Presentation on theme: "Case presentation Samane Nabi Emergency medicine resident"— Presentation transcript:
1Case presentation Samane Nabi Emergency medicine resident 93.5.14
2(HAZRAT_E_RASUL HOSPITAL) A 82 y old man withThe chief complaint ofWEAKNESScoming to ED(HAZRAT_E_RASUL HOSPITAL)At22:45 Pm
3CC: WeaknessPI:a 82 y old man was referred to ED With the chief complaint of generalized weakness which had been started 5 days before the entrance to ED.He complaint from intermittent burning retro sternal chest pain and epigastric pain that was radiated to the back with no relation to feeding It was accompanying with nausea, vomiting and cold sweating. content of vomiting was the eaten food and without blood and bile.He had no dyspnea. He had normal defication.no Melena. He had no fever.Patients with these symptom, was hospitalized for 2 days in another hospital before entrance to ED that due to the general deterioration, left center.
4Dyspepsia or epigastric discomfort + PMH:IHD +CCU addmition +HTN+DM-Dyspepsia or epigastric discomfort +
5Patient had not history of drug using. DH & HH:Patient had not history of drug using.Alcohol –Smoking –Opium –
7Patient was conscious, ill and pail and he had cold sweating. No JVD.Lung: normalHeart: s1 and s2 were detected with no pathologic sounds or murmurAbdomen: Guarding- , Distention-, Mild Epigastric Tenderness+Extremities: Extremity pulses were symmetrically full.
13The patient was transferred to the resuscitation room After 1 hour, the patient's clinical condition worsened.he opened the eyes with voicehis blood pressure was non measurable.Only carotid pulse was palpable.The patient was transferred to the resuscitation room
14Central vein line was inserted Foley catheter was inserted CVP:2Foley catheter was insertedUrine out put: 0
15RUSH EXAM: IVC WAS Collapsed No hypokinesia in heart, no tamponed no plural effusionIn inter loop and Morison patch there was non homogenous fluid
16In patient with septic shock Vancomycin and meropenem was administered.After received of 2 liters normal slain CVP was 6 and urine out put was 200 ccBP: 100/60PR: 90Surgery consultation was done.CXR was taken.
22D1 perforation with Purulent discharge Patient in 7 am transferred to operation room with Peritonitis diagnosis due to hallo viscus perforationOperation report:D1 perforation with Purulent dischargeDistal gastrectomy with wound closing and gasterogegenostomy
24After this surgery he transferred to SICU and because of anastomose leak and bowel evisceration Twice again operated.Patient any time win and after 30 days hospitalization and five times CPR expired.
25in ED, shock is rarely listed as a primary diagnosis.Arterial hypotension, defined as a systolic blood pressure (BP) below 100 mm Hg, is measured at least one time in 19% of ED patients; however, diagnosed traumatic, cardiogenic, or septic shock is less common, constituting about 1 to 3% of all ED visits.
26Patients in the ED are in shock with no obvious cause. Rapid recognition of shock requires immediate history and physical examinationIn general, patients with shock are ill, asthenic, pale, often sweating, and usually tachypneic or grunting, and often have a weak and rapid pulse.HR can be normal or low in shock.BP initially can be normal because of adrenergic reflexes.a single systolic BP less than 100 mm Hg in the ED is associated with a threefold increase in in-hospital mortality and a tenfold increase in sudden death.Shock can be strongly supported by the presence of a worsening base deficit or lactic acidosis.
27Urine output provides an excellent indicator of organ perfusion. The HR/systolic BP ratio may provide a better marker of shock than either measurement alone, a normal ratio is less than 0.8.Urine output provides an excellent indicator of organ perfusion.normal out put: >1.0 mL/ kg/hr , reduced: mL/kg/hr, severely reduced: <0.5 mL/ kg/hrA lactate concentration greater than 4.0 mM or a base deficit more negative than −4 mEq/L predicts the presence of circulatory insufficiency.
28Empirical Criteria for Diagnosis of Circulatory Shock
29MANAGEMENT: Monitoring Perfusion Status Quantitative Resuscitation all patients with shock, HR, BP, and oxyhemoglobin saturation are continuously monitoredQuantitative Resuscitationpulmonary artery catheterLactate clearanceMixed venous oxygen saturation (SvO2)VentilationRapid sequence intubation is the preferred method of airway control in most patients with refractory shock.Volume ReplacementThe goal in volume replacement is slightly elevated left ventricular end-diastolic volume, which is a difficult measurement to make in the ED. The CVP is most often used to estimate right ventricular filling pressure and is used in some quantitative resuscitation.
30Definitions and Criteria for Septic, Hemorrhagic, and Cardiogenic Shock
31Septic shock:Treatment begins by establishing adequate ventilation to correct hypoxia and acidosis and to reduce systemic oxygen consumption and left ventricular work. This often requires endotracheal intubation and sedation for mechanical ventilation.Etomidate !!!!The second goal is to achieve adequate ventricular filling. Initial volume replacement should include rapid infusion of 20 to 25 mL of crystalloid per kilogram. If hypo perfusion is persistent, 5- to 10-mL/kg boluses of a natural colloid (such as albumin) should be considered. Blood should be transfused in the ED to restore hematocrit to 30%.The third directive is to eradicate the infection with antimicrobial therapy and, where necessary, surgical drainage.
32Septic shock refractory to volume restoration (urine output or BP remains low, lactate increases) requires vasopressor support. norepinephrine ( μg/min)The use of corticosteroids in the treatment of sepsis and septic shock has been investigated with mixed results. Most current guidelines recommend that low-dose hydrocortisone be administered only to patients receiving chronic steroid replacement and in patients with refractory shock despite adequate fluid and vasopressor support