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Lactic Acid

Removed by liver, but only with oxygen

Catecholamine examples

Epinephrine
Norepinephrine

Where blood is shunted away from during shock

GI, Liver, Kidneys, Lungs

Anasarca

Extreme edema in lower extremities

Anaphylactic shock treatment

Depends on the severity
For severe:
Maintain airway
Administer epinephrine

Cardiogenic shock classic manifestation

Pink, frothy sputum

Cardiogenic shock definition

Systolic or diastolic disfunction

Cardiogenic shock diagnostics

Increased cardiac markers
Increased BUN and blood glucose
EKG changes
Echo (left ventricular dysfunction)

Cardiogenic shock treatmetn

Discover cause and treat

Diuretic effect on preload

Decreases preload

Vasodilator effect on afterload

Decreases afterload

Why CCB is not given with decreased contractility?

Contractility will be reduced even further

Beta blocker effect on heart

Reduces myocardial oxygen demand

Hypovolemic shock treatment

Fluid resuscitation
3:1 rule:
3ml of isotonic crystalloid for every 1ml of estimated blood loss

Neurogenic shock

Results is loss of sympathetic tone.
Occurs with spinal cord injury

Neurogenic shock effect on HR and BP

Heart rate and Blood pressure both decrease. Neurogenic shock is the only shock where this occurs.

Neurogenic shock effect on nervous system

Sympathetic system impacted. Parasympathetic system not impacted and it takes over.

Atropine

Treats bradycardia
Blocks parasympathetic nervous system.

Sepsis progression

Sepsis
Severe sepsis
Septic shock

Burn

Basically hypovolemic shock
Changes capillary permiability
Oncontic pressure disrupted
Manage for hypovolemic shock

Thermal burn

Caused by flame, flash, scald, or contact with hot objects.
Most common type of burn.

Tempid

Same as body temperature
98.6

Smoke inhalation

Inhalation of hot air or noxious chemicals.
Cause damage to respiratory tract.

Why bright cherry red skin color with smoke inhalation?

Hypoxic
Carbon monoxide replaces oxygen on hemoglobin.

Damage above epiglottis

Thermally produced.
Hot air, steam, or smoke.
Painful swelling is cue.

Damage below epiglottis

Related to length of exposure to smoke.
Pulmonary edema (12 to 24 H after) (ARDS)

ARDS x-ray

White out

Progression of pulmonary edema

After 1 hour: clear lung sounds.
After 6 to 10 hours: wheezes heard.
After 12 to 24 hours: NO lung sounds heard.

Iceberg effect of electrical burns

Most damage is under the skin.
Difficult to assess.

Lund-Browder chart

Used to assess percentage of body burned.
Based on capillary bed.

Face, Neck, and Chest burn

Increased risk for respiratory obstruction.
Assess breathing.
Monitor for complications

Phases of burn management

Prehospital
Emergent
Acute

Prehospital Phase

Remove from source of burn.
Stop burning process.

Emergent Phase

Lasts 24 to 48 hours.
Begins with fluid loss and edema formation and continues until fluid mobilization and diuresis begins.

Normal insensible loss

30 to 50 ml/H

Severely burned patient fluid loss

200 to 400 ml/H

Acute Phase

Begins with mobilization of extracellular fluid and subsequent diuresis

Acute Phase classic manifestations

Bowel sounds return.
Necrotic tissue begins to slough.
Partial thickness heal from edges.
Full thickness burn needs a graft.

Risk factors for hypothermia

Elderly
Alcohol
Diabetes

Hypothermia

Less than 95 degrees

Burns

Leading cause of unintentional death in children.

Burn treatment

IV fluids with large bore (200 to 400ml/hour)
Central line
Monitor CVP (will be low or zero)
Levophed
Pain medication
HOB kept low

Refractory stage

Completely anaerobic

Refractory stage Assessment

Decreased peristalsis (No bowel sounds)
Decreased pulse
Decreased blood pressure
Skin mottling
Liver enzymes elevated

Progressive stage Assessment

Decreased temperature
Decreased glucose
Decreased blood pressure
Decreased urine output

Compensatory stage assessment

Tachycardia
BP WNL
Warm, flushed skin
Increased glucose
CVP about zero
Decreased platelets
WBC > 12,000 or < 4,000

Compensatory stage treatment

Give bolus of NS until CVP > 8, unless Na is elevated.

Why Frothy, Pink Sputum with Cardiogenic Shock?

Left ventricle is not pushing forward and everything is backing up into lungs.

Dobutamine

Positive inotrope
Positive chronotrope

Electrical Burns treatment

EKG
Spine precautions (assume they fell)
Protect from further shock injury

Central lines with burns

Femoral
Internal jugular
Not the subclavian, due to pneumothorax

Anaphylactic treatment

Give epinephrine

Why give epinephrine?

Open bronchioles.
Stop histamine.

MODS succussfully resuscitated:

Increased urine output
Increased blood pressure
Decreased mottling
Increased LOC

Primary survey Burn care

A = Airway
B = Breathing
C = Circulation
D = Disability
E = Exposure

Shock progression

Compensatory stage
Progressive stage
Refractory stage

Compensatory stage goal

Restore cadiac output and tissue perfusion to vital organs.

Why is early recognition of Compensatory Stage important?

With Progressive or Irreversible stage, the mortality rate increases.

Neurogenic Shock treatment

Treat underlying problem
Atropine
Epinephrine
Dopamine

Neurogenic shock manifestations

Flaccid paralysis
Absence of reflexes
Hypotension
Bradycardia
Paralytic ileus
Loss of temperature regulation

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