CH 41 Mgmt. & Resus. of The Critical Patient

What is the first step when working with a critical patient?

Conduct a rapid assessment.

What must be developed after providing lifesaving treatment to a critical patient?

A differential field diagnosis.

What is essential for making decisions when caring for a critical patient?

Being well trained to make the right decision.

What are some common conditions encountered in critical patients?

Premorbid conditions, major trauma, and patients in the peri-arrest period.

What does the EMS approach to diagnosis involve?

Following a standard approach to determine a working diagnosis.

What mnemonic can be used for differential diagnosis of altered mental status?

M-T SHIP.

What should be considered for chest pain diagnosis?

Cardiac causes, GI system causes, musculoskeletal problems, respiratory causes, panic attack, shingles, and cancer in the chest.

What is intuition in critical decision making?

Pattern recognition and matching based on previous experience.

What is shock in the context of critical patients?

A state of collapse and failure of the cardiovascular system leading to insufficient perfusion of organs/tissues.

What is required for adequate perfusion?

A working cardiovascular system, adequate gas exchange, nutrients, and waste removal.

What does cardiac output (CO) refer to?

The volume of blood that the heart can pump per minute.

What factors influence blood pressure?

Cardiac output, systemic vascular resistance, and blood volume.

What is the formula for mean arterial pressure (MAP)?

MAP = DBP + 1/3 (SBP - DBP).

How is blood flow through capillary beds regulated?

By the capillary sphincters under the control of the autonomic nervous system.

What causes shock?

Inadequate cardiac output, decreased systemic vascular resistance, and inability of red blood cells to deliver oxygen.

What does the 'perfusion triangle' consist of?

The heart, blood vessels, and blood/body fluids.

What happens if one part of the perfusion triangle is not working properly?

It can result in shock.

What should be done if a patient is tachycardic and slightly hypertensive?

Obtain a 12-lead ECG and transmit it to a hospital.

What is the first action to take if a patient passes out and the monitor shows VF?

Begin chest compressions.

What is the purpose of administering an antidysrhythmic during cardiac arrest?

To manage abnormal heart rhythms

What should be updated once the patient is en route to the hospital?

Update the emergency department (ED) on patient status

What is the primary function of blood in relation to tissue cells?

Blood carries oxygen and nutrients through vessels to the capillary beds to tissue cells.

What mechanisms are triggered when blood pressure is failing?

Neural and hormonal mechanisms are triggered.

What neural mechanism compensates for falling blood pressure, and what are its effects?

The baroreceptor reflex, which increases sympathetic nervous system activity, causing tachycardia, increased contractility, and peripheral vasoconstriction.

Which nervous system controls bodily functions during shock?

The sympathetic nervous system.

What hormonal systems are activated when blood pressure falls?

The renin-angiotensin-aldosterone system (RAAS), antidiuretic hormone (ADH) release, and epinephrine/norepinephrine release.

How does RAAS help compensate for hypotension?

Angiotensin II causes vasoconstriction, and aldosterone causes sodium and water retention, increasing blood volume and blood pressure.

How does ADH help maintain blood pressure?

It causes water reabsorption in the kidneys and mild vasoconstriction, increasing circulating volume.

What happens to body fluids during shock?

Body fluids shift to maintain pressure.

What triggers the body's response to decreased perfusion?

Baroreceptors activate the vasomotor center to begin constriction of the vessels.

What is the typical systolic blood pressure (SBP) range that stimulates compensation mechanisms?

Between 60 and 80 mm Hg.

What is the overall response of the body to decreased perfusion?

To increase preload, stroke volume, and pulse rate.

What occurs if hypoperfusion persists?

Myocardial oxygen demand increases and cells switch to anaerobic metabolism.

What is the 'Golden Hour' in the context of shock?

If blood supply is inadequate to major organs for more than 60 minutes, they will develop complications.

What is the consequence of cellular ischemia due to decreased perfusion?

It leads to systemic acidosis and depletes energy reserves.

What happens to the sodium-potassium pump during ischemia?

Reduced ATP results in a dysfunctional pump, causing excessive sodium to diffuse into the cells.

What is the result of intracellular flooding in cells?

It explodes the membrane, leading to the last phase of shock.

What are the effects of lactic acid and carbon dioxide accumulation during shock?

They act as potent vasodilators and wash into the venous circulation.

What is Multiple-Organ Dysfunction Syndrome (MODS)?

A progressive condition characterized by failure of two or more organs that were initially unharmed.

What triggers the systemic response that leads to MODS?

Injury or infection triggers a massive systemic response resulting in the release of inflammatory mediators.

What are the three basic causes of shock?

Pump failure, low fluid volume, and poor vessel function.

What are the two phases of shock?

Compensated and decompensated shock.

What indicates compensated shock?

The body can still compensate for blood loss, and blood pressure is maintained.

What characterizes decompensated shock?

Blood volume drops more than 30%, and compensatory mechanisms begin to fail.

What is irreversible (terminal) shock?

The stage at which shock has progressed to a terminal stage with life-threatening reductions in cardiac output and tissue perfusion.

What is the mortality rate for patients with MODS?

The mortality rate ranges from 23% to 100%.

What systems are activated during the release of inflammatory mediators in MODS?

The complement system, coagulation system, and kallikrein-kinin system.

What is the impact of shock on white blood cells and blood clotting systems?

They are impaired, leading to decreased resistance to infection and potential disseminated intravascular coagulation (DIC).

What happens to organ functions if blood supply is inadequate for more than 60 minutes?

Vital organ damage cannot be repaired, and aggressive treatment usually does not result in recovery.

What is the first step in the scene size-up during a patient assessment?

Size up the scene for hazards.

What does the AVPU acronym stand for in assessing mental status?

Alert, Verbal response, Pain response, Unresponsive.

What sequence should be used if cardiac arrest is suspected?

CABDE sequence.

What should be assessed in patients with a pulse during the circulation assessment?

Determine if the pulse is adequate.

What is the significance of a drop in SBP or altered mental status?

It indicates the body can no longer compensate.

What is the priority in emergency medical care of a patient with suspected shock?

Airway and ventilatory support.

What should be done if signs of tension pneumothorax are present?

Perform needle chest decompression.

What are volume expanders used for in hypovolemic shock?

To maintain circulatory volume.

What are common crystalloids used in fluid replacement?

Normal saline and Lactated Ringer solution.

What are the three classifications of shock?

Cardiogenic, distributive, and hypovolemic.

What is the main characteristic of cardiogenic shock?

It results from a weakening pumping action of the heart.

What should be done to manage the airway in a patient with shock?

Maintain an open airway and suction as needed.

What is the purpose of IV therapy in patients with shock?

To provide immediate replacement of fluids and medications.

What are the signs of internal hemorrhage to look for in a patient with shock?

Signs may include altered mental status and signs of shock.

What is the recommended action if a patient is hypotensive?

Provide immediate transport to the emergency department.

What is the role of nonpharmacologic interventions in shock management?

They include proper positioning, prevention of hypothermia, and rapid transport.

What should be done if the patient is in decompensated shock?

They will need rapid intervention.

What is the purpose of administering high-flow supplemental oxygen?

To support ventilation in patients with shock.

What does the term 'MOI' stand for in patient assessment?

Mechanism of Injury.

What is the significance of assessing skin color, temperature, and condition (CTC)?

It provides information about the patient's circulation status.

What should be prioritized when assessing a high-priority patient?

History taking can be done en route to the emergency department.

What should be done if a patient is pinned and suspected of having shock?

Delay establishing IV/IO access until extrication is possible.

What is the effect of crystalloids on blood viscosity?

They thin the blood and dissolve clotting factors.

What is the purpose of maintaining body heat in shock patients?

To prevent hypothermia and support overall stability.

What are the nonhemorrhagic causes of hypovolemic shock?

Conditions that reduce tissue perfusion without blood loss.

What is the role of portable lactate monitors in shock assessment?

They help in identifying lactic acid buildup, indicating shock severity.

What is cardiogenic shock?

Occurs when the heart cannot circulate sufficient blood to maintain adequate peripheral oxygen delivery, most commonly caused by an AMI with left ventricle dysfunction.

What are common manifestations of cardiogenic shock?

Poor contractility, decreased cardiac output, or impaired ventricular filling.

Who is at the greatest risk for cardiogenic shock?

Older adults, patients with a history of diabetes mellitus, and patients with a history of AMI with an ejection fraction of less than 35%.

What is the recommended action for patients in cardiogenic shock?

Prolonged efforts to stabilize the patient are not recommended; expedite transport and secure the airway.

What is obstructive shock?

Occurs when blood flow in the heart or great vessels becomes blocked, not directly associated with loss of fluid, pump failure, or vessel dilation.

What is tension pneumothorax?

A life-threatening condition caused by damage to lung tissue that leads to obstructive shock.

What causes cardiac tamponade?

Blunt or penetrating trauma, tumors, or pericarditis that leads to blood leaking into the pericardium and compressing the heart.

What are the signs of cardiac tamponade?

Muffled heart sounds, merging of SBP and DBP, electrical alternans, and a small QRS complex on the ECG.

What is distributive shock?

Occurs when there is widespread dilation of the resistance or capacitance vessels, causing circulating blood volume to pool in vascular beds.

What are the most common types of distributive shock?

Septic, neurogenic, anaphylactic, and psychogenic shock.

What causes septic shock?

A widespread infection, usually from gram-negative bacterial organisms, activating an inflammatory-immune response that results in hypoperfusion.

How does septic shock present?

Similar to hemorrhagic shock, but patients usually have warm or hot skin.

What is neurogenic shock?

Usually results from spinal cord injury, leading to loss of normal sympathetic nervous system tone and vasodilation.

What characterizes spinal shock?

Flaccid paralysis, flaccid sphincters, and absent reflexes following a spinal injury.

What is anaphylactic shock?

A violent reaction to a substance to which a person has been sensitized, causing widespread vascular dilation.

What are the symptoms of hypovolemic shock?

Loss of appetite, nausea, vomiting, fainting when standing up, poor skin turgor, shrunken tongue, sunken eyes, and weak rapid pulse.

What should be administered to a dehydrated patient?

An IV infusion of normal saline or lactated Ringer solution.

What is the goal of monitoring in hypovolemic shock?

To save the brain, lungs, and kidneys, relying on the state of consciousness to determine organ perfusion.

What is respiratory insufficiency?

The inability to breathe in adequate amounts of oxygen, which can produce shock.

What is hypoxemic hypoxia?

A condition where tissues become hypoxic due to an abnormally low number of RBCs, even if pulse oximeter readings are adequate.

What is the first step in treating a patient in shock from poor respiration?

Seal any holes and stabilize impaled objects, then secure and maintain the airway.

What should be considered when transporting shock patients?

Limit scene time to 10 minutes or less and know how to access aeromedical transportation.

What factors influence the transport decision for shock patients?

The priority of the patient and the availability of a regional trauma center.