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systemic inflamatory response system (SIRS)
- systemic level acute inflamation, that may or may not be due to infection and is generally manifested as a combination of
- vital sign abnormalities including
- 1. fever
- 2. hypothermia
- 3. tachycardia
- 4. tachypnea
What does BUN & Creatine look at?
Complete Blood Count (CBC)
- 1. hemoglobin
- 2. hematocrit
- 3. red blood count
- 4. white blood count
- 5. differential
Hemoglobin Normal Values
- average 15
- male: 13.2 - 17.3 g/dl
- woman: 11.7 - 16 g/dl
- Amount of hemoglobin in a standardises sample of uncoagulated blood & it evaluates...
- 1. anemia
- 2. blood loss
- 3. volume replacement
Hemotocrit Average Value
CBC Rule of 5s
- Red Blood Count (RBC) = 15
- Hemoglobin (HBg) = 15
- Hematocrit (Hematocrit) = 45
Why is RBC important when evaluating Hemoglobin/Hemotocrit (H&H)?
Hemoglobin/Hemotocrit tells us if the pt is fluid depleted. RBC will tells us if the pt is hypovolemic depleted or are they just straight fluid depleted. RBC provided supporting evidence to an H&H.
- The percentage of red blood cells in circulation and it evaluates...
- 1. anemia
- 2. hydration
- 3. fluid balances/loss/replacement
Red Bood Count (RBC)
Number of red blood cells per microliter.
Hormone produced by the kidneys that promotes the formation of red blood cells in the bone marrow.
What type of H&H and RBC would you expect from burn patient?
Relatively normal RBC and low H&H due to the fact that the pt is not loosing a lot of red blood cells but they are loosing a lot of plasma. The pt is not bleeding but loosing a lot of fluid.
White Blood Count (WBC)m
- Determines the number of leukocytes per microliter. Normal values 4,000 - 10,000 cells. Evaluates...
- 1. infection
- 2. inflamatory response
Increased number of Bands could mean bacterial invection (greater than 6 pack)
Increased lymphocytes indicates viral infection.
Renin-Angiotensin-Aldosterone (RAA system)
- 1. BP low -> kidneys secrete Renin
- 2. Renin stimulates production of Angiotension I
- 3. ACE from the lungs converts Angiotensin I into Angiotensin II wh/ causes blood vessels to constrict resulting in increased BP
- 4. Angiotensin II also stimulates the secretion of the hormone aldosterone from the adrenal cortex
- 5. Aldosterone casuses the tubules of the kidneys to retain sodium and water
- 6. This increases the volume of fluid in the body, wh/ also increases BP
Sepsis, Severe Sepsis & Septic Shock
- inflamatory states resulting from the systemic response to bacterial infection. in severe cases there is a critical reduction in tissue perfusion. common causes...
- 1. gram negative organisms
- 2. staphylococci
- 3. meningocci
Mortality Rate of Severe Sepsis & Septic Shock
severe sepsis induced w/ hypotension despite adequate resuscitation along with the presence of perfusion abnormalities wh/ may include, but are not limited to lactic acidosis, oliguria, or an acute alteration in mental status (refractory to fluid resusitation).
a microbial phenomenon characterized by an inflammatory response to the presence of microorganisms or the invation of normally sterile host tissue by those organism.
presence of viable bacteria in the blood
production of not enough urine. kidneys shutting down.
at least 1 major organ sysem had failed
SIRS wh/ is secondary to infection. You have to have the infection for it to be sepsis.
severe SIRS wh/ is secondary to infection
Causes of SIRS.
- 1. trauma
- 2. severe burns
- 3. pancreatitis
- 4. ischemia
- 5. INFECTION
- I) in response to injury/infection, the local enviroment produces cytokines
- II) small amounts of cytokines are released into the circulation
- a. recruitment of inflammatory cells
- b. acute phase response
- c. normally kept in check by endogenous antiinflamatory mediators
- III) failure to control inflamatory cascade
- a. loss of capillary integrity
- b. stimulation of nitric oxide production
- c. maldistribution of microvascular blood flow
- e. organ injury and dysfunction
Criteria for SIRS
- 1. temp > 38.3 or < 36.0 C
- 2. tachypnea (RR>20 or MV> 10L)
- 3. tachycardia (HR>90, in the absence of intrinsic heart disease)
- 4. WBC> 10,000/mm3 or < 4,000/mm3 or > 10% of band forms on differential
Criteria for Severe SIRS
- Must meet criteria for SIRS, plus 1 of the following:
- 1. altered mental status
- 2. SBP < 90mmHg or fall of > 40mmHg from baseline
- 3. impaired gas exchange
- 4. metabolic acidosis (pH>7.3 & lactate > 1.5 x upper limit of normal)
- 5. oliguria (< 0.5mL/kg/hr) or renal failure
- 6. hyperbilirubinemia
- 7. coagulopathy
Pathophysiology of Sepsis
- 1) vasodilation
- a. activation of ATP - sensitive K+ channels in the vascular smooth muscle
- b. increases synthesis of NO
- c. deficiency of vasopressin
- 2) intravascular volume depletion
- a. increased capillary permiability to 3rd spacing fluid
- b. concurrent volume loss from vomiting and diarrhea
- 1. pneumonia
- 2. UTI / tubes in the body
- 3. abdominal surgery
- 4. cellulitis
- 5. IV drug users
- 6. untreated wounds
- 7. bed ridden
Clinical Signs indicating the State of Septic Shock
- 1. Hyperdynamic State (warm shock)
- a. tachycardia
- b. elevated or normal cardiac output
- c. decreased systemic vascular resistance
- (state paramedic typically finds the pt in)
- 2. Hypodynamic State (cold shock)
- a. low cardiac output
- (treat them like a cardiogenic shock pt - downward spiral has begun)
Multiple Organ Dysfunction Syndrome (MODS)
presence of altered organ dysfunction in the septic patient. last stop before death!
What is the problem with ARDS patients?
Very difficult to ventilate them. Lungs won't expand.
Treatment of SEPSIS patients.
- 1. fluid resuscitation (rapid large volumes)
- 2. vasopressors (you decide to go to vasopressors afteryou have delivered 1L - dopamine, dobutamine, levophed)
- 3. antibiotics
- 4. vetilatory support
- (activated protein C, steroids, glycemic control, nutrition)