Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download Chapter 1: Introduction to Critical Care Transport
Document related concepts
no text concepts found
Transcript
Pulmonary Artery Pressure Monitoring (1 of 3) Central venous catheter passed through right atrium, right ventricle, past tricuspid valve, and into pulmonary artery Allows monitoring of: – Right ventricular function – Pulmonary vascular status – Left ventricular function (indirectly) PAP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Artery Pressure Monitoring (2 of 3) Specific parameters measured – CO – Right arterial pressure – Right ventricular pressure – Pulmonary artery pressure – Pulmonary artery wedge pressure (PAWP) PAP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Artery Pressure Monitoring (3 of 3) Catheter – Flow-directed, balloon-tipped pulmonary artery catheter Swan-Ganz catheter Dual lumen Distal port Proximal port Balloon inflated to: “Float” catheter into position Measure pulmonary wedge pressures PAP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Waveform Interpretation Pressure changes during systole and diastole Waveforms classified as: – Right atrial – Right ventricular – Pulmonary artery pressure – Pulmonary artery wedge pressure PAP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Indications of PA Catheter Placement (1 of 2) Diagnosis of shock states and shock types Diagnosis of high-pressure versus low-pressure pulmonary edema Assessment of vascular tone Assessment of myocardial contractility, including determination of cardiac output Assessment of intravascular fluid balance Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Indications of PA Catheter Placement (2 of 2) Analysis of mixed venous oxygen saturation Monitoring and management of complicated AMI Assessment of hemodynamic response to therapies Management of hemodynamic instability after cardiac surgery Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Insertion of PA Catheter (1 of 2) Catheter placed in vein Catheter fed into vein until distal tip in right atrium Distal balloon inflated with 1.5 cc of air Distal tip “floated” through tricuspid, into right ventricle, through pulmonic valve, and into pulmonary artery Balloon allowed to “wedge” itself in branch of pulmonary artery Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Insertion of PA Catheter (2 of 2) Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Right Atrial Pressure Mean right atrial pressure – 8 mmHg Right Atrial Pressure Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Right Ventricular Pressure (1 of 2) Right-atrial end-diastolic pressure – 0–8 mmHg – Equal to right atrial pressure when tricuspid valve opens Right Ventricular Pressure Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Right Ventricular Pressure (2 of 2) Right-atrial systolic pressure – 15–30 mmHg – Opens pulmonic valve Propels blood into pulmonary artery – Higher-pressure chamber Right Ventricular Pressure Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Artery Pressure (2 of 4) Systolic – 15–30 mmHg – Equal to right ventricular systolic pressure PAP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Artery Pressure (3 of 4) Diastolic – 8–15 mmHg – Reflects resistance of pulmonary vascular bed Left-ventricular end-diastolic pressure also PA diastolic pressure is indirect measurement of left ventricular pressure PAP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pulmonary Artery Wedge Pressure (PAWP) Measures left-atrial and ventricular end-diastolic pressure – More accurate than estimate from pulmonary artery diastolic pressure PAWP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ PAWP 8–12 mmHg Catheter tip placed in pulmonary artery – In-place pulmonary artery catheter used – Balloon on distal tip inflated – Balloon advanced until it lodges in branch of pulmonary artery Forward blood flow stopped Static column of blood created Branch of artery Pulmonary capillaries Pulmonary vein Left atrium Open mitral valve During diastole Left ventricle Balloon deflated after measurements completed PAWP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Complications of PA Catheterization Pulmonary injury – During needle puncture Dysrhythmias Infection Pulmonary artery rupture PAWP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Preparation for Hemodynamic Monitoring Prime the flush system Connect the transducer to the monitor Leveling the transducer Zero the pressure system to atmospheric pressure Calibrate the pressure system Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-aortic Balloon Pump (IABP) (1 of 6) Augments weakened heart’s cardiac output Percutanous placement of balloon catheter in aorta – Insertion site: Femoral – Balloon placed about 2 cm distal to aortic arch Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-Aortic Balloon Pump (IABP) (1 of 3) Provides mechanical circulatory support for failing heart Catheter – 30-cm balloon on distal end Balloons sized according to height – Placed in aorta distal to left of subclavian artery – Inserted in femoral artery – During operation, rapidly inflated and deflated with 35–40 ml of helium IABP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-aortic Balloon Pump (IABP) (2 of 6) Balloon inflated during ventricular diastole – Displaces blood forward and backward Forward Increases systemic blood flow Increases CO by 10 to 20 percent Backward Increases coronary artery filling Increases myocardial perfusion Balloon deflated during onset of ventricular systole – Decreases afterload – Improves ejection fraction (EF) Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-Aortic Balloon Pump (IABP) (2 of 3) IABP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Indications for IABP Therapy Cardiogenic shock Left ventricular failure Drug-induced cardiovascular failure Septic shock Cardiac surgery preparation IABP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-Aortic Balloon Pump (IABP) (3 of 3) IABP pump – Rate adjustable 1:1, 1:2, 1:8 – Inflation volume adjustable ©Craig Jackson/In the Dark Photography IABP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-aortic Balloon Pump (IABP) (3 of 6) Transport management of patient on IABP includes: – Evaluating patient response to treatment in terms of: Hemodynamic status Dysrhythmia control Systemic perfusion Relief of symptoms of cardiac ischemia Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-aortic Balloon Pump (IABP) (4 of 6) Transport management of patient on IABP includes: – Observing such early signs of complications from IABP therapy as: Limb ischemia Bleeding Infection Thrombus formation Displacement of balloon catheter Arterial damage Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-aortic Balloon Pump (IABP) (5 of 6) Ensure proper IABP functioning, including: – – – – Correct timing Consistent triggering Appropriate troubleshooting of all alarm situations Safe operation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Intra-aortic Balloon Pump (IABP) (6 of 6) Air medical transport considerations Hypobaric environment can impeded IABP functioning – Volume decreases on ascent – Volume decreases on descent IABP must be reprimed – During ascent – At altitude – During descent Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ IABP Contraindications Gross aortic insufficiency Peripheral vascular disease with poor femorals Irreversible brain damage Chronic end state heart disease Dissecting aortic or thoracic aneurysms Peripheral vascular disease IABP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Side Effects and Complications Limb ischemia Bleeding at insertion site Thrombocytopenia Immobility of balloon catheter Balloon leak or rupture – Helium embolization – Thrombus formation Infection Aortic dissection Compartment syndrome IABP Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Summary Critical care paramedics will most likely not be required to establish/insert hemodynamic monitoring catheters – Must be familiar with insertion technique, however Must be prepared to: – Interpret data – Use data in differential diagnosis and treatment decisions Manage complications of devices Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Shock (1 of 2) Shock is often unrecognized in early stages – Clinical signs and symptoms can vary – Clinical signs and symptoms can be subtle – Many different presentations Shock is not a primary diagnosis – Physiologic adaptation to an insult – Body is attempting to preserve vital functions Shock is a “rude unhinging of the machinery of life” Samuel Gross, 1862 Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Shock (2 of 2) Shock results from changes in: – Circulating volume – Cardiac function – Peripheral vascular resistance Shock can cause changes in organ systems – – – – Cardiovascular Respiratory Renal Gastrointestinal Classified in stages – Compensatory – Progressive – Irreversible Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Shock Defined Local or systemic hypoperfusion resulting in an inability to meet cellular demands – Can affect tissue, organs, or organ systems – Can result from insult to: Heart Lungs Blood vessels Blood Nervous system Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Compensatory Mechanisms Counter effects of shock state Inability to correct insult may lead to death Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cell Physiology Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Glycolysis From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ TCA Cycle From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Cell in Shock (1 of 7) Peripheral tissues cannot store oxygen – Rely on constant perfusion – Deliver oxygen – Remove metabolic waste Oxygen uptake (VO2, oxygen consumption) – The amount of oxygen taken up by the mitochondria in the body – The amount of oxygen consumed Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Cell in Shock (2 of 7) Metabolic requirement for oxygen (MRO2) – Rate at which oxygen is metabolized to water in the mitochondria – Water is byproduct of the TCA (Krebs) cycle Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Cell in Shock (3 of 7) VO2 must match or exceed MRO2 for aerobic respiration to occur – VO2 MRO2 Normal metabolism Aerobic respiration Complete oxidation of one molecule of glucose results in production of: 36 molecules of ATP Water Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Cell in Shock (4 of 7) When VO2 falls below MRO2, anaerobic metabolism occurs – Oxygen uptake fails to meet metabolic demand for oxygen – VO2 MRO2 anaerobic metabolism Anaerobic respiration results in production of: Two molecules of ATP Pyruvic acid Pyruvic acid converted to lactic acid Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ The Cell in Shock (7 of 7) Oxygen-carrying capacity of hemoglobin – (1.34 mL/g of Hb) Normal VO2 100–160 mL/min/m2 V02 Cardiac Output (CO) 13.4 Hb (Sa02 Sv02) Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Precursors to Shock Inadequate CO Inadequate Hb concentration or oxygen-carrying capacity Inadequate arterial oxygen saturation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sodium/Potassium (Na/K) Pump (1 of 2) Most energy produced by cell drives sodium/potassium pump Maintains ionic gradient across cell membrane – Intracellular environment Sodium: 10 mEq/L Potassium: 140 mEq/L – Extracellular environment Sodium: 140 mEq/L Potassium: 4 mEq/L Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sodium/Potassium (Na/K) Pump (2 of 2) From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Sodium/Potassium Pump Dysfunction Lack of ATP production in anaerobic metabolism results in failure of the Na/K pump – Sodium moves to the intracellular environment Osmotic shift of water into cell – Swelling – Lysis Clinically significant organ damage may occur Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Organ Systems in Shock When cell lysis involves many cells, organ function is compromised Shock develops Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neurohumoral Responses in Shock (1 of 3) Overall effects termed compensatory mechanisms – Increased heart rate – Increased myocardial contractility – Increased peripheral vasoconstriction – Renal retention of salt and water to maintain plasma volume – Assembling of metabolic fuels Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neurohumoral Responses in Shock (2 of 3) Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neurohumoral Responses in Shock (3 of 3) Compensatory mechanisms can only be tolerated for a short period due to: – Myocardial stress – Decreased blood flow to nonvital organs Ischemia Lactic-acid production and accumulation (metabolic acidosis) Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Symptoms of Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neurohumoral Agents and Effects Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hormonal and Nervous Factors Influencing Blood Pressure Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Norepinepherine Vasoconstriction Increased myocardial contractility Compensation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Epinephrine Increased heart rate Increased myocardial contractility Compensation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Angiotensin II Vasoconstriction Promotes secretion of antidiuretic hormone Compensation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Antidiuretic Hormone(ADH) Increases water retention in kidneys Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Aldosterone Promotes Na and water retention in kidneys Compensation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cortisol Suppresses immune and inflammatory response Promotes protein catabolism Increases blood glucose Compensation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Stages of Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Compensated Shock Body able to detect decrease in CO – Baroreceptors – Chemoreceptors Stages of Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Baroreceptor Reflex From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chemoreceptor Reflex From Essentials of Anatomy & Physiology, 2nd ed., by Frederick H. Martini, Ph.D. and Edwin F. Bartholomew, M.S. Copyright © 2000 by Frederic H. Martini, Inc. Published by Pearson Education, Inc. Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Compensated Shock Body able to compensate for decrease in CO – Compensatory mechanisms activated Increased peripheral vasoconstriction Increased heart rate Increased myocardial contractility – Maintenance of blood pressure – If insult not recognized and corrected, will proceed to progressive stage of shock Stages of Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Progressive Shock Anaerobic metabolism, tissue hypoxia appreciated Additional compensatory mechanisms activated – Water retention in kidney – Profound vasoconstriction – Increased heart rate – Increased myocardial contractility Stages of Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Decompensated Shock Cellular death – Can occur suddenly or over days Prognosis poor Stages of Shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ General Management of Shock Correct the underlying problem Provide supportive care while attempting to identify the insult – Airway Ensure patency – Breathing Adequate ventilation, oxygenation – Circulation Ensure adequate tissue perfusion Volume resuscitation Vasoactive medications – Correct acid-base abnormalities – Conserve body temperature Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Initial Assessment and Management Same as any other critically ill patient Goal is to identify and treat any potentially lifethreatening injuries Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Airway First priority Assessed immediately Controlled with: – Chin lift – Jaw thrust – Insertion of BLS airway adjunct OPA/NPA – Endotracheal intubation Assure cervical spine stabilization when warranted Source: Courtesy of Mark C. Ide Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Breathing and Ventilation Assessment – Verify presence of bilateral breath sounds on auscultation – Assess rate and depth of respirations – Expose chest and inspect for signs of trauma Anterior, lateral, and posterior Management – Administer 100 percent oxygen via appropriate method – Assess ventilatory status with capnography Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Circulation (1 of 2) Assessment – Blood pressure – Pulse rate and quality – Skin color/temperature – Capillary refill time Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Circulation (2 of 2) Management – BLS maneuvers Raise legs – IV cannulation Fluid administration Vasopressors Dopamine Dobutamine Epinephrine Norepinephrine Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Disability, Neurologic Deficit Assessment – AVPU – GCS – Level of consciousness – Motor, sensation – If altered, rule out: Trauma Substance abuse Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Examine/Exposure Remove all clothing to fully expose patient Cover with blankets to preserve heat once exam is complete Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Exam/History Re-evaluation of initial assessment followed by complete head-to-toe exam Necessary to ensure that all acute and chronic insults/disease is identified and considered Allows for trend identification Review of studies – Imaging – Laboratory Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Patient History Understand the circumstances surrounding the injury/illness – Mechanism of injury (MOI) – History of present illness (HPI) Medical history important to identify comorbidities – – – – Pre-existing disease Medications/alcohol/illicit drugs Allergies Tetanus immunization history AMPLE Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Performing the Detailed Exam Head-to-toe exam – Head/face – Neck/cervical spine – Chest Anterior, lateral, posterior – – – – – – Abdomen Perineum/genitalia Back/spine Extremities Vascular Neurological Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management and Further Evaluation Management is same as for any critically ill patient ABCDE method for prioritizing the management of life threats Specific management for shock can occur after management of potential life threats – Management of potential life threat may help manage shock as well Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ General Treatment Considerations Airway management and ventilation key – Begin aggressive airway management early – Endotracheal intubation when necessary Use of NMBAs when necessary Confirm placement with ETCO2 detection ETCO2 monitoring Mechanical ventilation Must be familiar with patient needs, available vent settings Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Fluid Resuscitation (1 of 2) IV access – Peripheral IV access Two large-bore IV lines – Central venous cannulation if: Peripheral IV access cannot be obtained Administration of large volumes of fluid are anticipated Hemodynamic monitoring is required Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Fluid Resuscitation (2 of 2) Goal is to achieve no more than 75 percent of preinjury blood pressure – Permissive hypotension Prevents: Excessive bleeding Loss of coagulation factors 200 mL fluid boluses Re-evaluate, repeat as needed Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemoglobin-Based, Oxygen-Carrying Solutions (HBOCs) Major development in emergency and critical care medicine Differ from traditional IV volume expanders – Can transport oxygen – Contain polymerized hemoglobin Obtained from human, bovine blood Removed from red blood cells Isolated No infectious agents, antigenic proteins, other blood constituents Hemoglobin molecules joined into large chains Polymerization Compatible with all blood types Does not require: Typing Testing Cross-matching Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Volume Expanders (1 of 3) Hypertonic saline – Showed potential initially – Recent evidence suggests it is no more effective than standard isotonic crystalloids Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Volume Expanders (2 of 3) Colloids – Popular outside the United States Australia – No more or less effective than crystalloids Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Volume Expanders (3 of 3) Blood and blood products – O negative used if time for typing and crossmatching does not exist Typed and cross-matched products preferred – Whole blood versus packed red blood cells Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pharmacological Agents For shock unresponsive to fluid bolus administration – Dopamine – Dobutamine – Epinephrine – Norepinepherine Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hemodynamic Monitoring Noninvasive means initially – Heart rate – Heart rhythm – Blood pressure Invasive monitoring: Normal values – Urine output: 0.5–1.0 mL/hr Via foley Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Arterial Blood Gas: Normal Values (1 of 2) pH: 7.35–7.45 PaO2: 80–100 mmHg Oxygen saturation: 96 to 98 percent PaCO2: 35–45 HCO3: 22–26 mEq/L Base/excess: 3 mEq/L Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Arterial Blood Gas: Normal Values (2 of 2) Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Additional Assessment and Management Complete blood cell count and differential Platelet count Complete serum chemistry profile (includes electrolytes) Prothrombin and activated partial thromboplastin times (PT and PTT) Serum lactate Urinalysis Serum amylase Arterial blood gases 12-lead EKG Pregnancy test for all females of child-bearing age Blood, sputum, and urine gram stains and cultures Blood products – Packed red blood cells – Fresh frozen plasma Drug toxicity screening, if indicated Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Imaging Tests CT Ultrasound X-rays Echocardiogram Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Classifications of Shock Hypovolemic Obstructive Distributive Cardiogenic Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hypovolemic Shock Secondary to decrease in circulating blood volume – Etiologies include: Hemorrhage Trauma GI bleeding Other methods of fluid loss Dehydration Excess diuretic use GI loss Sweating Burns Fluid shift Sepsis Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs/Symptoms of Hypovolemic Shock Altered mental status Diaphoresis Tachycardia, tachypnea Pallor, mottling Thirst Collapsed veins, increased skin turgor Decreased urine output, oliguria, concentrated urine Hypotension Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Hypovolemic Shock Volume resuscitation – Crystalloids – Colloids – Vasopressors only after volume resuscitation Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Obstructive Shock Secondary to impedance of normal blood flow – Etiologies Cardiac tamponade Tension pneumothorax Pericarditis Compression of great vessels Supine hypotension syndrome Pulmonary embolism Aortic dissection Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Obstructive Shock Mirror those of hypovolemic and cardiogenic shock – Signs and symptoms specific to etiology Tension pneumothorax Cardiac tamponade Pulmonary embolism Aortic dissection Management Specific to etiology Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Obstructive Shock Specific to etiology Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Distributive Shock Characterized by: – Decrease in vascular resistance or – Increased venous capacity secondary to vasomotor dysfunction Can be further classified as: – Septic shock – Anaphylactic shock – Neurogenic shock Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Septic Shock Occurs secondary to systemic infection Predisposing factors – Immunoinsufficiency – Nosocomial infection Release of endotoxins by infecting organism – Vasodilation – Increased cell membrane permeability Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Septic Shock Fever Chills, diaphoresis Petechial rash Pulmonary edema Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Septic Shock Identification and removal of infection source Fluid therapy Vasopressors Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anaphylactic Shock Exaggerated, systemic response to an allergen – Profound vasodilation – Third spacing of fluid – Bronchospasm Etiologies – Food, drug allergies – Administration of blood products – Envenomation Speed and severity of symptoms vary – Can occur over minutes or days Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Anaphylactic Shock Dyspnea Bronchospasm Dysphagia Rashes, flushing Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Anaphylactic Shock Epinephrine Antihistamine Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Neurogenic Shock Results from disruption of sympathetic nervous system secondary to cervical or thoracic spinal injury – Can also occur secondary to: Severe head injury Migration of spinal anesthesia – Reduction in peripheral vascular resistance Widespread vasodilation below level of insult – If insult below level of T6, bradycardia develops Secondary to unopposed vagal tone Prevents compensatory tachycardia Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Neurogenic Shock Bradycardia – If insult below T6 Hypotension Warm, flushed skin Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Neurogenic Shock Fluid administration Vasopressors Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Cardiogenic Shock Results from hearts inability to maintain sufficient CO Often result of myocardial insult – Ischemia secondary to: AMI Trauma Myocardial contusion – Dysrhythmia – Vascular insufficiency Left ventricular failure results in pulmonary hypertension and edema Treatment goal is to restore cardiac output Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Signs and Symptoms of Cardiogenic Shock Vary with etiology Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Management of Cardiogenic Shock Volume replacement Vasopressors IABP placement Ventricular assist devices Pacemaker CABG Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Summary Early identification of shock and aggressive management are important Clinical trends guide continued treatment Appreciation of resources and proficiency with pharmacology and equipment important Bledsoe/Benner, Critical Care Paramedic © 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Related documents