Clin Med- Fernandez 3

drraythe's version from 2016-02-03 22:57

Fluid compartments & losses continued

Question Answer
What’s the major monitoring thing you should be doing?BODY WEIGHT!
What are 7 major things you should monitor if you're concerned about fluids?BODY WEIGHT
Physical exam
Central venous pressure
Edematous paws
When monitoring fluids, you will do a physical exam-what 2 Parameters & specific body system will you focus on?Hydration parameters
Perfusion parameters
RESPIRATORY rate/auscultation
What are some big signs must you look out for which might indicate over hydration?Edematous paws
Nasal discharge
Jugular venous distension
Interstitial pitting edema
Pulmonary edema
What is chemosis?Edematous conjunctiva
How much fluid did an animal lose if they lost 1kg?1L!
What respiratory signs will you get from over hydration?You’ll get PULMONARY EDEMA: Tachypnea → crackles → wheezes → dyspnea
Explain an Indwelling urinary catheter & why you'd use this when referring to fluid monitoring?When a U catheter is in the bladder so that you can compare urine output to fluid input. Q4Hr (every 4 hours).
When will the fluid ins match the fluid outs?After deficits replaced & losses accounted for
What are the renal Parameters you are looking at in fluid therapy?BUN
(Measure serially & compare-determine pre-renal vs. renal azotemia)
Increasing USG may be sign of inadequate...?Renal perfusion. (BUN & creatinine might rise)
What is lactate an indicator of?Tissue perfusion
What is DO2??Oxygen delivery to tissues
Moderate to marked elevations of lactate might indicate...Hypoperfusion
Perfusion parameters
EFC loss-hypovolemic
If you want to measure central venous pressure, what must you do? Where is the catheter? What does this measurement tell us about?Measuring this requires sterile placement of central venous catheter. IT measures the pressure in the Vena Cava, specifically. It tells us about VOLUME!
If you want to discontinue fluids, how would you do this? (General & specific) What must you be careful of & what would you want to tell the owners?You must SLOWLY TAPER THEM OFF THE FLUIDS! Do this in a Gradual 24 hour reduction – 20% q6-8h (high flow rates might take longer). 1 of the reasons why is that the high volumes of water given can cz renal medullary washout → this will lead to impaired urine concentrating ability, for up to several days! Be sure to tell parents that Water requirements may remain ↑ at home.


Question Answer
What is the definition of shock?Circulatory system failure to supply oxygen & nutrients to meet metabolic & cellular demand
*******shock can be clinically defined as abnormalities in perfusion Parameters, like... (6)Mentation
MM color
Extremity temp
HR, Pulse quality
How are perfusion & mentation related?Perfusion to brain affected....Supply dependent on O2
How are perfusion (/shock) & the color of MM related? (2 situations)(1) Vasoconstriction & anemia – white/pale
(2) Vasodilation – venous pooling, red
What is the HR like during shock?Tachycardia is a compensatory mechanism to ↑ CO
When doing a survey for shock-you do the "ABCs"(& D+E too)...what does this mean??Airway
D & E are least important, they are Disability & External assessment
ABC's → airway. When surveying the airway, what are you checking? What should you do if there is a problem?You want to determine patency (open/unobstruction) of airway. If there are any issues, you might want to give O2 supplementation, intubate, or consider tracheotomy
In a shock PTx, what are some methods of providing O2 supplementation?Flow by
ABC's → breathing. When surveying breathing, what are you checking? (4)The resp RATE, the resp EFFORT, the character of the breathing & breath sounds
ABC's → circulation. When surveying circulation, what are you checking? (7)MM color
Pulse rate
Pulse quality
Rate rhythm
What are the 6 colors MMs can be & what does it all mean?(1) Pink: Normal
(2) Pale: Anemia, Poor perfusion
(3) Hyperemic: Shock, SepsiS
(4) Cyanosis: Hypoxia
(5) Icterus: Hepatic dz, Hemolysis
(6) Brown: Methemoglobinemia
What is normal CRT? What does a prolonged CRT indicate? What does a SHORTENED CRT indicate?Normal is 1-2 seconds. >2 seconds indicates poor perfusion. <1 2nd indicates a hyperdynamic state
ABC's → D for disability. What does this mean?Refers to level of consciousness, ambulation & sensation
ABC's → E for external assessment. What are 7 examples of things you're assessing?Fractures
Open wounds
SHOCK is an even that happens on the _________ level in the bodyCELLULAR! Shock = Inadequate cellular energy production (this is bc “Normal” energy metabolism requires oxygen!! Lack of O2 = failure of energy production)
****what are the 3 main types of shock she is focusing on? (Name a few other types?)(1) Hypovolemic
(2) Cardiogenic
(3) Distributive (others may incld: Metabolic, Hypoxemic, Obstructive, Traumatic)
What is important to note when learning about the different types of shock?PTx can suffer from more than 1 type of shock at a time!
What are 4 events which lead into shock?(1) ↓ effective circulating volume
(2) Reduced oxygen carrying capacity of blood
(3) Reduction in cardiac pumping efficiency
(4) Alterations in vascular tone & responsiveness
*What is DO2?Rate at which oxygen delivered to tissues
*What is VO2?Rate at which O2 removed from blood for tissues
What is the "critical point"? (Hint: DO2 & VO2)As DO2 (delivery rate of oxygen) ↑, the VO2 (rate at which tissues take up delivered oxygen) ↑ also. HOWEVER, at some point, the DO2 does NOT continue to ↑ at a fixed rate-there is a "critical point" where the DO2 cannot ↑ as rapidly
What is lactate a useful indicator of? Why?Indicator of PERFUSION! bc it is produced from ANAEROBIC respiration which happens when O2 isnt being delivered (low DO2)
Explain how lactic acidosis results in an energy deficit, which eventually ends in death?Mitochondrial dysfxN
Failure to maintain cell membrane ion gradients
Loss of transmembrane potential
Reversal of polarity
Intracellular swelling
Intracellular ion scavenging
****Remember the Na-K ATPase…requires energy to run*
What are the 3 stages of shock?(1) "Early" compensated
(2) "Late" uncompensated
(3) Terminal or irreversible
Describe "early" (compensated) shockBlood flow is normal or ↑ & may be mal-distributed; vital organ..... Fxn is maintained
Describe "late" (uncompensated) shockMicro-vascular perfusion is compromised; significant reductions in effective circulating volume
Describe terminal/irreversible shockInadequate perfusion of vital organs; Irreparable damage; Death cannot be prevented
What is KEY to recognizing shock?EARLY recognition of cardiovascular instability is KEY!
What is hypovolemic shock? Describe the pathology of itShock in which there is ↓ effective circulating volume (“ECV”) (ECV = volume of arterial blood perfusing tissues). Bc of this Loss of circulating volume, there is a severe ↓ in tissue perfusion. This volume loss can be due to external or internal blood loss, or excessive loss of other body fluids
How does the body attempt to compensate for hypovolemic shock?The 1° compensation is an ↑ in sympathetic tone, which leads to vasoconstriction. There is also an ↑ in cardiac contractility. There will be tachycardia (which will initially ↑ the cardiac output), Microvasculature alterations which will mobilize fluid from interstitium, there will be reduced renal perfusion & RAAS activation! ↑ Na+ & H2O retention. All of this will result in ↑ INTRAVASCULAR VOLUME
*****Describe how early (compensated) shock appears clinically(Tricky to ID) There will be mild depression
Normal or slightly reduced pulse quality
Sluggish (2-2.5s) CRT
+/- Pale MM color
*****Describe how late (uncompensated) shock appears clinicallySevere depression
Pulse quality poor
Delayed CRT (>3s)
Pale MM’s
**What is the "shock organ" in dogs? Cats? (The 1st organ to go in shock & show signs)Cats: liver
**What is the heart's rxn to shock in dogs? Cats?Dogs: Tachycardia
Cats: Bradycardia
What phase in shock can you detect in dogs but not in cats?A hyperdynamic phase
If I say Distributive “vasodilatory” shock....what 3 conditions are suspect?ANAPHYLAXIS! Also sepsis & vascular obstruction.
Distributive “vasodilatory” shock has ↓ perfusion how?There is a loss of systemic vascular resistance (H2) ← (this is in the notes. I think this refers to H2 histamine receptors). & this results in MALDISTRIBUTION OF BLOOD FLOW.
Distributive “vasodilatory” shock → what are the 2 phases of this type of shock?Hyperdynamic & hypodynamic phases
Describe the HYPERDYNAMIC phase of distributive (vasodilatory) shockThere is tachycardia (for ↑ CO)
Fever (sepsis)
Bounding pulses
RAPID CRT (<1sec)
Hyperemic mucus membranes (blame the cytokines)
Peripheral vasodilation (Nitric oxide mediated)
Describe the HYPODYNAMIC phase of distributive (vasodilatory) shock (& why is this happening?)HYPO happens when compensatory mechanisms start to fail, resulting in hypoperfusion & reduced cardiac output. However, the CS are not necessarily different (tachycardia, prolonged CRT, pale or possibly icteric MMs, hypothermia). ***BUT, organ damage & failure are imminent
What is "cardiogenic shock”?A ↓ in “forward flow” from the heart....Failure of the heart as a pump!
Describe some conditions which can result in cardiogenic shockCongestive heart failure
Cardiac tamponade
Drugs → myocardial depression (anesthetics, β-blockers, Ca channel blockers)
Describe the pathophysiology of cardiogenic shock (what is happening & what are the problems?)In the case of cardiogenic shock, Volume status is adequate…..BUT can’t reach tissues!! There is: Forward flow failure = systolic failure, Restrictive filling = failure of diastole (HCM=hypertrophic cardiomyopathy) & reduced CO (reduced tissue perfusion). All of this → SHOCK
List some additional CS you'd see in cardiogenic shock (aside from usually shock signs)Crackles
Heart murmur
Abdominal distention
Fluid thrill
What are the 6 tests/assessments which are part of the emergency database? (Why do we look at each test?)PCV (hydration, RBCs)
Total protein (oncotic)
Lactate (tissue perfusion)
Glucose (metabolic status, sepsis)
Blood smear (check immune system)
USG (renal fxn)
Goal directed therapy → Physiologic end points: what are the things you want to fix/treat/etc?Mentation
Pulse quality
Extremity temp
Goal directed therapy → what are the indirect indices you can use to attempt to determine shock?Lactate, base deficit, urine output
Mixed/central venous oxygen saturatioN
Gastric intramucosal pH
What serves as end points of resuscitation from shock?Resolution of abnormalities in the perfusion Parameters!!
What are the 4 characteristics of terminal shock?(1) NOT responsive to aggressive therapy
(2) ↓ CNS blood flow (vasoconstrictive response)
(3) ↓ Coronary blood flow (which leads to myocardial damage → vicious cycle)
(4) Cytokine release (cell damage & death)
***Event leading to shock for... hypovolemic shock? Distributive shock? Cardiogenic shock?(1) Blood, salt/water loss “fluid”
(2) Sepsis, anaphylaxis, obstruction “tubes”
(3) Failure of the heart as a “pump”
***Vascular tone for... hypovolemic shock? Distributive shock? Cardiogenic shock?(1) Constriction
(2) Dilation
(3) Constriction
***Cardiac output for.... hypovolemic shock? Distributive shock? Cardiogenic shock?(1) ↓
(2) ↑ then ↓
(3) ↓
***Systemic vascular resistance for... hypovolemic shock? Distributive shock? Cardiogenic shock?(1) ↑
(2) ↓
(3) ↑
***Mechanism for organ damage for... hypovolemic shock? Distributive shock? Cardiogenic shock?(1) Ischemia
(2) Inflammatory mediators (cytokines)
(3) Ischemia