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Shock

Shock

by majkhands21, Oct. 2008

Subjects: shock

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226 Cards in this Set

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	What syndrome is characterized by decreased tissue perfusion & impaired cellular metabolism?	Shock!
	What happens when a cell experiences a state of hypoperfusion?	The demand for O2 and nutrients exceeds the supply
	What does low blood flow indicate?	Cardiogenic & Hypovolemic shock
	What does maldistribution of blood flow indicate?	Septic, anaphylactic, neurogenic shock
	What is known as the heart's inability to pump the blood forward & it primarily affects the left ventricle?	Systolic dysfunction
	What happens when the systolic dysfunction affects the right side of the heart?	The pulmonary circulation is compromised
	What are some causes of systolic dysfunction?	MI, cardiomyopathies, blunt cardiac injury, severe systemic or pulmonary HTN, and myocardial depression from metabolic problems
	What is an impaired inability of the right or left ventricle to fill during diastole? What occurs when there is decreased filling of the ventricle?	Diastolic dysfunction Decreased stroke volume
	What are some causes of diastolic dysfunction?	Cardiac tamponade and cardiomyopathy
	What are some other causes of Cardiogenic shock?	Dysrhythmias (brady or tachy) Structural factors (valve abnormalities:stenosis), tension pnemothorax, ventricular septal rupture
	What are the clinical manifestations of a pt with Cardiogenic shock?	tachycardia, hypotension, narrowed pulse pressure, possible chest pain, tachypnea, cyanosis, crackles, rhonchi, increased Na+ and H2o retention, decreased renal flow, less urine output, pallor, cool, clammy, decreaed cerebral perfusion, anxiety, confusion, less bowel sounds, N/V, increased cardiac markers, blood glucose, BUN, ECG: dysrhythmias, Echo: left ventricular dysfunction, CXR: pumlonary infiltrates
	Why would a pt have tachypnea and pulmonary congestion with crackles in cardiogenic shock?	With an increase in the workload of the heart, the myocardial now needs more O2. The heart's inability to pump blood forward will result in a low CO (< than 4L/min) and cardiac index (< than 2.1 L/min/m2)
	What occurs when there is a loss of intravascular fluid volume and the volume is inadequate to fill the vascular space?	Hypovolemic shock
	What results when fluid is lost through hemorrhage, GI loss (vomit, diarrhea), fistula drainage, diabetes insipidus, hyperglycemia, or diuresis	Absolute hypovolemia
	What occurs when fluid volumes move out of the vascular space into the extravascular space (aka 3rd spacing)? Ex: seen is sepsis, confinement of fluid from bowel obstruction, ascites, loss of blood volume from Fx site, and burns	Relative hypovolemia
	What happens when there is a loss of intravascular volume?	Decreased venous return to heart, decrease preload, decrease stroke volume, and decreased CO
	What happens if there is a 15% total blood volume loss (approx 750 ml)? A loss from 15% to 30%?	Pt may compensate *Will result in a SNS mediated response: increase in HR, CO, and respiratory rate and depth
	What do you do when a pt has a loss from 15% to 30% of total blood volume?	The pt is anxious and urine output will decrease, so if you give a crystalloid fluid replacement the tissue dysfunction is generally reversible.
	What do you do if the loss is > than 30%?	Need immediate replacement of blood or blood products
	What occurs with a loss of 40% or >?	loss of autoregulation in the microcirculation and irreversible tissue destruction occurs
	What are the clinical manifestations of Hypovolemic shock?	Decreased preload & stroke volume, CRT, tachypnea to bradypnea (late), less urine output, pallor, cool, clammy, anxiety, confusion, agitation, absent bowel sounds, less Hct, Hgb, increased lactate and urine specific gravity, changes in electrolytes
	What is a hemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the 5th T5 vertebra or above and last up to 6 weeks?	Neurogenic shock
	What occurs in a neurogenic shock?	Massive vasodilation w/o compensation due to loss of SNS vasocontrictor tone and leads to pooling of blood in blood vessels, tissue hypoperfusion, and impaired cell metabolism
	What else can cause neurogenic shock?	spinal anesthesia can block transmission of SNS impulses, drugs like benzodiazepines, opioids which depress vasomotor center of medulla
	What are the most important clinical manifestation of neurogenic shock?	hypotension from massive vasodilation and bradycardia (from unopposed parasympathetic stimulation)
	What is the pt at risk for with neurogenic shock?	Initially the pt's skin will be warm, but then the heat dissipates: HYPOTHERMIA
	What is a transient condition that is present after an acute spinal cord injury and they experience the absence of all voluntary and reflex neurogenic activity below level of injury?	Spinal shock
	What are the clinical manifestations of Neurogenic shock?	up/down temperature, BRADYCARDIA, HYPOTENSION, dysfunction r/t level of injury, bladder dysfunction, decreased skin perfusion, cool or warm dry skin, flaccid paralysis, loss of reflex activity, bowel dysfunction
	What in an acute and life threatening hypersensitivity (allergic) reaction to sensitizing substance (drug, chemical, vaccine, food, insect venom)	Anaphylactic shock
	What occurs in Anaphylactic shock?	immediate reaction causes massive vasodilation, release of vasoactive mediators, and increase in capillary permeability: fluid leaks from vascular space to interstitial space
	What can Anaphylactic shock cause?	Respiratory distress d/t laryngeal edema or bronchospasm, and circulatory failure
	What are the clinical manifestation of Anaphylactic shock?	chest pain, 3rd spacing, swelling of lips and tounge, SOB, edema of larynx/epiglottis, wheezing, rhinitis, stridor, flushing, pruritis, urticaria, angiodema, anxiety, feeling of doom coming, confusion, decreased LOC, metallic taste, cramping, abd pain, N/V, diarrhea, incontinence, sudden onset, Hx of allergies, exposure to media contrast
	What is a systemic inflammatory response to a documented or suspected infection?	Septic shock
	What is the presence of sepsis with hypotension despite fluid resuscitation along with the presence of tissue abnormalities?	Septic shock
	What happens in Septic shock?	The body's automatic protective response to an antigen is exaggerated causing an increase in inflammation and coagulation, and decrease in fibrinolysis *release of cytokines, TNF, IL-1, platelet activating flactor ( forms microthrombi and obstructs microvasculature), IL-6 & 8
	What occurs from body's automatic protective response in septic shock?	damage to the endothelium, vasodilation, increased capillary permeability, neutrophil and platelet aggregation and adhesion to the endothelium
	What are the clinical manifestations of Septic shock?	up/down temp, decreased EF, hyperventilation l/t respiratory alkalosis: then pt can no longer compensate then l/t respiratory acidiosis, hypoxemia, resp failure, ARDS, pulm HTN, crackles, less urine output, warm flushed skin, cool and mottled(late), confusion, agitation, coma (late), GI bleeding, paralytic ileus, up/down WBC, low platelets, increased glucose, lactate, urine specific gravity, decreaed urine Na+, positive blood cultures
	What occurs with a persistence of a high CO and a low SVR beyond 24 hrs?	Hypetension and MODS
	In this stage the body activates neural, hormonal, and biochemical compensatory mechanisms to overcome anaerobic metabolism and to maintain homeostasis?	Compensatory stage
	What is the 1st clincal sign of shock? what occurs?	Fall in BP *drop in BP from decrease in CO/narrowed pulse pressure: barareceptors in carotid/aortic bodies activate SNS which stimulates vasoconstriction and release of Epi/norepinephrine, so blood flow to vital organs (heart, brain) is maintained, while not maintaining flow to nonvital organs (kidneys, GI tract, skin, lungs (shunted/diverted)
	What is the 1st strategy is managing pts at risk for anaphylactic shock? What is the drug of choice? why?	Prevention!! get a thorough history Epinephrine: causes peripheral vasoconstriction and bronchdilation and opposes the effect of histamine Benadryl-blocks the massive release of histamine from allergic reaction
	What are highly effective for edema of the larynx?	nebulized bronchodilators and aerosolized epinephrine
	What results from leakage of fluid out of the intravascular space into the interstitial space as a result of increaed vascular permability and vasodilation?	Hypotension
	How do you assess tissue perfusion?	V/S eval, LOC, peripheral pulses, CRT, skin (temp, color, moisture), and urine output
	What is the primary goal for a pt who had an MI?	They are at risk for cardiogenic shock, so goal is to limit the size of the infarction by restoring coronary blood flow through thrombolytic therapy, percutaneous intervention, or surgical revascularization
	What can reduce the myocardial demand for oxygen?	Rest, analgesics, sedation, and judicious use of paralytic agents (if pt is intubated)
	Who should receive premedications? for exampe?	Pts with severe allergies or at high risk. They should wear medical alert tag, be instructed about the availability of special kits that have equip and meds (EpiPen) Also, for high risk to contrast media have Benadryl (diphenhydramine) or Solu-medrol (methylprednisone) as a premed
	What are some ways to decrease the risk of infection in the hospital?	decrease # of indwelling catheters (central lines, urine cath), use aseptic tech during invasive procedures, strict handwashing, change/dispose equipment or clean it when due
	In a neurologic status, when should orientation and LOC be assessed?	Every hour or more often
	What is the best indicator of cerebral flow?	Pt's neurologic status: look for changes in behavior, restlessness, hyperalertness, blurred vision, confusion, parathesis, agitation?
	When should the cardiovascular status be assessed during shock therapy?	Every 15 minutes
	Is the Trendelenburg position necessary to use when the pt has hypetension? why?	There is no definitive research that says yes. It could actually cause compromised pulmonary function and IICP
	The presence of what heart sound indicates heart failure?	S3
	How often is the pt's response to fluids and med admin assessed?	Every 10 to 15 minutes
	How often is the respiratory status assessed?	The rate, depth, and rhythm every 15 to 30 mins Breath sounds every 1 to 2 hours
	What does increased rate and depth indicate?	The patient is attempting to correct metabolic acidosis
	Where should you put the pulse oximetry probe?	Nose, ear, or forehead d/t poor peripheral circulation
	What would you do if the pt had a PaO2 below 60mmHg (absence of chronic lung disease)?	indicates hypoxemia and need for higher O2 concentrations of different mode of O2 admin
	What does a low PaCO2 with a low pH and low bicarb indicate?	The pt is attempting to compensate for metabolic acidosis
	What does a rising PaCO2in presence of low pH and low PaO2 indicate?	need for intubation and mechanical ventilation
	What urine output indicates inadequate perfusion to the kidneys?	< than 0.5 ml/kg/hr *hourly measurements of urinary output are essential
	What type of temperatures should be assessed hourly? What about normal temps?	With elevated or subnormal temps, Tympanic or pulmonary aterial temps q hr *Checked every 4 hours
	Monitor the pt's skin for what?	temp, pallor, flushing, cyanosis, diaphoresis, and piloerection, CRT (peripheral perfusion)
	Check bowel sounds when?	every 4 hours and check for abdominal distention
	Impaired tissue perfusion predisposes the pt to what?	skin breakdown and infection
	What is beneficial for the pt during oral care?	moist swabbing of the tounge and oral mucosa with saline solution or diluted mouthwash. No lemon glycerin can cause further drying
	When should passive ROM be performed?	Every 3-4x/day and turn pt every 1-2 hours
	What are some medications used to decrease anxiety, pain, and need for o2 demand?	benzodiazepine (lorazepam:Ativan), opioid (morphine, propofol:Diprivan, and neuromuscular blocking agent (cisatracurium:Nibbex)
	What can occur during anaphylaxis?	Arrhythmias and decreased cardiac contractility, Pulmonary problems, along with inadequate circulation can cause extreme hypoxia
	What is the Tx for anaphylaxis?	Treatment for this client includes epinephrine, benadryl, corticosteroids, in addition to emergency treatment (ABCs)
	Neurogenic shock typically occurs as the result of?	head trauma and spinal cord injury, spinal anesthesia, vasomotor center depression, and adrenergic-blocking agents such as Cardura or Hytrin which may impair nerve impulse transmission and decrease sympathetic tone.
	Patients in neurogenic shock usually have initial symptoms such as?	hypotension, bradycardia, hypothermia, and warm, dry skin
	Neurogenic type of shock can be caused by?	deep general or spinal anesthesia, brain injury to medulla, spinal cord injury to T-6 or above, prolonged medullary ischemia, and an overdose of barbiturates
	__________ is often diagnosed and treated late in the disease process leading to poor outcomes and premature death.	Septic shock
	___________ are the most common cause of septic shock.	Nosocomial infections
	What leads to hypotension, altered coagulation, inflammation, impaired circulation at a cellular level, anaerobic metabolism, changes in mental status and multi-organ failure?	Septic shock, the result of an overwhelming infection
	Early stages of septic shock demonstrate a??	a low or normal BP, increased temperature (can be low grade), normal urine output, increased pulse, and an alert, anxious client. Many times the patient doesn’t look that sick.
	In the later stages of septic shock, th pt has s/s of what??? Clients may require???	blood pressure drops, pulse increases, and pallor occurs. require intubation and may be acidotic.
	Once a diagnosis of sepsis has been determined what happens next?	Antibiotic therapy should be administered in a timely manner and given within minutes rather than hours.
	Clinical Manifestations of Cardiogenic Shock?	Heart’s ability to pump is compromised MI - most common cause of cardiogenic shock SBP <90 or <30 from baseline Oliguria Rapid, thready pulse, dyspnea, tachycardia, anxiety, confusion, crackles
	Treatment of Hypovolemic Shock?	Restore fluid volume and blood pressure Administer oxygen Elevate head of bed, if not otherwise contraindicated Medications: Epinephrine, Norepinephrine, Dobutamine
	What does dobutamine (Dobutrex) do? what type of shock is it used for? what are the nursing implications?	Increases myocardial contractililty, decreases ventricular filing pressures, increases CO/stroke volume, incre/decre HR *Used in cardiogenic shock with severe systolic dysfunction or septic shock with normal CO that is not meeting metabolic demands NI: do not admin in same line with NaHCO3, watch for infiltration, monitor HR, BP, may need vasopressor due to hypotension effect
	Common practice dictates that crystalloids are used for fluid volume loss of less than.... Whole blood is for when.....	than 1500 mL while whole blood is used if the volume loss is greater or if the only cause of the hypovolemia is blood loss
	Nurses should be aware that vasopressors should not be started until........	the patient has an adequate fluid volume or fluid volume has been replaced
	If hypotension is evident the head of the bed........	would not be raised
	Clinical Manifestations of Hypovolemic Shock?	Altered or decreased level of consciousness Anxiety and restlessness Decreased urine output Delayed capillary refill Increased heart rate Pale, cool and clammy skin Systolic blood pressure < 90 or 40 below baseline
	In the initial stage of shock.......	the body experiences a reduced cardiac output, cells switch from aerobic to anaerobic metabolism leading to lactic acidosis which results from a buildup of lactic acid in the blood and a lowering of the pH. The compensatory stage is characterized by the body’s attempt to regain homeostasis and improve tissue perfusion.
	In the progressive stage......	the body has lost its compensatory mechanisms, which sustained tissue perfusion to this point. This decrease in perfusion results in electrolyte imbalance, metabolic acidosis and respiratory acidosis. The clinical symptoms convey the severity of the patient’s condition.
	In the refractory state.......	There is irreversible cellular and organ damage. Shock becomes unresponsive to the treatment and death is soon to follow
	The body essentially maintains homeostasis and the patient may be asymptomatic when......	there is a fluid loss of less then 750 ml, the body may enter the compensated state and changes to vital signs may be subtle and difficult to detect
	With the fight or flight response the catecholamines are released and vasoconstriction occurs as the nervous system move the blood.......	away from the non-vital organs of the abdomen and extremities and toward the cardiovascular system
	_____ can occur because the heart is unable to clear the blood quickly from the atrium in an effort to compensate the remaining non-ischemic myocardium contracts rapidly. This action raises the oxygen demands of the heart, which increase the workload.	Congestive Heart Failure
	Oxygen is necessary to combat the effects of........	cardiac ischemia and chest pain
	Reperfusion of the myocardium can occur as a result of?	thrombolysis, or mechanical revascularization by means of invasive procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)
	________ are used to reduce left ventricular afterload.	Vasodilators such as sodium nitroprusside (Ntiropress): lowers BP and decreases pre/afterload)
	The goal of head injury is to......	control intracranial pressure and prevent secondary injury and complications
	How would a nurse manage hemorrhage?	As a nurse, first apply direct pressure to the site using universal precautions. Next, if hemorrhage does not subside, apply pressure over arterial points. The extremity may also be elevated.
	When would you use a tourniquet?	A tourniquet is only applied as a last resort in which the bleeding has not subsided and death could occur should the bleeding continue.
	After bleeding has been controlled, the affected area.........	may need to be immobilized. If there is a penetrating object, such as a knife in the chest, it is not to be removed. Simply immobilize the object and transport to the ER. A tetanus vaccine may be ordered to prevent complications. Cleansing of the wound using sterile saline may be ordered.
	As a primary responder at the scene of an accident.......	you must first consider the risk to yourself then you must perform a primary assessment. This includes immobilizing the spine, airway, breathing, and circulation
	In trauma care the secondary assessment includes??	a head to toe survey looking for hemorrhage and a systems assessment. Later, diagnostic workups will be conducted including chemistries and tests, and pharmacological interventions.
	Airway maintenance should progress rapidly from the least to the most invasive method. Treatment includes......	opening the airway using the jaw-thrust maneuver, suctioning or removal of foreign body, insertion of a nasopharyngeal airway or intubation. If intubation is not possible, and emergency tracheotomy will be performed to open the airway. **Clients should be ventilated with 100% oxygen before intubation or a tracheotomy.
	At the scene of the injury, the cervical spine is......	immobilized with a rigid cervical collar or a cervical immobilization device (CID). Towel rolls are taped to a backboard on either side of the head. Finally, the client’s forehead is taped to the backboard
	Should we use sandbags?	Sandbags should not be used because the weight of the bags could move the head if the client must be log rolled.
	Delayed capillary refill time and altered mental status are the most significant signs of?	shock!!
	The use of the pneumatic antishock garment is a temporary strategy that can be considered for?	pelvic fracture bleeding with hypotension
	Signs of heat exhaustion include?	fatigue, lightheadedness, nausea, vomiting, diarrhea, tachypnea and feelings of impending doom
	Hypotension and mild to severe temperature elevation are due to?	dehydration
	Heat exhaustion is characterized clinically by?	Tachycardia Dilated pupils Mild confusion Ashen color Profuse diaphoresis Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) due to dehydration
	How do you treat heat exhaustion?	Place patient in cool area and remove constrictive clothing Place moist sheet over patient to decrease core temperature Provide oral fluid Replace electrolytes Initiate normal saline IV solution if oral solutions are not tolerated
	What is a heat stroke?	Failure of the hypothalamic thermoregulatory processes Vasodilation, increased sweating and respiratory rate deplete fluids and electrolytes, specifically sodium Sweat glands stop functioning and core temperature increases (>104º F [40º C])
	What can occur in a heat stroke?	-Altered mentation, absence of perspiration, and circulatory collapse can follow -Cerebral edema and hemorrhage may occur as a result of direct thermal injury to the brain -neurologic symptoms occur, such as hallucinations, loss of muscle coordination, and combativeness
	What is the treatment for a heat stroke?	Treatment: Stabilize patient’s ABCs and rapidly reduce temperature Cooling methods Remove clothing Cover with wet sheets Place patient in front of large fan Immerse in ice water bath Administer cool fluids or lavage with cool fluids -Administration of 100% oxygen compensates for the client’s hypermetabolic state
	What occurs when there is decreased blood flow to kidney in the compensatory stage?	The Renin-angiotensin system Renin is released, which activates angiotensinogen to produce angiotensin I, which is converted to angiotensin II. Angiotensin II is a potent vasoconstrictor that causes both arterial and venous vasonstriction. The net result in an increase in venous return to the heart and increase in BP. Angiotensin II also stimulates Aldosterone, which results in Na & H2o reabsorption, and K+ excretion by the kidneys. The increase of Na raises the serum osmolality and stimulates release of ADH which increases H20 reabsorption by kidneys, thus increasing blood volume. The increase in total circulating volume results increase in CO and BP
	In the compensatory stage, with a decrease of blood flow to the GI tract & skin due to shunting what can occur?	Paralytic ileus *pt feels cool and clammy except in early septic shock where they feel warm and flushed due to a hyperdynamic state
	What occurs when blood is shunted away from the lungs?	Increases pt's physiologic dead space: the anatomic dead space and any inspired air will not participate in gas exchange resulting ventilation-perfusion mismatch *arterial oxygen levels will decrease and pt will compensate increase in rate and depth of respirations
	When does the progessive stage of shock begin? features of this stage?	When the compensatory mechanisms fail *must prevent development of MODS -decreased cellular perfusion and resulting altered capillary permeability
	What is anasarca and when is it seen?	an increase in systemic interstitial edema or diffuse profound edema progressive stage
	What is the 1st system to display signs of dysfunction?	pulmonary system: the pulmonary arterioles constrict, result PA pressure. There is movement of fluids: result tachypnea, crackles, overall increase of work of breathing
	Why does metabolic acidosis occur in the progressive stage?	from an inabililty to excrete acids and reabsorb bicarbonate
	Why is a person predisposed to erosive ulcers and GI bleeding and increases risk of bacterial translocation from GI tract to blood in the progressive stage?	As the blood supply to the Gi tract is decreased, the normally protective mucosal barrier becomes ischemic
	The loss of the functional ability of the liver leads to failure of the liver to......	metabolize drugs and waste products such as ammonia (NH3) and lactate *also, liver loses its ability to function as an immune organ and bacteremia can occur
	What are the clinical manifestations of a pt in the Refractory stage?	unresponsive, areflexia, pupils unreactive and dilated, profound hypotension, decreased CO, bradycardia, irregular rhythm, decreased BP inadequate to perfuse vital organs, severe hypoxemia, respiratory failure, ischemia gut, anuria, metabolic changes from accumulation of waste products, DIC, hypothermia, mottled, cyanotic, decreased blood glucose, increased ammonia, lactate, and K+, METABOLIC ACIDOSIS
	What is the cornerstone of therapy for septic, hypovolemic, and anaphylatic shock is?	Volume expansion with the admin of appropriate fluid *start by inserting two large-bore iv catheters into the antecubital veins
	Why are colloids effective volume expanders?	because the size of their molecules keeps them in the vascular space for a longer period of time
	What happens if a pt is not responding to 2 to 3 L of crystalloids?	blood administration and central venous or PA pressure monitoring may be instituted *also indwelling catheter to monitor urine output and status
	What are the 2 complications that can occur when the pt requires large amts of fluid?	Hypothermia and coagulopathy
	How do you protect the client from hypothermia? from coagulopathy?	By warming both the crystalloid and colloid solutions *if receiving large volumes of packed RBCs, remember they don't contain clotting factors. So the clotting factors need to be replaced.
	What do you do if a pt has persistent hypotension after aduquate fluid resuscitation?	A vasopressor (dopamine, norepinephrine) or an inotrope (dobutamine) may be added *based on pts physiological goal
	What is the primary goal of drug therapy? Why are the drugs given via central line?	is the correction of decreased tissue perfusion *these meds have vasoconstrictor properties and may have deleterious effects of admin peripherally and the drug extravasates
	When are vasopressor drugs generally used? Examples of vasopressors?	pts who have been unresponsive to other therapies. These drugs cause severe peripheral vasoconstriction and increase in SVR which increases workload of heart Ex: Dopamine, Epinephrine, Norepinephrine, Phenylephrine
	What must you do before giving a vasopressor drug?	must give adequate fluid resuscitation ensure blood volume
	Name two vasodilator drugs Nursing implications?	nitroglycerin (Tridil) : use glass bottles for storage. Used in cardiogenic shock: decreases BP & preload while dilating coronary arteries sodium nitroprusside (Nipride) : arterial/venous vasodilation, decreases preload/afterload; decreases CO/BP; used in Cardiogenic shock; PROTECT solution from light by wrapping with opaque covering; admin with D5W ONLY; monitor for cyanide toxicity (tinnitus, hyperreflexia, confusion, seizures)
	What is one of the primary manifestations of hypermetabolism in shock?	protein-calorie malnutrition
	What drugs dilate coronary arteries? reduce preload? reduce afterload? reduce HR nd contractibility?	-Nitrates -diuretics -vasodilators - b-adrenergic blockers
	What is the management for hypovolemic shock?	Fluid resusciatation by calculating using 3:1 rule (3ml of isotonic crystalloid for every 1 ml of EBL)
	What is the management for pts with septic shock?	They require large amts of fluid replacement like 6 to 10 L of isotonic crystalloids and 2 to 4 L of colloids
	What would you give in addition to fluid replacement in a septic shock pt?	Vasopressin (Pitressin) an ADH, which will increase urine output, start low dose, will increase BP but could decrease stroke volume.....so
	In septic shock, if you give vasopressin (Pitressin) to increase the BP which may decrease stoke voume, what other drug would you give to offset that effect?	To offset the decrease in stroke volume give an inotropic agent (dobutamine) Also, IV corticosteriods are recommended for pts who require vasopressor therapy, despite fluid resuscitation, to maintain BP
	In septic shock, which drug interrupts the body's response to severe sepsis, including bleeding and clotting abnormalities? What is its most common serious adverse effect?	drotrecogin alpha (Xigris): anticoagulant effect, profiibrinlytic and antiinflammatory properties Bleeding!!!! * monitor signs of bleeding, hgb, platelets, PT, PTT
	What should the glucose levels be maintained at in septic shock?	< than 150mg
	What other drugs are given prophylaxis in septic shock?	famtidine (Pepcid) for stress ulcers & Lovenox for DVT
	What is the specific tx of neurogenic shock?	is dependent on the cause *whatever the cause, make sure the definitive tx of hypotension and bradycardia are treated
	What happens in neurogenc shock and hypotension?	It's a result of a loss of sympathetic tone, associated with peripheral vasodilation and decreased venous return
	What are the drugs used in neurogenic shock? what's given to treat bradycardia?	Vasopressors (phenylephrine: Neo-Synephrine) to maintain BP and organ perfusion *atrophine (AtroPen)
	What else should you monitor for in a pt with neuorgenic shock?	hypothermia due to hypothalamic dysfunction
	What drug is given to pts with a spinal cord injury to prevent secondary spinal cord damage caused by the release of chemical mediators?	Solu-Medrol
	What kind of fluids would you resuscitate with in anaphylactic shock?	Colloids
	What would you give if significant hypotension persists after 1 to 2 hours of aggressive therapy in anaphylactic shock? monitor for what???	give IV corticosteroids hydrocortisone (Solu-Cortef) to decrease inflammation and reverse increased capillary permeability to increase BP and HR *monitor for hypokalemia and hyperglycemia
	When would you give blood/blood products?	All types of shock if Hgb is < 12g/dl or if the pt does not respond to crystalloids
	Name types of colloids	Hetastarch (Hespan): for all types except cardiogenic and neurogenic Human serum albumin, plasma protein fraction: for all types except cardiogenic and neurogenic Dextran, 40, 70: can increase the risk of bleeding
	What device can decrease SVR and left ventricular workload? It is inserted into the femoral artery and placed in aorta	IABP Intraaorti balloon pump
	What type of colloid should never be used in a pt with liver failure?	Lactated Ringer
	Who would the 1st to see a MD in the emergency triage?	Cardiac arrest pts, intubated trauma pt, severe overdose, SIDS
	What is involved with a Primary survery?	Focues on ABCD (disabililty) and serves to ID life threatening conditions
	What is associated with "A" Airway?'' Who is at risk for airway compromise?	cervical spine stabilization and/or immobilization *seizures, near-drowning, anaphylaxis, foreign body obstruction, cardiopulmonary arrest
	What are the s/s of a pt with a compromised airway?	dyspnea, inability to vocalize, presence of foreign body in airway, trauma to face or neck
	What are the Tx of opening the airway?	Jaw-thrust maneuver (avoid hyperextension), suctioning and/or removal of foreign body, insert nasopharyngeal or oropharyngeal airway (will cause gagging if pt conscious), and endotracheal intubation
	What drug is given in rapid-sequence for securing an unprotected airway? One sedates and other for paralysis to facilitate intubation while minimizing the risk of aspiration and airway trauma.	Sedation: etomidate (Amidate) Paralysis: succinycholine (Anectine)
	What type of O2 should be given for a critically injured ir ill pt with increased metabolic and oxygen demand?	High flow oxygen 100% via a non-rebreather mask
	Primary survey focuses on....	airway, breathing, circulation, and disability (ABCD) *Identifies life-threatening conditions -If life-threatening conditions related to ABCD are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey
	Nearly all immediate trauma deaths occur because?	Because of airway obstruction. -Saliva, bloody secretions, vomit, laryngeal trauma, facial trauma, and the tongue can obstruct the airway.
	Primary: "A" Airway with cervical spine stabilization and/or immobilization Signs/symptoms?	In patient with compromised airway: Dyspnea Inability to vocalize Presence of foreign body in airway Trauma to face or neck
	Primary: "B" Breathing: Assess for dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension Next step?	-Administer high-flow O2 via a nonrebreather mask -Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions -Monitor patient response
	Primary "C" Circulation: Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) Assess what? Assess skin for color, temperature, moisture Assess mental status and capillary refill Insert two large-bore IV catheters Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s solution	-Assess skin for color, temperature, moisture -Assess mental status and capillary refill -Insert two large-bore IV catheters -Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s solution
	Primary "D" Disability: Measured by patient’s level of consciousness	AVPU A = alert V = responsive to voice P = responsive to pain U = unresponsive -Glasgow Coma Scale: -Assess arousal aspect of patient’s consciousness -Pupils: Size, shape, response to light, equality
	Shivering during a heatstoke........tell me about it?	Shivering: Increases core temperature, complicates cooling efforts Treated with IV chlorpromazine Aggressive temperature reduction until core temperature reaches 102º F (38.9º C) *Monitor for signs of rhabdomyolysis, myoglobinuria (lead to acute renal failure!), and disseminated intravascular coagulation
	What happens when the core temperature drops?	BMR decreases two or three times. The cold myocardium is extremely irritable, so any movement can precipitate ventricular fibrillation. Decreased renal blood flow decreases GFR, which impairs water reabsorption and leads to DEHYDRATION. Cold blood becomes thick and acts as a thrombus, placing the client at RISK FOR STROKE, myocardial infarction, pulmonary emboli, acute tubular necrosis and renal failure. Lactic acid accumulation may cause to METABOLIC ACIDOSIS.
	Treatment of hypothermia focuses on managing and maintaining?	ABCs, rewarming the client, correcting dehydration, acidosis and cardiac arrhythmias.
	Passive external rewarming involves?	moving the client to a warm dry place, removing damp clothing and placing warm blankets on the client
	External rewarming involves? Watch for??	body-to-body contact, fluid or air-filled warming blankets or heat lamps. -The client must be closely monitored for vasodilation and hypotension during rewarming.
	Active core rewarming is used for? Techniques used?	Moderate to profound hypothermia and refers to heat applied directly to the core -Techniques include heated humidified oxygen, warmed intravenous fluids, and peritoneal, gastric, or colonic lavage with warmed fluids. Hemodialysis or cardiopulmonary bypass may be considered as treatment based the patient’s response
	Rewarming should be discontinued once the core temperature reaches??	95º F (35º C)
	To decrease absorption of an ingested poison one can do what?	Gastric lavage -Intubate before lavage if altered level of consciousness or diminished gag reflex -Perform lavage within 2 hours of ingestion of most poisons
	How do you induce emesis? any warnings?	Ipacae syrup followed by 250 to 500 ml of water is used to induce emesis. *However, Ipecac is potentially cardiotoxic if emesis does not occur or if a large dose is given to the patient.
	Lavage is contraindicated in patients who?? any potential problems?	ingest caustic agents, coingested sharp objects, or ingested nontoxic substances. *Problems associated with lavage include epistaxis, esophageal perforation and aspiration.
	The most effective intervention for management of poisonings is?	administration of activated charcoal orally or via a gastric tube
	How does charcoal work?	Toxins adhere to charcoal and are excreted through the gastrointestinal tract rather than absorbed into the circulation. -Most effective intervention: Administer orally or via gastric tube within 60 minutes of poison ingestion *Charcoal does not absorb ethanol, alkali, iron, boric acid, lithium, methanol or cyanide.
	What are the C/I with charcoal?	Contraindications: -Diminished bowel sounds -Paralytic ileus -Ingestion of substance poorly absorbed by charcoal
	As a general rule, dry substances should be?	brushed from the skin and clothing before water is used
	With the exception of mustard gas, most toxins can be?	Safely removed with water or saline. *Water mixes with mustard gas and releases chlorine gas
	________ are given together with activated charcoal to stimulate intestinal motility and increase elimination?	Cathartics such as sorbitol, magnesium citrate or magnesium sulfate *Multiple doses of cathartics should be avoided because of potentially fatal electrolyte abnormalities
	Whole bowel irrigation is controversial and involves administration of? Effective for what?	A nonabsorbable bowel evacuant solution Golytely. -The solution is administered every 4 to 6 hours until stools are clear. -This process can be effective for swallowed objects such as cocaine-filled balloons or condoms.
	Chelation therapy may be considered for?	heavy metal poisoning such as lead
	Management for a snake bite include what?	-Venous access with a large-bore catheter and administration of crystalloids to maintain blood pressure -CBC -Urinalysis and electrolytes -Coagulation Studies -Antivenin therapy is used in mild to moderate reactions -Nursing interventions -Assess for edema -Measure circumference every 30 to 60 minutes -Treat pain with Tylenol -Aspirin and other NSAIDS may exacerbate bleeding -Narcotics are avoided since they may cause respiratory depression -Tetanus prophylaxis
	What should be avoided is one is bit by a venomous snake?	Caffeine, alcohol, and smoking increase the spread of venom and should be avoided
	Tell me about Sarin? Antidote?	Sarin gas enters the body through the eyes and skin. It acts by paralyzing respiratory muscles. Sarin: Toxic nerve gas that can cause death within minutes of exposure *Antidotes for nerve agents: Atropine, pralidoxime chloride
	Tell me about Radiologic dispersal devices (RRDs) (“dirty bombs”):	Mix of explosives and radioactive material -When detonated, blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination -Main danger from RRDs: Explosion
	Blast injuries result from?	Supersonic over pressurization shock wave that results from explosion causing damage to the lungs, middle ear and gastrointestinal tract.
	Tell me about Mass casualty incident (MCI):	Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources -Examples would include massive fire, flood and category 3 -5 hurricanes MCIs usually involve large numbers of casualties (>100), physical/emotional suffering, and permanent changes within community. MCIs always require assistance from people and resources outside community (e.g., American Red Cross, Federal Emergency Management Agency [FEMA]
	System of colored tags designates both seriousness of injury and likelihood of survival: What do the colots mean?	-Green (minor injury) or yellow (non–life threatening injury) tag indicates noncritical injury -Red tag indicates life-threatening injury requiring immediate intervention -Black tag identifies the dead or those expected to die
	What are the risk factors for hypothermia?	Risk factors Elderly Certain drugs Alcohol Diabetes
	What should you look for in a pt who might have breakdown of skeletal muscle (rhabdomyolsis) which l/t myoglobinuria?	Urine color (tea color), amt, pH, and myoglobin in urine
	What does warming place a pt at risk for?	Afterdrop: a further drop in core temperature wich occurs when cold peripheral blood returns to the central circulation
	What area shoud be warmed 1st?	The core should be warmed 1st before the extremities
	In a bee sting what meds are given?	Most severe reactions require IM or IV antihistamines (Benadryl), sub q epinephrine, and corticosteroids (dexamethsone (Decadron)
	What is the tx for a black widow spider bite?	Cooling to the area to slow action of neurotoxin. IV access should be started and O2 admin. Clean wound and gice tentanus prophylaxis. -Muscle spasms are given calcium gluconate, diazepam (Valium), or methocarbonal (Robaxin)
	What are the s/s of a black wodow spider bite?	N/V, abd cramping, HTN, dyspnea, parathesis, and tachycardia -usually peak 2-3 hrs after onset -muscle spams & HTN 12-24 hrs
	What are the s/s of a brown recluse bite?	initial bite 6-12hrs itching, erythema then a painful blue-purple develops a ring around bite and may necrose. Wound can go deep into tissues then systemically, fever, chills, joint pain, malaise, N/V
	What is the tx of a brown recluse spider bite? Monitored for what in hospital?	Initial 1st clean bite with mild antiseptic soap, provide cool compress, and elevate effected extremity Secondary : analgesia, tetanus prophylaxis, antihistamines, corticosteriods, and Abx. Some pts need surigal debridement. to enhance tissue healing may use hyperbaric O2. For deep crater wounds, Dapsone (Avlosulfon) *hemolysis, DIC, and ARF
	What pain med is given to a pt who was bit by a poisonous snake?	Tylenol (acetaminophen)
	What do you give for Tylenol (acetaminophen) poisoning?	Activated charcoal
	What do you give for acids, alkalis, & aspirins?	immediate dilution (water, milk), corticosteroids for alkali burns -No induced vomitting!!!
	What do you give for bleach poison?	washing of exopsed skin and eyes, diltution with h2o and milk, gastric lavage, prevent vomitting and aspiration
	What is given for phenobarbital or salicylate poisoning?	Sodium bicarbonate to raise pH
	What may be added to the IV fluids to enhance secretion of amphetamines and quinidine?	Vitamin C
	What can phosgene do if inhaled at high concentrations?	severe respiratory distress, pulmonary edema, death
	What would you do for someone who was exposed to Botulism?	Induce vomitting, give enema, antitoxin, mechanical ventilation, penicilin, no vaccine, toxin can be inactivated by heating food or drink to 212 F or 100 C for at least 10 mins
	How is botulism spread?	spread or air or food, improper can foods, contaminated wound, no person to person
	How is small pox treated and tranmissed?	prevent by vaccine or ameliorated by vaccine when 1st given after exposure -highly contagious, person to person, by air dropets, handling contaminated goods
	How is anthrax spread and treated?	no person to person, found in nature, infects wild and domestic hoofed animals, dierct contact of bacteria, spores are dormant but become active once in host *Abx, Cipro, penicilin, doxycycline, vaccine (limited)
	What does small pox (virus) look like on a persom?	sudden onset of symptoms, fever, HA, myalgia, lesions that progress from macules to papules to pustular vesicles, malaise, back pain
	What are the clinical manifestation of botulism?	abd cramps, diarrhea, N/V, cranial nerve palsies, skeletal muscle paralysis, resp failure
	How do you get hemorrhagic fever and how is it treated?	carried by rodents and mosquitoes, direct person to person by body fluids, virus also aerolized * no known treatment, must isolate
	In acute radiation syndrome what are the 1st symptoms?	The first symptoms of ARS typically are nausea, vomiting, and diarrhea. These symptoms will start within minutes to days after the exposure, will last for minutes up to several days, and may come and go. Then the person usually looks and feels healthy for a short time, after which he or she will become sick again with loss of appetite, fatigue, fever, nausea, vomiting, diarrhea, and possibly even seizures and coma. This seriously ill stage may last from a few hours up to several months.
	What else can occur in acute radiation syndrome?	People with ARS typically also have some skin damage. This damage can start to show within a few hours after exposure and can include swelling, itching, and redness of the skin (like a bad sunburn). There also can be hair loss. As with the other symptoms, the skin may heal for a short time, followed by the return of swelling, itching, and redness days or weeks later. Complete healing of the skin may take from several weeks up to a few years depending on the radiation dose the person’s skin received
	During what assessment would you -initate CPR if absent pulse -if shock symptoms or hypotension start two large bore IV's to infuse NS or LR -admin blood if ordered -use pneumatic antishock garment -obtain blood samples -control bleeding	During primary survey "C" Circulation
	What is an indication of a fracture of the base of the frontal portion of the skull?	"Racoon eyes" periorbital ecchymosis
	red tag means what?	life threatening needs immediate attention ex shock
	green tag means what?	minor injury ex. sprains
	yellow tag means what?	non life threating ex. open fracture
	black tag means what?	deceased or about to die ex. dead or massive head trauma
	What are the parameter for the Glasgow Coma Scale? When is it used?	Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Minor, GCS ≥ 13 *GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS and doctors as being applicable to all acute medical and trauma patients. In hospital it is also used in chronic patient monitoring, in for instance, intensive care
	Is glucose elevated in a pt with shock?	At 1st in shock it is elevated d/t the SNS stimulation and cortisol release; insulin sensitivity develops -Then it lowers d/t liver dysfuntion
	What are the labs value of sodium in a pt with shock?	It is INCREASED found early in shock becuase of increases secretion of Aldosterone, causing renal retention of sodium -Then if excess hypotonic fluid is given may be decreased
	What are the labs value of potassium in a pt with shock?	It is DECREASED found early in shock becuase of increases secretion of Aldosterone, causing renal excretion of potassium -Could be increased from cell death, or acute renal failure, or presence of acidosis

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