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

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Presentation on theme: "Acute Care Workshop Dr Stephanie Sim Dr Sharon Christie Dr James Shaw Dr Lysa Owen."— Presentation transcript:

1 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 pO 2 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% O 2 is not as well as someone breathing air with the same O 2 sats! A patient with PaO 2 of 9kPa is getting better if it was 8 before and he is on the same concentration of O 2, but getting worse if it was previously 10kPa!

7 Blood pressure Related to 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 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 Preload ↓↓HYPOVOLAEMIA/ HAEMORRHAGE Myocardial contractility ↓↓ CARDIOGENIC SHOCK

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) Class IClass IIClass IIIClass IV Blood loss (ml) Up to >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 Decreased Respiratory Rate >35 Urine Output ml/hr > 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 O 2, RR, SpO 2, 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 Intracellular Fluid (ICF) Extracellular Fluid (ECF) InterstitialPlasma 9.4 litres 4.6 litres 28 litres

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 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 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’ Carries oxygen well! Expensive Risk of transfusion reactions Infection risk etc

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

21 Main points 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


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