale
respirations rapid or may be slow
lethargy, coma
anuria
hypothermia

Question 16

Sepsis/Septic Shock treatment

Answer 16

1. fluids (30 mL/kg crystalloid)
2. Add vasopressor if still hypotensive (norepi/Levo first, then epi added)
3. If BP still low, add Vasopressin (alpha receptors may not be responding)
4. blood cultures asap
5. antibiotic therapy after cultures
6. serum lactate asap and repeat in 2-4 hours
7. ID source of infection
8. If MAP remains < 65 OR lactate >= 4, reassess fluid status
9. Inotropic therapy (Dobutamine) for patients with cardiac dysfunction
10. oxygenation

Goal is:
MAP >65, decreased lactate, normalization of heart rate, UO > 0.5 mL/kg/hr, warm extremities, Baseline mentation, source control, oxygenation

Question 17

Anaphylactic shock

Answer 17

severe allergic reaction; usually occurs after previous exposure to the substance: shock occurs in 30% of cases; hives, angioedema (88%); respiratory tract involvement (50%)

pathophysiology:
antigen-antibody reaction -> histamine released which leads to:
increased capillary permeability, massive dilation, and decreased cardiac output -> hypotension
bronchospasm, laryngeal edema, and urticaria

Treatment:
1. remove agent
2. O2
3. epinephrine IM
4. aggressive fluid resuscitation (1-4L)
5. antihistamine: Benadryl
6. Inhaled beta-adrenergic agents (bronchospasm)
7. steroids IV

Question 18

SOFA score

Answer 18

unlike the bedside qSOFA, the SOFA (sepsis organ failure assessment) utilizes lab results to assess the extent of a patient’s organ dysfunction. Six organ systems are evaluated, and each is assigned a score from 0-4.
1. hypotension (Cardiovascular)
2. GCS (neurological)
3. PaO2/FiO2 (pulmonary)
4. Serum creatinine or urine output (renal)
5. Bilirubin level (hepatic)
6. platelet count (hematologic)

The mortality rate is 50% if the score increases in the first 96 hours after admission

Question 19

Dexmedetomidine (Precedex)

Answer 19

Loading dose not recommended d/t risk of hypotension and bradycardia

Do NOT paralyze patient while on precedex.

May not need mechanical ventilation

Sedation vacation may not be indicated

Question 20

Ketamine

Answer 20

Give slow IV push over at least 1 min; faster rates of administration may cause respiratory depression

May cause increase in B/P and/or HR or hypersalivation

May produce psychosis, including auditory and visual hallucinations; pretreatment with a benzodiazepine reduces incidences of psychosis

Question 21

Lorazepam (Ativan)

Answer 21

1-20 mg/hr

Contact physician if a rate >10 mg/hr is needed

Turn off daily and assess unless a contraindication exists for sedation vacation; attempt to manage sedation with PRN dosing with midazolam; if you need to resume, then resume at half the previous dose

Use a 0.22-micron filter for continuous infusions

Consider checking the serum osmolarity

Doses >20 mg/hr have been associated with metabolic acidosis and renal insufficiency d/t solvent, propylene glycol

Question 22

Midazolam (Versed)

Answer 22

1-20 mg/hr

contact the physician if a rate >10 mg/hr

Turn off daily and assess unless a contraindication exists for sedation vacation

attempt to manage sedation with PRN dosing with midazolam; if you need to resume, resume at half the previous dose

Question 23

Propofol (Diprovan)

Answer 23

5-80 mcg/kg/min
Status epilepticus: rates up to 150 mcg/kg/min

Turn off daily and assess unless contraindication exists for sedation vacation; attempt to manage with PRNs; if need to resume, resume at half the previous dose

only use for ventilated patients

do not paralyze

no analgesic properties

propofol infusion syndrome may occur with prolonged use or in higher doses

monitor triglycerides at baseline and q48 hrs

change the tubing every time a bottle is changed OR a minimum of q 12hrs

count as a source of calories (lipids)

Question 24

Flumazenil (Romazicon)

Answer 24

Benzodiazepine reversal

repeat doses, 0.2 mg at 1-minute intervals, maximum 4 doses, until patient awakens

for re-sedation, give repeat doses at 20-minute intervals as needed with 3 mg max in one hour

onset 1-2 minutes
peaks 6-10 minutes

May wear off before the effects of the benzo. Monitor for return of sedation and respiratory depression for at least 2 hours.

Use with caution for those with a history of prolonged use. A seizure may occur with reversal.

Question 25

SAT (Spontaneous Awakening Trial)

Answer 25

1. Screen the patient:
   no myocardial ischemia
   no active seizures
   no alcohol withdrawal
   no paralytic drip
   stable intracranial pressure
   not recent increase in the sedation drip to maintain the RASS goal
2. turn off sedation drip
3. Monitor the patient for awakening and tolerance to drug withdrawal.
   Signs of SAT failure:
   dangerous agitation
   sustained tachypnea, increased work of breathing
   sustained drop in SpO2 < 90%
   acute arrhythmia
   hypotension
4. determine if the sedation should be discontinued and replaced with PRN dosing, restarted at half the dose, or returned to the pre-SAT dose

Question 26

Naloxone (Narcan)

Answer 26

Opioid reversal

0.4-2 mg IV q2min until effect to a max dose of 10 mg

duration is 1-2 hours; repeated doses may be needed

Question 27

Fentanyl (Sublimaze)

Answer 27

25-200 mcg/hr

If patient receives regularly >1week, do not suddenly stop; taper by 10-20% to prevent withdrawal

Weaning is not necessary if replaced with equianalgesic dose by alternate route

Use caution if patient is not mechanically ventilated, has sleep apnea, significant cardiovascular/pulmonary disease, the elderly, and obese

consider a sedation vacation

Question 28

Hydromorphone (Dilaudid)

Answer 28

0.2-3 mg/hr

If patient receives regularly >1week, do not suddenly stop; taper by 10-20% to prevent withdrawal

Weaning is not necessary if replaced with equianalgesic dose by alternate route

Use caution if patient is not mechanically ventilated, has sleep apnea, significant cardiovascular/pulmonary disease, the elderly, and obese

consider a sedation vacation

Question 29

morphine

Answer 29

1-10 mg/hr

If patient receives regularly >1week, do not suddenly stop; taper by 10-20% to prevent withdrawal

Weaning is not necessary if replaced with equianalgesic dose by alternate route

Use caution if patient is not mechanically ventilated, has sleep apnea, significant cardiovascular/pulmonary disease, the elderly, and obese

consider a sedation vacation

If the patient is elderly, active metabolite may accumulate, resulting in renal insufficiency and increased sedation

monitor the duration of therapy; consider and alternate opioid