test 4 Flashcards
shock
imbalance between cellular o2 supply and demand.
inadequate tissue perfusion
life threatening response to alterations in circulation
microcirculatory system
portion of vascular bed between the arterioles and venules.
functions include:
-delivering o2 and nutrients into the cell
-removing metabolic waste products
-regulating blood volume
-constriction and dilation to regulate blood flow to cells in need of O2 and nutrients
shock pathophys
alteration in at least 1 of 4 components:
blood volume
myocardial contractility
blood flow
vascular resistance
if one component isn’t working another one will try to compensate
stage 1 shock: initiation
hypoperfusion: inadequate delivery or extraction of o2
no obvious clinical signs
reversible, we want to catch it in this stage
stage 2 shock: compensatory
sustained reduction in tissue perfusion
initiation of compensatory measures, often from hyperventilation
stage 3 shock: progressive
failure of compensatory mechanisms
profound cardiovascular effects- vasoconstriction, increased lactic acidosis, decreased cardiac output, interstitial edema
pt will show classic signs of shock
THIS STAGE RESPONDS POORLY TO FLUID REPLACEMENT
Stage 4 shock: refractory
prolonged inadequate tissue perfusion. organs begin failing
systemic inflammatory response syndrome (SIRS)
widespread systemic inflammatory response
most frequently associated with sepsis, but could be infection, trauma, shock, pancreatitis, ischemia
shock assessment- neuro
initially anxiety/restlessness, then coma
cardio shock assessment
tachycardia, hypotension
pulmonary shock assessment
early- rapid, deep respirations
later- shallow rr, poor gas exchange
shock hematology/integumentary assessment
DIC
cyanosis, temp
GI/liver shock assessment
slow intestinal activity
altered liver enzymes, clotting disorders, increased susceptibility to infection, inability to detox meds
serum lactate levels
measure of overall state of shock
indicator of decreased o2 to cells
general management of shock
treat underlying cause, fluids, pharmacotherapy, mechanical therapy, minimize o2 consumption
hypovolemic shock
inadequate intravascular blood volume
cardiogenic shock
heart fails to act as an effective pump
obstructive shock
physical impairment to adequate circulating blood flow
s/s- Chest pain, hypoxia, dyspnea, jugular vein distention
distributive shock
3 types: neurogenic, anaphylactic, septic
widespread vasodilation and decreased vascular tone resulting in a relative hypovolemia
hypovolemic shock management
eliminate underlying cause
fluids
blood
MAP 65-70
monitor lab values
cardiogenic shock management
decrease preload- diuretics, venous vasodilation
increase cardiac output
decrease afterload
Promote contractibility, decrease o2 demand, increase o2 supply
management of obstructive shock
treat the cause
disruptive shock- Neurogenic
interruption of sympathetic nervous system impulse
causes- upper spinal cord injury, spinal anesthesia, nervous system damage, vasomotor depression
s/s- BRADYCARDIA, hypotension, hypothermia
treatment- IV fluids, rewarm, vasopressors, immobilization of spinal injuries
distributive shock- anaphylactic
introduction of an antigen into a sensitive individual
caused by severe allergic reaction
treatment- epi, Benadryl, fluid
distributive shock- septic
from microorganisms
management=prevention
treatment- abx, glycemic control, temp control
multiple organ dysfunction syndrome (MODS)
progressive dysfunction of 2 or more organ systems
commonly caused by sepsis
organs severely affected- lungs, splanchnic bed, liver, kidneys
MODS S/S
tachypnea/hypoxemia
petechiae/bleeding
jaundice
abdominal distention
oliguria-anuria
tachycardia
hypotension
change in LOC
pulmonary is affected first
MODS treatment
abx
provide adequate tissue o2
support organ function
level 1 trauma
highest level of trauma
level 2 trauma
can take trauma but may transfer to level 1 if needed
level 3 trauma
community hospital, no trauma
level 4 trauma
can do ACLS, will stabilize then transfer
prevention
primary- preventing the event, ie; speed limits
secondary- minimize the impact of the traumatic event, ie; helmet, seatbelt
teritary- maximize pt outcomes after a traumatic event through emergency response teams
golden hour in trauma
first hour of emergent care, focusing on rapid assessment, resuscitation, and treatment
mass casualty incident triage
black tag- pts who are not breathing
red tag- pts who are actively dying but could be saved, critical condition- treat first
yellow tag- pts probably have a hour or so, actively dying but more stable then red tags
green tags- no immediate treatment until others are treated
blunt trauma
Level of impact- sports, MVA, falls
penetrating trauma
impalement of foreign objects in body
the higher the velocity the higher the force
blast trauma
caused by explosive force
tissue and organ injury
gas containing organs- eardrums, lungs, intestines
primary survey for trauma
done in 1-2 mins
Airway
Breathing
circulation
disability
expose pt, warm
identify life threatening injuries
secondary survey
SAMPLE- s/s, allergy, meds, past med history, last time eat, events leading up to cause
full vitals, comfort measures, head to toe, labs, scans
tension pneumothorax intervention
needle decompression, chest tube
pneumothorax intervention
chest tube
open chest wound intervention
seal the wound on 3 sides
prepare for chest tube insertion
pulmonary contusion intervention
early intubation, mechanical ventilation
frail chest
from broken ribs
early intubation and mechanical ventilation
spinal cord injury intervention
avoid movement of neck and immobilize
observe RR and accessory muscle use
monitor for signs of neurogenic shock (bradycardia, hypotension)
decreased level of consciousness interventions
raise HOB
CT to rule out stroke
intubation and mechanical vent
intraosseous procedure (IO)
in bone marrow
only in emergency situations when they can’t get in IV or central lines
this can only stay in for 24 hours
ongoing s/s of shock
tachycardia, tachypnea
narrowing pulse pressure
falling Pa02 (less than 60)
decreasing urine output
increased serum lactate levels
falling hematocrit
Massive fluid protocol/resuscitation (MTP)
large amount of blood in a small amount of time. If pt is getting this its very concerning and they are near death
Hypothermia complications
myocardial dysfunction, dysrhythmias, coagulopathies, reduced perfusion, decreased metabolic rate
what do we want cerebral contusion pressure at
above 50 mm Hg
what shock to think of with spinal cord injury
neurogenic. vasopressors may be needed
basilar skull fracture
Raccoon eyes, CSF leakage, battle sign, halo sign
base of cranium involving 5 bones
don’t use nasopharyngeal airway for this
cardiac temponade
bleeding into pericardial space.
Pressure eventually stops heart. Drops Cardiac output
s/s- low o2, restlessness, low bp, dizziness, tachycardia
treatment- pericardiocentresis
Becks triad- JVD, hypotension, muffled heart sounds
aortic disruption
life threatening injury requiring emergency surgery
s/s- weak pulses, pain, hoarseness
tension pneumothorax
increased pressures cause compression of heart and great vessels, cardiovascular collapse
hemothorax
blood in pleural space
will cause hypotension and resp distress
chest tube needed, monitor blood volume output
open pneumothorax
air in pleural space
hypoxia and hemodynamic instability
3 side occlusion dressing, chest tube
pulmonary contusion
bruising of lung tissue ultimately leads to ARDS
long term mechanical ventilation needed
compartment syndrome 5 Ps
pain
pallor
pulses
paresthesia
paralysis
rhabdomylosis
muscle breakdown- increased myoglobin and potassium
can result in AKI
we want IV fluids to cause UO above 100 mL/hr
fat embolism
Fat can be released from bone marrow after fracture and travels to pulmonary circulation
occurs 1-3 days after fracture
s/s- resp distress, petechial rash, decreased LOC
No definite treatment
DIC
Microthrombi, then body can’t clot then will bleed out.
high mortality rate
damage control surgery
First surgery is only for stabilization then they will eventually come back and do repairs
highest morbidity of burns
burns covering more then 50% of body
inhalation injuries
very young and elderly pts
first thing to do w chemical burn
remove the agent
what can electric burn effect
heart rhythm
when does mx edema occur post burn
24-48 hours
when to give fluids to burn pts
if more then 20% TBSA is burned
give 4 mL/%
admin half of fluids over 8 hours, then other half over 16 hours
what do we want to prevent in burns
infections
if pt has facial burns, how often do we give oral care
q4h
grafts
biological- from your skin
biosynthetic- from lab. more likely to reject
used for partial thickness and full thickness burns
sole source of energy for cerebral metabolism
glucose
how many segments in spinal cord
31
Glasgow coma
eye opening, verbal response, motor response
best score 15
comatose 8
near death 3
normal ICP
0-15 mmHg
normal cerebral perfusion (CPP)
CPP= MAP-ICP
Normal: 60-100
cushings triad
set of signs indicative to ICP
elevated systolic BP
widening pulse pressure
bradycardia
irreg respirations
most common ICP monitor
ventricular
nursing management in ICP
HOB elevated
don’t suction unless needed
cluster care
decrease stimulation
control BP
targeted temp control
When they induce hypothermia on a pt to help the body rest and heal
basilar fracture
raccoon eyes/battle sign
bruising behind ears
runny nose
fluid from ears
what is the worst TBI
Contusion
stroke types
ischemic- from clot
hemorrhagic - from bleed
stroke management
immediate CT
2 IVS
ABC
blood sugar- make sure its not hyperglycemia
manage BP
BEFAST
balance
eyes
face
arms
speech
time
drug for ischemia less then 3 hours of symptoms
tPA
TNK- not yet approved
subarachnoid hemmorhage
Usually from aneurysm. Treated by clipping or coiling
“worst headache of my life”
status epilectus
Continuously having seizures
First drug given is Ativan, then Keppra
assess BG, Neuro, resp, cardio
bacterial meningitis
stiff neck, headache, petechial rash, photophobia, fever, vomitting
positive kernig sign, positive brudzinski sign
dx by lumbar test
abx, neuro checks, droplet isolation, seizure precautions, anti-pyretic
spinal shock vs neurogenic
Spinal shock- electrical silence below injury
Neurogenic shock- loose autonomic function
both: Maintain good BP function, monitor breathing, temp, bowel and bladder function
drug: Solu-Medrol. insulin will be needed with this
what happens if auto-regulation is lost
hypertension increasing cerebral blood flow
