Surgery - fluids/shock
Terms
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- K secretion is increased by
- high urine flow rates increased Na delivery to distal tubule alkalosis presence of poorly reabsorbed luminal anion increased mineralcorticoid activity
- K secretion is decreased by
- low urine outputs decreased Na delivery to distal tubule decreased K stores decreased mineralcorticoid activity
- Signs/symptoms of hyperkalemia
- Neuromuscular: weakness ascending paralysis flaccid paralysis dysphagia respiratory arrest ileus CV: hypotension syncope cardiac arrest Arrythmias: bradycardia heart blocks asystole ventricular fibrillation
- Treatment of hyperkalemia
- calcium gulconate (if EKG changes) insulin albuterol (epi) sodium polystyrene sulfonate hemodialysis
- Fluid adjustments
- fever (add 2-2.5mg/kg.day for each degree above 37) Third space loss drains and tubes body fluid loss
- Maintenence therapy
- Fluid: 1500ml + 20ml/kg/day for every kg above 20 Sodium: 1-2mEq/kg/day K: 0.5-1mEq/kg/day
- IV fluid contents - D5W
- glucose hypoosmolar
- IV fluid contents - 0.9% NaCl
- Na and Cl hyperosmolar
- IV fluid contents - LR
- Na, Cl, HCO3, K, Ca same osmolality as extracellular fluid
- Shock
- inadequate perfusion of tissues - inadequate delivery of oxygen and nutrients to meet metabolic demands
- MAP
- normal >65
- EJ
- normal > 55%
- CO
- normal 4-8L/min
- CI
- cardiac index CO/BSA normal 2.5-4L/min
- SVR
- systemic vascular resistance normal 800-1400
- PCWP
- pulmonary capillary wedge pressure normal 7-15mmHg
- PAP
- pulmonary artery pressure normal 20-30/6-15mmHg
- MPAP
- mean pulmoary artery pressure normal 10-17 mmHg
- SVO2
- mixed venous oxygen saturation normal 65-75%
- Swan-Ganz catheter
- Ballow creates sealed communication between the pulm capillaries and left atrium which allows for the PCWP to approx the left atrial pressure
- Cardiogenic shock - definition/causes
- pump failure MI cardiomegaly valvular disease arrythmia pulmonary HTN cardiac tamponade tension PTX diaphragm rupture positive pressure ventilation
- Cardiogenic shock - hemodynamic parameters
- HR - inc CO - dec SVR - inc CVP/PCWP - inc
- Cardiogenic shock - PE
- distended neck veins rales S3 peripheral edema kussmauls sign pulsus paradoxus
- Cardiogenic shock - Treatment
- optimize volume status w/o overloading lungs Decreased afterload - nitrates, ACEI HR control - BB, anti-arrythmic, pacemaker Inotropy - epi, dobu, dopa, mili
- Cardiogenic shock - cardiac tamponade
- causes decreased diastolic filling and hypertension Beck's triad
- Beck's triad
- hypotension jugular venous distension muffled heart sounds
- Hypovolemic shock - hemodynamics
- HR - inc CO - dec SVR - inc CVP/PCWP - dec
- Hypovolemic shock - class I
- <15% decreased PP orthostatis hypotension flat neck vein increased Hct
- Hypovolemic shock - class II
- 15-30% thirst Tachycardia Tachypnea mod hypotension cool clammy skin
- Hypovolemic shock - class III
- 30-40% Oliguria MS changes dec SBP
- Hypovolemic shock - class IV
- >40% EKG - ischemia Arrhythmias severe hypotension cold, pulseless skin
- Hypovolemic shock - treatment
- 2 large bore IV 2L LR/NS transfuse PRBC if unresponsive
- Septic shock - definition/causes
- severe infection resulting in systemic inflammatory response, arterial vasospasm, and ultimate hemodynamic collapse and mutlisystem organ failure infections
- Septic shock - hemodynamics
- HR - inc CO - inc SVP - dec CVP/PCWP - dec
- Septic shock - PE
- fever, chills, rigors bounding arterial pulses warm/flushed skin hypotension hyperglycemia
- Early sepsis triad
- hyperventilation confusion respiratory alkalosis
- SIRS
- temp >38 HR > 90 RR > 20 WBC >12000
- Sepsis
- SIRS + infection
- Severe sepsis
- SIRS + infection + organ dysfunction
- Septic shock
- SIRS + infection + hemodynamic instability
- Septic shock - treatment
- treat underlying cause ICU care fluids vasopressors abx ventilators
- Neurogenic shock - cause
- spinal cord injury above T4 results in loss of sympathetic tone/adrenergic stimluation
- Neurogenic shock - hemodynamics
- HR - dec CO - dec SVR - dec CVP/PCWP - dec
- Neurogenic shock - PE
- warm, flushed skin bradycardia venous pooling
- Neurogenic shock - treatment
- vasoactive agents (phenylephrine, vasopressin) fluids (watch for pulm edema)
- Time frame for type/screen/cross
- type <10 min type and screen 20-30 min type and cross 45-60 min
- Storage time - PRBC
- 42 days
- Storage time - platelets
- 5-7 days
- Storage time - frozen plasma
- 1 year
- Storage time - thawed plasma
- 5 days
- Storage time - cryo
- 1 year
- Storage time - thawed cryo
- 4 hours
- ABDCE of trauma
- Airway Breathing - vent/O2 Circulation - hypovol, tamponade, hemorrhage control Disability - coma, pupils, spinal/brain injury Exposure - undress patient Environment - prevent hypothermia
- Trauma labs
- Crossmatch, ABG, CBC, UA, Chem7, Coags, tox screen Beta HCG
- Trauma imaging
- triple - CXR, pelvic XR, C-spine CT head/chest/ab/C-spine Angiography, FAST, spine films, ext films
- Tension PTX
- absent breath sounds, JVD, hypertympanic, pleuritic chest pain, hypotension Needle thoracostomy in 2nd intercostal space in MCL Chest tube - 4th intercostal space in midaxillary line
- General signs of shock
- mental status changes, acidosis, oliguria, poor cutaneous perfusion
- PRBC indication
- correction of volume and/or anemia due to blood loss
- Platelets indication
- correction of throbocytopenia <50000 procedural <15000 asymptomatic
- FFP
- correction of vit K dependant clotting factors bleeding/surgery in patients with deficiencies
- Cryo
- blooding in the setting of hypofibrinogemia
- Chelating reaction
- hypocalcemia