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55 Cards in this Set

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Define Shock
circulatory insufficiency that creates and imbalance between tissue oxygen supply and oxygen demand.
Identify the consequence of decreased venous oxygen content
global tissue hypoperfusion associated with decreased venous oxygen content and metabolic acidosis (lactic acidosis).
List the 4 categories of shock by etiology
1. hypovolemic: inadequate circulating volume 2. cardiogenic: inadequate cardiac pump function 3. distributive: peripheral vasodilatation & maldistribution of blood flow 4. obstructive: extra cardiac obstruction to blood flow
Identify the first compensatory mechanism that occurs in shock, what happens when this is not sufficient and identify the marker of the severity of the tissue oxygen supply-to-demand imbalance.
1)Increase in cardiac output
2)Amount of O2 extracted from Hg by tissues increases, which decreases the mixed venous O2 saturation. 3)Lactic acid levels used to measure this, also O2 sat,(pulmonary artery)
List the autonomic responses that occur during shock
1.arteriolar vasoconstriction 2.increase heart rate & contractility increasing cardiac output 3. constriction of venous capacitance vessels augmenting venous return 4. release of the vasoactive hormones epinephrine, norepinephrine, dopamine, & cortisol increasing arteriolar/venous tone 5. release antidiuretic hormone & activation of renin-angiotensin
Identify important elements of a patient’s history that are important in assessing for possible shock
Hx: cardiovascular disease, CP, CHF, neurologic diseases, Rx's, anaphylactic rxn to new med, drug toxicity
Identify the most common categories of significant hemorrhage, and give a few examples of each.
Common nontraumatic causes of hemorrhage include gastrointestinal bleeding, vascular aneurysm rupture, and ruptured ectopic pregnancy
Explain what happens to the cardiovascular system during acute hemorrhage
causes decreased cardiac output & vital organ perfusion only maintained at expense of nonvital organs. Progressive vasoconstriction in splenic, musculoskeletal, & cutaneous vascular beds allow sustained critical perfusion to heart, brain, & kidneys. Renal perfusion also sacrificed in severe states.
Differentiate hemorrhage and shock caused by cardiac tamponade, tension pneumothorax, and spinal cord injury.
Cardiac Tamponade: increased central venous pressure.
Tension Pneumothorax: unilaterally diminished breath sounds
Spinal Cord Injury: presence of neurologic deficits, warm skin, and lower than expected pulse rate
Identify the features of acute hemorrhage and how this can differ in the elderly
those with preexisting cardiac dz may show more severe S/S with less blood loss
Identify the features of acute hemorrhage and how this can differ in the patients on beta-blockers,
can mask some early S/S
Identify the features of acute hemorrhage and how this can differ in the athletic patients
can lose considerable amounts of blood before they appear ill
Identify the features of acute hemorrhage and how this can differ in patient with intra-abdominal hemorrhage
up to 1/3 who sustain intra-abd hemorrhage severe enough to develop hypotesnion (systolic < 90) will not develop tachycardia b/c of vagal stimulation from blood in peritoneal cavity
Identify the classic features of acute hemorrhage
tachycardia; tachypnea; narrow pulse pressure; decreased urine output; cool clammy skin; poor capillary refill; low central venous pressure and later stages: hypotension & altered mental status.
Identify those groups of people most susceptible to septic shock.
ID of systemic inflammatory response syndrome (SIRS) doesn't confirm Dx of infection or sepsis cause the features of SIRS can be seen in many other conditions like trauma, pancreatitis, burns, or infection. SIRS isn't a Dx, or good indicator of outcome
Describe how clinical features change as blood loss progresses from < 20%
Cool, clammy skin, Delayed capillary refill; ↓ pulse pressure; Maybe tachycardia. Generally normal BP though narrow pulse pressure
Describe how clinical features change as blood loss progresses from less than 20-40%
Tachycardic. Tachypneic. Postural changes in BP. confused. Agitated. If not resuscitated: hypotension & oligouria; respirations quicken & become deeper; tachycardia worsens; skin becomes mottled
Describe how clinical features change as blood loss progresses from less than >40%
Tachycardia; profound hypotession; either tachypnea or irregular respirations; markedly ↓ urine output; ↓ or absent peripheral pulses; pallor; lethargy and obtundation
Identify the fluids of choice in resuscitation and for the hemodynamically unstable patient
Rapid Infusion of 20–40 ml/kg as fast as possible, typically over 10–20 min
Identify the fluids of choice in resuscitation for the management of acute hemorrhage
Isotonic crystalloid, either 0.9% NaCl [normal saline (NS)] or ringer’s lactate (RL)
For blood transfusion therapy, explain the following: Who can wait for fully cross-matched blood
patient who appears to be stable
For blood transfusion therapy, explain the following: When early transfusion is particularly important
in elderly and those with significant respiratory and/or cardiac disease
For blood transfusion therapy, explain the following: When aggressive therapy is mandated
hemorrhaging pt exhibiting any degree of hemodynamic instability or signs of end-organ hypoperfusion
For blood transfusion therapy, explain the following: Treatment of the moribund patient
(quickly approaching death) type O immediately if available
Identify the most frequent sites for infection
lungs, abdomen and urinary tract
List risk factors for gram-negative bacteremia
DM, lymph diseases, cirrhosis, burns, invasive procedures and/or devices, chemotherapy
List risk factors for gram-positive bacteremia
vascular catheters, indwelling devices, burns, IV drugs
List risk factor for fungemia
immunocompromised
Explain how sepsis starts and its effects on hypotension and multiple organ system failure.
Starts as focus infection (uti, pneumonia, cellulites, abscess) resulting in bl strea invasion or proliferation of organisms at infected site, growing
organisms release exogenous toxins, hosts rxn to toxins result in release of endogenous mediators including complement, kinins, & coag factors,
release myocardial depressant substances results in depression of myocardial fxn, dilation of ventricles & vasodilation, result in generalized
cardiovascular insufficiency leading to refractory hypotension & multiple organ system failure & death
Describe the causes of cardiogenic shock.
impairment of heart’s pumping action to the degree that there is insufficient blood flow to the tissues to meet resting metabolic demands. The usual cause is contractile failure of the myocardium
Identify the following regarding cardiogenic shock from acute MI: How frequently it occurs
50,000 to 70,000 deaths/year in U.S. Reported incidence of cardiogenic shock after acute MI is 5-7%
Identify the following regarding cardiogenic shock from acute MI: When it usually occurs
occurs early in course of acute MI, typically in 7 hours from onset after symptoms to recognition of shock
Identify the following regarding cardiogenicshock from acute MI: Independent risk factors
advanced age, female gender, large MI as indicated by marked increases in creatinine kinase, anterior wall infarction, previous MI, previous CHF, multivessel disease, proximal occlusion of left anterior descending coronary artery, and DM
Briefly identify treatment for cardiogenic shock regarding the following: Pain control and what to pay attention to:
using IV notro or morphine; monitor and maintain systemic BP
Briefly identify treatment for cardiogenic shock regarding the following: What to give if there is no pulmonary edema
boluses of NS (100-250 mL)
Briefly identify treatment for cardiogenic shock regarding the following: When fluid administration should be the first action
RV infarct
Briefly identify treatment for cardiogenic shock regarding the following: Initial drug to be given in the absence of profound hypotension:
dobutamine initially
Briefly identify treatment for cardiogenic shock regarding the following: Initial drug to be given with profound hypotension:
dopamine if systolic is <70 mmHg
Briefly identify treatment for cardiogenic shock regarding the following: When an intraaortic balloon pump should be used
when above measures have failed to reverse shock
Briefly identify treatment for cardiogenic shock regarding the following: Reperfusion modality of choice
percutaneous transluminal coronary angioplasty if available within 60 minutes; if not available then fibrinolytics
Define anaphylaxis and identify the most common causes.
severe systemic hypersensitivity rxn characterized by hypotension or airway compromise that's potentially life threatening and caused by chemical and IgE mediators released from mast cells
Identify the following regarding anaphylaxis: Type of hypersensitivity reaction
The “classic” anaphylaxis (type I hypersensitivity) pathway involves the production of IgE and requires two separate exposures to either an antigen or a hapten-protein antigenic complex.
Identify the following regarding anaphylaxis: Type of Ig involved
IgE
Describe how anaphylaxis presents, how soon it begins, and when most fatalities occur.
pruritis, cutaneous flushing, & urticaria. Next: fullness in throat, anxiety, chest tightness, SOB, lightheaded, LOC, lump in throat & hoarseness signal life threatening laryngeal edema in pt with symptoms of anaphylaxis. Onset: within 60 minutes of exposure. faster onset = more severe rxn, with 1/2 fatalities in 1st hour
Identify the patient who may require intubation when presenting with anaphylaxis.
If the patient is beginning to experience respiratory distress and/or 100% O2 therapy is not resolving hypoxemia
Identify when epinephrine can be given subcutaneously and when IV administration is indicated.
SQ: less severe sx'x: decreasing blood pressure without hypotenstion (systolic >90mmHg) symptomatic dyspnea, abdominal cramps, urticaria. IV: SQ nonresponsive or severe symptoms (severe bronchospasm, laryngeal edema, sx's upper airway obstruction, respiratory arrest, or signs of shock)
Identify the second-line drug Antihistamines which is used in anaphylaxis and their indications for use
all patients with anaphylaxis should receive antihistamines particularly an H1 blocker such as diphenhydramine
Identify the second-line drug Corticosteroids which is used in anaphylaxis and their indications for use
all patients with anaphylaxis should receive corticosteroids such as methylprednisone
Identify the second-line drug Glucagon which is used in anaphylaxis and their indications for use
For patients taking beta blockers with hypotension refractory to fluids and epinephrine
Identify the second-line drug Albuterol which is used in anaphylaxis and their indications for use
If wheezing or tightness is part of patient’s presentation, a bronchodilator, such as a continuous albuterol nebulizer should be instituted
Identify the second-line drug Aminophylline which is used in anaphylaxis and their indications for use
for severe bronchospasm refractory to bronchodilator treatments
Discuss the medications that might be given to a patient on beta-blockers.
Pt's taking BB with hypotension refractory to fluids & epinephrine, glucagons should be used in a dose of 1 mg IV every 5 min. until hypotension resolves, followed by an infusion of 15 ug/min
Describe the treatment of a minor allergic reaction
ID and remove causative agent. give oral, intramuscular, or IV diphenhydramine 25-50 mg and observed at least 1 hour. If the pt stable, he/she can be discharged with antihistamine & prednisone 20 mg bid or 40 mg qd for 4 days.
Describe the characteristics and treatment of neurogenic shock, identify the spinal cord injury level where this is most likely to occur.
injury above T1 should be capable of disrupting spinal tracts that control entire sympathetic system. T1-L3 has potential to disrupt sympathetic outflow; the higher the injury in this zone, more likely or more severe the resulting neurogenic shock. cervical region is most commonly injured, followed by thoracolumbar junction, thoracic region, and lumbar segments.
EM: Shock
EM: Shock