Shock/ACLS/Diagnostics Flashcards
ABCDE algorithm
Airway
Breathing
Circulation
Disability
Exposure
How do I know the airway is adequate?
Patient is alert and oriented.
Patient is talking normally.
There is no evidence of injury to the head or neck.
You have assessed and reassessed for deterioration.
Signs and symptoms of airway compromise
High index of suspicion
Change in voice / sore throat
Noisy breathing (snoring and stridor)
Dyspnea and agitation
Tachypnea
Abnormal breathing pattern
Low oxygen saturation (late sign)
what is the most difinitive way to manage airway?
oral intubation
How to assess Breathing
- assess along with airway
- determine whether respirations are adequate
- determine if both lungs are working equally- auscultation, expansion, palpation, percussion
Percussion of pneumo vs hemo-thorax
hypo-resonant= hemothorax
hyper-resonance = pneumothorax
signs and symptoms of tension pneumothorax
ABCDE
Assess circulation
Ensure adequate tissue oxygenation and delivery and blood volume
What to do for circulation in trauma
STOP THE BLEEDING!
EXTERNAL HEMORRHAGE
Usually just need pressure
Coagulating agents (EX: Quikclot) may be helpful
Suture closed quickly (Don’t worry about cosmesis. You can re-do it later.)
Tourniquets on extremities. Try not to use for over 1 hour.
Blood pressure calculation
Systemic vascular resistence
What is the first factor to change in BP?
The SVR is the first thing to change. It will become higher.
Capillary refill can easily be assessed at the fingers or toes.
Delay of greater than 2 secondsshould be suspicious for blood loss, even if the BP is normal
Heart rate can be an indicator of hemorrhagic shock in about 50% of trauma patients
who are people that can fool you?
Children
Elderly—heart blocks, dysrhythmia, medication
Trained athletes
Pacemaker patients
Pregnant patients
when should you take manual BP?
All initial trauma BP should be MANUAL not automated.
what do you do if you cannot get pedal or radial pulse?
IO access - quickest is tibia
sternal and humeral also acceptable
what do you do if you give 1L of crystalloid (IV fluid) and the patient is still hypotensive
assume hemorrhage, GIVE WHOLE BLOOD
If you must givecomponent therapy, give 1:1:1 PRBC:FFP:PLATELETS
Permissive hypotension
just know basics for exam
What is a FAST
bedside echo
Sx of pericardial tamponade
Beck’s Triad is a common board exam question.
ECG Triad
POCUS Triad
Can occur with as little as 50-60cc of blood in the pericardium
Becks Triad
- hypotension
- JVD jugular vein distension
- muffled heart sounds
cardiac tamponade & pericarditis
ECG Triad
- Sinus Tachycardia
- low voltage
- electrical alternans
Causes other than hemorrhagic shock for hypotension
- neurogenic shock
- cardiogenic shock
- septic shock
slide 40
Trauma in Pregnancy
O negative mothers get RHOGAM
Fetal distress may be a sign of hemorrhage
Mothers will need a pelvic exam to check for blood. Possible premature labor and placental abruption.
ABCDE
Disability Assessment
Assess pupils
Level of consciousness
Response to stimuli
AVPU scale
Glasgow Coma Scale (GCS)
AVPU scale
Alert
Responsive to vocal stimuli
Responsive to painful stimuli
Unresponsive
if you see tracheal deviation and diminished breath sounds what do you think of?
tension pneumothorax
what to do when GCS less than 8
If not already done, intubate
Frequently repeat neuro exam and document
CT scan ASAP
Early neurosurgical consultation
ABCDE
Exposure
what to do
Remove all clothes & blankets
Thorough physical exam
Re-cover with warm blankets
Prevent hypothermia
If unresponsive to 1000 cc IVF begin
intravenous fluid
blood transfusion
Contraindications to NG tube placement in trauma
Severe midface trauma
Distributive Shock
General
Excess vasodilation and altered distribution of blood flow: decrease CO, decrease SVR, decrease PCWP
4 types
Distributive shock
4 types
Septic shock: look for signs infection; treat infection
Anaphylactic shock: IgE mediated; look signs allgergic reaction; treat allergy
Neurogenic Shock: acute spinal cord injury, anesthesia; fluids/pressors/steroids
Endocrine shock: adrenal insufficiency; IV hydrocortisone- does not respond to fluids/pressors
Obstructive Shock
general
Decrease blood flow due to physical obstruction of heart or great vessels- pressure decreases heart’s ability to pump blood
obstructive shock
Management
Oxygen, fluid resuscitation, inotropic support, mechanical support ( IABP)
Treat underlying cause:
Pulmonary emboli: CT PE protocol; heparin, thrombolytics
Pericardial tamponade: echocardiogram; pericardiocentesis
Tension pneumothorax: xray; needle decompression
Dissection: EFAST, CTA, TEE; surgical cx
Cardiogenic Shock
general
Decrease cardiac output, decrease perfusion, increase systemic vascular resistance (often increase respiratory effort)
Etiology: myocardial infarction, myocarditis, valvular disease, congenital heart disease, cardiomyopathy, arrhythmias
cardiogenic shock
presentation
Decrease cardiac output (with preserved volume; CVP 8-12, PCWP > 15), hypotension, vasoconstriction ( increase SVR)
Cardiogenic Shock
Management
Oxygen, fluid resuscitation ( smaller amount bc not a volume problem), inotropic support (rx to increase cardiac output: dobutamine, epinephrine, amrinone), consider Intra-aortic balloon pump
Hypovolemic Shock
general
Loss of blood or volume (hemorrhage/volume loss)
Etiology: GI bleed, AAA rupture, hemoptysis, trauma, ectopic pregnancy, postpartum hemorrhage, vomiting, bowel obstruction, pancreatitis, burns, diabetic ketoacidosis
hypovolemic shock
presentaion
Tachycardia, hypotension, decrease urine output, pale cool skin/extremities, decrease capillary refill, poor skin turgor, dry mucous membranes, altered mental status (usually no assoc respiratory symptoms)
Vasoconstriction (increased SVR), hypotension, decrease cardiac output and decrease pulmonary capillary pressure
hypovolemic shock
management
ABCDE, 2 large bore iv lines or central line, volume resuscitation, control source of hemorrhage, prevent hypothermia, treat coagulopathies
Universal blood is O-negative
Consider transfusion of whole blood
Circulatory Shock
general
In adequate perfusion due to low cardiac output or low systemic vascular resistance
4 types of circulatory shock
Hypovolemic ( loss of blood or fluid)
Cardiogenic ( reduced cardiac output)
Obstructive (obstruction to circulation)
Distributive (maldistribution of circulation)
Circulatory Shock
Presentation of shock
Due to inadequate perfusion/oxygenation will see altered mental status, decrease peripheral pulses, tachycardia, cool/mottled skin, hypotension
circulatory shock
Management
Airway: assess
Breathing: reduce workload assoc with tachypnea ( +/- mechanical ventilation/sedation)
Circulation: fluid resuscitation ( NS/LR vs whole blood), monitor urine output, HR, BP
Delivery of Oxygen: ABGs, lactate levels
Endpoint of Resuscitation: urine output, HR, BP
what does epi do
increases CO but decreases SVR
systemic vascular resistance
glossary of terms
GDMT
OMT
EF
HFrEF
HFpEF
HEmrEF
RSVP
GDMT: Guideline-directed medical therapy
OMT: optimal medical therapy
EF: Ejection fraction
HFrEF: Heart failure with reduced left ventricular ejection fraction (EF≤0.40)
HFpEF: Heart failure with preserved left ventricular ejection fraction (EF≥0.50)
HFmrEF: Heart failure with midrange ejection fraction (EF<0.50 but >0.40)
RVSP: Right ventricular systolic pressure
what is normal EF
55-65%
Tests of perfusion
Treadmill ( bruce protocol)
Treadmill with MPS
Stress echo
PET
arteriogram
determine if the heart is getting enough O2
Plain stress test or exercise stress test
Information about perfusion, chronotropic competence, METs, arrhythmia, exercise tolerance
look at ST on ECG - checking for blockage
bruce protocol- start walking w specific increase in incline and speed on treadmill
Lexiscan- medication you can give a pt that cannot ambulate to get HR up
chronotropic competence/incompetence
Incompetence is the inability to get HR up to expected max (age adjusted)
stress test
Instructions to patient:
hold BB/ CCB (diltiazem) 48 hours if treadmill, no caffeine 24 hours
Patient presents to stress lab for stress test. bp 220/100 hr-125 rr-16.
cancel stress test
Patient presents to stress lab for plain treadmill r/o ischemia. Resting ECG reveals LBBB
contraindicated bc left bundle branch block could mask ST changes
they would need a stress test with imaging
Patient presents for plain treadmill to evaluate for chronotropic incompetence. They did NOT hold their BB
stop test, reshcedule or switch to lexiscan
Sress Echo
Information about heart valves and est RVSP (R ventricular systolic pressure)
Can look for ASD/VSDs ( bubble study)
test for perfusion
limited by larger body habitus
tests for anatomy
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Cardiac CTA
Heart Catheterization
Cardiac MRI
2-d echocardiogram (echo)
Transesophageal echocardiogram (TEE)
Cardiac MRA
Cardiac CTA
A=angiogram
A coronary computed tomography angiogram (CTA) uses advanced CT technology, along with intravenous (IV) contrast material (dye), to obtain high-resolution, 3D pictures of the moving heart and great vessels
at time of test HR must be <60 - might give BB to pt
must be able to hold breath for 20 sec intervals
cardiac CTA
Alternative to stress echo
MPS- but has radioactive dye?
Heart Cath
Dye exposure
LEFT heart cath
they go into artery usually femoral or radial, then put puffs of due to look at all the arteries
Right cath
looks at hemodynamics of the heart, checks pressures of ventricles and atria, does not go into arteries
Flow wire (FFR) heart cath
put wire in that checks pressure where there are lesions in vessels to it it is hemodynamically significant
Heart cath intravascular ultrasound (IVUS)
get US of actual lesion inside vessel/heart
Left heart cath PROs
PRO:
99.9% accurate “the dye don’t lie”
Can evaluate anatomy and perfusion, details of lesion
Quick turn around/ immediate interpretation
Final stop- can determine +/- “fix” while there
What do you do for following findings in patient pending heart cath?
A- GFR 45, creat 1.9 on metformin and ace?
B-severe hx peripheral artery disease with decreased femoral pulse
C- allergy to contrast dye
D- patient on warfarin/apixaban
E- patient on asa and Plavix daily
A- hold metformin/ace 48 hours, pre hydrate NS, watch creatinine for spike first 48 hours, NO LV gram- no dye exposure! ( can get echo to evaluate LV)
B- notify surgeon, evaluate other access sites esp radial arteries vs L groin
C- what is allergy? Pre medicate
D- when was last dose? Why are they on it/ can it be held?
E-do nothing, they can continue meds
after stent placement pts are prescribed for a year
dual antiplatelet
When will I order a LHC? Left heart cath
-STEMI/ACS
+ ischemia on stress test
+ >80% lesion on CTA
Pre-valve work up
If you have high suspicion for blockage- this is the only was to “fix” it
Right heart cath
Measures pressures in the chambers of the heart:
RA: right atrial pressure
RV: right ventricular pressure
PA: pulmonary artery pressure
PCW: pulmonary capillary wedge
LA: left atrial pressure
LV: left ventricular pressure
Echocardiogram
for anatomy of heart and perfusion
Trans thoracic ( TTE) vs trans esophageal (TEE)
Ultrasound to evaluate the heart tissues ( muscle and valves) and their movement
MOST ACCURATE TEST for ejection fraction (EF)
Cardiac MRI
magnetic resonance imaging
Imaging for anatomy of heart
information re cardiovascular tissue/muscle (congenital defects, valves, vasculature), muscle function (inflammatory) and tumors
May be used for pre-procedural/surgical “mapping”
55 yo male referred after work up for syncope revealed significant left ventricular hypertrophy on echo with severe diastolic dysfunction- no valvular disease, ef 65%
What test do you order to find out more about his muscle?
Cardiac mri
worried about amloidosis
Cardiac MRA
seen in stroke protocol, no radiation, with or w/o dye
information about vessels not muscle or tissue
Test for electrophysiology
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ECG
Telemetry
Ambulatory Electronic monitoring (AEM)
Treadmill
EP study
telemetry
Continuous tracing usually 2-5 leads
Primarily for arrythmia detection but can see ST segment
Ambulatory Event Monitoring
Worn by patient for period of time
Can be continuous or triggered
Duration 24 hours-4 weeks
Important to order correctly based on symptoms
Keep in mind skin sensitivity
29 yo presents for episodes of palpitations 2-3 hours in duration 1-2 x a week. Most conclusive initial test:
1- ECG
2- AEM 48 hours
3-AEM 30 days
4- refer for EP test
3-AEM 30 days
Treadmill
perfusion and electrical
Ecg tracing during test will show heart rate variability, exercise/rate induced changes
Important concept: patient terminated vs technician terminated
EP study
advanced invasive testing of electrical system of the heart performed by EP
Can perform mapping, induce arrythmias
Requires venous access
Arterial Brachial Index (ABI)
Looking for peripheral arterial disease
if range is .7 or less refer to cardio
if mild you treat with asa and statan
58 yo female presents with complaints of R buttock burning when she walks. PMHX: DM, HTN, elevated BMI. Improves with rest, worsens w activity. No trauma/injury. Physical exam unremarkable
1- ultrasound lower extremities
2- CTA
3- arteriogram
4- ABIs
4- ABIs bc non invasive
62 yo Male pmhx: htn, tobacco, fam hx AAA presents for yearly follow up. you note enlarged abdominal aorta on physical exam.
1) echo
2) CTA
3) abdominal ultrasound
4) mra
3) abdominal ultrasound
84 yo presents visual disturbances. Reports intermittent “blind spots” resolve spontaneously. Just had eye exam and told normal. Pmhx: HTN ( diet), arthritis. No Rx. VS WNL. On physical exam R carotid bruit
1- MRA
2-CTA
3-carotid doppler
4-coronary calcium score
3-carotid doppler
Patient PMHx CAD, HTN, HLP presents for follow up stress test results. Asymptomatic with no complaints MPS report reads:
10 minutes of bruce protocol , 12 METS , no CP, no ecg changes. Nl vs. No reversible ischemia with global hypokinesis EF 40%.
What do you do?
1-tell them test results look good. Continue tlc/rx
2-send for heart cath
3-order echocardiogram
4-order MUGA
3-order echocardiogram
Asx but echo to check EF
what do you need to know
You need to be comfortable with when to/not to/how to order: plain stress test, stress test w imaging ( MPS/stress echo), echocardiogram, heart cath
* if echocardiogram shows hypertrophy ( > 1.5mm) and you need to rule out infiltrative disease order MRI
* to concretely r/o blockage need heart cath
*echo is starting place to work up valves/murmurs
62yo pt pmhx: HTN, DM presents yearly ov. No complaints. Rx: lisinopril 10 mg po BID, metformin 500 mg po bid. Vs: 148/90, 88, 16. on physical exam you hear a II/VI crescendo decrescendo murmur.
1-ECG
2- stress test
3-echo
4-stress echo
3-echo to check valves
56 yo male CAD hx PCI last year, HTN, HLP, DM, + tobacco presents with exertional chest wall discomfort , assoc DOE, DAT. No symptoms at rest. Rx: asa 81mg daily, atorvastatin 40 mg hs, metoprolol 50 mg po bid, metformin 500 mg po bid. Vs: 128/72, 68, 16. physical exam: WNL
1- ecg
2-stress echo
3-stress MPS
4-heart cath
5-troponin
*any instructions to the patient?
2-stress echo- if blockage found then heart cath
not MPS because probably took metropolol that day, could do lexiscan
stable angina
