Common Critical Conditions

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Common Critical Conditions in the ICU

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  • Common Critical Conditions

    1. 1. <ul><ul><ul><li>“ Never let what you cannot do interfere with what you can do” </li></ul></ul></ul>CRITICAL CONDITIONS Sherry L. Knowles, RN, CCRN, CRNI
    2. 2. <ul><li>OBJECTIVES </li></ul><ul><li>Recognize the signs & symptoms of several common (critical) medical conditions. </li></ul><ul><li>Describe the current treatment modalities of those common (critical) medical conditions. </li></ul><ul><li>Discuss the overall management of select (critical) medical conditions. </li></ul><ul><li>Identify the nursing interventions of several common (critical) medical conditions. </li></ul>CRITICAL CONDITIONS
    3. 3. <ul><li>Respiratory Failure </li></ul><ul><li>ARDS </li></ul><ul><li>Acute MI </li></ul><ul><li>CHF </li></ul>CRITICAL CONDITIONS <ul><li>GI Bleed </li></ul><ul><li>DKA </li></ul><ul><li>Shock </li></ul><ul><li>Sepsis </li></ul>
    4. 4. <ul><li>DEFINITION </li></ul><ul><ul><li>A respiratory system that fails to maintain adequate gas exchange. </li></ul></ul><ul><ul><li>Acute loss of adequate oxygenation at the tissue level. </li></ul></ul><ul><ul><li>PaO 2 < 60 mmHg and/or PaCO 2 > 50 mmHg @ 21% FiO 2 </li></ul></ul><ul><ul><ul><li>In chronic hypercapnia: pH < 7.35 </li></ul></ul></ul><ul><ul><li>Respiratory failure may be evidenced by a high or low pCO2 level. </li></ul></ul>RESPIRATORY FAILURE
    5. 5. <ul><li>TYPES OF FAILURE </li></ul><ul><ul><li>Hypercapnic Respiratory Failure is ineffective ventilation (increased PaCO 2 ), with normal oxygenation (normal alveolar-arterial O2 gradient). </li></ul></ul><ul><ul><li>Hypoxemic Respiratory Failure is characterized by low PaO 2 , markedly elevated P(A-a)O 2 gradient, and usually low PaCO 2 , reflecting adequate ventilation, but inadequate gas exchange. </li></ul></ul>RESPIRATORY FAILURE
    6. 6. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Neurological </li></ul></ul><ul><ul><ul><li>Restlessness, Agitation, Headache Disorientation, Seizures,  LOC </li></ul></ul></ul><ul><ul><li>Cardiovascular </li></ul></ul><ul><ul><ul><li> Heart Rate, Hypertension (early), Hypotension (late), Chest Pain , Dysrhythmias </li></ul></ul></ul><ul><ul><li>Respiratory </li></ul></ul><ul><ul><ul><li> Respirations,  Respiratory Effort </li></ul></ul></ul>RESPIRATORY FAILURE
    7. 7. <ul><li>CAUSES </li></ul><ul><ul><li>V/Q Mismatch </li></ul></ul><ul><ul><ul><li>Ventilation / Perfusion Mismatch </li></ul></ul></ul><ul><ul><ul><li> V/Q ratio =  ventilation to perfusion </li></ul></ul></ul><ul><ul><li>Intrapulmonary Shunt </li></ul></ul><ul><ul><ul><li>Perfusion without ventilation </li></ul></ul></ul><ul><ul><li>Cardiac Failure </li></ul></ul><ul><ul><ul><li>May result in pulmonary congestion </li></ul></ul></ul>RESPIRATORY FAILURE
    8. 8. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><ul><li> UOP, Edema </li></ul></ul></ul><ul><ul><li>Gastrointestinal </li></ul></ul><ul><ul><ul><li> Bowel Sounds, Nausea/Vomiting, Abd Distention, Bleeding </li></ul></ul></ul><ul><ul><li>Integumentary </li></ul></ul><ul><ul><ul><li>Cool, clammy, pale skin, Decreased Capillary Refill </li></ul></ul></ul>RESPIRATORY FAILURE
    9. 9. <ul><li>TREATMENT </li></ul><ul><ul><li>Protect the Airway </li></ul></ul><ul><ul><ul><li>Intubation (if needed) </li></ul></ul></ul><ul><ul><ul><li>Bronchodilators </li></ul></ul></ul><ul><ul><ul><li>Hydration (as appropriate) </li></ul></ul></ul><ul><ul><ul><li>Mucolytic (if appropriate) </li></ul></ul></ul>RESPIRATORY FAILURE
    10. 10. <ul><li>TREATMENT </li></ul><ul><ul><li>Correct the Acid-Base Imbalance </li></ul></ul><ul><ul><ul><li>ABG’s </li></ul></ul></ul><ul><ul><ul><li>Bronchodilators </li></ul></ul></ul><ul><ul><ul><li>Mechanical or non-invasive ventilation </li></ul></ul></ul><ul><ul><ul><li>Treat the Cause </li></ul></ul></ul><ul><ul><ul><ul><li>Reduce sedation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Add sedation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Bring fever down </li></ul></ul></ul></ul>RESPIRATORY FAILURE
    11. 11. <ul><li>TREATMENT </li></ul><ul><ul><li> FiO 2 </li></ul></ul><ul><ul><ul><li>Ineffective with shunting </li></ul></ul></ul><ul><ul><ul><li>Prolonged O2 > 40% may cause O2 toxicity (lung damage) </li></ul></ul></ul><ul><ul><ul><li>Must use caution with CO2 retainers </li></ul></ul></ul><ul><ul><ul><ul><li>Chronic hypercapnia causes CO2 retainers to use hypoxic (O 2 ) drive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Too much O2 can depress respirations </li></ul></ul></ul></ul>RESPIRATORY FAILURE
    12. 12. <ul><li>NURSING INTERVENTIONS </li></ul><ul><ul><li>Monitor the Patient </li></ul></ul><ul><ul><ul><li>Monitor ABG’s </li></ul></ul></ul><ul><ul><ul><li>Monitor respiratory status </li></ul></ul></ul><ul><ul><ul><li>Monitor response to therapies </li></ul></ul></ul><ul><ul><li>Report Changes </li></ul></ul><ul><ul><ul><li>Watch for improvement </li></ul></ul></ul><ul><ul><ul><li>Keep respiratory status well documented </li></ul></ul></ul><ul><ul><li>Treat Causes </li></ul></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Mucolytics </li></ul></ul></ul>RESPIRATORY FAILURE
    13. 13. <ul><li>DEFINITION </li></ul><ul><ul><li>Syndrome that causes damage to the alveolar-capillary interface. </li></ul></ul><ul><ul><li>Causes an acute lung injury that causes  pulmonary capillary permeability and alveolar flooding. </li></ul></ul><ul><ul><li>Characterized by non-cardiogenic pulmonary edema, respiratory distress, and hypoxemia. </li></ul></ul>ARDS
    14. 14. <ul><li>CAUSES </li></ul><ul><ul><li>Aspiration Injuries </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Multiple Blood Transfusions </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>Shock States </li></ul></ul><ul><ul><li>Severe Pancreatitis </li></ul></ul><ul><ul><li>Embolism </li></ul></ul>ARDS
    15. 15. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Low Pa O2 </li></ul></ul><ul><ul><li>Intrapulmonary Shunting </li></ul></ul><ul><ul><ul><li>Low Pa O2 despite high FiO 2 </li></ul></ul></ul><ul><ul><li>Pulmonary Crackles </li></ul></ul><ul><ul><li>Diffuse bilateral alveolar infiltrates </li></ul></ul><ul><ul><li>Low or normal PAWP </li></ul></ul>ARDS
    16. 16. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><ul><li>Irritability, confusion, hyperventilation, tachypnea, dyspnea, tachycardia </li></ul></ul></ul><ul><ul><li>Late </li></ul></ul><ul><ul><ul><li>Increasing respiratory insufficiency,  pulmonary compliance (  pulmonary vascular resistance), PCO 2 retention, frothy sputum, pulmonary crackles </li></ul></ul></ul>ARDS
    17. 17. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Barotrauma </li></ul></ul><ul><ul><li>Pulmonary Fibrosis </li></ul></ul><ul><ul><li>Pulmonary Emboli </li></ul></ul><ul><ul><li> Cardiac Output </li></ul></ul><ul><ul><li>Renal Failure </li></ul></ul><ul><ul><li>Nosocomial Pneumonia </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>DIC </li></ul></ul>ARDS
    18. 18. <ul><li>TREATMENT </li></ul><ul><ul><li>Maintain Oxygenation </li></ul></ul><ul><ul><ul><li>BiPAP, CPAP </li></ul></ul></ul><ul><ul><ul><li>Intubation </li></ul></ul></ul><ul><ul><ul><li>PEEP </li></ul></ul></ul><ul><ul><ul><li>ABG Monitoring </li></ul></ul></ul><ul><ul><li>Maintain Vascular Volume </li></ul></ul><ul><ul><ul><li>IVF </li></ul></ul></ul><ul><ul><ul><li>Fluid Restriction </li></ul></ul></ul><ul><ul><li>Treat the Cause </li></ul></ul><ul><ul><ul><li>Antibiotics </li></ul></ul></ul>ARDS
    19. 19. <ul><li>DEFINITION </li></ul><ul><ul><li>Infarction occurs due to mechanical obstruction of a coronary artery (or branch) caused by a thrombus, plaque rupture, coronary spasm and/or dissection. </li></ul></ul>ACUTE MI
    20. 20. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Complains vary and may include crushing chest pain (which may or may not radiate), back, neck, jaw, teeth and/or epigastric pain, nausea/vomiting and dizziness. </li></ul></ul><ul><ul><li>ST elevations on ECG </li></ul></ul><ul><ul><li>Elevated cardiac enzymes </li></ul></ul>ACUTE MI
    21. 21. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li> PAWP,  CO,  SVR, dysrhythmias, S 4 , cardiac failure, cardiogenic shock </li></ul></ul><ul><ul><li>Diaphoresis, pallor, referred pains </li></ul></ul><ul><ul><li>Diabetics and women often present abnormal symptoms </li></ul></ul>ACUTE MI
    22. 22. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Dysrhythmias, heart failure, pericarditis, ventricular aneurysms, ventricular thrombus, VSD, mitral regurgitation, papillary muscle (or chordae tendineae) rupture, pericardial effusions, pericarditis </li></ul></ul>ACUTE MI
    23. 23. <ul><li>TREATMENT </li></ul><ul><ul><li>Time Is Heart Muscle </li></ul></ul><ul><ul><li>The goal of treatment for an AMI is to relieve pain, limit the size of the infarction and to prevent complications, primarily lethal dysrhythmias </li></ul></ul><ul><ul><li>Prompt ECG </li></ul></ul>ACUTE MI
    24. 24. <ul><li>TREATMENT </li></ul><ul><ul><li>Usual medications include O 2 , NTG, MSO 4 , aspirin, heparin, beta-blockers, and ace inhibitors. May also include thrombolytics or Gp2a3b inhibitors </li></ul></ul><ul><ul><li>Cardiac Catheterization (with angioplasty, atherectomy and/or stent) </li></ul></ul><ul><ul><li>IABP, CABG, Education </li></ul></ul>ACUTE MI
    25. 25. <ul><li>TREATMENT </li></ul><ul><ul><li>IWMI </li></ul></ul><ul><ul><ul><li>Fluids </li></ul></ul></ul><ul><ul><ul><li>Inotropics </li></ul></ul></ul><ul><ul><ul><li>Afterload reducing medications </li></ul></ul></ul><ul><ul><li>AWMI </li></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Inotropics </li></ul></ul></ul><ul><ul><ul><li>Afterload reducing medications </li></ul></ul></ul>ACUTE MI
    26. 26. <ul><li>NURSING INTERVENTIONS </li></ul><ul><ul><li>O 2 </li></ul></ul><ul><ul><li>Bedrest </li></ul></ul><ul><ul><li>Serial ECG’s </li></ul></ul><ul><ul><li>Serial cardiac enzymes </li></ul></ul><ul><ul><li>Keep pain free (NTG. MSO 4 ) </li></ul></ul><ul><ul><li>Aspirin, heparin, beta-blockers, ace inhibitors, Gp2a3b inhibitors, thrombolytics, PTCA, IABP, CABG </li></ul></ul>ACUTE MI
    27. 27. <ul><li>DEFINITION </li></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><ul><li>A condition in which the heart cannot pump sufficient blood to meet the metabolic needs of the body. </li></ul></ul></ul><ul><ul><ul><li>Pulmonary (LVF) and/or systemic (RVF) congestion is present. </li></ul></ul></ul>CHF
    28. 28. <ul><li>DEFINITION </li></ul><ul><ul><li>Pulmonary Edema </li></ul></ul><ul><ul><ul><li>Fluid in the alveolus that impairs gas exchange by altering the diffusion between alveolus and capillary; acute left ventricular failure causes cardiogenic pulmonary edema. </li></ul></ul></ul><ul><ul><ul><li>Non-cardiogenic pulmonary edema is a synonym for Adult Respiratory Distress Syndrome (ARDS). </li></ul></ul></ul>CHF
    29. 29. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Sympaththetic nervous system stimulation </li></ul></ul><ul><ul><ul><li>Tachycardia </li></ul></ul></ul><ul><ul><ul><li>Vasoconstriction and increased SVR </li></ul></ul></ul><ul><ul><li>Renin-angiotensin-aldosterone system activation </li></ul></ul><ul><ul><ul><li>Hypo perfusion to the kidneys (rennin) </li></ul></ul></ul><ul><ul><ul><li>Vasoconstriction (angiotension) </li></ul></ul></ul><ul><ul><ul><li>Sodium and water retention (kidneys) </li></ul></ul></ul><ul><ul><ul><li>Ventricular dilation </li></ul></ul></ul><ul><ul><li>See Handout </li></ul></ul>CHF
    30. 30. <ul><li>FUNCTIONAL CLASSIFICATIONS </li></ul><ul><ul><li>Class I </li></ul></ul><ul><ul><li>Class II </li></ul></ul><ul><ul><li>Class III </li></ul></ul><ul><ul><li>Class IV </li></ul></ul>CHF
    31. 31. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Respiratory Failure </li></ul></ul><ul><ul><li>Dysrhythmias </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Progressive Deterioration </li></ul></ul><ul><ul><li>Acute Renal Failure </li></ul></ul><ul><ul><li>Fluid & Electrolyte Imbalances </li></ul></ul>CHF
    32. 32. <ul><li>TREATMENT </li></ul><ul><ul><li>Improve Oxygenation </li></ul></ul><ul><ul><li>Decrease Myocardial Oxygen Demand </li></ul></ul><ul><ul><li>Decrease Preload </li></ul></ul><ul><ul><li>Decrease Afterload </li></ul></ul><ul><ul><li>Increase Contractility </li></ul></ul><ul><ul><li>Manage Dysrhythmias </li></ul></ul>CHF
    33. 33. <ul><li>CAUSES </li></ul><ul><ul><li>PUD </li></ul></ul><ul><ul><li>Stress Ulcers </li></ul></ul><ul><ul><li>Esophageal Varicies </li></ul></ul><ul><ul><li>Portal Hypertension </li></ul></ul><ul><ul><li>Mallory Weiss Syndrome </li></ul></ul>GI BLEED
    34. 34. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Hematemesis </li></ul></ul><ul><ul><li>Hematochezia </li></ul></ul><ul><ul><li> BP </li></ul></ul><ul><ul><li> H & H </li></ul></ul><ul><ul><li> BUN </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Syncope </li></ul></ul>GI BLEED
    35. 35. <ul><li>TREATMENT </li></ul><ul><ul><li>Hemodynamic Stabilization </li></ul></ul><ul><ul><ul><li>Blood, IVF, NGT, antacids, H 2 blockers, antibiotics, serial H & H’s and clotting factors </li></ul></ul></ul><ul><ul><li>Vasopressin (Pitressin) </li></ul></ul><ul><ul><li>Sengstaken-Blakemore or Minnesota Tube </li></ul></ul><ul><ul><li>Sclerotherapy </li></ul></ul><ul><ul><li>Laser Electorcautery </li></ul></ul><ul><ul><li>Surgery </li></ul></ul>GI BLEED
    36. 36. <ul><li>NURSING INTERVENTIONS </li></ul><ul><ul><li>Large Bore IV’s </li></ul></ul><ul><ul><li>Type & Cross Match Blood </li></ul></ul><ul><ul><li>Serial H & H’s (q4hr) </li></ul></ul><ul><ul><li>Monitor Clotting Factors </li></ul></ul><ul><ul><li>Watch for Complications </li></ul></ul><ul><ul><ul><li>ARF, ARDS, DIC </li></ul></ul></ul><ul><ul><li>Maintain Tubes </li></ul></ul><ul><ul><ul><li>NG, Blakemore or Minnesota Tube </li></ul></ul></ul>GI BLEED
    37. 37. <ul><li>DEFINITION </li></ul><ul><ul><li>Serious or life-threatening complication usually from diabetes mellitus type I. </li></ul></ul><ul><ul><li>Results from relative or absolute insulin deficiency. </li></ul></ul>DKA
    38. 38. <ul><li>CAUSES </li></ul><ul><ul><li>Type I DM </li></ul></ul><ul><ul><li>Insufficient Insulin Dosing </li></ul></ul><ul><ul><li>Poor Compliance </li></ul></ul><ul><ul><li>Malfunctioning Insulin Pump </li></ul></ul><ul><ul><li>Phenytoin (Dilantin) </li></ul></ul><ul><ul><li>Thiazide/Sulfonamide Diuretics </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><ul><li>New Onset DM </li></ul></ul>DKA
    39. 39. <ul><li>SIGNS & SYMPTOMS   </li></ul><ul><ul><li>Sudden Onset (hours) </li></ul></ul><ul><ul><li>Serum Glucose 300-800 </li></ul></ul><ul><ul><li>Ketones Strongly Positive </li></ul></ul><ul><ul><li>Serum pH < 7.3 (Ketoacidosis) </li></ul></ul><ul><ul><li>Fruity Acetone Breath (Ketones) </li></ul></ul><ul><ul><li>Kussmaul Respirations </li></ul></ul><ul><ul><li>Serum Osmolarity < 350 </li></ul></ul>DKA
    40. 40. <ul><li>SIGNS & SYMPTOMS   </li></ul><ul><ul><li>Thirst (polydipsia) </li></ul></ul><ul><ul><li>Dry Mouth </li></ul></ul><ul><ul><li>Dry Skin </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Kussmaul Respirations </li></ul></ul><ul><ul><li>Polyuria </li></ul></ul>DKA <ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Mental confusion </li></ul></ul><ul><ul><li>Changes in LOC </li></ul></ul><ul><ul><li>Mental confusion </li></ul></ul><ul><ul><li>Changes in LOC </li></ul></ul>
    41. 41. <ul><li>TREATMENT </li></ul><ul><ul><li>Reverse Dehydration </li></ul></ul><ul><ul><ul><li>Rapid IVF Replacement </li></ul></ul></ul><ul><ul><ul><ul><li>NS, then ½ NS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Continue NS If Needed </li></ul></ul></ul></ul><ul><ul><ul><li>Prevent Hypoglycemia </li></ul></ul></ul><ul><ul><ul><ul><li>D5½ NS when Glu 250 </li></ul></ul></ul></ul>DKA
    42. 42. <ul><li>TREATMENT </li></ul><ul><ul><li>Restore Normal Glucose Levels </li></ul></ul><ul><ul><ul><li>Give Rapid Acting Insulin </li></ul></ul></ul><ul><ul><ul><li>Frequent Glu Monitoring (q ½ - 1 hr) </li></ul></ul></ul><ul><ul><ul><li>Monitor Serum and Urine Ketones </li></ul></ul></ul>DKA
    43. 43. <ul><li>TREATMENT </li></ul><ul><ul><li>Replenish Electrolytes </li></ul></ul><ul><ul><ul><li>Watch for Dilution </li></ul></ul></ul><ul><ul><ul><li>Monitor Electrolytes Frequently </li></ul></ul></ul><ul><ul><ul><li>Insulin Lowers Serum K </li></ul></ul></ul>DKA
    44. 44. <ul><li>ADDITIONAL INTERVENTIONS </li></ul><ul><ul><li>Monitor Frequent Accuchecks (q1hr) </li></ul></ul><ul><ul><li>Monitor Serial Serum Glucose (q4hr) </li></ul></ul><ul><ul><li>Monitor Serial Electrolytes (4hr) </li></ul></ul><ul><ul><li>Monitor Anion Gap (q4hr) </li></ul></ul><ul><ul><li>Monitor Serum & Urine Ketones </li></ul></ul>DKA
    45. 45. <ul><li>DEFINITION </li></ul><ul><ul><li>Inadequate perfusion to the body tissues </li></ul></ul><ul><ul><li>Low blood pressure with impaired perfusion to the end organs </li></ul></ul><ul><ul><li>May result in multiple organ dysfunction </li></ul></ul>SHOCK
    46. 46. <ul><li>TYPES OF SHOCK </li></ul><ul><ul><li>Hypovolemic Shock </li></ul></ul><ul><ul><li>Cardiogenic Shock </li></ul></ul><ul><ul><li>Distributive Shock </li></ul></ul><ul><ul><li>Obstructive Shock </li></ul></ul>SHOCK
    47. 47. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><li>The body attempts to compensate for shock: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><ul><li>Attempts to deliver more blood to the tissues </li></ul></ul></ul><ul><ul><li>Vasoconstriction </li></ul></ul><ul><ul><ul><li>Attempts to maintain adequate BP in order to adequately perfuse the body tissues </li></ul></ul></ul><ul><ul><li>Increased ADH Secretion </li></ul></ul><ul><ul><ul><li>ADH makes the body hold onto water in an effort to maintain volume and thus enough blood pressure to perfuse the body tissues </li></ul></ul></ul>SHOCK
    48. 48. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Hypovolemic Shock: </li></ul></ul><ul><ul><ul><li>Low BP , tachycardia, orthostatic hypotension, </li></ul></ul></ul><ul><ul><ul><li>restlessness, confusion, agitation (or listless), </li></ul></ul></ul><ul><ul><ul><li>thirst, pallor, cool, clammy skin,  resp. rate, </li></ul></ul></ul><ul><ul><ul><li> UOP,  CO,  PAWP,  CVP,  SVR, </li></ul></ul></ul><ul><ul><ul><li> lactate levels </li></ul></ul></ul>SHOCK
    49. 49. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Cardiogenic Shock: </li></ul></ul><ul><ul><ul><li>Low BP , tachycardia, restlessness, confusion, </li></ul></ul></ul><ul><ul><ul><li>agitation (or listless), thirst, pallor, cool, </li></ul></ul></ul><ul><ul><ul><li>clammy skin,  resp. rate,  UOP,  CO, </li></ul></ul></ul><ul><ul><ul><li> PAWP (low with RVF),  CVP,  SVR, </li></ul></ul></ul><ul><ul><ul><li>JVD, peripheral edema, ventricular gallop, </li></ul></ul></ul><ul><ul><ul><li>dyspnea, pulmonary crackles,  lactate levels </li></ul></ul></ul>SHOCK
    50. 50. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Anaphylactic Shock: </li></ul></ul><ul><ul><ul><li>Low BP , tachycardia, orthostatic hypotension, </li></ul></ul></ul><ul><ul><ul><li>restlessness, confusion, agitation (or listless), </li></ul></ul></ul><ul><ul><ul><li>thirst, pallor, warm feeling, pruritus, hives, </li></ul></ul></ul><ul><ul><ul><li>angioedema, bronchoconstriction, wheezing, </li></ul></ul></ul><ul><ul><ul><li>laryngoedema, dyspnea, cool, clammy skin, </li></ul></ul></ul><ul><ul><ul><li> UOP,  CO,  PAWP,  CVP,  SVR, </li></ul></ul></ul><ul><ul><ul><li> lactate levels </li></ul></ul></ul>SHOCK
    51. 51. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Obstructive Shock: </li></ul></ul><ul><ul><ul><li>Low BP, tachycardia, restlessness, </li></ul></ul></ul><ul><ul><ul><li>confusion, agitation (or listless), pallor, </li></ul></ul></ul><ul><ul><ul><li>cool, clammy skin,  UOP,  CO, </li></ul></ul></ul><ul><ul><ul><li>symptoms related to cause </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>SHOCK
    52. 52. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Septic Shock: </li></ul></ul><ul><ul><ul><li>Early Stage (Hyper-dynamic, Warm Phase) </li></ul></ul></ul><ul><ul><ul><li>Normal BP, tachycardia, confusion, agitation (or listless),  resp. rate,  temp, normal color, normal or  UOP,  CO, normal PAWP,  CO,  SVR,  </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>SHOCK
    53. 53. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Septic Shock: </li></ul></ul><ul><ul><ul><li>Late Stage (Hypo-dynamic, Cold Phase) </li></ul></ul></ul><ul><ul><ul><li>Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>SHOCK
    54. 54. <ul><li>TREATMENTS </li></ul><ul><ul><li>Hypovolemic Shock: </li></ul></ul><ul><ul><ul><li>Volume (IVF, Blood) </li></ul></ul></ul><ul><ul><li>Cardiogenic Shock: </li></ul></ul><ul><ul><ul><li> CO </li></ul></ul></ul><ul><ul><ul><li> Preload & Afterload </li></ul></ul></ul><ul><ul><ul><li> Myocardial Demand </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>SHOCK
    55. 55. <ul><li>TREATMENTS </li></ul><ul><ul><li>Anaphylactic Shock: </li></ul></ul><ul><ul><ul><li>Epinephrine </li></ul></ul></ul><ul><ul><ul><li>IVF </li></ul></ul></ul><ul><ul><ul><li>Vasoconstrictors </li></ul></ul></ul><ul><ul><ul><li>Support/Maintain Airway </li></ul></ul></ul><ul><ul><li>Obstructive Shock: </li></ul></ul><ul><ul><ul><li>Treat the Cause </li></ul></ul></ul>SHOCK
    56. 56. <ul><li>TREATMENTS </li></ul><ul><ul><li>Septic Shock: </li></ul></ul><ul><ul><ul><li>IVF (150cc/hr or wide open) </li></ul></ul></ul><ul><ul><ul><li>Treat Cause (pan culture, antibiotics) </li></ul></ul></ul><ul><ul><ul><li>Vasoconstrictors in warm phase </li></ul></ul></ul><ul><ul><ul><li>Treat temp if needed </li></ul></ul></ul><ul><ul><ul><li> </li></ul></ul></ul>SHOCK
    57. 57. <ul><li>DEFINITION </li></ul><ul><ul><li>SIRS </li></ul></ul><ul><ul><ul><li>Systemic Inflammatory Response </li></ul></ul></ul><ul><ul><ul><li>Manifested by two or more of the following: </li></ul></ul></ul><ul><ul><ul><ul><li>Temp > 38C or < 36C, HR > 90/min, RR > 20/min, CO2 < 32 mmHg, WBC > 12,000 or < 4,000 or > 10% (immature) bands </li></ul></ul></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><ul><li>Inadequate perfusion to the body tissues due to bacteremia. </li></ul></ul></ul>SEPSIS
    58. 58. <ul><li>DEFINITION </li></ul><ul><ul><li>Severe Sepsis </li></ul></ul><ul><ul><ul><li>Sepsis associated with organ dysfunction, hypo-perfusion or hypotension. </li></ul></ul></ul><ul><ul><li>Septic Shock </li></ul></ul><ul><ul><ul><li>Systemic response to infection. </li></ul></ul></ul>SEPSIS
    59. 59. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Early Stage (Hyper-dynamic, Warm Phase) </li></ul></ul><ul><ul><ul><li>Normal BP, tachycardia, confusion, agitation (or listless),  resp. rate,  temp, normal color, normal or  UOP,  CO, normal PAWP,  CO,  SVR,  </li></ul></ul></ul>SEPSIS
    60. 60. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><ul><li>Late Stage (Hypo-dynamic, Cold Phase) </li></ul></ul><ul><ul><ul><li>Low BP, tachycardia, orthostatic hypotension, restlessness, confusion, agitation (or listless), thirst, pallor, cool, clammy skin,  UOP,  CO,  PAWP,  CVP,  SVR,  lactate levels </li></ul></ul></ul>SEPSIS
    61. 61. <ul><li>COMPLICATIONS </li></ul><ul><ul><li>Acute Renal Failure </li></ul></ul><ul><ul><li>Multiple Organ Failure </li></ul></ul><ul><ul><li>Disseminated Intravascular Coagulation </li></ul></ul><ul><ul><li>Death </li></ul></ul>SEPSIS
    62. 62. <ul><li>TREATMENT </li></ul><ul><ul><li>Give IVF (150cc/hr or wide open) </li></ul></ul><ul><ul><li>Treat the Cause (Pan culture, antibiotics,) </li></ul></ul><ul><ul><li>Give Vasoconstrictors in warm phase (vasoconstrictors are contraindicated in cold phase). </li></ul></ul><ul><ul><li>Treat Temperature as needed </li></ul></ul><ul><ul><li>Consider Protein Activated C (Xigris) </li></ul></ul>SEPSIS
    63. 63. <ul><ul><ul><li>THE END </li></ul></ul></ul>CRITICAL CONDITIONS
    64. 64. <ul><ul><ul><li>THANK YOU </li></ul></ul></ul>CRITICAL CONDITIONS
    65. 65. <ul><ul><ul><ul><ul><li>Johanson WG and Peters JI. &quot;Respiratory Failure.&quot; IN: Textbook of Respiratory Medicine , Murray and Nadel, eds.; 1988. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Morris AH. &quot;Acute Respiratory Failure.&quot; IN: Therapeutic Strategies in Current Therapy in Critical Care Medicine , JE Parrillo, ed.; 1987. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pontoppidan H, Geffin B and Lowenstein E. Acute respiratory failure in the adult, Parts I-III. N Engl J Med 287:690-698, 743-752, 799-806, 1972. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pingleton SK. Complications of acute respiratory failure. Am Rev Respir Dis 137:1463-1493, 1988. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Heffner JE. Tracheal intubation in mechanically ventilated patients. Clin Chest Med 9:23-35, 1988. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Stauffer JL. Medical Management of the Airway. Clin Chest Med 12:449-482. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Bone RC. Symposium on Respiratory Failure. Med Clinics of N Amer 67:551-750, 1983. </li></ul></ul></ul></ul></ul>REFERENCES

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