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Acute Care Workshop. Dr Stephanie Sim Dr Sharon Christie Dr James Shaw Dr Lysa Owen. Plan for today. Learning Objectives Powerpoint presentation (on Blackboard) Demonstration of ABCDE Split into 2 groups Simulation Break at half time then swap.

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acute care workshop

Acute Care Workshop

Dr Stephanie Sim

Dr Sharon Christie

Dr James Shaw

Dr Lysa Owen

plan for today
Plan for today
  • Learning Objectives
  • Powerpoint presentation (on Blackboard)
  • Demonstration of ABCDE

Split into 2 groups

  • Simulation
  • Break at half time then swap
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

Outcomes Acute care Workshop
oxygen cascade
Oxygen cascade
  • Series of steps: atmospheric air mitochondria
  • pO2 at any stage in subsequent steps
remember
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!
blood pressure
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

blood pressure1
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

Myocardial contractility ↓↓ CARDIOGENIC SHOCK

Preload ↓↓HYPOVOLAEMIA/ HAEMORRHAGE

blood pressure2
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

response to shock
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
causes of shock
Causes of Shock
  • Haemorrhagic (70Kg man)
signs of shock
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

assessment of shock
Assessment of shock
  • Airway
  • Breathing – give O2, RR, SpO2, Breath Sounds
  • Circulation – stem bleeding/obtain adequateiv 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
fluid homeostasis
Fluid Homeostasis

Normal 70 Kg male = 42litre (60%) Water

Extracellular

Fluid (ECF)

Intracellular Fluid (ICF)

9.4 litres

4.6 litres

28 litres

Interstitial

Plasma

normal physiology
Normal Physiology

Compartment volume maintained by

  • Oncotic pressure (retains fluid)
  • Hydrostatic pressure (forces fluid out of vessel)
  • Osmotic gradients
  • Electrolyte pumps
types of fluid replacement
Types of fluid replacement
  • Crystalloids
  • Colloids
  • Blood
crystalloids
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!)

colloids
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
blood
Blood

Pros/Cons : Well recognised

  • Replaces ‘like with like’
    • Carries oxygen well!
  • Expensive
  • Risk of transfusion reactions
  • Infection risk etc
distribution of fluids
Distribution of Fluids

ECF

ICF

Interstitial Fluid

Circulation

5%Dextrose

(essentially WATER)

0.9% Saline

Blood

Colloid (expands plasma

volume due to oncotic pressure)

main points
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
outcomes acute care workshop1
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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