face multisystem revie · • decrease in gcs • hypotension • decrease in platelets •...

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CCRN®/PCCN® Review Course - Day 1 ©TCHP Education Consortium, September 2003, Rev. May 20191

Multisystem ReviewTCHP CCRN Review

Lynelle Scullard MSN RN CCRN‐K CNRN

Traumatic Injuries

• Face

• Thoracic

• Abdominal

• Orthopedic

• Burns

Facial injuries

• Lefort I• “mustache fracture”

• Maxillary fracture

Facial injuries

• Lefort II• Infraorbital rim

• Triangular

• “nose”

Facial injuries

• Lefort III• Across the orbits

• “glasses”

Facial injuries

• Management• AIRWAY

• Is it CSF?

• Surgical repair



Thoracic injuries

• Fractures

• Contusions

• Tears

Fractures

• Ribs

• Flail chest

• Management• Respiratory

• TCDB

• Pain!

Contusions

• Pulmonary• CXR “blossoms”

• May not look bad at first, or show up at all

• Same processes as ARDS

• Possibly limit fluids

Contusions

• Cardiac • Problem is dysrhythmias

• Treat the SX as usual

Tears

• Aortic • Transection immediate death

• Lac w/ pseudo aneurysm survivable

• Widened mediastinum

• Same care as HTN rupture

Tears

• Valves• Can be valve or papillary muscles

• Same SX as valve insuff

• Poor CO



Tears

• Diaphragm• Rupture of diaphragm with bowel contents into lungs

• Difficult to diagnose

• R protected by liver

• Surgical repair

Abdominal Injuries

• Liver

• Spleen

• Kidneys

• Bowel

Liver

• Most frequently injured organ

• Bleeding

• Coagulation studies

Spleen

• Most frequent injured organ for blunt trauma

• Profound bleeding• Delayed bleeding/rupture

• Vaccinate • H‐flu• Pneumococcal• streptococcal

Kidneys

• Bleed• Retroperitoneal

• Surgical removal

• Usual care

Bowel

• Penetrating

• Retroperitoneal bleeding

• Difficult to diagnose

• High infection/complication rate



Orthopedic Injuries

• Extremities

• Pelvis

• Complications

Extremity injury

• Realignment

• Open… OR and antibiotics

• Bleeding

• Pulses etc.

Pelvis

• Massive bleeding

• Retroperitoneal bleeding

• Bladder

• Immobilize, keep aligned

• Acetabular fx assoc. w/ femur fx

Orthopedic injury complications

• Compartment syndrome• Elev. pressures in fascia (>30)

• 4 ‘p’s pain, paresthesia, pulseless, pallor

• Fat emboli/DVT/PE• Showers….ARDS

• Rhabdomyolysis• Pelvis, femur

• Large spill of myoglobin from muscle death

• CK, tea colored urine, low urine

• Fluids, bicarb, mannitol

Poisoning

• Overdose

• Acetaminophen

• Benzo’s

• B‐Blockers

• Ca channel blockers

• Digitalis

• Nipride

• Opioids

• Tricyclic antidepressants

• Treatment

• N‐acetylcysteine

• Flumazinal

• Glucagon

• Calcium, glucagon

• Digibind, charcoal

• Nitrites, thiosulfate

• Naloxone

• Bicarb

ASA overdose

• Coma, lethargy

• Metabolic acidosis

• Tx;• Bicarb

• Dialysis



Acetaminophen overdose

• N‐acetylcysteine (best w/in 12hrs)

• Confused, agitated

• Liver primary organ

• Asymptomatic 24hrs

• Mild sx, but labs 24‐72hrs

• 72hrs progressive

AACN practice alert: pain

• 1. Use a standardized scale (CPOT or BPS)

• Use patient self report

• Avoid pain assessment based on VS

• Use a proxy known to patient

Awakening & Breathing Trial Coordination

Delirium Assessment & Management

Early Exercise & Progressive

Mobility

ABCDE Bundle Components The Problem• Negative outcomes of prolonged ventilation

• VAP• Immobility• Delirium

• Sedation used to relieve anxiety and agitation• Oversedation

• Undersedation

• Harmful outcomes

Wake Up and Breathe Protocol

© 2008 Vanderbilt University. All rights reserved.

Delirium Assessmentand Management



Delirium Defined

• Acute change in consciousness accompanied by inattention and either a change in cognition or perceptual disturbance

• Three subtypes:

• Hyperactive: Agitation, restlessness, attempts to remove catheters, emotionally labile

• Hypoactive: Flat affect, withdrawal, apathy, lethargy, decreased responsiveness

• Mixed: Combination of hypoactive and hyperactive

Evidence‐Based ManagementAssess for presence of delirium

• Baseline risk factors to identify susceptibility

• Pre‐existing dementia

• History of baseline hypertension

• Alcoholism

• Admission severity of illness

• Standardized assessment tool to detect delirium that would otherwise go undetected

• Two valid and reliable tools

• Confusion Assessment Method for the ICU (CAM‐ICU)

• Intensive Care Delirium Screening Checklist (ICDSC)

Stop, Think and (Perhaps) Medicate

• Stop

• Do any medications (especially benzo‐diazepines) need to be stopped or lowered?

• Is the patient on the minimal amount of sedation necessary? Do any titration strategies need to be used, such as a targeted sedation plan or daily sedation cessation?

• Do the sedative drugs need to be changed?


• THINK• Toxic situations

• CHF, shock, dehydration

• Deliriogenic medications

• New organ failure

• Hypoxemia• Infection or sepsis• Immobilization• Non‐pharmacologic interventions employed?

• Glasses, hearing aids, reorientation, sleep protocols, noise

control

• K+ or electrolyte problems


• Medicate

• No FDA‐approved drug to treat delirium

• Haloperidol (Haldol) and atypical antipsychotics (ziprasidone [Geodon], quetiapine [Seroquel])

• Traditionally recommended medication class to treat

delirium

• Little evidence to support treatment

• All patients receiving antipsychotics should be routinely monitored for side effects, especially QT prolongation

Early Exercise and Progressive Mobility



The Problem• ICU‐acquired weakness – Acute onset of neuromuscular/functional impairment without plausible etiology

• Impairs ventilator weaning and functional mobility

• Patients with ICU‐acquired weakness require approximately 20 additional ventilator days

• Increased mortality

• Effects persist well after discharge

Evidence‐Based Management

• Early mobility protocols (early exercise, progressive mobility)

• Progress from passive to active range of motion (early PT)

• Sitting position in bed• Dangle• Stand & Transfer• Ambulation

• Screen for participation

• Two‐step process• Safety screen• Mobility protocol

Anaphylaxis: When the Immune System Goes Nuts

Histamine and other substances released in mass

Massive vasodilation

Increase in capillary permeability

(IGE stim-mastcell-histamine-platlet activating factor)

Symptoms of Anaphylactic Shock

• Hypotension

• Tachycardia

• Decreased SVR

• Edema

• Wheezing/SOB

• Nausea/vomiting

Treatment for Anaphylaxis

• ABC’s

• Epinephrine SQ 1:1000 Q10‐15”

• 1mg/ml IM new method

• Steroids (hydrocortisone 5mg/Kg)

• Benadryl

All of anaphylaxis interventions

Epinephrine IV 5-10 mcg

Fluid volume resuscitation (lose 40% into interstitium)

Epi or dopamine drips

?Amrinone or milrinone (bronchdilates)

Tx for Anaphylactic Shock



CLABSI

• Sterile insertion

• Remove ASAP

• Scrub the hub

• Dry and intact dressing

CAUTI

• Remove/do not insert Foley

• Sterile insertion

• Perineal care

• Bag below bladder

• Securement

VAE

• Extubate ASAP

• HOB at least 30

• Oral hygiene and subglottic sx

MRSA and VRE

• Hand hygiene

• Protective measures

• Public education

• Surveillance

Sepsis and Multiple SystemOrgan Failure

• SIRS

• Sepsis

• Severe sepsis

• Septic shock

• MSOF

Systemic Inflammatory Response Syndrome (SIRS)

• Definition•

• Two or more

•HR > 90•Temp > 38º C (100.4º F) or <

36º C (96.8º F)•RR > 20 or PaCO2 < 32 mmHg•WBC > 12K < 4K, or > 10%

bands



Sepsis

• Definition

HR > 90

Temp > 38º C (100.4º F) or < 36º C (96.8º F)

RR > 20 or PaCO2 < 32 mm Hg

WBC > 12K < 4K, or > 10% bands

Infection causes inflammatory response

Hyperglycemia >120altered mental state

C-reactive protein>2

Severe Sepsis

• Definition

• Sepsis+• Organ dysfunction

• Hypoperfusion

• Hypotension or

or

Arterial hypoxemiaacute oliguria

creatinine increasecoagulation abnormalities

thrombocytopeniahyperlactemia

arterial hypotension

Sepsis mimics

• Pancreatitis

• Trauma

• Burns

• Cardiac surgery

• ARDS

• Diabetic ketoacidosis

• Neuroleptic malignant syndrome

• Drug reaction

• Aspiration pneumonitis

5/23/2019

Sepsis is now defined as

• “a life‐threatening organ dysfunction caused by dysregulated host response to infection”

• “life threatening condition that arises when the bodies response to an infection injures its own tissues and organs”

• Response is excessive, creating an increased risk of morbidity and mortaility

Early is key

• Infection no longer defined

• SIRS and severe sepsis removed from definitions

• Septic shock:• A subset of sepsis

• Circulatory, cellular, metabolic alterations assoc. with higher mortality than sepsis alone

CMS, research, and you

• CMS still supports SIRS and old definitions

• Research still uses severe sepsis definitions

• YOU need to know when you patient is getting sicker and how to manage them



Risks

• Weakened immune system

• Chronic conditions • Artificial devices• Surgery• Inappropriate antibiotics• Poor nutrition • *** greatest risk may be the pathogens that medical and nursing professionals carry on unwashed hands!***

qSOFA

• Bedside screening tool

• One point for each:

• Altered mentation

• SBP 100 mmHg or less

• RR 22 or greater

• Two or more points is a positive screen

5/23/2019

Sepsis

• SOFA >2 PLUS

• Suspected or documented infection

• Decrease in P/F ratio

• Decrease in GCS

• Hypotension

• Decrease in platelets

• Increase in bilirubin

• Increase in creatinine levels and oliguria

5/23/2019

P/F ratio

• PaO2/FiO2

• Normal is greater than 380• 80/.21

• 90/.30=300 (ALI)

• 80/.40=200 (ARDS)

Septic shock (In addition to sepsis)

• Vasopressors needed to keep MAP>65, and

• Lactate > 2.0 mmol/L,

• Despite adequate fluid resuscitation.

5/23/2019



Cytokine Released by Effect

TNF‐α Dendritic cellsMacrophageNeutrophilT‐cell

Attracts other inflammatory cellsFever, catabolismEdema, vasodilation

IL‐1 Dendritic cellsMacrophageT‐cell

Similar to and synergistic with TNF‐α

NO Many Vasodilation

TGF‐β T‐cell Suppresses lymphocytes

IL‐10 B‐cellT‐cell

Suppresses pro‐inflammatory cytokinesEnhance B‐cell function

5/23/2019

Lactate/Lactic acid

• Causes of lactic acidosis:

• Type A: impaired tissue perfusion

• Type B1: disease states (sepsis)

• Type B2: drug‐related

• Type B3: inborn error of metabolism

• Lactate rises in sepsis for many reasons

• Higher lactate levels predict mortality

5/23/2019

Septic Shock

• Symptoms• Hyperdynamic

• (warm sepsis)

• Hypodynamic

• (cold sepsis)

Hyperdynamic State

• Mental • Confusion

• Lethargy

• Agitated

• hypoperfusion injury

Hyperdynamic State

• Cardiac• Tachycardic HR >140

• Hypotensive SBP<90

• Hemodynamics:• CO >8

• SVR<800

• RA, W low

• SVO2 high (75‐85%)

Despite multiple fluid

Flushes.

Hyperdynamic State

• Pulmonary • Tachypnea

• Low SaO2

• Crackles

• ARDS• shunting

• increased dead space

• VAP



Hyperdynamic State

• Renal• Oliguric

• fluid redistribution

• hypoperfusion

• nephrotoxins

• BUN, Cr go up• 20:1 10:1

Hyperdynamic State

• GI/liver• Hypoactive BS

• translocation of bacteria

• Liver enzymes climb• translocation of bacteria into portal circ, cytokines cause further inflammation

Hyperdynamic State

• Endocrine• Insulin resistance From catecholamines)

• Relative adrenal insufficiency

• hypopituitary

Hyperdynamic State

• Labs • ABG:

• pH acid

• pO2 low

• Bicarb low

• Coagulopathies

• Lactate

Hypodynamic State

• Mental • Comatose

Hypodynamic State

• Cardiac• Tachycardic

• Hypotensive

• Severe edema

• Hemodynamics• CO low <4

• SVR high >1200

• RA W high



Hypodynamic State

• Pulmonary • ARDS

• Poor gas exchange• Permissible hypercapnea

• PEEP,PCV

• Prone position

• Flolan

Hypodynamic State

• Renal • Anuric

• ARF

• Acidotic

• Dialysis?

Hypodynamic State

• GI/liver• Transmigration of bacteria

• Ulceration/bleed

• Dumping lg amts from NG

• Blood sugar drops…. D10

• develop DIC

Hypodynamic State

• Endocrine• Myocardial depressant factor (MDF)

• Slows HR down in an effort to conserve tissue.

• Adrenal insufficiency

Hypodynamic State

• Labs• Acidotic

• DIC?

• K+?

• Ca++?

Septic Shock

• Symptoms• Refractory hypotension

• Tachy

• CO low, SVR high

• Edematous

• Microvascular clotting



Procalcitonin

• Prohormone of calcitonin, released by lung and intestine in response to endotoxin

• More accurate at identifying bacterial sepsis than other available markers

• Can be elevated in major trauma, burns, major abdominal or cardiac surgery, MODS, ESRD

• Can be used to shorten antibiotic courses

5/23/2019

Initial management

• A one‐hour bundle is promoted by SSG:

• Measure lactate level

• Obtain blood cultures before administering antibiotics

• Administer broad‐spectrum antibiotics

• Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L

• Apply vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg

5/23/2019

3 hour bundle

• Measure lactate

• Obtain blood cultures before antibiotics• Delay considered > 45”

• 2 sets

• Administer broad‐spectrum antibiotics• ASAP

Fluids

• CVP> 8

• ScvO2 >70%

• “normalization” of lactate levels

6 hour bundle

• In addition to 3 hour

• Vasopressors MAP >65 (after fluids)

• If lactate >4 or hypotension persists reassess volume and perfusion

• Reassess lactate if initially elevated

Re‐assessment of volume

• VS

• Capillary refill

• Skin

• Or 2:• CVP

• ScvO2

• Bedside ultrasound

• PLR or fluid challenge



SvO2 or ScvO2

• Balance of supply vs demand

• Supply • O2 delivery (hgb, O2)

• transport CO

• Demand• O2 consumption

The 5 “S’s” of O2 consumption

•sepsis•spiking•seizing•shivering•struggling

SvO2

• < 60%• Delivery reduced

• Consumption increased

• Not fully resuscitated

• >75%• Increased delivery or decrease demand

• Obstruction or maldistribution

Dynamic assessments of fluid status• Pulse pressure variation

• With and without expiratory hold

• Stroke volume variation

5/23/2019

Fluids

• Initial resuscitation with 30 cc/Kg recommended by the SSG

• Adequate fluid resuscitation is notoriously difficult to judge

• Positive fluid balance later in the ICU stay is associated with mortality

• Albumin is probably no better or worse than crystalloid

5/23/2019

Vasoactive meds

• Norepinephrine is first line for hypotension

• Increased preload, arterial vasoconstriction, and slight inotropy are all beneficial

• Improved mortality when used instead of dopamine

• Epinephrine

• Vasopressin and epinephrine can be added

• Dopamine remains an option in selected cases

• Dobutamine can be used if inotropy is needed (i.e. persistent hypoperfusion)

5/23/2019

Severe Sepsis: Initial recognition and resuscitation

90

Expected Practice• Administer vasopressors if necessary to achieve a mean arterial pressure of 65 mmHg

• If Venous Oxygen saturation goal not attained consider;

• Additional fluids

• Blood transfusion

• Dobutamine infusion



Angiotensin‐II

• Renin‐angiotensin system had previously not been exploited for hypotension

• ATHOS‐3 study published in 2017 showed improved MAP with decreased adverse effects and organ dysfunction

• Place in therapy not yet clear

5/23/2019

Antibiotic choice

• Start broad‐spectrum, then narrow based on cultures

• Choice is based on likely site of infection/organism and local resistance data

• Usually includes a carbapenem (i.e., meropenem), extended spectrum PCN (piperacillin/tazobactam), or late generation cephalosporin (cefepime)

• Vancomycin also often added

• Add another broad‐spectrum antibiotic of a different class (i.e., gentamicin) in septic shock

5/23/2019

Unproven/controversial therapies

• Methylene blue

• Vitamin C, hydrocortisone, thiamine

• Sodium bicarbonate

• Steroids

• Also dozens of drugs targeting the inflammatory pathway

• ECMO

5/23/2019

Surviving Sepsis Campaign

• Blood products• PRB’c for hgb < 7

• higher hgb increases delivery but not consumption

• EPO not recommended

• FFP not recommended unless actively bleeding or an invasive procedure planned

• platlets given <5000 reguardless• risk of bleeding and count 5‐30,000

• . 50,000 for surgical/invasive procedures


• Ventilation • “low” TV 6ml/predicted body wt

• goal of lower TV: plateau pressures<30

• hypercapnia if needed to keep TV /PP low

• PEEP based on FiO2

• prone positioning

• HOB 45 degrees


• Glucose control• maintain serum glucose <150

• insulin drip

• enteral feeding

• Renal replacement• continuous venoveno hemofiltration

• Bicarb• not recommended



Nursing interventions

• Hand Hygiene• CDC: 1 in 25 patients develop HAI

• Monitoring

• Rescue, RRT

MODS (MSOF)

• Definition• Widespread dysfunction from endothelial cell damage in multiple organs

• Primary• Direct injury/insult to organ(s)

• Secondary • Results from sepsis process

• Lungs, liver, kidneys most common

MODS

• Causes • Primary

• Aspiration leading to ARDS

• PE

• Trauma to ABD

• Secondary• Hypoperfusion

• Microemboli

MODS

• Symptoms • APACHE II criteria

• One or more of the following in each category

APACHE II criteria

• Cardiovascular failure • HR </= 54/min

• MAP </= 49mmHg

• V‐tach, V‐fib or both

• Serum pH </= 7.24 with

• PaCO2 </= 40mmHg

APACHE II criteria

• Respiratory failure • RR <5/min or > 49/min

• PaCO2 > 50 mmHg

• P(A‐a)O2 .350mmHg

• Vent/CPAP dependent day 4



APACHE II criteria

• Renal failure • UO <479mL/24h or <159mL/8h

• Serum BUN > 100mg/dL

• Serum Creatinine >3.5 mg/dL

APACHE II criteria

• Hepatic failure • Serum Bilirubin >6 mg/dL

• PT >4 seconds over control (without systemic anticoagulation)

APACHE II criteria

• Hematologic Failure • WBC <1000/uL

• Platelets < 20,000/uL

• Hematocrit < 20%

APACHE II criteria

• CNS failure • GCS</= 6 (without sedation)

When is perfusion restored???? HR

BP

UO

Mental status

Skin perfusion

Normal in compensated shock; resuscitation stops

80‐85% trauma pts normal BP have signs of cellular hypoperfusion

Goals of resuscitation/perfusion

• Restore adequate O2 delivery

• Resolution of existing oxygen debt

• Elimination of anaerobic metabolites

• Key: early recognition and aggressive management



Questions??? Practice questions

• 1. Hypertonic solutions in burn resuscitation offer which of the following advantages?

• A. Delayed need for nutrition

• B. Less wound edema

• C. Lower serum sodium and lower serum osmolality

• D. Less sepsis

2. As a nurse caring for the patient with a flail chest and femur fracture, your

care should be focused on:

A. Turn, cough, deep breathingB. Pain controlC. Psychosocial issues related to the traumaD. Both a and bE. All of the above

3. A 22 yo male with an open book pelvis fracture has been receiving 125cc/hr of D5NS. His urine output for the last 2 hrs has been 28cc’s, and is dark in color. Myoglobinuria is suspected. What orders do you expect?

a. Increase IV fluids until urine output is 75-100cc an hour

b. Alkalinization of urine by adding NaHCO3 to IV fluids

c. Administration of mannitold. All of the above

4. A 36 yo female has taken “the whole bottle” of acetaminophen. Some of the orders you may expect for this patient are:

A. Charcoal LavageB. N-acetylcysteineC. Syrup of ipecacD. Both a and b

5. Which of the following clinical signs are consistent with the diagnosis of severe sepsis?

A. Svo2 of 0.81 and a cardiac index of 6.0B. Svo2 of 0.81 and a PCWP of 5C. CI of 6.0 and a PCWP of 5D. All the above



• 6. Which of the following would explain the Svo2 of 0.81?

• A. Increased O2 consumption and increased O2 delivery• B. Increased O2 consumption and pericapillary shunting• C. Increased O2 delivery and pericapillary shunting• D. All of the above

• 7. Which of the following would be indications of an improvement in the septic condition?

• A. Decrease in PCWP

• B. Increase in Pao2

• C. Decrease in Svo2

• D. Increase in CI

• 8. Which of the following are the most characteristic responses of the cardiovascular system to sepsis?

• A. Increased EF and increased CO

• B. Increased EF and reduced SVR

• C. Increased CO and reduced SVR

• D. All of the above

• 9. Expected treatment for sepsis includes

• A. Increased IV fluids

• B. Positive inotropes

• C. Control of blood sugar

• D. a and c

• E. All of the above

• 10. Acidosis that is common in sepsis and MODS can be from

• A. Patient over breathing the vent/hyperventilating

• B. Poor perfusion to GI tract

• C. Poor perfusion to kidneys

• D. Microvascular emboli

• E. b, c, and d

• 11. A patient with a cardiac contusion starts having runs of V‐tach. You would expect to

• A. get a 12 lead ECG

• B. draw serial troponins

• C. check serum electrolytes

• D. prepare for pericardial thoracentesis

• E. all but d



12. When the intracellular demand for oxygen exceeds the supply in the septic patient, the nurse would expect to find:

• A. An increase in carbon dioxide

• B. An increase in lactic acid

• C. A decrease in oxygen saturation

• D. A decrease in hydrogen ion concentration

13. In planning care for a patient in early sepsis, the nurse will anticipate progression to septic shock in what percentage of cases?

• A. 30%

• B. 40%

• C. 50%

• D. 60%

15. The most reliable indicator for evaluating the adequacy of tissue perfusion during septic shock is related to:

• A. oxygen consumption

• B. Renal function

• C. Hemodynamic status

• D. Respiratory status

16. Laboratory data 24 to 48 hours after toxic ingestion of acetaminophen will likely demonstrate elevation of serum levels of:

• A. total bilirubin

• B. Alkaline Phosphatase

• C. Amylase

• D. Glucose

References• http://www.aacn.org/WD/Practice/Content/practicealerts.content?menu=Practice

(accessed 5.2016)

• CLABSI, Delirium, CAUTI, VAE, Pain, Sepsis, ABCDE bundle

• Kleinpell, R. Implications for the new international sepsis guidelines for nursing. American Journal of Critical Care. 22(3):212‐222, May 2013.

• Radomski, M. Critical Care for the Patient With Multiple Trauma. Journal of Intensive Care Medicine. 31(5):307‐318, June 2016.

• Gotts, J. Sepsis: pathophysiology and clinical management. BMJ. 353:i1585, May 28, 2016

• Nealy, K. Managing drug‐resistant organisms in acute care. Nursing Critical Care. 11(3):16‐22, May 2016

• Alexander, E. Strategies for the Management of Sepsis. AACN Advanced Critical Care. 30(1):5‐11, April 2019

• Glow, S. Caring for Patients With Sepsis According to the Guidelines. http://www.clinicalkey.com/nursing/

face multisystem revie · • decrease in gcs • hypotension • decrease in platelets •...

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