Trauma; the scenario I’m going to present to you is kind of an abbreviated advanced trauma/life support scenario. What you want to do is pick up injuries that are likely to be life threatening or cause long term morbidity quickly and treat them effectively and resuscitate each problem as you discover it. After the patient has been stabilized, you are going to go back and do a little more thorough exam with a secondary survey, and then begin definitive therapy.
More information about trauma
The primary survey; it’s very easy to get distracted by the fractured femur sticking out of the thigh, the foot that’s twisted on backwards. Other than blood loss, that’s not going to kill them. What’s going to kill them is the fact that while you are looking at their ankle they quit breathing. So be very systematic in your assessment; airway, breathing, maintain cervical spine precautions with the airway. Cervical spine injuries in children with survivable injuries are relatively uncommon. That doesn’t mean you should ignore them. I would not let someone asphyxiate because you are concerned about intubating them. Breathing; listen to the lungs for asymmetry. Think about pneumothorax, hemothorax. Circulation; IV access and fluid resuscitation. Remember you can put interosseus needles in, using bone marrow needles, up to the age of six and maybe even a little bit beyond. It may be very effective in initial fluid resuscitation. If somebody has a crushing chest injury, be suspicious of pericardial effusions and the need for pericardial centesis. In keeping with the ABC’s, we end up with D which stands for disability, which really reflects the neurologic status. Advanced trauma life support talks about the AVPU system of assessing the level of consciousness. A, being alert, V means that they respond to verbal commands, P to painful, and U means they are unresponsive.
Abnormal uterine bleeding articles
Pupillary response and lateralizing weakness; you are looking for very gross neurologic changes. You are not writing letters in the palm of their hand and asking them what they are. This is a very quick neurologic survey to make sure that they don’t have any potentially life threatening or long term morbidity-threatening problems.
So overall, what is going to be the therapy for your shock state? You are going to treat the underlying cause. If you are suspicious that somebody has septic shock, some antibiotics might be a good thing to do. You are going to stabilize their airway and breathing, that is, if they have quit breathing you are going to breathe for them, and you are going to administer fluids. And this is where you are going to want to pay attention to the underlying etiology of the shock. For all of the forms that we talked about, other than cardiogenic shock, fluids are going to be your mainstay of therapy and may require very large volumes of fluid. Usually given in 20 ml/kg aliquots and they may end up getting 100 ml/kg over a couple of hours. Now if you are concerned that someone is in cardiogenic shock, that is not going to help them out. You are going to make their cardiogenic shock worse. So I think that certainly if they don’t respond to an initial fluid resuscitation you are going to want to reassess all of the suggestive findings of cardiogenic shock; liver size, pulmonary findings, jugular venous distention.
Canadian pharmacy blog
If the fluid is not being effective, regardless of the form of shock, or if you are dealing with cardiogenic shock you are going to want to move on to inotropic agents and vasoactive agents. Some of them that are utilized include epinephrine, which affects all of your receptors – alpha, beta receptors – and maybe your first drug of choice in septic shock because of it’s nice effects on the vasculature. Norepinephrine is a potent vasoconstrictor and something you may lean towards with a severe distributive shock. Dopamine has multiple effects which may be beneficial. If you are dealing with a specific cardiogenic shock, you are looking for something with good inotropic support – that is, increase the contractility of the heart. Dobutamine and milrinone are likely to be the drugs that you are going to utilize. Oftentimes combination drugs are used, either similar classes or different classes. It would not be unusual to combine milrinone and dobutamine, or milrinone and another inotropic agent, or the combination of vasoactive agents, vasoconstrictors such as epinephrine and norepinephrine plus a little dopamine to hopefully help renal perfusion.
Canadian viagra online pharmacy
Remember one member of distributive shock, that is spinal cord injury, should get high doses of steroids given early as it has been shown to improve long term spinal cord function.
Trauma is the leading cause of death in children more than one year of age. Under a year of age it’s kind of a whole hodgepodge of congenital difficulties. Once you get to a year of age, if you’ve made it that far, you are most likely to die of trauma than anything else. The key to trauma is to prevent it. Anticipatory guidance, seat-belts, don’t have open windows on third stories where children are likely to plummet to their death.
Cardiogenic shock; typically, although not always, there is a suggestive medical history. When you look at the patient you may in fact see a big scar running down the middle of their sternum. Always a warning sign that something has happened to their heart. So get a medical history. Tachycardia will essentially always be present unless the cause of their shock is that they are having a bradydysrhythmia. You can obviously be in shock because you have a heart rate of 30 and you are not tachycardic. You will have poor perfusion, again, the compensatory mechanism of vasoconstriction. Some clinical clues that in fact you are dealing with cardiogenic shock, rather than hypovolemic shock, will be pulmonary exam; you may hear rales throughout the lung fields, you may hear the heart shifted over and enlarged. You may have a gallop rhythm. Your heart may be large by chest x-ray. The liver might be quite large, and although we don’t typically look for jugular venous distention on children, you can certainly observe it. So look for it, you may find it. These are all things that would suggest a cardiac function problem rather than hypovolemia or other etiologies of shock.
Order canadian viagra online
Septic shock; again, history may be very helpful. Certainly if somebody is very febrile it’s one of the things you will entertain. The findings will be similar in that you will be tachycardic. The thing that will be different oftentimes about septic shock, especially early on, is that you will have systemic vasodilation which will make your skin look very well perfused. So if someone shows up hypotensive, with instantaneous capillary refill, don’t be reassured by the capillary refill. It’s because they are inappropriately vasodilated and they are undoubtedly septic. Again, your heart and liver will be small early on. On laboratory examination you may see either a high white count or a low white count. Septic shock is really a combination of distributive shock where you have misdistribution of your fluids, cardiogenic shock where your heart doesn’t work so well, and hypovolemia where you likely have had volume loss.
A pure distributive shock will be a shock state where your blood flow is not appropriate for your body. You may have a history – if someone has a knife wound to their spinal cord, you might suspect that they’ve lost all their sympathetic enervation to the lower half of their body. They vasodilated and they are not distributing their blood flow appropriately. Anaphylactic shock where you have vasodilation is a form of distributive shock. Again, tachycardia. Very sensitive finding. You will be hypotensive and much like septic shock, you will be warm and well perfused, at least until your blood pressure begins to fall significantly.
Shock can be seen at three different phases. Compensated shock; which just maintains that the patient, through compensatory mechanisms, is able to maintain a blood pressure. It doesn’t mean that they are able to maintain perfusion to the tissues. It just means that they are not yet hypotensive. A de-compensated shock means that they are no longer able to maintain a blood pressure and at some phase your patient is going to enter irreversible shock, which – no matter what you do at that point – your patient is destined to die. Obviously you would like to see patients in the early phases of shock and not in the later phases. There is an easy way to remember normal blood pressures, which is in your handout. Systolic pressure should be greater than 60 mmHg up to a month, 70 from a month to a year, and 70+ the quantity two times the age, if you are above a year of age. Obviously if you are 60-year-old your normal blood pressure should not be 190. These are minimal blood pressures, these are not normal blood pressures. They are good estimates of 5th percentile. So if you are below these you are hypotensive.
What are the shock patterns that you can see in patients? We are going to talk about these a little bit, each individually; hypovolemic shock, cardiogenic shock, septic shock and distributive shock. Hypovolemic shock; you would like to have some sort of a history suggesting that your patient is hypovolemic. Lack of intake, vomiting, diarrhea, something that would decrease their volume status. Tachycardia is very sensitive for hypovolemia. That is, if you are hypovolemic you will undoubtedly be tachycardic. Some children will get tachycardic just seeing your approach. So it’s not a very specific indicator, but it is sensitive. Poor perfusion, the body’s compensation to hypovolemia, is to vasoconstrict peripheral tissue beds so you will see cold, cool extremities with delayed capillary refill. And since your intravascular volume is small, your heart size will be small and your liver will be small, which may be discernible on physical examination.
Recent Comments