Shock - Differential Diagnosis Framework
MAP = CO x SVR
Hypovolemic (↓ Intravascular volume):
• Hemorrhage, dehydration due to renal/Gl losses, poor PO intake, severe burns, third-spacing
• ↓ CO, ↑ SVR, ↓ PCWP
• Exam: ↓ JVP, extremities, narrow pulse pressure, pallor
Cardiogenic (Intra-cardiac pump failure):
• Severe heart failure, acute MI, arrhythmia
• ↓ CO, ↑ SVR, ↑ PCWP
• Exam: ↑ JVP, extremities. narrow pulse pressure, S3, crackles
Obstructive (Extra-cardiac pump failure):
• Mechanical → tension PTX, cardiac tamponade, Vascular → PE, PAH
• ↓ CO, ↑ SVR, ↓ PCWP
• Exam: ↑ JVP, extremities. narrow pulse pressure, other findings based on cause
Distributive (↓ Vascular tone):
• Sepsis. neurogenic, anaphylaxis, release syndrome, infusion reactions, adrenal crisis, drugs/toxins
• ↑ CO, ↓ SVR, ↓ PCWP
• Exam: ↓ JVP, warm extremities, wide pulse pressure
by Lauren Banaszak, MD @LaurenBzak via @uw_IMresidency
#Shock #Differential #Diagnosis #table #comparison #criticalcare
Acute Respiratory Distress Syndrome – ARDS: Clinical Cheat Sheet
An acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, lung congestion with hypoxemia and bilateral radigraphic opacities, associated with decreased lung compliance.
Berlin criteria (2013)
● Acute onset over 1 week or less
● Bilateral opacities consistent with pulmonary edema must be present; they may be detected on CT or CXR
● PaO2/FiO2 ratio <300mmHg with a minimum of 5 cmH20 PEEP
● Volume overload with heart failure should be ruled out either subjectively or an “objective assessment“ (e.g. echo
cardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis.
Management
● Early resuscitation, appropriate antibiotic agents, and source control if sepsis-associated ARDS.
● Conservative fluid-management
● Supportive management with early enteral nutrition
● Treat the underlying cause
● Glucortecoids may improve oxygenation in pneumonia and are harmful if started >14 days after dx of ARDS
Usama Nasir MD @usamanasirmd - Visualmed
#Acute #RespiratoryDistress #Syndrome #ARDS #Summary #CheatSheet #Diagnosis #Management #CriticalCare
It is important to recognize Acute Decompensated Heart Failure (ADHF) as more than just simply a clinical diagnosis but rather as a condition with a wide range of possible clinical presentations. Patients presenting with ADHF typically fall into 1 of 4 recognized hemodynamic profiles that when appropriately identified, provide a particularly useful framework to guide therapy. The correct profile can be determined based on two clinical parameters: perfusion status and congestion.
The assessment of a patient suspected to be in ADHF starts with a good history & exam. Signs of poor perfusion include cool extremities, fatigue, altered mental status and low urine output. Signs of congestion include Crackles/Rales on auscultation, JVD, Orthopnea/PND and Peripheral Edema. Some exam findings may be more specific rather than sensitive making the diagnosis challenging. Imaging and more importantly, bedside ultrasound are excellent at evaluating hemodynamics and cardiac function (“the squeeze”) along with presence of pulmonary edema (“B-lines). ECG is vital while lab markers such as BNP/NT-proBNP and Troponin may be elevated and helpful in establishing a diagnosis.
Adequate perfusion without congestion (Warm & Dry) is the treatment goal with emphasis placed on prevention. Most patients, however, are adequately perfused but congested on presentation (“Warm & Wet”). They may benefit from LV afterload reduction (Vasodilators) which augment forward flow to the kidneys where excess volume can then be excreted using diuretics. The poorly perfused and non-congested profile (“Cold & Dry”) usually results from the overdiuresis of a Wet & Warm patient causing hypovolemia needing a little fluid. This is not uncommon and can be prevented by adjusting the dose and/or transitioning to oral therapy when our patients have achieved negative fluid balance and are clinically improved. Poorly perfused and congested (“Cold & Wet”) is essentially Cardiogenic Shock. These patients need inotrope therapy and afterload reduction. Cardiac cath if acute coronary syndrome is the determined cause and perhaps even mechanical support (Balloon pump, Impella, LVAD, ECMO). “Warm & Dry” is the treatment goal with emphasis then placed on prevention.
#diagnosis #differential #algorithm #management #cardiology #treatment #table #foamed #heartfailure #chf #criticalcare #icu #clinical #pharmacology
ExtraCorporeal Membrane Oxygenation (ECMO) Fundamentals
Definitions:
• ExtraCorporeal Membrane Oxygenation (ECMO) provides prolonged pulmonary and/or circulatory support by removing venous blood, pumping it across an artificial lung (oxygenator or membrane lung) for gas exchange, & returning it to the pt.
• VV ECMO: artificially oxygenated Venous blood is returned to the Venous side (right atrium), providing no circulatory support, & adding the artificial lung in series with the native lung
• VA ECMO: artificially oxygenated Venous blood is returned to the Arterial side (aorta), providing circulatory support, and adding artificial lung in parallel with the native lung.
Indications:
• VV: Refractory hypoxemia/mixed respiratorv failure used as a bridge to recovery or transplant
• ECCO2R: Refractory hypercapnia similar to VV but with lower flow/smaller sized cannula
• VA: Pulmonary & Circulatory Support (VA) - cardiac arrest, overdose, massive PE, cardiogenic shock, etc. Used as a bridge to recovery, transplant, or destination device.
by Nick Mark MD @nickmmark
#ECMO #ExtraCorporeal #Membrane #Oxygenation #diagnosis #management
