ACCS REVIEW -TERRY’S SECTION

T E R R E N C E S H E N F I E L D B S , R RT- A C C S , R P F T,

N P S , A E - C

DIFFICULT AIRWAYS

Difficult Airway Issues

– Types of airway complications

• Inflammation

• Anatomic changes due to trauma

• Excessive soft tissue (tongue, uvula etc.)

– Patency (openness of the airway )

– Mallampatti Classification Scores

• Full visibility of tonsils, uvula and soft palate

MALLAMPATTI SCORE

TYPES OF CHEST X-RAYS

– AP (anterior to posterior)

• Most common in hospitals, use when determining proper position

of an ET tube. AP X-ray done at maximal inhalation. May help

detect small Pneumothorax.

– PA ( posterior to anterior)

• Most often done standing. Generally not good for critical care

patients as they are not usually ambulatory.

– Lateral

• Help visualize the lungs as a 3-dimensional body , If AP chest X-ray

reveals a round object (infiltrate) is observed then lateral X-ray is

done. That round object can me cancerous mass, etc.

NORMAL CHEST X-RAY DESCRIPTION

– Bilateral radiolucency

– Sharp costophernic angles

– Hemi-diaphragms are dome shaped, right

higher than left

– Trachea is midline.

NORMAL CHEST X-RAY PNEUMOTHORAX

RUL PNEUMONIA

ATELECTASIS

PLEURAL EFFUSION -EXCESS FLUID

ACCUMULATION IN PLEURAL SPACE

MAIN-STEM INTUBATION

DIAGNOSTIC IMAGING– Lateral decubitus

• Helpful in detection pleural effusions

• Described as having a concave superior border or interface

– Oblique

• Any diagonal or non-traditional angle

• Increase the 3-dimensionality of the lung, helpful in spotting internal

issues such as masses, blebs, or lesions.

– Neck x-rays

• May be used to examine inflammation in the upper airway

• Used to determine malformations in anatomy sustained from trauma

PLACEMENT X-RAYS– Artificial airway placement and function.( ET Tube end of line should be 2-5cm above

carina, level with 4th rib or T-4.)

– Useful in detecting herniated cuff

– Chest tube placement.( Should be in pleural space)

– Central venous catheter placement (Tip should rest in the right atrium or vena cava)

– Pulmonary artery catheter placement (Distal end in the pulmonary artery , not

wedged balloon not inflated, properly placed when tip is over the right lower lung

field on X-ray)

– Nasogastric tube positioning (should be found in the stomach or small bowel)

PET SCAN– Positron Emission Tomography

– Live video-like color images of organs of the body

– Differs from CT scan or MRI by showing the function of the organs

– Used to detect FUNCTIONALITY of organs.

– Movement such as blood flow, cardiac contractions, etc.( helpful in

determining the adequacy of blood flow to the heart)

– Useful in checking brain function and spreading of cancer, and

pulmonary single nodules or suspected cancerous masses

– “Positive” results indicates something is wrong with organ functions and

“Negative” results indicates organs are functioning properly.

ULTRASOUND

– Creates a visual, live (moving )image of internal organs

– Involves no radioactive material and therefore is safer for the patient

– Works by broadcasting sound waves through the outer skin of the

body and detecting the bounce-back patterns. A computer then builds

an image of organs and tissues.

– May be use to crudely and inexpensively assess the size of organs,

masses, etc.

– Ultrasound is commonly used to assess: pleural effusion (Lungs)

ECHOCARDIOGRAPHY

– May be used to closely examine cardiac function, including

assessment of blood flow through the heart, valve functions, stroke

volume, ejection fraction etc.

– Use to determine poor blood flow or blockage if suspected.

– Does not penetrate bone, so blood flow in the brain cannot be

assessed using echocardiography.

– If a pleural effusions is suspected, thoracic ultra sound is the best

option.

MRI

• Useful in detecting masses, lesions, or nodules without the

use of radioactive materials.

• Must be done with no metal objects near the machine, must

use fluidic ventilator with no metal parts, No Oxygen tanks in

the area.

• Provides a 3-dimensional view of the anatomy

• Aortic MRI Image.

V/Q SCAN (LUNG SCAN)

– Perfusion:

• Refers to the process in which gas molecules(oxygen and

carbon dioxide) move between the alveoli and blood stream.

• Abnormal when blood flow around the alveoli is hindered.

• A Pulmonary Embolism (clot in the pulmonary vasculature)

will cause dead space disease ( alveoli that are not

connected to an adequately flowing blood supply).

VENTILATION– Refers to the adequacy of gases penetrating all aspects of the lungs.

– The patient breathes in a gas tagged with Xenon

– Xenon gas shows up on radiographic procedures so the gas can be

seen penetrating different segments or the lung.

– Dark areas of the lungs indicate the absence of ventilation in that area.

• VQ scan should be done when suspecting a pulmonary

embolism from the following signs and symptoms :

Tachycardia, bronchitis, emphysema, pleural effusion, tumors.

Dyspnea

Chest pain (non-cardiogenic)

VENTILATION/PERFUSION SCAN

• Scan showing pulmonary embolism in the right upper zone

INDICES OF RESPIRATORY PHYSIOLOGY AND MECHANICS

–Oxygenation

• Arterial PO2

• SPO2 (Oxygen saturation by pulse Oximeter)

• SAO2 ( Oxygen saturation by Hemoximeter)

• Presence of Cyanosis

• PAO2/FIO2 ratio = 200/ .4%= 500

• PAO2 ( alveolar oxygen tension) = PAO2 = ( FiO2 * (Patm – PH2O)) –

(PaCO2 / RQ)

WORK OF BREATHING

– Calculated

• WOB= delta pressure X delta Volume

• Normal WOB = 0.5-0.07 J/L (joules per liter)

• Above 0.7 is considered high and indicates excessive work of breathing.

– Factors that increase WOB

• Larger spontaneous VT

• Increased spontaneous RR

• Restrictive lung disease ( decreased lung compliance, increase recoil, and

decreased elastance).

• Asthma , Fixed upper airway obstruction, Sarcoidosis, Pulmonary fibrosis

and ARDS.

• HeliOx decrease WOB.

END-TIDAL CO2 VALUES

– Normal : 35-45 torr (correlates closely to arterial CO2

and PACO2)

– PetCO2 values of 20 mm Hg or less are usually associated

with dead space disease ( poor blood flow around alveoli)

– PetCO2 value greater than 50 mm Hg indicate current or

pending ventilatory failure in the patient.

NEUROLOGICAL MONITORING

• EEG (Electroencephalography)

– Electronic tracing of the brain waves similar to and ECG of the heart

– Used to determine :

1) Brain death – Absence of brain waves

2) Seizure activity

3) Sleep problems such as these seen with obstructive or sleep apnea.

• Respiratory Function( the function of respiratory system)

– The function of respiratory system may be altered by internal issues such as :

(pneumonia, asthma ) or neurological conditions( Myasthenia Gravis, Gullian Barre’

Syndrome or Muscular dystrophy)

4 MAIN USES OF CAPNOGRAPHY

• Severity of asthma patients

• Monitoring head injured patients

• Cardiac arrest

• Tube confirmation

CARBON DIOXIDE CLEARANCE-82

TERMINOLOGYSidestream

An indirect method of measuring exhaled CO2 in non-intubated patients

Mainstream

Direct method of measuring exhaled CO2 with intubated patients

CORE CONCEPTS

• What is the characteristic shape of a capnogram for a COPD patient?

• Describe how to determine the severity of an asthma attack using

capnography?

• What level should you maintain a severe head injured patient’s CO2 at?

• What are two ways that capnography can assist during CPR?

Shark Fin

ASTHMATIC WAVEFORMS

COPD patients have a difficult time exhaling gases

This is represented on the capnogram by a shark fin appearance

Moderate Attack

Mild Attack

ETCO2 & ASTHMA

Severe Attack

ETCO2 & ASTHMA

Time To Get MOVING!!!

The asthmatic who looks tired and has a shark fin appearance on the

capnogram…

IS HEADED FOR RESPIRATORY ARREST

THE HEAD INJURED PATIENT

Carbon dioxide dilates the cerebral blood

vessels, increasing the volume of blood in the

intracranial vault and therefore increasing ICP

Recognizing the

head injured

patient and

titrating their

CO2 levels to the

30-35 mmHg

range can help

relieve the

untoward effects

of ICP.

Titrate EtCO2

THE HEAD INJURED PATIENTTitration IS NOT hyperventilation. Intubating a

head injured patient and using Capnography

gives a means to closely monitor CO2 levels.

Decreases ICP and slows down herniation

Keep them between 30 and 35 mmHg

ETCO2 AND CARDIAC ARREST

The capnograph of an intubated cardiac arrest

patient is a direct correlation to cardiac output.

Increase in CO2 during CPR can be an early indicator of ROSC

TERMINATION OF RESUSCITATION

EtCO2 measurements during a resuscitation

give you an accurate indicator of survivability

for patients under CPR.

Non-survivors <10 mmHg

Survivors >30 mmHg(to discharge)

ET TUBE VERIFICATION

• Verification of proper tube placement

There is simply NO BETTER WAY to confirm proper tube placement than with

waveform capnography…. PERIOD!!!

Inadequate Seal

TROUBLESHOOTING

As air escapes around the cuff during BVM respirations the

waveform will distort, alerting you to a possibly deflated or

damaged ET cuff

Obstruction

TROUBLESHOOTING

An obstructed ET tube may have an erratic EtCO2 value

with a very irregular waveform.

Rebreathing

TROUBLESHOOTING

A capnogram that does not touch the baseline is indicative of a

patient who is rebreathing CO2 through insufficient inspiratory

or expiratory flow.

QUIZ

HYPOVENTILATION

REBREATHING

ESOPHAGEAL TUBE

ASTHMA

NORMAL

WAS THAT FUN!

NEUROLOGIC MONITORING

• General treatment of suspected Neuromuscular diseases.

• When a disease is suspected start begin monitoring vital functions such

as vital capacity, tidal volume MIP Etc.

• Head Trauma( cause the centers of the brain in charge of respiration to

respond abnormally)

Frequent monitoring of ventilatory parameters (VT,VC,MIP)

is important for suspected head trauma patients as the

ventilatory drive can disappear without warning.

STROKE: CEREBRAL VASCULAR ACCIDENT

Blood flow may be altered by blood clot ( Ischemic stroke) or a bleed( hemorrhagic stroke)

• The term “ Hemi paretic” may be used to describe the location of a stroke as

right brain or left brain.

• Early CT scan is vital link to survivability and damage prevention

• Patient should not be treated with blood thinner when treating a bleeding stroke.

• Hemorrhagic (bleeding)type stroke has no definitive treatment just keep blood

pressure low, reduce extent of injury

• Ischemic (clot) type strokes-treat with thrombolytic medications ASAP.

– TPA( tissue plasminogen activators) OR Alteplase

• Please Do Not give ASPIRIN or HEPARIN to Hemorrhagic Stroke Victim.

PRECAUTION TO TAKE WHILE TRANSFERRING STROKE VICTIM

– Special care must be taken to prevent aspiration

– Ventilation equipment must be ready as stroke victims can deteriorate quickly

– Diligent bronchial hygiene is important as coughing mechanisms may be easily

interrupted by stroke

– Prophylactic antibiotic therapy to prevent pulmonary infection.

• Level of Consciousness

Wakefulness

Alertness

Awareness

TERMS REFERRING TO AN ALTERED LEVEL OF CONSCIOUSNESS

– Altered mental status

– Clouded-mild form of altered mental status

– Confusion-more profound altered mental status

– Lethargy-severe drowsiness from which the patient can be

awakened by moderate stimuli.

– Obtunded-may awaken to stimuli but patient shows a disinterest in

the environment of people around them.

– Stupor-responds only to vigorous, repeated stimuli.

– Coma- unconscious, unresponsive, not arousalble to any stimuli.

LEVEL OF CONSCIOUSNESS AND COMA SCALES

BREATHING PATTERNS ASSOCIATED WITH COMATOSE STATES

– Cheyne-Stokes

• Cycles of a specific breathing pattern

• Gradual increase in rate and depth of respiration , followed by gradual

decrease in rate and depth , followed by periods of apnea.

• Each apnea period lasts 30-45 seconds, sometimes a long as 60 seconds

• Each complete cycle ( apnea period to apnea period) takes up to 3

minutes.

• Associated with ingestional errors( drug overdose) and elevated

intracranial pressure problems( head trauma, etc.)

CHEYNE -STOKES

LEVEL OF CONSCIOUSNESS

• Biots

– Deep, rapid respiration at rate of 24/min or more

– Increased rate and depth of respirations

– Unpredictable periods of apnea-vary in length and frequency.

– Often associated with central nervous system (CNS) problems.

• Apneustic

– Includes and end-expiratory “grunt” or “cramp”

– Followed by long, gasping inspiration

BRAIN DEATH CRITERIA

• Brain death criteria are used to determined whether

or not the brain is functioning.

– 3 key criteria :

1) unresponsiveness

2) absence of reflexes

3) Presence of apnea

*Unresponsiveness determination by verbal stimuli and

painful stimuli

*Cranial reflexes include pupillary response , ocular

reflex, pharyngeal reflexes and tracheal reflexes.

*In Apnea determination patient removed from

ventilatory support and observed for spontaneous

breathing attempts (only Oxygen provided but no

ventilatory assistance).

SEIZURES• Common causes

– Electrolyte imbalance-sodium , potassium

– Abnormal levels of glucose

– Brain infection or injury

– Drug abuse

– Electric shock

– Extreme febrile conditions

– Poisoning

– Stroke

– Severe hypertension

– Withdrawal from alcohol or medications

SIGNS AND SYMPTOMS

– Blackout

– Confusion

– Drooling or frothing at the mouth

– Loss of bowel or bladder control

– Convulsions

– Clenching of teeth

• Key Treatment during Seizures

– Maintaining an airway

– Medications such as Dilantin( Phenytoin)

CARDIOVASCULAR

Assessment of this system may be done physically by palpation,

inspection, and auscultation.

Neck veins- significant jugular vein distension (neck veins protrude) often

related to:

• Right heart failure

• Elevated central venous pressure (CVP)

• COPD during an exacerbation

• Congestive heart failure (CHF)

CARDIOVASCULAR

• Cold ,clammy skin

– Indicates a current MI

– The data suggests an ECG be done immediately

– MI is confirmed on ECG with elevated S-T segments

• Heart sounds

– Auscultation of heart sounds reveals sounds called S1,S2,S3 and S4

– S1 and S2 are considered normal- no abnormalities

– S3 and S4 heart sounds indicate that something is wrong.

– A “murmur” also indicates a problem with the heart pump.

– Stenosis ( narrowing and stiffening of vessels)

CARDIOVASCULAR

• Pulse

– Weak and thread –indicates poor cardiac output

– Strong and bounding –generally normal, but may also be associated with

hypertension

– Irregular rhythm-may indicate a problem

• Blood pressure

– Normal is 120/80 mm Hg

– Hypertension = BP>140/90

– Hypotension= BP<90/60

DIAGNOSTIC TESTING

• Cardiopulmonary Stress Testing

– Test the function of the heart and lungs when stress is placed on them , also called

exercise tolerance testing.

– Usually involves walking at various paces on a treadmill , if patient cannot walk

cardiac stress testing can be done chemically-giving a medication

– Chemical stress medications

• A) adenosine

• B) lexiscan

• C) dipyridamole

24-HOUR HOLTER MONITORING• Measurements associated with the

procedure:

• ABGs, ECG, Blood pressure, HR

• 24-Hour Holter Monitoring ( Holter

monitoring should be done if he suspected

cardiac events are NOT potentially life

threatening, suspected events such as

ventricular tachycardia, etc. are deadly.

• With such suspicions, the patient should be

admitted to the hospital for 24- hour

observance.

DIAGNOSTIC TESTING

• Cardiac Electrophysiology Study (EP) or (EPS)

– Minimally invasive method of assessing the electrical responsiveness of the heart

and the function of the electrical pathways through and around the heart.

– Patient is NPO 12 hours prior to the exam.

• Cardiac Angiography

– Coronary artery catheterization.

– Lack of flow into certain parts of the coronary arteries indicates blockage.

– Plaque or narrowing of the arteries may be detected.

• Echocardiography

– It is use in visualize aspects of the heart, type of ultrasound.

ELECTROCARDIOGRAPHY

• Electrocardiography:

– Provide moving color images of the heart and blood flow

– Helpful in visually discovering the function of cardiac valves

– Good tool to visually find the source of abnormal heart sounds such as murmurs, or S3 and S4

heart sounds.

– The computer can calculate stroke volume and ejection fraction by measuring the cross

sectional distance of vessels, especially the left ventricular outflow tract.

• Common measurement and normal values

Stroke volume(SV)

o Normal 50-100ml

o When multiplied by heart rate, cardiac output can be calculated.

ELECTROCARDIOGRAPHY

Ejection Fraction(EF)

o Normal : 50-70%

o EF may be lower due to faulty mitral valve or weak left or right heart muscle.

Cardiac Output(CO)

o Normal 4-8 L/min

Cardiac index ( CI)

o CI = QT/BSA (body surface area)

o Cardiac output (QT) is 6 L/Min . What is cardiac index?

C.I =6 L /min/m =3.0L/min/m

• Stroke volume Index(SVI)

• SVI = (stroke volume)/BSA

ELECTROCARDIOGRAPHY( ECG, EKG)

• Cardiac Electrophysiology:

– Electrical impulse starts high in

the right atrium at the SA node,

which is known as the pacemaker

of the heart.

ECG RECORDING EQUIPMENT AND SUPPLIES

• There are a total of 12 leads, first 6 leads are chest leads

• Best lead to determine the left ventricle is LEAD V5(chest lead 5)

• Best lead to determine overall electrical condition of the heart is LEAD II.

• Rate Definition:

– Acceptable range (60-100bpm)

– Bradycardia (<60bpm)

– Tachycardia (>100bmp)

– Flutter(>200bpm)

– Fibrillation( very fast, uncountable)

ELECTROCARDIOGRAPHY

• Rhythms:

• Sinus rhythm: all the bumps are there, especially the “P” wave.

• Sinus tachycardia-treat with oxygen

ELECTROCARDIOGRAPHY

• Sinus Bradycardia-stimulate heart with atropine

• Premature ventricular contraction(PVC)-treat with oxygen if occasional,

lidocaine if frequent

ELECTROCARDIOGRAPHY• Asystole - confirm in two chest leads, treat with chest compressions, epinephrine, atropine

DO NOT SHOCK ASYSTOLE !

ELECTROCARDIOGRAPHY

• Ventricular fibrillation(V-Fib)- Treat with defibrillation at 360

joules(monophasic) or 150 joules(biphasic). Repeat 360 (or 150 if biphasic)

joules as many times as necessary.

• Ventricular tachycardia (V-tach)- Treat with defibrillation if no pulse. Treat

with defibrillation at 360 joules monophasic or 150 biphasic.

• V-tach, V-fib are deadly rhythms and thus constitute an emergency.

ELECTROCARDIOGRAPHY- HEART BLOCKS

• 1st degree heart block - Distance between the beginning of the “p” wave to the

beginning of the QRS complex(p-r interval) is greater than 0.20 sec ( five small boxes or

one large box).

May treat with atropine- Not extremely dangerous.

ELECTROCARDIOGRAPHY- HEART BLOCKS

• 2nd degree heart block - “P” wave present, but occasionally misses the corresponding

QRS complex.

May treat with atropine or pacing-make an electronic pacemaker, but do not turn the pacer on.

ELECTROCARDIOGRAPHY- HEART BLOCKS

• 3rd Degree heart block - No obvious coordination between the “P” wave and the

QRS interval. May skip “P” waves on one beat and have a “P” wave in the middle of the

QRS complex on the next. The wave is largely distinguishable as a 3rd degree block because

it is unpredictable from one moment to the next and you cannot identify all of the waves

consistently.

Patient needs a pacemaker.

ELECTROCARDIOGRAPHY

• 3rd degree heart block

ELECTROCARDIOGRAPHY

• Axis

– Hypertrophy-hypertrophy will cause an axis deviation in the direction of the

hypertrophy.

– Infraction-tissues are dead-electricity cannot flow through dead tissues., so

axis will deviate away from the infracted tissue.

• The Three “MI”s.

– Saying someone has had an “MI” could have one of three meanings. It could

mean Myocardial Ischemia

– Myocardial Infraction

– Myocardial Injury

ELECTROCARDIOGRAPHY

• Ischemia - Current lack of oxygen to the cardiac muscle. In such a case. The “T” wave

will flip up-side –down and show a negative deflection.

Injury - Cardiac tissue in the current state of dying( not dead yet, but soon). If this

happens. The “S-T” segment will be elevated from the baseline

ELECTROCARDIOGRAPHY

• Infraction - Dead tissue, old or fresh will produce a permanent profound “Q” wave.

A profound “Q” wave is defined as ½ the height of the “R” wave or a “Q” wave that is one

small box wide( height and width).

ELECTROCARDIOGRAPHY

– Injury and Infraction - Could see both at the same time. If so, the patient is

having (or has had) a heart attack and there is tissue death. And , there is tissue

currently dying. The cardiac muscle is not receiving enough oxygen.

CONGESTIVE HEART FAILURE (CHF)

• May be chronic or acute condition

• Primary issue is with the left heart, though it causes right heart problems as well.

• The left heart is unable to pump effectively

• Because the left heart is having difficulty ejecting all of the blood through the lungs and

to the left heart than the left heart can handle.

• This overload or preload of the left heart causes it to enlarge and fail.

• When the left heart becomes congested, the blood backs up into the lungs, which

decreases pulmonary efficiency(oxygenation decreases).

• The final result, in an acute CHF episode, is what looks like severe respiratory distress.

But the cause is failure of the left heart to pump effectively.

• Results in venous distension (protruding neck veins).

CHF • CHF treated by:

– Diuretic medications like furosemide(Lasix) to reduce the work of the heart.

– 100% oxygen to lower the work of the heart.

– Administering medication to strengthen left heart contractions(digitalis also called

digoxin).

• Coronary Artery Diseases (CAD) (Atherosclerosis)

– Coronary arteries are that vessels the wrap around the heart muscle and feed the

heart oxygen.

– When they become blocked by plaque build up and /or they harden, oxygenated blood

may ultimately have difficulty reaching the heart’s muscle tissue. Overtime , CAD can

weaken the heart and bring about CHF or cardiac arrhythmias.

PULMONARY HYPERTENSION– High blood pressure of pulmonary arteries, arteries can harden and make right heart work

harder, causing right heart enlargement and ultimately right heart failure.

– PH is manifested hemodynamically as high pulmonary artery pressures (PAP) and elevated

pulmonary vascular resistance (PVR).

– PH may be caused by left heart failure, causing blood to back up in the pulmonary

vasculature, raising pulmonary blood pressure.

• Treatment:

– Medications: Sildenafil (Revatio)

– Hydralazine (Apresoline)

– Flolan

– Inhaled Nitric Oxide(NO)

– Prostacyclin

HYPERTENSION• Systemic Hypertension:

• High blood pressure

– usually greater than 140/90

• Multiple ways to lower BP

– Increase the contractility the heart muscle through medications.

– Reduce blood volume by administering diuretics

– Cause vasodilation through medication

• Increase cardiac contractility

– Digitalis

• Reduce blood volume

– Increases urine output

– Causes excretion of K+, Na , and H2O

HYPERTENSION

• Vasodilation:

– Prostacyclin

– Dobutamine HCL(Dobutrex) increase CO and HR, decreases BP

and can increase potential for arrhythmia.

TYPES OF SHOCK-ANAPHYLACTIC

• Regardless of type, FLUID ADMINISTRATION is the initial action for SHOCK.

• Anaphylactic shock

– Shock that result from exposure to foreign substances.

– Release of histamine

– Deadliest kind of shock

– Rash, swelling of the face, inflammation of internal tissues such as the

esophagus.

– Treatments:

• Administration of fluid

• Epinephrine

SHOCK- CARDIOGENIC

• Cardiogenic shock:

– Blood pressure failure due to damage and dysfunction of the heart.

– Lack of sufficient blood flow to key organs of the body

– Often happens prior to , during or just after a heart attack

– Elevated S-T segments and pronounced Q waves.

• Treatment

• Short term solution:

• Dobutamine

• Dopamine

• Epinephrine

• Levosimendan

• Mirione

• Norepinephrine

SHOCK- CARDIOGENIC

• Longer-term solution:

– Depends on the cause of the shock

• Coronary artery bypass graft

• Cardiac catheterization and angioplasty and possible stent placement.

• Septic shock

– Loss in blood pressure due to widespread infection of the body

– Indwelling catheters are often the most likely source

• Treatment of septic shock:

– Fluid administration

– Antibiotic therapy

– CPR

– Corticosteroids

– Drotrecogin alpha if severely ill

– Careful management of blood sugar

SHOCK- HYPOVOLEMIC

• Hypovolemic shock

–Loss of blood pressure due primarily to a lack of

blood volume or lack of fluid

–Loss usually occurs over a short period of time

–Associated with MVA

Treatment of hypovolemic shock:

–Administer fluids and blood or blood products (such

as plasmenogen)

–IV fluid administration of dextran

SHOCK- NEUROGENIC

• Neurogenic shock

– Loss of blood pressure due to damage in the brain

– Head (central nervous system)or spinal cord injury may be the cause

– inflammation

– Bradycardia may be an early sign

– Treatment of Neurogenic Shock:

– Fluid

– Dopamine (intropin)

• Increases cardiac contractility

– Vasopressin

• Antidiuretic hormone or ADH

– Atropine

• If bradycardia is present

SEPSIS = SERIOUS

• Systemic inflammatory response to the presence of infection

• Can progress to circulatory systemic dysfunction, multiple organ system dysfunction, and death

• High morbidity and mortality

• Older persons, infants, and immunocompromised patients are at increased risk

• Incidence is 3 cases per 1,000 people

• Hospitalized patients-incidence is 2%

A COMPLEX CASCADE

• Inflammation is the body’s response to a chemical, traumatic, or infectious insult

• The inflammatory cascade is a complex process that involves humoral and

cellular responses

• Following an insult, local cytokines are produced and released

• Unregulated release of proinflammatory mediators (cytokines) can elicit toxic

reactions and promote cellular adhesion

• Cell damaging proteases are released (prostaglandins), leading to fever, tachycardia,

ventilation/perfusion abnormalities, acidosis, and activation of the clotting cascade

PINNING DOWN THE CULPRIT

• 64.9% of all sepsis cases are patients over age 65

• Causes of sepsis include: pneumonia, UTI, diarrhea, meningitis, cellulitis,

arthritis, wound infection, endocarditis, and catheter-related infection

• Sepsis may start as systemic inflammatory response syndrome (SIRS)

– See next slide

DIAGNOSIS OF SIRS

Requires two or more of the following:

• Body temperature greater than 100.4° F or less than 96.8° F

• Heart rate greater than 90 beats/minute

• Respiratory rate greater than 20 breaths/minute

• Partial pressure of carbon dioxide less than 32 mm Hg

• White blood cell count greater than 12,000/mm3 or less than 4,000/mm3

or greater than 10% immature neutrophils or bands

DEFINITIONS• A patient with systemic manifestations of infection plus a documented infection has sepsis

• A patient with sepsis complicated by organ dysfunction, tissue hypoperfusion, or sepsis-induced hypotension

has severe sepsis

• Tissue hypoperfusion is defined as an elevated serum lactate level or oliguria

– Lactate level above 4.0 mmol/L is associated with a 27% mortality rate

– Lactate level of 2.5-4.0 mmol/L has a 7% mortality rate

– Lactate level below 2.5 mmol/L below 5% has less that 5% mortality rate

• Sepsis-induced hypotension:

– Systolic BP of greater than 90 mmHg

– Mean arterial pressure of less than 70 mmHg

– Decrease in systolic BP of greater than 40 mmHg below normal in the absence of other causes

SIGNS OF ACUTE ORGAN SYSTEM FAILURE

• Cardiovascular

Tachycardia

• Arrhythmias

• Hypotension

• Elevated central venous and pulmonary artery pressures

• Respiratory

• Tachypnea

• Hypoxemia

• Renal

• Oliguria- small urine production

• Anuria- failure of kidneys to produce urine

• Elevated creatinine- Approximately 0.6 to 1.2 milligrams (mg) per deciliter (dL) in adult males and0.5 to 1.1 milligrams per deciliter in adult females.

SIGNS OF ACUTE ORGAN SYSTEM FAILURE

• Hematologic

• Jaundice

• Elevated liver enzymes

• Decreased albumin

• Coagulopathy

• GI• Ileus (absent bowel sounds)

• Hepatic

• Thrombocytopenia

• Coagulopathy

• Decreased protein C levels

• Increased D-dimer levels

• Neurologic

• Altered consciousness

• Confusion

• Psychosis

COMPLICATIONS

• Acute respiratory distress syndrome (ARDS)

• Acute renal failure

• GI complications

• Disseminated intravascular coagulation (DIC)

– abnormal clumps of thickened blood (clots) form inside blood

vessels. These abnormal clots use up the blood's clotting factors,

which can lead to massive bleeding in other places. Causes include

inflammation, infection, and cancer.

• Multiple organ dysfunction syndrome (MODS)

ARDS

• Abrupt onset of respiratory distress with three components: severe

hypoxemia, bilateral pulmonary infiltrates, and absence of heart failure or

fluid overload

• Three phases of ARDS:

• Acute exudative—profound hypoxemia, inflammation, and diffuse

alveolar damage

• Fibroproliferative—decreased compliance and increased dead space

• Resolution—may take 6 to 12 months or longer

DISSEMINATED INTRAVASCUL AR COAGUL ATION (DIC)

• Caused by coagulation cascade activation

• Clots are formed, blocking small vessels

• Depletion of platelets and coagulation factors increases the risk of bleeding

• Fibrin deposits in organs can cause ischemic damage and failure

MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

• Occurs when multiple organs are damaged

• Kidneys, liver, lungs, brain, and heart may be affected

• Mortality rate increases with the number of failing organs

DIAGNOSIS OF MODS

• Early detection is key

• Aggressive treatment has been shown to decrease mortality by 30%

for septic patients and 50% for non-septic patients

• Lab tests include:

• Serum electrolytes

• Complete blood cells count

• Coagulation studies

• Arterial blood gas (ABG) analysis

• Cultures of sputum, urine, cerebrospinal fluid, and wound drainage

TREATMENT BUNDLE• Give 100% oxygen via non-rebreather mask

• Obtain two separate blood cultures before antibiotic therapy

• Initiate antibiotic therapy

• Initiate fluid resuscitation

• Measure the patient’s lactate and hemoglobin-A lactate levels

• Insert a urinary catheter to monitor hourly urine output

OXYGEN & BLOOD CULTURES

• Metabolic demands may require intubation/mechanical ventilation if

ABGs deteriorate or blood pH decreases

• Obtain two separate blood cultures: one percutaneously and one via

each vascular access device unless recently inserted

ANTIBIOTIC THERAPY

• Broad-spectrum antibiotic is used initially; discontinued in 3 to 5 daysthen therapy is modified after cultures

• Single antibiotic therapy may last 7 to 10 days; may be longer in

immunocompromised patients or in undrainable infections

• The dosage is adjusted based on renal function

FLUID RESUSCITATION

• Fluid resuscitation is a corner stone of sepsis therapy

• Crystalloid solutions: 0.9 sodium chloride or lactated Ringer’s

• Colloids: albumin

• Keep mean arterial pressure above 65 mmHg, wedge pressure at 6-12

mmHg, and central venous pressure at 8-12 mm Hg

• Fluid challenges may be given based on BP and urine output

LACTATE AND HEMOGLOBIN -A LACTATE LEVELS

• Septic shock is diagnosed when the lactate level is greater than 4

mmol/L in the presence of severe sepsis

• Consider a blood transfusion for a patient with a hemoglobin value of

less than 7 g/dL

MEDICATIONS

• Antibiotics — should be started within the first hour

• Vasopressors — norepinephrine is the drug of choice to restore

hemodynamic stability

• Corticosteroids — indicated in adult patients with hypotension not

responding to fluids or vasopressors

• Drotrecogin Alfa — approved for treatment of severe sepsis; inhibits

thrombosis and inflammation and reduces risk of death by 20%

DROTRECOGIN ALFA

• Recommended for severe sepsis/septic shock in patients at high risk for death

• Patients should be carefully evaluated

• FDA label warning: Not to be given to patients with one organ dysfunction, who

have recently undergone surgery, or those not at high risk for death

• Contraindicated in patients with active internal bleeding

END OF LIFE

• Consist of multidisciplinary care team such as MD, RN, RT, Family, social

services

• Explores three dimensions

– Physical

– Emotuional

– Spiritual

• What is palliative care?

– Not only intended for end of life care

– Focuses on minimizing suffering

• What is hospice

• Incurable diseases

• Less than 1 year to live

END OF LIFE

• Consist of multidisciplinary care team such as MD, RN, RT, Family, social

services

• Explores three dimensions

– Physical

– Emotuional

– Spiritual

• What is palliative care?

– Not only intended for end of life care

– Focuses on minimizing suffering

• What is hospice

• Incurable diseases

• Less than 1 year to live