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1

significant levels of troponin

I - 0.35T - 0.2

2

cardiac tamponade

muffled heart sounds↑ CVPparadoxical pulse (gt 10mm)- abnormally large decrease in SBP during inspiration

3

CURB-65

PNEUMONIA! ConfusionB*U*N gt 7Respiratory rate g/e 30BP - SBP gt/eq 90 or DBP lt/eq 60)65Scoring:0-1: outpatient treatment2: hospital admission3-5: ICU consideration

4

SIRS Criteria

2+ of...HR gt 90RR lt 20 - 32 gtT lt 36 - 38 gt- 96.8 - 100.4FWBC lt 4k - 12k gt- immature neuts gt 10

5

sepsis

SIRS likely s/t infection; positive cultures add to validity but not requiredPROBABLE OR CONFIRMED INFECTION!!!clinical s/s: tachycardic, tachypnic, hypotensive, hypoxic, confused/lethargic/agitated, hyperthermic → Hypothermic

6

severe sepsis

sepsis + at least 1 sign of hypoperfusion or organ dysfunction (new, not explained by other etiology)

7

septic shock

severe sepsis associated with - refractory hypotension (BP lt 90/60) despite adequate fluid resus - and/or serum lactate gt 4.0occurs with evidence of perfusion abnormalities: lactic acidosis, oliguria, AMS- not perfusing brain, kidneys, lungs can’t compensate, other organ dysfunctions

8

shock: management & hemodynamics goals

supportive therapy while finding/managing/tx shock source- MAP gt 60- CVP 8-12- CI gt 2.1- UOP gt 0.5 mg/kg/hr- SaO2 gt 92%- SVO2 gt 70remember: septic has its own criteria

9

ARDS: definition

acute lung injury manifested by non-cardiogenic pulmonary edemaresult of inflammatory lung injury

10

2 things present in all shock

- inadequate tissue perfusion- cellular hypoxia (leads to dysfunction

11

s/s hypovolemic shock apparent when

gt 15% volume lost

12

vasopressors + hypovolemic shock

CAUTION. fill before you squeeze!

13

main causes of obstructive shock x3

THINK FILLING & EMPTYINGdecreased ventricular fill:- cardiac tamponade- tension pneumothoraxdecreased ventricular emptying- main PA or saddle PE

14

volume/vasopressor + obstructive shock

gentle - it's temporizing

15

shock + vasopressin

adjunct if not getting a good response from patient

16

#1 cause of cardiogenic shock

MI

17

neurogenic shock classic triad

bradycardiamassive vasodilationhypothermiad/t parasympathetic overstimulation

18

neurogenic shock: avoid what drug and why?

phenylephrine - unopposed A1 activity could potentially worsen the shockbradycardia d/t reflex vagus nerve - it's a CNS effect esp at high doses

19

anaphylactic shock meds list

EPINEPHRINE !!! - CV collapse without- vasopressor & mast cell stabilizer (prevent histamine release)IM 1:1,000 → Dose 0.1-0.5mg q10-15 minIV 1: 10,000 → Dose 0.1 – 0.25mg q 5-15min H1 blocker: Benadryl (only block receptor)H2 blocker: Famotidine (Pepcid)Respiratory: AlbuterolCorticosteroid: methylprednisolone

20

epinephrine + anaphylactic shock

- CV collapse without- vasopressor & mast cell stabilizer (prevent histamine release)IM 1:1,000 → Dose 0.1-0.5mg q10-15 minIV 1: 10,000 → Dose 0.1 – 0.25mg q 5-15min

21

late phase anaphylactic reactions

- 6-12 hrs after initial rxn- typically follow favorable response to treatment- treated the same wayimplications: - airway mgmt: keep pts intubated 14-16 hours- line maintenance: leave big IVs in- ICU care: code cart & epi nearby

22

anaphylactic shock + airway management important implication

keep intubated 14-16 hours after event - concern for late anaphylactic reaction

23

sepsis: hemodynamic goals

within 6 hours of presentation/symptomsCVP g/e 8-12mmHg MAP g/e 65mmHgUOP g/e 0.5ml/kg/hrSVO2 g/e 70%Lactate lt 2mmol

24

surviving sepsis: goal directed treatment within 3 hours

Within 3 hours presentation of SIRS + strong indication organ failing- Measure lactate level- Obtain cultures before abx:-- 2 blood cultures-- +/- Urine culture- broad spectrum antibiotics - 30ml/kg crystalloid “fluid challenge” for: --hypotension OR-- lactate g/e 4mmol/L

25

surviving sepsis: goal directed treatment within 6 hours

Within 6 hours presentation of SIRS + strong indication organ failing- vasopressors (for hypotension that doesn't respond to initial fluid resuscitation) -- GOAL: MAP g/e 65mmHg-- NE first, then dopamine, then vasopressin - if persistent hypotension after initial fluid administration (MAP lt 65mmHg) ORinitial lactate was g/e 4mmol/L, re-assess volume status + tissue perfusion-re-measure lactate if initial elevated

26

septic shock treatment considerations

- Fluids (crystalloids; albumin if needed)- Vasopressors (NE, epi, vasopressin) -Inotropes if cardiac dysfxn (Dobutamine, esp. w/ HF)- Corticosteroids (only if unable to meet hemodynamic goal)- Blood product administration (Goal Hgb 7-9g/dL)- Sedation if intubated (Propofol, not benzos: ICU delirium risk)- BG monitoring q2h/insulin use (goal BG 110-180 mg/dL)- Renal replacement therapy in ARF- Early but slow enteral feeding (GI perf/peritonitis – be cautious) - DVT/GI prophylaxis (Lovenox, heparin, PPI/H2 antagonist)

27

septic shock

- Fluids (crystalloids; albumin if needed)

28

septic shock - Vasopressors

NE, epi, vasopressin

29

septic shock inotropes

- if cardiac dysfxn (Dobutamine, esp. w/ HF)

30

septic shock - corticosteroids

only if unable to meet hemodynamic goal

31

septic shock - goal hgb

Goal Hgb 7-9g/dLwith blood product admin

32

septic shock - Sedation if intubated

Propofol, not benzos: ICU delirium risk

33

septic shock - BG monitoring

q2h/insulin use (goal BG 110-180 mg/dL)

34

septic shock + ARF?

renal replacement therapy

35

septic shock - early but slow enteral feeding

GI perf/peritonitis – be cautious

36

septic shock - DVT/GI prophylaxis

Lovenox, heparin, PPI/H2

37

documentation/evaluation of volume resuscitation in septic shock x2

EITHER repeat focused exam (after initial fluid resuscitation) -- VS, CV, cap refill, pulse, skin findingsOR 2+ → CVPScvO2 Bedside CV USdynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

38

how do we know a shock patient is better?

- stable VS with ↓ pharm/non-pharm support: HR 60-90, MAP gt 65, CVP 8-12- adequate UOP: 0.5 - 1.0 ml/kg/hr- evidence of adequate O2 delivery/utilization: SVO2 65 - 75- lactate levels normalized- improvements in PE

39

SIRS: hypotension refractory to fluid replacement consideration

(a) hang 1000mL NS/LR, 200mL stays in vascular bed-- LR requires functional liver to create buffer(b) hang 1000mL D5W bag, 800mL stays in vascular bed guidelines: LR or NS

40

ARDS: first major change

Inability to oxygenateFurther destruction of alveoli- shunting (blood passing by non-vent alveoli & bypassing ventilated)refractory to O2 increase: junk in alveoli = UP THE PEEP

41

ARDS: second major change

Narrowing of small airways Damage to lung microvasculature- V/Q imbalance d/t alveolar dead space (alveoli full of junk) = no gas exchange

42

ARDS: third major change

Elevated pulmonary artery pressure (vasoconstriction d/t hypoxia)Increased PVR*Not an increase in wedge!*

43

ARDS: first phasedefinition + s/s

exudative - first 72 hours- angry neuts increase lung injury & cap permeability-- increased alveolar edema-- macrophages + mediators = pulmonary bed vasoconstriction = V/Q mismatch (blood bypass ventilated alveoli) = pulm htnclinical s/s: may only see tachypnea & dyspnea• Coarse crackles• Cyanosis• Tachycardia• Lungs less compliant• Dec ventilation of alveoli• Hypercapnia

44

ARDS: second phasedefinition + s/s

proliferative - 4 to 21 days- resolution of pulmonary edema- type II pneumocytes hyperplasia- proliferation fibroblasts- hemorrhagic exudate → granulation tissue (hyaline membrane)s/s: PROGRESSIVE HYPOXEMIA

45

ARDS: third phasedefinition + s/s

remodeling & fibrosis - 14 to 21 days- alveoli + bronchioles obliterated- decreased FRC- more V/Q mismatch/shuntingclinical s/sinitial: restlessness, respiratory alkalosis s/t hyperventilation (↑ pH, ↓ paCO2, HCO2 normal) + non-specific complaintsrapid progression to: respiratory distress, non-compliant lungs (more P to get same TV), crackles everywhere, elevated pulmonary airway pressure (PIIP), REFRACTORY HYPOXEMIAP/F lt 200

46

P/F definition for ARDS

lt 200

47

normal PF

gt 286lt 200 represents significant shunt gt 20% - ARDS

48

a/A + PaO2/PAO2

a/A - what's available in blood vs what's available in alveoliP/P - % O2 diffusing across alveoli into bloodnormal: gt 45% or 0.75

49

diagnostic criteria for ARDS

• Bilateral pulmonary infiltrates (whiting out on CXR)• PCWP lt 18mmHg (no LVHF - normal 5-12)• Severe hypoxemia• PaO2/FiO2 lt 200

50

Berlin Criteria Definition of ARDS

mild: P/F 201-300moderate: P/F 101 - 200severe: P/F lt 100

51

ARDS management goals

maximize pulmonary gas exchangeoptimize O2 delivery to tissuesprevent further organ injury

52

septic shock: evidence of perfusion abnormalities

occurs with evidence of perfusion abnormalities (lactic acidosis, oliguria, mental status changes, other organ dysfunctions)

53

EF + sepsis

low d/t myocardial depressant factor

54

sepsis causes

bacteria 85% of time- gram neg (like e coli) release endotoxins - inflammatory cascade- gram pos

55

surviving sepsis: fluid resuscitation

crystalloids - begin in ED- 1st 30 min bolus 500-1000cc (cryst)- 30 ml/kg/hr for hypotension or lactate gt 4GOAL: CVP g/e 8 or CVP on vent g/e 12 goals not met? consider PBRC (goal hct g/e 30%)

56

surviving sepsis: blood products considerations

consider PRBC if hgb lt 7- goal hct g/e 30%platelets - plt lt 5000- plt 5-30k + high risk for bleeding

57

surviving sepsis: mechanical ventilation considertions

- target TV 6ml/kg (low)- PEEP (beware tension pneumo)- permissive hypercapnia- sedation: intermittent bolus OR continuous with daily interruption/lighting to produce awakening

58

MODS

begins with SIRS = subtle changes = dysfunction/ progressive failure 2+ organ systems d/t circulating mediators + clinical conditions

59

SIRS to MODS transition

a) Failure to control source of inflammation/infectionb) Persistent perfusion deficitc) Flow-dependent O2 consumption (abnormal DO2 & VO2)d) Necrotic tissue

60

SIRS/MODS patho summary

a) Maldistribution of vol → vasodilated + third spacing b) Imbalance O2 supply/ demand (abnormal DO2 and VO2)c) Hypermetabolicif A + C can't be fixed MODS OCCURSthe problem: inflammatory/immune response is over-activated, the body can’t clear the mediators and toxic metabolites fast enough and a self-perpetuating cycle exists

61

when does MODS occur?

after SIRS when vasodilation, third spacing, and hypermetabolic state can't be fixed

62

MODS: hyperdynamic CV response

INITIAL RESPONSE↑ CO, HR, DO2, VO2↓ PAWP, CVP, SVR

63

MODS: hypodynamic CV response

many mediators = myocardial depressants; their continued influence = ↓ myocardial contractility/function ↓ CO, DO2, VO2↑ CVPTachycardia, dysrhythmias, weak pulses

64

why does MODS hypodynamic CV response happen?

many mediators = myocardial depressants; their continued influence = ↓ myocardial contractility/function

65

cranial nerve III vs IV, VI

CN III is PERRLACN III, IV, VI is EOM intact - each is responsible for 2 movements

66

stage 1 hypertension + drugs

140-159/90-99Thiazide OR consider ACEi, ARB, CCB, BB (no comorbs)

67

stage 2 hypertension + drugs

≥ 160/100 2 drugs - Thiazide + ACEi, ARB, CCB, BB (no comorbs)

68

Target Organ Damage (MI, HF, CVA, DM, CKD) + htn drugs

- combo diuretic, ACEi, ARB, CCB, BB, Aldactone- lifestyle modification & pharm- if BP > 20/10 above goal → thiazide + other.

69

use diaphragm

Diaphragm: medium-high sounds,S1, S2

70

use bell

Bell: low pitched sounds mitral stenosis, diastolic murmurs, S3, S4

71

S3

indicates difficulty w/ passive filling LA to LV (mitral valve is open & blood is flowing in) VENTRICULAR gallop – “Kentucky”PASSIVE FILLING into noncompliant LVearly diastolic, bell, mitral area Left lateral position may increase the soundAssociate with HF (chronic or AMI)

72

S4

“atrial kick" - difficulty with active filling, LA actively contracting (typically, compensate↑ CO by ~25% but if bad contraction—heart will lose atrial kick = s4) 
- ventricle can no longer take any more ATRIAL gallop – “Tennessee”Blood entering noncompliant ventricle during ATRIAL CONTRACTIONlate diastolic, bell, mitral areaLeft lateral position may increase the soundAssociated with CHF, MI, AoS, HTN, and CAD A-fib will NOT have an S4 (no atrial kick)

73

you will not hear this heart sound with afib

S4 because a fib has no atrial kick

74

summation gallop

S3 and S4 Implies significant HF

75

S1

Best heard with the diaphragm Loudest at the apex Mitral and tricuspid valves close

76

S2

Best heard with the diaphragm Loudest at the base Aortic and pulmonic valves close

77

heart failure - decrease in CO leads to?

RAAS activation:sodium retention secondary to ALDOSTERONEfluid retention ADHvasoconstriction increases afterload - ANGIOTENSIN II

78

neurohormonal model

accounts for the effects of- prolonged sympathetic stimulation (first)- prolonged angiotensin release (kidneys need more volume)- prolonged aldosterone releaseserves as the basis for the treatment of heart failure

79

systolic heart failure: loop diuretics

do not impact neurohormonal model!

80

heart failure: beta blockers positive benefits

reduce sympathetic nervous system response by decreasing circulating catecholaminesreduce overstimulation of renin angiotensin system

81

most common reason for diastolic heart failure

chronic hypertension

82

acetaminophen consideration

Interferes with warfarin to prolong PT/INR Steven Johnson Syndrome

83

Tetraology of Fallot

Pulmonary stenosis, VSD, and R to L Shunt (cyanotic)

84

alpha nerve fibers release

NE - eye dilation, clammy, hypo bowelPERIPHERAL vasoconstriction, ↓ UOP, cool skin, gas exchange, bowel sounds

85

beta nerve fibers release

Epi - ↑ BG, heart & lung vasodilation, blood flow=O2 deliveryNE - ↑ free fatty, tissue perfusion, myocardial O2 needs

86

prolonged stress response is what?

medulla secreting more catecholamines

87

BP goal for young, healthy (less than 60)

lt 140/90

88

BP goal for older adult (60+)

lt 150/90

89

Max. Target HR

220 – Age

90

ideal body weight

Women: 100 lb + 5 lb for every inch over 5 feet Men: 106 lb + 6 lb for every inch over 5 feet

91

caloric need

IBW x 10 = basal caloric needs
• Basal caloric needs + [IBW x activity level]= total cals neededActivity level • 3= Sedentary • 5= Moderate • 10= Strenuous