Shock Flashcards
What vasopressors are best for cardiogenic shock or right heart failure?
which one should you not use?
DON’T USE NEOSYNEPHRINE - neo is just alpha so gonna make it harder for heart to pump
- vaso, epi, and dobuatamine - may need levo with the dobutamine afterload reduction
- vaso good in RV failure in true PAH because it helps with perfusion of pulmonary vasculature
- milrinone ok just need to watch the kidney function. Also if it’s not left heart failure it can cause a lot more vasodilation and hypotension (cruz)
When do you think about starting vasopressin and stress dosed steroids?
Often when they’re on around 20 of levo and still in shock then add vaso and stress dose steroids
What pressor might you use in someone in septic shock but with afib with RVR and HR in the 120s?
Often can use neosynephrine (but remember not to use in cardiogenic shock)
How much tPa do you give for acute PE?
50 mg bolus push then 50 mg over two hours
When do you restart heparin gtt after you push tPa?
After PTT is <1.5x the ULN
What does diastolic inversion of the right atrium mean? What sign is this?
you see this in cardiac tamponade
What do you see in acute PE?
McConnel’s sign - right ventricular free wall akinesis with sparing of the apex - so the apex looks like a trampoline
If someone is in cardiac tamponade, how much fluid do you want to pull off?
Even if you pull off like 50cc, that might be enough for them to stabilize
What are the causes of obstructive shock?
PE, Pulmonary hypertension, tension pneumothorax, cardiac tamponade, autopeep, abdominal compartment syndrome
What do you need to get done when you start MTP for GI bleed?
Probably call GI, get a CTA, may have to call IR or surgery
What should you do if they’re in septic shock and you don’t know where it’s coming from?
scan their whole body according to varner
What do you want on hand if you are intubating someone in anaphylactic shock?
A Frova tube - slim like the bougie but you can bag through it.
How do you use the Frova tube?
Pre-load the ET tube on the Frova, put lube on the end of the frova
- if there’s resistance, don’t force it. Rotate it and advance gently
- then you remove the stiffening stylet and continue to advance no more than 10 cm, depends on size of patient
What are the causes of distributive shock?
- adrenal insufficiency
- anaphylaxis
- neurogenic
- sepsis
If you do a cosyntropin stimulation test on someone with likely adrenal insufficiency, what should their cortisol go to?
It should go above 20-25
How high can a lasix drip go?
40 mg/h per Prisma attending but 20 mg/h per uptodate
might want to add metolazone or a thiazide like diuril
how much glucagon do you give beta blocker toxicity?
3-10 mg bolus (usually 5 mg)
- then if you get response can give glucagon gtt (but may cause vomiting)
- can give dopamine - the one time to use dopamine
- can try atropine
What is shock index?
HR/SBP = 0.8 - 1 is normal
>.8 means they might crash with intubation
>1 is high shock index
What findings favor a lower GI bleed?
What’s your algorhythm of action?
- hx of lower GIB - age >50yo - clots per rectum
- suspect lower GIB or endo not available then Place NG tube and lavage
- neg lavage or unable to place
- Is patient actively exsanguinating? Yes - IR
No - order CTA abd/pelvis - No source? - if no active critical bleed, can go with GI in am
- Source? go to IR
What favors an upper GIB and whats your step process of action?
- history of upper GIB - age <50 - central abd discomfort - BUN/Cr > 30 - cirrhosis
- suspect upper GIB, place NG tube, call endo, they need upper endoscopy!
- If GI can’t identify source, call IR
how much protamine do you use for heparin reversal?
1 mg/ 100 U heparin for up to 2 hours after heparin
then .5 mg per 100U heparin for like another 2 hours
then .25 mg per 100 U
up to 50 mg at a time
What MAP goal do you want in a GI bleed?
60
What do you want to setup when intubating a patient with hematemesis?
- Multiple suctions - can put one in the esophagus - or you can put ETT in the esophagus and blow up the balloon
- glidescope - have direct ready because getting blood on the scope may obstruct your airway
What is your anatomy for femoral central line placement?
medial to lateral - vein, artery, nerve - so vein is medial to the artery
- so feel for artery and then could go 1cm medial if no US
What is the reversal agent for warfarin?
How long does it take to work?
How long do the others last?
Vitamin K (5-10mg IV) and Prothrombin complex (kcentra) or FFP
- vitamin K is going to take 60-12 hours
- Kcentra and FFP will only last about 8 hours
How do you reverse Xa inhibitors?
What are the Xa inhibitors?
rivaroxaban, apixaban, fondaparinux
- if it’s been less than two hours since they took it, can give activated charcoal
- otherwise, Kcentra (2000 units or 25-50 units/kg)
- andexanet alfa - there’s a high dose and a low dose
How do you reverse dabigatran?
praxaban - 5g ( yes, grams)
How can you try to reverse tPa?
- Tranexamic acid - 1gram loading dose and another gram over an hour
- cryoprecipitate - 10 units
When is it actually useful to give cryoprecipitate?
How much do you give?
For tPa reversal - give 10 units
Why and when do you want to give Ca is MTP?
How much and what kind?
- because Ca will chelate the citrate, which can lead to coagulopathy
- give after one round of MTP - give CaCl 1-2g or 3-6g Cagluconate
What are some goals to be able to stop MTP?
- obs bleeding stopped and shock resolved
- platelets >50K
- fibrinogen >100-200
- INR <2 (not helpful in cirrhotics)
Who should you call if the patient has recurrent GI bleed?
whoever worked on them - see if GI wants to scope them again if they’re the ones that placed clips
What do you do if someone comes in with esophageal bleed and has banding but the banding fails?
consult IR
Who do you call for bleeding gastric varices?
What about bleeding esophageal varices?
- gastric: IR - will do balloon occluding retrograde transvenous obliteration of the gastric varices - can also potentially do TIPS.
- esophageal: GI
What is the specific management of hematochezia and likely lower GIB
- CTA to visualize where the bleed is - colonoscopy not gonna be helpful -> if bleeding sent to IR
(RBC scan is useless and is gonna take too long)
What bipap settings might you do for acute status asthmaticus?
10 PS over 6 PEEP
ketamine gtt
can give precedex if needed, opioids
How is intubation different for status asthmaticus?
- want biggest ETT possible - 8.5-9 if you can (need at least an 8 for a bronch)
- use ketamine - 2mg/kg - make sure you paralyze as well - an you’ll need propofol (ketamine not enough to sedate I guess)
- if they need pressor, epinephrine will help reduce potential bronchospasm
- can try using heliox
What are the vent settings for status asthmaticus?
- they’re gonna be kinda acidotic, don’t jack up respiratory rate - so RR around 12-14
- tend to use volume control - try to keep inspiratory pressure < 35
- I-time should be about 1
- they shouldn’t require a lot of FiO2
- minute ventilation should be 4-6L per minute
- can try using heliox
