1. Dr Stephanie Sim Dr Sharon Christie Dr James Shaw Dr Lysa Owen
Acute Care Workshop
Dr Stephanie Sim
Dr Sharon Christie
Dr James Shaw
Dr Lysa Owen

2. Plan for today Learning Objectives
Powerpoint presentation (on Blackboard)
Demonstration of ABCDE
Split into 2 groups
Simulation
Break at half time then swap

3. Outcomes Acute care Workshop
Describe the pathophysiology of hypoxia and hypotension
Identify when a patient is acutely unwell
Demonstrate ability to assess an acutely unwell patient using ABCDE
Initiate appropriate management
Demonstrate awareness of specific treatment regimens

4. Hypoxia

5. Oxygen cascade Series of steps: atmospheric air mitochondria
pO2 at any stage in subsequent steps

6. Remember Context is really important….
A patient with ‘normal values’ when breathing at a rate of 40 bpm, is not as well as someone breathing at a rate of 12bpm
A patient with Sats of 96% on 60% O2 is not as well as someone breathing air with the same O2 sats!
A patient with PaO2 of 9kPa is getting better if it was 8 before and he is on the same concentration of O2,but getting worse if it was previously 10kPa!

7. Blood pressure Related to Blood Pressure
Arterial & venous system with organ autoregulation
Blood Pressure
Cardiac Output (CO) X Systemic vascular resistance (SVR)
Heart Rate X Stroke Volume

8. Blood pressure Related to Blood Pressure
Arterial & venous system with organ autoregulation
Blood Pressure
Cardiac Output (CO) X Systemic vascular resistance (SVR)
Heart Rate X Stroke Volume
Afterload ↓↓ SEPSIS/ ANAPHYLAXIS/ NEUROGENIC
Myocardial contractility ↓↓ CARDIOGENIC SHOCK
Preload ↓↓HYPOVOLAEMIA/ HAEMORRHAGE

9. Blood pressure THEREFORE Blood Pressure depends on
Circulating blood volume
↓ in hypovalaemia/ haemorrhage
Pump function
↓ in cardiogenic shock
Systemic vascular resistance
↓ in sepsis
↓ in anaphylaxis

10. Response to shock Tachycardia, Tachypnoea
Progressive peripheral vasoconstriction (if possible)
Shift to anaerobic metabolism for hypoxic cells, then lose the ability to generate ATP, loss of electrical gradient and cell death

11. Causes of Shock Haemorrhagic (70Kg man) Up to 750 750-1500 1500-2000
Class I
Class II
Class III
Class IV
Blood loss (ml)
Up to 750
>2000
Blood loss
(% volume)
Up to 15%
15-30%
30-40%
>40%
Pulse rate
<100
>100
>120
>140
Blood pressure
Normal
Decreased
Pulse pressure
Normal or increased
Respiratory Rate
14-20
20-30
30-40
>35
Urine Output ml/hr
>30
5-15
Negligible
CNS/Mental status
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic

12. Signs of shock Tachycardia, tachypnoea and vasoconstriction
=> Diagnosis of shock until proven otherwise
(relying on BP drop delays diagnosis)
Relative to normal (kids, young adults, elderly)
Varying ability to mount response (B blocker, Ca channel blocker, paced, etc)
Urine output – indicator of renal blood flow
Should be >0.5ml/Kg/hour
Acid Base Abnormality
Respiratory alkalosis initially> Metabolic Acidosis

13. Assessment of shock Airway
Breathing – give O2, RR, SpO2, Breath Sounds
Circulation – stem bleeding/obtain adequate iv access/assess tissue perfusion (P,BP,CRT) ?Fluids required (likely to be)
Disability – AVPU, BM, Pupils
Exposure – Complete examination re possible cause, temp, TPAR
?Catheterisation

14. Fluid Homeostasis Normal 70 Kg male = 42litre (60%) Water 28 litres
Extracellular
Fluid (ECF)
Intracellular Fluid (ICF)
9.4 litres
4.6 litres
28 litres
Interstitial
Plasma

15. Normal Physiology Compartment volume maintained by
Oncotic pressure (retains fluid)
Hydrostatic pressure (forces fluid out of vessel)
Osmotic gradients
Electrolyte pumps

16. Types of fluid replacement
Crystalloids
Colloids
Blood

17. Crystalloids Eg. Dextrose, Saline, Hartmans Pros/Cons:
True solutions - substances which will diffuse through
a semi-permeable membrane
Pros/Cons:
Easily available
Cheap
Variable volume of distribution (can end up in undesirable
spaces!)

18. Colloids Pros/Cons : Eg. Gelofusine, “glue” – Greek
Substance which does not diffuse through a
semipermeable membrane.
Large particles (protein or carbohydrate) that are
suspended in water
Pros/Cons :
Stays in intravascular space
Relatively expensive
Risk of anaphylaxis
No proven benefit over saline in hypovolaemia

19. Blood Pros/Cons : Well recognised Replaces ‘like with like’ Expensive
Carries oxygen well!
Expensive
Risk of transfusion reactions
Infection risk etc

20. Distribution of Fluids
ECF
ICF
Interstitial Fluid
Circulation
5%Dextrose
(essentially WATER)
0.9% Saline
Blood
Colloid (expands plasma
volume due to oncotic pressure)

21. Main points *Fluids* ( in almost all cases)
Recognise patient is unwell
Treat early (ideally before hypoxic, hypotensive)
Optimise what you can (ABCDE) *Remember Oxygen*
General measures to improve blood pressure
*Fluids* ( in almost all cases)
Inotropes
Specific measures to treat cause
Monitor response
Urine output, ABGs
Blood pressure/ cardiac monitor
Central lines etc
Etc

22. Any Questions?

23. Outcomes Acute care Workshop
Describe the pathophysiology of hypoxia and hypotension
Identify when a patient is acutely unwell
Demonstrate ability to assess an acutely unwell patient using ABCDE
Initiate appropriate management
Demonstrate awareness of specific treatment regimens