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Shock summary Shock summary Presentation Transcript

  • Acute Medicine: Shock Hypovolaemic Shock Invxs FBC - ↑Hct in acute alcoholic binge due to diuresis. Hct is an InaccurateDefinition – inadequate tissue and organ perfusion leading to a hypoperfusion state & eventual marker of bld loss acutely.cellular hypoxia and its attendant sequelae. GXM 6 units U/E/CrS/S: Hypotension, ↓urine output, tachycardia, diaphoresis, AMS Troponin T & Cardiac enzymes Coagulation profile with DIVC screen (PT/PTT, pltlet, D-dimer)Types of Shock ABG – metab acidosis, ↑lactate, base deficits are poor Px factors ‘White’ shock ‘Red’ shock UPT - ?ectopic pregnancy? Ask for LMP Examine abdomen for pulsatile AAATypes Hypovolaemic Cardiogenic Neurogenic Septic AnaphylacticCauses Haemorrhage AMI Spinal injury Infxns Fluid Rx 1 L crystalloid fast infusion w/in 1 hr Assess response Burns Dysrhythmia Subsequent colloid or whole blood infusion Ruptured ectopic pregnancy ± CVP line Used to guide fluid Rx, esp in CCF patients Severe GE Acute pancreatitisS/S Pallor Pallor Warm skin Fever, rigors Fever, rigors Cardiogenic Shock Cold clammy skin Cold clammy N/↓ heart Warm skin Warm skin ECG Manage accordingly – refer acute coronary syndrome & ↑peri vas Ω skin rate Trop T & cardiac enzymes ACLS notes ↑peri vas Ω Neuro deficitInvxs ↓ Hct (late) Cardiac FBC enzymes Bld C/S Neurogenic Shock ECG Hx/PE Trauma – site, mechanism, force Neuro exam, DRE – document initial neurological deficitsAlso, Obstructive Shock due to tension pneumothorax, cardiac tamponade or pulmonary Immobilize Immobilize spine in neutral positionembolism Invxs C-spine X-ray (AP & lat) – ensure visualization up to C7/T1 junction ± Swimmer’s view (visualize C7/T1 jn) & open mouth view (visualize C1/2Management injury) Thoracic & lumbar spine X-ray (AP & lat)General Mx ± CT scanAirway Maintain airway – consider intubation if necessary ± MRI laterBreathing 100% O2 via non-rebreather mask Fluid Rx Titrate fluid resus with urine outputCirculation 2 large bore (14-16G) cannulae ± vasopressors if BP does not respond to fluid challenge ± Inotropic support ± IV methyl 30 mg/kg over 15mins, followed by 5.4mg/kg/h for nxt 23 hrs o IV dopamine 5-10μg/kg/min prednisolone Indications – non-penetrating spinal cord injury & w/in 8 hrs of injury o IV dobutamine 5-10μg/kg/min (esp for cardiogenic shock) Contraindications o IV norepinephrine 5-20μg/kg/min (esp for septic shock) o <13YOMonitoring Pulse oximetry o pregnancy ECG o mild injury of the cauda equina / nerve root BP o abdominal trauma present Heart rate o major life-threatening morbidity Urine output – catheterize patient Disposition Refer Ortho / NeuroSx
  • Obstructive Shock ndTension Decompression: insert 14G cannula over 2 intercostals space in mid- Septic ShockPneumothorax clav. Line Sepsis = ≥ 2 of the following present:Cardiac IV fluid bolus 500ml N/S o o Temp >38 or <36 Ctamponade ± IV dopamine infusion 5μg/kg/min o HR > 90bpm Prepare for pericardiocentesis o RR > 20 breaths/min OR PaCO2<32mmHgPul Embolism Invx o 3 3 WCC>12000/mm , <4000/mm ,or >10% immature forms FBC Hx / PE Identify site of infxn – UTI (indwelling cathether), gallbladder dz, peritonitis, GXM 6 units pneumonia, appendicitis, immunocompromised state U/E/Cr Invx FBC - ↑ TW DIVC screen (D-dimer) U/E/Cr ABG DIVC screen – PT/PTT, pltlet, fibrinogen, D-dimer o ↓ PaO2 & N/↓ PaCO2 Bld C/S (2 different sites) o widened alveolo-arterial P02 gradient (AaPO2 >20mmHg) Capillary bld glucose ECG (may be normal) ABG o non-specific ST depression & T wave inversion CXR – pneumonia, ARDS o Sinus tachycardia ECG o Right heart strain Urine dipstick – UTI Right axis deviation Urine C/S Transient RBBB Fluid Rx Rapid infusion 1-2L crystalloids T wave inversion in V1-3 P pulmonale ± CVP line insertion S1Q3T3 ± Inotropic if no response to fluid Rx o Exclude DDxes – MI, pericarditis support Noradrenaline (drug of choice) - 1μg/kg/min OR CXR (may be normal) Dopamin 5-20μg/kg/min rd o Westermark sign – oligaemic lung fields Empirical ABx Immunocompetent w/o obvious 3 gen cephalosporin (IV ceftriaxone o Pul infarcts – wedge shape opacities w apex pointing source 1g) OR towards the hilum Quinolones (ciprofloxacin 200mg) o Atelectasis Immunocompromised w/o Anti-pseudomonal ABx (IV ceftazidime o Pleural effusions obvious source 1g) OR o Raised diaphragm Quinolone o Consolidation PLUS aminoglycoside (Gentamicin o ‘Plump’ pul. arteries 80mg) o Exclude DDxes – pneumothorax, pneumonia, L heart Gram-positive (burns, FB / lines IV cefazolin 2g failure, tumour, rib #, massive pleural effusion, lobar present) IV vancomycin 1g if hx of IVDA, collapse indwelling cath. Or penicillin allergy ± Spiral CT, Echo, MRI, lung scintigraphy, pulmonary angiogram (gold Anaerobic source (intra-abdo, IV metronidazole 500mg + std) biliary, female genital tract, ceftriazone 1g + IV gentamicin 80mg aspiration pneumonia) Rx Pain relieve – use Opioids with caution Fluid Rx & inotropic support if haemodynamically unstable Anticoagulation Rx: o IV heparin 5000U bolus or SC fraxiparine (0.4ml if <50kg; 0.5ml if 50-65kg; 0.6ml if >65kg) o Convert to Oral warfarin later ± Thrombolysis o Intra pul. arterial urokinase fro 12-24 hrs Surgical o Complete IVC ligation or partial caval interruption
  • Anaphylactic ShockDefinitions Urticaria – oedematous & pruritic plaques w pale centre & raised edges Angioedema – oedema of deeper layers of the skin. Non-pruritic. May be a/w numbness & pain Anaphylaxis – severe systemic allergic rxn to an Ag. Ppt by abrupt release of chemical mediators in a previously sensitized patient Anaphylactoid rxn – resembles anaphylactic rxn, but due to direct histamine release from mast cells w/o need for prior sensitizationCommon causes Drugs – penicililns & NSAIDS commonest, aspirin, TCM, sulpha drugs Food – shellfish, egg white, peanuts Venoms – bees, wasps, hornets Environment – dust, pollen Infections – EBV, HBV, coxsackie virus, parasitesStop Pptant Stop administration of suspected agent / flick out insect stinger with tongue blade Gastric lavage & activated charcoal if drug was ingestedAirway Prepare for intubation or cricothyroidectomy – ENT/Anaesthesia consultFluid Rx 2L Hartman’s or N/S bolusDrug Rx Adrenaline Normotensive – 0.01ml/kg (max 0.5ml) 1:1000 dilution SC/IM Hypotensive – 0.1ml/kg (max 5ml) 1:10,000 dilution IV over 5 mins Glucagon Indications: failure of adrenaline Rx OR if adrenaline is contraindicated eg IHD, severe HPT, pregnancy, β-blocker use 0.5-1.0mg IV/IM. Can be repeated once after 30mins Antihistamines Diphenhydramine 25mg IM/IV Chlorpheniramine 10mg IM/IV Promethazine 25mg IM/IV Cimetidine For persistent symptoms unresponsive to above Rx 200-400mg IV bolus Nebulised for persistent bronchospasm bronchodilator Salbutamol 2:2 q20-30mins Corticosteroids Hydrocortisone 200-300mg IV bolus, q 6hr Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT- Campus, Terengganu, ou=Internal Medicine Group, email=wunna.hlashwe@gmail. com Reason: This document is for UCSI year 4 students. Date: 2009.02.19 09:32:18 +0800