Sepsis
- Life-threatening organ dysfunction from suspected infection
- Sepsis = infection + organ dysfunction (hypotension, acute hypoxemia; oliguria; lactate >2 mmol/L; abrupt mental status change; plt <100k; coagulopathy
Septic shock
- Sepsis + refractory hypotension & >1 organ failure (SBP<90, MAP <65, lactate >4 after fluid resuscitation)
- In sepsis CO and SVR initially high d/t compensation for the loss of volume and perfusion.
-In shock, myocardial contractility and CO are low d/t pancreatic release of myocardial depressant factor, vasodilation –> decrease SVR <800
Sepsis bundle
1st 3-hr bundle:
- Lactate
- Blood culture prior to antibiotics
- Board spectrum antibiotics
- Crystalloid 30 ml/kg for hypotension or lactate >4
1st 6-hr:
- vasopressors if refractory to fluid resuscitation to maintain MAP>65
- 1st: Norepinephrine, 2nd: vasopressin
- Epinephrine
- Re-measure lactate
- Fluid responsiveness test w/ passive leg raise or fluid challenge
Anaphylactic shock
- a serious allergic or hypersensitivity reaction with a rapid onset and can progress to death without prompt treatment
- S/S: hypotension, angioedema,laryngeal edema, tongue swelling, branchospasm
- Monitor airway
- 1st: Epinephrine 1:1000 strength 0.3 mg IM
- 2nd: Diphenhydramine 25-50mg IV/PO/IM
- Ranitidine, Famotidine
- Steroids (prednisone, Methylprednisolone)
- Massive vasodilation w/ fluid shifts that decrease afterload and preload –> volume resuscitation with possible colloids
- Refractory hypotension: epinephrine, dopamine, norepinephrine
Neurogenic shock
- Trauma to the spinal cord causes an interruption of autonomic pathways –> SNS lost: altered vagal tone and decreased vascular resistance d/t vasodilation
- Decreased CO, SVR –> tissue perfusion, cellular metabolism
- Neurogenic shock triad: 1. Bradycardia; 2. hypotension; 3. Impaired thermoregulation
- Tx: immobilization with C-collar, IV fluid resuscitation, strict I/O (excessive fluid can swell the spinal cord and cause damage)
Autonomic dysreflexia
- SCI above T6
- Opposite to neurogenic shock; exaggerated sympathetic response: HA, diaphoresis, increased BP
- Occurs with noxious stimuli: bladder distension, fecal impaction, pressure sores
- Tx: Sit up with HOB>45 to reduce the risk of triggering a hypertensive crisis by promoting venous drainage and minimizing sympathetic nervous system stimulation
Hypovolemic shock
- Reduced intravascular volume (or reduced preload) –> reduce CO & lead to inadequate tissue perfusion
- Hemorrhagic (blood loss) vs. non-hemorrhagic (fluid loss)
Hemodynamic profiles:
- Low BP, Narrow pulse pressure - SBP decrease, DBP increase
- Low CVP <2
- Low PAOP
- Low CO/CI
- Low SvO2<60
- High HR
- High SVR >1200
Tx:
- IV crystalloids if hypotensive
- Blood produces (PRBC : plasma: platelet) = 1:1:1
- Massive Transfusion Protocol (MTP) - 10 units of pRBCs in 24 hours or 5 units in <3 hours
Opioid overdose
- oxycodone, fentanyl, morphine, heroin
- S/S: Bradycardia, hypotension, respiratory depression
- Tx: Naloxone (Narcan) binds to opioid receptors - monitor for recurrent respiratory depression & repeat 12 min up to 10 mg
Benzodiazepine overdose
- Midazolam, lorazepam, alprazolam
- S/S: hypotension, respiratory depression, confusion, stupor, coma
-Tx: Flumazenil (Romazicon) - reassess for re-sedation and q1-6 min up to 1 mg; monitor for benzo withdrawal - seizures!
Alcohol withdrawal
- Sudden cessation or reduction of alcohol leads to brain hyperexcitability
- Withdrawal seizures: peak 12-48 hrs, grand mal seizures occur
- Delirium tremens: 48-96 hrs; delirium, agitation, tachycardia, hypertension, fever, diaphoresis
Treatment for DTs
- Benzodiazepines (Lorazepam or Valium)
- Librium
- Dexmedetomidine (Precedex): alpha 2 agonist, monitor for bradycardia
- Low dose antipsychotics: haldol, quetiapine (Seroquel) - monitor for prolonged QTc
- Phenobarbital - anti-convulsant
- Anti-seizure meds: Carbamazepine Valporic acid, Gabapentin, Pregabalin
- IV fluids: correct volume deficits result from diaphoresis, lack of oral intake, or insensible loss
- Glucose & thiamine (Vitamin B1) to prevent Wernicke’s encephalopathy - gait disturbance, nystagmus, eye muscle paralysis, and Korsaoff syndrome decreased spontaneity, amnesia, denial of memory loss by making up facts
- Correct Mg, K, Ph
Acetaminophen Overdose
- Leads to toxic ingestion & acute liver failure
- 7.5 to 15 grams can cause toxicity
- Liver toxicity: peak AST or ALT >1000 IU/L
- Assess plasma acetaminophen 2-24 hours after ingestion
-Tx: N-Acetylcysteine (Mucomyst or NAC) - limits the accumulation of the metabolite to prevent hepatocellular damage; activated charcoal w/in 4 hours
Aspirin (Salicylate) Overdose
- Anion gap (+gap)
- Primarily metabolic acidosis; respiratory alkalosis d/t brain stimulation of respiratory center
- Monitor serum salicylate levels >40 mg/dL is toxic
- S/S: vomiting, tinnitus, confusion, hyperthermia, irregular breathing (lead to respiratory alkalosis), multiple organ failure
-Tx: activated charcoal, sodium bicarb infusion, alkaline diuresis, IVF, HD
Beta-blocker Overdose
- Side effects: bradycardia, hypotension d/t vasodilation and renin blockade, decreased CO, B1 receptor blockade, heart block from prolonged AV conduction
- Neurotoxicity - lethargy, decrease in LOC, seizure
- Antidote: Glucagon - reverses B1 blockade; mimics (+) inotroic effects
- Atropin, pacing for bradycardia
CCB Overdose
- Ca++ influx into myocardial cell is essential & determines strength of contraction
- Effects: (-) inotropic effect –> reduce CO, brady cardia, prolonged AV conduction, vasodilation, bronchial dilation
- Neuro: lethargy, decreased LOC, generalized seizure, hyperglycemia (inhibits insulin release)
- Tx: calcium chloride 10% IV, calcium gluconate 10% IV, Atropine, catecholamine (epi, levo, dop) if continued hypotension
Tricyclic Antidepressant (TCA) Overdose
- Amitriptyline or nortriptyline to treat depression
- S/S: hyperthermia, hypotension, tachycardia (wide QRS - give bicarb), prolonged QTc (give anti-arrhythmic), confusion, seizure, dilated pupils, cardiac arrest
- Tx: activated charcoal, sodium bicarb, magnesium IV
Cocaine Toxicity
- cocaine = alpha and beta stimulant
- Effects: tachycardia, hypertension, fever, coronary spasm/MI
- Tx; BZD, vasodilators if hypertensive, avoid beta-blockers to leave unopposed alpha-receptor stimulation
Delirium
- Acute brain dysfunction, inattention, confusion, disorganized thinking
- Wax and wane
- Hyperactive & hypoactive
- Monitor: CAM-ICU, RASS
- PADIS guideline: Pain, Agitaiton, Delirium, Immobility, Sleep disturbance
- Treat the pain first
- Minimize sedation, avoid BZD unless ETOH withdrawal
Rhabdomyolysis
- Muscle injury releases myoglobin into the blood, and large protein molecules can lead to acute kidney injury
- Most cases are reversible
- Causes: trauma, crush injuries, immobilization, extreme temps, cocaine meth, ETOH, statins (rare)
- Dx: CPK, myoglobin, urine myoglobin, electrolytes, BUN/Creat
- S/S: dark, brown/reddish urine, muscle pain, muscle weakness, abdominal pain, fever, N/V
- Complications: AKI from myogloinurina, metabolic acidosis
- Tx: IVF, dialysis if needed, monitor for compartment syndrome - fasciotomy if warranted
Carbon Monoxide Poisoning
- Replaces oxygen on hemoglobin cells
- S/S: hypoxia, HA, altered LOC, seizures
- Tx: FiO2 100%, hyperbaric oxygen therapy, Mech vent
