Hypovolemic Shock
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Differentiating Between Anxiety, Syncope & Anaphylaxis
Differentiating between anxiety, syncope & anaphylaxis Dr. Réka Gustafson Medical Health Officer Vancouver Coastal Health Introduction Anaphylaxis is a rare but much feared side-effect of vaccination. Most vaccine providers will never see a case of true anaphylaxis due to vaccination, but need to be prepared to diagnose and respond to this medical emergency. Since anaphylaxis is so rare, most of us rely on guidelines to assist us in assessment and response. Due to the highly variable presentation, and absence of clinical trials, guidelines are by necessity often vague and very conservative. Guidelines are no substitute for good clinical judgment. Anaphylaxis Guidelines • “Anaphylaxis is a potentially life-threatening IgE mediated allergic reaction” – How many people die or have died from anaphylaxis after immunization? Can we predict who is likely to die from anaphylaxis? • “Anaphylaxis is one of the rarer events reported in the post-marketing surveillance” – How rare? Will I or my colleagues ever see a case? • “Changes develop over several minutes” – What is “several”? 1, 2, 10, 20 minutes? • “Even when there are mild symptoms initially, there is a potential for progression to a severe and even irreversible outcome” – Do I park my clinical judgment at the door? What do I look for in my clinical assessment? • “Fatalities during anaphylaxis usually result from delayed administration of epinephrine and from severe cardiac and respiratory complications. “ – What is delayed? How much time do I have? What is anaphylaxis? •an acute, potentially -
Hypovolemic Shock and Resuscitation Piper Lynn Wall Iowa State University
Iowa State University Capstones, Theses and Retrospective Theses and Dissertations Dissertations 1997 Hypovolemic shock and resuscitation Piper Lynn Wall Iowa State University Follow this and additional works at: https://lib.dr.iastate.edu/rtd Part of the Animal Sciences Commons, Physiology Commons, Surgery Commons, and the Veterinary Physiology Commons Recommended Citation Wall, Piper Lynn, "Hypovolemic shock and resuscitation " (1997). Retrospective Theses and Dissertations. 11754. https://lib.dr.iastate.edu/rtd/11754 This Dissertation is brought to you for free and open access by the Iowa State University Capstones, Theses and Dissertations at Iowa State University Digital Repository. It has been accepted for inclusion in Retrospective Theses and Dissertations by an authorized administrator of Iowa State University Digital Repository. For more information, please contact [email protected]. INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly fi-om the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter &ce, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overiaps. -
Fluid Resuscitation Therapy for Hemorrhagic Shock
CLINICAL CARE Fluid Resuscitation Therapy for Hemorrhagic Shock Joseph R. Spaniol vides a review of the 4 types of shock, the 4 classes of Amanda R. Knight, BA hemorrhagic shock, and the latest research on resuscita- tive fluid. The 4 types of shock are categorized into dis- Jessica L. Zebley, MS, RN tributive, obstructive, cardiogenic, and hemorrhagic Dawn Anderson, MS, RN shock. Hemorrhagic shock has been categorized into 4 Janet D. Pierce, DSN, ARNP, CCRN classes, and based on these classes, appropriate treatment can be planned. Crystalloids, colloids, dopamine, and blood products are all considered resuscitative fluid treat- ment options. Each individual case requires various resus- ■ ABSTRACT citative actions with different fluids. Healthcare Hemorrhagic shock is a severe life-threatening emergency professionals who are knowledgeable of the information affecting all organ systems of the body by depriving tissue in this review would be better prepared for patients who of sufficient oxygen and nutrients by decreasing cardiac are admitted with hemorrhagic shock, thus providing output. This article is a short review of the different types optimal care. of shock, followed by information specifically referring to hemorrhagic shock. The American College of Surgeons ■ DISTRIBUTIVE SHOCK categorized shock into 4 classes: (1) distributive; (2) Distributive shock is composed of 3 separate categories obstructive; (3) cardiogenic; and (4) hemorrhagic. based on their clinical outcome. Distributive shock can be Similarly, the classes of hemorrhagic shock are grouped categorized into (1) septic; (2) anaphylactic; and (3) neu- by signs and symptoms, amount of blood loss, and the rogenic shock. type of fluid replacement. This updated review is helpful to trauma nurses in understanding the various clinical Septic shock aspects of shock and the current recommendations for In accordance with the American College of Chest fluid resuscitation therapy following hemorrhagic shock. -
Bradycardia; Pulse Present
Bradycardia; Pulse Present History Signs and Symptoms Differential • Past medical history • HR < 60/min with hypotension, acute • Acute myocardial infarction • Medications altered mental status, chest pain, • Hypoxia / Hypothermia • Beta-Blockers acute CHF, seizures, syncope, or • Pacemaker failure • Calcium channel blockers shock secondary to bradycardia • Sinus bradycardia • Clonidine • Chest pain • Head injury (elevated ICP) or Stroke • Digoxin • Respiratory distress • Spinal cord lesion • Pacemaker • Hypotension or Shock • Sick sinus syndrome • Altered mental status • AV blocks (1°, 2°, or 3°) • Syncope • Overdose Heart Rate < 60 / min and Symptomatic: Exit to Hypotension, Acute AMS, Ischemic Chest Pain, Appropriate NO Acute CHF, Seizures, Syncope, or Shock Protocol(s) secondary to bradycardia Typically HR < 50 / min YES Airway Protocol(s) AR 1, 2, 3 if indicated Respiratory Distress Reversible Causes Protocol AR 4 if indicated Hypovolemia Hypoxia Chest Pain: Cardiac and STEMI Section Cardiac Protocol Adult Protocol AC 4 Hydrogen ion (acidosis) if indicated Hypothermia Hypo / Hyperkalemia Search for Reversible Causes B Tension pneumothorax 12 Lead ECG Procedure Tamponade; cardiac Toxins Suspected Beta- IV / IO Protocol UP 6 Thrombosis; pulmonary Blocker or Calcium P Cardiac Monitor (PE) Channel Blocker Thrombosis; coronary (MI) A Follow Overdose/ Toxic Ingestion Protocol TE 7 P If No Improvement Transcutaneous Pacing Procedure P (Consider earlier in 2nd or 3rd AVB) Notify Destination or Contact Medical Control Revised AC 2 01/01/2021 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 1 Bradycardia; Pulse Present Adult Cardiac Adult Section Protocol Pearls • Recommended Exam: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Identifying signs and symptoms of poor perfusion caused by bradycardia are paramount. -
Update on Volume Resuscitation Hypovolemia and Hemorrhage Distribution of Body Fluids Hemorrhage and Hypovolemia
11/7/2015 HYPOVOLEMIA AND HEMORRHAGE • HUMAN CIRCULATORY SYSTEM OPERATES UPDATE ON VOLUME WITH A SMALL VOLUME AND A VERY EFFICIENT VOLUME RESPONSIVE PUMP. RESUSCITATION • HOWEVER THIS PUMP FAILS QUICKLY WITH VOLUME LOSS AND IT CAN BE FATAL WITH JUST 35 TO 40% LOSS OF BLOOD VOLUME. HEMORRHAGE AND DISTRIBUTION OF BODY FLUIDS HYPOVOLEMIA • TOTAL BODY FLUID ACCOUNTS FOR 60% OF LEAN BODY WT IN MALES AND 50% IN FEMALES. • BLOOD REPRESENTS ONLY 11-12 % OF TOTAL BODY FLUID. CLINICAL MANIFESTATIONS OF HYPOVOLEMIA • SUPINE TACHYCARDIA PR >100 BPM • SUPINE HYPOTENSION <95 MMHG • POSTURAL PULSE INCREMENT: INCREASE IN PR >30 BPM • POSTURAL HYPOTENSION: DECREASE IN SBP >20 MMHG • POSTURAL CHANGES ARE UNCOMMON WHEN BLOOD LOSS IS <630 ML. 1 11/7/2015 INFLUENCE OF ACUTE HEMORRHAGE AND FLUID RESUSCITATION ON BLOOD VOLUME AND HCT • COMPARED TO OTHERS, POSTURAL PULSE INCREMENT IS A SENSITIVE AND SPECIFIC MARKER OF ACUTE BLOOD LOSS. • CHANGES IN HEMATOCRIT SHOWS POOR CORRELATION WITH BLOOD VOL DEFICITS AS WITH ACUTE BLOOD LOSS THERE IS A PROPORTIONAL LOSS OF PLASMA AND ERYTHROCYTES. MARKERS FOR VOLUME CHEMICAL MARKERS OF RESUSCITATION HYPOVOLEMIA • CVP AND PCWP USED BUT EXPERIMENTAL STUDIES HAVE SHOWN A POOR CORRELATION BETWEEN CARDIAC FILLING PRESSURES AND VENTRICULAR EDV OR CIRCULATING BLOOD VOLUME. Classification System for Acute Blood Loss • MORTALITY RATE IN CRITICALLY ILL PATIENTS Class I: Loss of <15% Blood volume IS NOT ONLY RELATED TO THE INITIAL Compensated by transcapillary refill volume LACTATE LEVEL BUT ALSO THE RATE OF Resuscitation not necessary DECLINE IN LACTATE LEVELS AFTER THE TREATMENT IS INITIATED ( LACTATE CLEARANCE ). Class II: Loss of 15-30% blood volume Compensated by systemic vasoconstriction 2 11/7/2015 Classification System for Acute Blood FLUID CHALLENGES Loss Cont. -
Approach to Shock.” These Podcasts Are Designed to Give Medical Students an Overview of Key Topics in Pediatrics
PedsCases Podcast Scripts This is a text version of a podcast from Pedscases.com on “Approach to Shock.” These podcasts are designed to give medical students an overview of key topics in pediatrics. The audio versions are accessible on iTunes or at www.pedcases.com/podcasts. Approach to Shock Developed by Dr. Dustin Jacobson and Dr Suzanne Beno for PedsCases.com. December 20, 2016 My name is Dustin Jacobson, a 3rd year pediatrics resident from the University of Toronto. This podcast was supervised by Dr. Suzanne Beno, a staff physician in the division of Pediatric Emergency Medicine at the University of Toronto. Today, we’ll discuss an approach to shock in children. First, we’ll define shock and understand it’s pathophysiology. Next, we’ll examine the subclassifications of shock. Last, we’ll review some basic and more advanced treatment for shock But first, let’s start with a case. Jonny is a 6-year-old male who presents with lethargy that is preceded by 2 days of a diarrheal illness. He has not urinated over the previous 24 hours. On assessment, he is tachycardic and hypotensive. He is febrile at 40 degrees Celsius, and is moaning on assessment, but spontaneously breathing. We’ll revisit this case including evaluation and management near the end of this podcast. The term “shock” is essentially a ‘catch-all’ phrase that refers to a state of inadequate oxygen or nutrient delivery for tissue metabolic demand. This broad definition incorporates many causes that eventually lead to this end-stage state. Basic oxygen delivery is determined by cardiac output and content of oxygen in the blood. -
Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Alexander Roederer University of Pennsylvania, [email protected]
University of Pennsylvania ScholarlyCommons Departmental Papers (CIS) Department of Computer & Information Science 4-13-2015 Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Alexander Roederer University of Pennsylvania, [email protected] James Weimer University of Pennsylvania, [email protected] Joseph Dimartino University of Pennsylvania Health System, [email protected] Jacob Gutsche University of Pennsylvania Health System, [email protected] Insup Lee University of Pennsylvania, [email protected] Follow this and additional works at: http://repository.upenn.edu/cis_papers Part of the Computer Engineering Commons, and the Computer Sciences Commons Recommended Citation Alexander Roederer, James Weimer, Joseph Dimartino, Jacob Gutsche, and Insup Lee, "Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients", 6th Workshop on Medical Cyber-Physical Systems (MedicalCPS 2015) . April 2015. 6th Workshop on Medical Cyber-Physical Systems (MedicalCPS 2015) http://workshop.medcps.org/ in conjunction with CPS Week 2015 http://www.cpsweek.org/2015/ Seattle, WA, April 13, 2015 An extended version of this paper is available at http://repository.upenn.edu/cis_papers/787/ This paper is posted at ScholarlyCommons. http://repository.upenn.edu/cis_papers/781 For more information, please contact [email protected]. Towards Non-Invasive Monitoring of Hypovolemia in Intensive Care Patients Abstract Hypovolemia caused by internal hemorrhage is a major cause of death in critical care patients. However, hypovolemia is difficult to diagnose in a timely fashion, as obvious symptoms do not manifest until patients are already nearing a critical state of shock. Novel non-invasive methods for detecting hypovolemia in the literature utilize the photoplethysmogram (PPG) waveform generated by the pulse-oximeter attached to a finger or ear. -
Management of Hypovolaemic Shock in the Trauma Patient (Full Guideline)
HypovaolaemicShock_FullRCvR.qxd 3/2/07 3:03 PM Page 1 ADULT TRAUMA CLINICAL PRACTICE GUIDELINES :: Management of Hypovolaemic Shock in the Trauma Patient HYPOVOLAEMIC SHOCK GUIDELINE blood O-neg HypovaolaemicShock_FullRCvR.qxd 3/2/07 3:03 PM Page 2 Suggested citation: Ms Sharene Pascoe, Ms Joan Lynch 2007, Adult Trauma Clinical Practice Guidelines, Management of Hypovolaemic Shock in the Trauma Patient, NSW Institute of Trauma and Injury Management. Authors Ms Sharene Pascoe (RN), Rural Critical Care Clinical Nurse Consultant Ms Joan Lynch (RN), Project Manager, Trauma Service, Liverpool Hospital Editorial team NSW ITIM Clinical Practice Guidelines Committee Mr Glenn Sisson (RN), Trauma Clinical Education Manager, NSW ITIM Dr Michael Parr, Intensivist, Liverpool Hospital Assoc. Prof. Michael Sugrue, Trauma Director, Trauma Service, Liverpool Hospital This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Insititute of Trauma and Injury Management. © NSW Institute of Trauma and Injury Management SHPN (TI) 070024 ISBN 978-1-74187-102-9 For further copies contact: NSW Institute of Trauma and Injury Management PO Box 6314, North Ryde, NSW 2113 Ph: (02) 9887 5726 or can be downloaded from the NSW ITIM website http://www.itim.nsw.gov.au or the NSW Health website http://www.health.nsw.gov.au January 2007 HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page i blood O-neg Important notice! 'Management of Hypovolaemic Shock in the Trauma Patient’ clinical practice guidelines are aimed at assisting clinicians in informed medical decision-making. -
2.3. Heart Sound and Auscultation
Dinesh Kumar Dinesh Dinesh Kumar CARDIOVASCULAR DISEASE ASSESSMENT DISEASE CARDIOVASCULAR AUTOMATIC HEART FOR SOUND AUTOMATIC ANALYSIS AUTOMATIC HEART SOUND ANALYSIS FOR CARDIOVASCULAR DISEASE ASSESSMENT Doctoral thesis submitted to the Doctoral Program in Information Science and Technology, supervised by Prof. Dr. Paulo Fernando Pereira de Carvalho and Prof. Dr. Manuel de Jesus Antunes, and presented to the Department of Informatics Engineering of the Faculty of Sciences and Technology of the University of Coimbra. September 2014 OIMBRA C E D NIVERSIDADE NIVERSIDADE U September 2014 Thesis submitted to the University of Coimbra in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Information Science and Technology This work was carried out under the supervision of Professor Paulo Fernando Pereira de Carvalho Professor Associado do Departamento de Engenharia Informática da Faculdade de Ciências e Tecnologia da Universidade de Coimbra and Professor Doutor Manuel J Antunes Professor Catedrático da Faculdade de Medicina da Universidade de Coimbra ABSTRACT Cardiovascular diseases (CVDs) are the most deadly diseases worldwide leaving behind diabetes and cancer. Being connected to ageing population above 65 years is prone to CVDs; hence a new trend of healthcare is emerging focusing on preventive health care in order to reduce the number of hospital visits and to enable home care. Auscultation has been open of the oldest and cheapest techniques to examine the heart. Furthermore, the recent advancement in digital technology stethoscopes is renewing the interest in auscultation as a diagnosis tool, namely for applications for the homecare context. A computer-based auscultation opens new possibilities in health management by enabling assessment of the mechanical status of the heart by using inexpensive and non-invasive methods. -
Septic, Hypovolemic, Obstructive and Cardiogenic Killers
S.H.O.C.K Septic, Hypovolemic, Obstructive and Cardiogenic Killers Jason Ferguson, BPA, NRP Public Safety Programs Head, CVCC Amherst County DPS, Paramedic Centra One, Flight Paramedic Objectives • Define Shock • Review patho and basic components of life • Identify the types of shock • Identify treatments Shock Defined • “Rude unhinging of the machinery of life”- Samuel Gross, U.S. Trauma Surgeon, 1962 • “A momentary pause in the act of death”- John Warren, U.S. Surgeon, 1895 • Inadequate tissue perfusion Components of Life Blood Flow Right Lungs Heart Left Body Heart Patho Review • Preload • Afterload • Baroreceptors Perfusion Preservation Basic rules of shock management: • Maintain airway • Maintain oxygenation and ventilation • Control bleeding where possible • Maintain circulation • Adequate heart rate and intravascular volume ITLS Cases Case 1 • 11 month old female “not acting right” • Found in crib this am lethargic • Airway patent • Breathing is increased; LS clr • Circulation- weak distal pulses; pale and cool Case 1 • VS: RR 48, HR 140, O2 98%, Cap refill >2 secs • Foul smelling diapers x 1 day • “I must have changed her two dozen times yesterday” • Not eating or drinking much Case 1 • IV established after 4 attempts • Fluid bolus initiated • Transported to ED • Received 2 liters of fluid over next 24 hours Hypovolemic Shock Hemorrhage Diarrhea/Vomiting Hypovolemia Burns Peritonitis Shock Progression Compensated to decompensated • Initial rise in blood pressure due to shunting • Initial narrowing of pulse pressure • Diastolic raised -
Outpatient Approach to Palpitations RANDELL K
Outpatient Approach to Palpitations RANDELL K. WEXLER, MD, MPH; ADAM PLEISTER, MD; and SUBHA RAMAN, MD, MSEE The Ohio State University, Columbus, Ohio Palpitations are a common problem seen in family medicine; most are of cardiac origin, although an underlying psychiatric disorder, such as anxiety, is also common. Even if a psychiatric comorbidity does exist, it should not be assumed that palpitations are of a noncardiac etiology. Discerning cardiac from noncardiac causes is important given the potential risk of sudden death in those with an underlying cardiac etiology. History and physical examination followed by targeted diagnostic testing are necessary to distinguish a cardiac cause from other causes of palpitations. Standard 12-lead electrocardiography is an essential initial diagnostic test. Cardiac imaging is recommended if his- tory, physical examination, or electrocardiography suggests structural heart disease. An intermittent event (loop) monitor is preferred for documenting cardiac arrhythmias, particularly when they occur infrequently. Ventricular and atrial premature contractions are common cardiac causes of palpitations; prognostic significance is dictated by the extent of underlying structural heart disease. Atrial fibrillation is the most common arrhythmia resulting in hos- pitalization; such patients are at increased risk of stroke. Patients with supraventricular tachycardia, long QT syn- drome, ventricular tachycardia, or palpitations associated with syncope should be referred to a cardiologist. (Am Fam Physician. 2011;84(1):63-69. Copyright © 2011 American Academy of Family Physicians.) atients often present to family phy- CARDIAC STRUCTURAL CAUSES sicians with palpitations. However, Mitral valve prolapse is the most common this may mean different things structural heart disease leading to palpita- to different people. -
Distributive Shock
ASK THE EXPERT h EMERGENCY MEDICINE/CRITICAL CARE h PEER REVIEWED Distributive Shock Garret E. Pachtinger, VMD, DACVECC VETgirl; Veterinary Specialty and Emergency Center Levittown, Pennsylvania Clinical Clues YOU HAVE ASKED ... Distributive shock is generally associ- What is distributive shock, and ated with altered vasomotor tone— notably inappropriate vasodilation (eg, how do I treat it? sepsis, systemic inflammatory response syndrome), excessive vasoconstriction THE EXPERT SAYS ... (eg, following trauma or anaphylaxis), or abnormalities in normal blood flow Shock (ie, inadequate cellular energy (eg, obstructive diseases such as gastric production or the body’s inability to dilatation-volvulus [GDV] or pericardial supply cells and tissues with oxygen and effusion)—resulting in maldistribution nutrients and remove waste products1-3) of blood flow. can cause quick clinical deterioration and requires rapid identification and Patients with septic distributive shock treatment. Distributive shock is a gen- often have hyperemic mucous mem- eral classification for syndromes that branes caused by uncontrolled vasodila- cause massive maldistribution of blood tion from inflammatory mediators and flow (seeReferences , page 96). Anaphy- cytokine release (see References, page lactic, obstructive, and septic shock are 96). Patients with anaphylactic or GDV = gastric dilatation- common forms of distributive shock. obstructive distributive shock show volvulus October 2016 cliniciansbrief.com 93 ASK THE EXPERT h EMERGENCY MEDICINE/CRITICAL CARE h PEER