9.2 Shock / Hypotension Flashcards

Question

Hypoadrenal Shock | Definition

Answer 1

⇒Normally⇐ Illness, Qx or Trauma ⇓ ↑cortisol (in excess by adrenal glands) ⇒Adrenal insufficiency⇐ complicates the host response to Illness, Qx or Trauma

Answer 2

``` ▸Most common: ▹Chronic administration of high doses of exogenous glucocorticoids ▸Less common: ▹Idiopathic atrophy ▹Etomidate for intubation ▹Tb ▹Metastatic disease ▹Amyloidosis ```

Answer 3

▸ACTH stimulation test | ▹Cortisol ≦9µg/dL change poststimulation

Answer 4

▸Dexamethasone 4mg IV ▹empiric tx meanwhile Dx test (because doesn't interfere with ACTH test, like Hydrocortisone) ▸Hydrocortisone 100mg q6-8h ▹ONCE DIAGNOSED

Answer 5

▸Systemic hypoperfusion due to a myocardial dysfunction

Answer 6

``` ▸Acute myocardial infarction (most common) ▹CS is leading cause of death in MI ▹ST elevation MI (STEMI): Shock typically associated. ▹non-STEMI: less common ▸Cardiomyopathy ▸Myocarditis ▸Cardiac tamponade ▸Critical valvular heart disease ```

Answer 7

``` Ischemia ⇓ ↓myocardial contractility ⇓ ↓cardiac output ↓BP ⇓ A & B ``` A. Hypoperfusion of myocardium ⇓ Ischemia ``` B. Diastolic dysfunction ⇓ ↓Left Ventricle end-diastolic pressure (LVEDP) ⇓ Pulmonary congestion ⇓ Ischemia ```

Answer 8

``` ▸ECG (invaluable) ▹Q waves ± >2mm ST elevation ▸CXR ▹Pulmonary vascular congestion ▹Pulmonar edema ▸Echocardiogram ▹Define the etiology ```

Answer 9

↑WBC (with left shift) ↑BUN & ↑Cr ↑Hepatic transaminases (hepatic hypoperfusion) ↑Lactic acid ↑Cardiac markers (CPK-MB, Troponine I & T)

Answer 10

▸Chest pain ▸HR 90-110x' and weak ▸sBP <90mmHg

Answer 11

▸Goal is maintain adequate systemic and coronary perfusion ▹MAP >60 or sBP ≧90 ▸Reperfusion-Revascularization ▸Vasopressors

Answer 12

▸Norepinephrine ▹Initial vasopressor therapy ▹2-4µg/min ▹If sBP 10µg/kg/min (∝ dose): ↑BP

Answer 13

▸Systemic inflammatory response syndrome (SIRS): 2 or more of ▹38.5ºC ▹HR >90 ▹Respiratory rate >20 ▹WBC 12 or 10% bands ▸Sepsis: SIRS + infection ▸Severe sepsis: sepsis + signs of end-organ dysfunction ▸Septic shock: sepsis + ↓BP (despite fluid resuscitation or need cathecolamines)

Answer 14

``` ▸Arterial hypoxemia ▸Oliguria (0.5 mg/dL ▸Coagulation abnormalities (INR >1.5 or aPTT >60 sec) ▸Ileus (absent bowel sounds) ▸Thrombocytopenia (12,000) ```

Answer 15

``` ▸Fever ▸Tachypnea ▸↑HR ▸↓BP ▸local signs of infection ▸cool extremities ```

Answer 16

``` ▸Blood cultures x3 (from different sites) ▸Urinalysis ▸Urine C&S (Culture & Sensitivity) ▸Culture of any wounds ▸CXR (pneumonia) ▸Lactate ▸CBC + differential ▸Electrolytes ▸BUN & Cr ▸Liver enzymes ▸ABG ▸INR ▸PTT ```

Answer 17

▸After samples of blood have been taken ▸Maximal doses (adjust in renal Px) ▸IN THE FIRST HOUR ▸Pseudomonas unlikely: ▹(Ceftriaxone or Piperacillin-Tazobactam or Meropenem) ± Vancomycin ▸Pseudomonas possible: ▹(Ceftazidime or Meropenem or Pip-Taxo) AND (Ciprofloxacin or Gentamicin) ▸Activated protein C ▹Modulate coagulation and inflammation in severe sepsis ▸Hydrocortisone (50mg c/6hrs IV) ▹For unresponsive px to fluid resuscitation (NS) and vasopressors ▸Removal of source of infection ▹Foley and catheters should be replaced ▸Heparinization prevent thrombosis (if not contraindication)

Answer 18

``` (In 6 hours) 1. Antibiotics Community infection or Nosocomial (MRSA & Pseudomonas) Within the first hour of Dx 2. CVP Boost to 8-12 (normal 2-5) Normal Saline (NS) 3. Vasopressors (∝ & β) Goal MAP >65 Norepinephrine Dopamine 4. No better perfusion (SvO₂10⇒Dobutamine ```

Answer 19

▸ Exaggerated immune response (classically IgE) ▸Hallmark: Onset within seconds - minutes after exposure ▸Anaphylactoid reaction: non-IgE mediated, first exposure

Answer 20

``` ▸Foods (nuts, shellfish, etc.) ▸Stings ▸Drugs ▸Radiographic contrast media ▸Blood products ▸Latex ```

Answer 21

▸Remove causative agent; secure ABCs ▸Epinephrine ▹∝ & β effects (↑BP & bronchial smooth-muscle relaxation) ▹On scene - epi-pen if available ▹Moderate (minimal airway edema, mild bronchospasm) -Adult: 0.3-0.5 mL IM q5-20min (1:1000) -Child: 0.01 mL/kg/dose - 0.4 mL/dose (1:1000) ▹Severe (laryngeal edema, severe bronchospasm and severe ↓BP) -adults: 1mL IV or ETT -child: 0.01 mL/kg IV or ETT ▸Diphenhydramine 50 mg IM or IV q4-6h ▹For urticaria-angioedema ▸Methylprednisolone 50-100 mg IV ▸Salbutamol via nebulizer if bronchospasm ▸Glucagon 5-15 µg q1min IV (Px with β-blockers or cardiac disease) ▸Monitor for 4-6 h in ER ▸Follow up with family doctor en 24-48 h ▹Can have second phase (biphasic reaction) ▸3-day course of: ▹H₁ antagonist: Cetirizine 10 mg PO day ▹H₂ antagonist: Ranitidine 150 mg PO day ▹Corticosteroid: Prednisone 50 mg PO day

9.2 Shock / Hypotension Flashcards

Hypotension/shock is a frequently encountered, life-threatening emergency. Regardless of the underlying cause, certain general measures are usually indicated that can be life-saving. (45 cards)