Medical-Surgical II Past Paper PDF

UNIT TWO PART PART THREE MANAGEMENT OF CARDIOVASCULAR DISORDERS SUB-UNIT MANAGEMENT OF COMMON VASCULAR DISORDERS Lecturer: Mr. Nour M.Ahmed UNIVERSITY BURAO Course Tit...

UNIT TWO PART PART THREE MANAGEMENT OF CARDIOVASCULAR DISORDERS SUB-UNIT MANAGEMENT OF COMMON VASCULAR DISORDERS Lecturer: Mr. Nour M.Ahmed UNIVERSITY BURAO Course Title: Medical-Surgical II MANAGEMENT OF COMMON VASCULAR DISORDERS BY Mr Nour 10/1/2024 M.Ahmed 1  Shock Definition: Shock is a syndrome characterized by decreased perfusion of the tissues in the body which if prolonged leads to irreversible multiple organ failure. Classification ▪ Hypovolemic ▪ Cardiogenic ▪ Distributive a) Obstructive b) Anaphylactic c) Neurogenic d) Septic e) Respiratory shock Tell:+252-63-7423353 10/1/2024 2 Email:[email protected]  RHEAMATIC HEART DISEASE ❑Rheumatic heart disease is a condition in which the heart valves have been permanently damaged by rheumatic fever. ❑Rheumatic fever is an inflammatory disease that can affect many connective tissues, especially in the heart. Untreated or under-treated strep infections put a person at increased risk. Tell:+252-63-7423353 10/1/2024 3 Email:[email protected]  Complications - Renal Failure - Hepatic Failure - Metabolic Acidosis - Coma, Death Tell:+252-63-7423353 10/1/2024 4 Email:[email protected]  Hypovolemic shock definition: This is due to loss of intravascular fluid volume (blood and/ or fluid loss). Causes - Excessive haemorrhage ( e.g. trauma, internal bleeding, such as in the gastrointestinal tract) - Excessive fluid loss (e.g. diarrhoea, vomiting, severe burns) - Intestinal obstruction (mechanical or paralytic ileus) Tell:+252-63-7423353 10/1/2024 5 Email:[email protected]  clinical manifestation ❑Symptoms -Fainting - Palpitations - Sweating (cold sweat) - Restlessness, clouding of consciousness ❑Signs - Pallor - Cold extremities - Tachycardia - Hypotension : Systolic BP 30ml/hr Most patients will respond to the initial fluid bolus Tell:+252-63-7423353 10/1/2024 8 Email:[email protected]  cont….. If they respond initially and subsequently deteriorate, there may be an ongoing occult haemorrhage Consider blood transfusion (if haemorrhage is >25% of total blood volume) Fluid should be given quickly and slowed only when BP rises and urine flow is adequate Give Oxygen 6 L/min via nasal or facial masks if indicated Continue to monitor BP, pulse and urine output Recommendations - Refer to ICU if needed - Refer for surgical intervention if indicated Tell:+252-63-7423353 10/1/2024 9 Email:[email protected] MANAGEMENT OF COMMON VASCULAR DISORDERS 11 10/1/2024 BY Mr Nour M.Ahmed  Cardiogenic shock Definition: This is advanced cardiac failure with inadequate peripheral tissue perfusion. Hemodynamic criteria are: - Sustained hypotension for at least 30min( SBP15mmHg) - Low cardiac index( 15mmHg) - Elevated capillary wedge pressure( >15mmHg) Tell:+252-63-7423353 10/1/2024 12 Email:[email protected]  Causes - Valvular Heart Disease - Myocardial Infarction (Right or Left) - Pericardial Tamponade - Myocarditis - Hypertensive Obstructive Cardiomyopathy - End stage cardiomyopathy - Myocardial contusion Tell:+252-63-7423353 10/1/2024 13 Email:[email protected]  clinical manifestation - BP less than 90mmHg systolic - Weak or undetectable pulse - Cold extremities - Peripheral cyanosis - Poor urine output - Pulmonary signs (Crepitations, Dyspnoea) - Raised JVP Tell:+252-63-7423353 10/1/2024 14 Email:[email protected]  Investigations - CBC - Serum urea, creatinine and electrolytes - Cardiac Enzymes (LDH, Troponin, Creatinine Kinase) - CXR - ECG - Echocardiography Tell:+252-63-7423353 10/1/2024 15 Email:[email protected]  MANAGEMENT - Non-Pharmaceutical Oxygen to keep saturation >90% Large bore IV cannula IV fluid bolus (if predominant right heart failure) Urinary Catheter Pharmaceutical Diuretics if predominant left heart failure and pulmonary congestion (avoid otherwise): Frusemide eg 40mg IV stat and monitor response Tell:+252-63-7423353 10/1/2024 16 Email:[email protected]  CONT….. Management of underlying cause → Ischaemia: Aspirin 100mg po stat, Morphine 2-10mg IV/IM for pain, Glyceryl Trinitrite (if BP permits, contraindicated in hypotension), Thrombolysis (see Pulmonary Embolus chapter) → For Pericardial Tamponade: pericardiocentesis Recommendation - Refer to ICU or a tertiary center - All patients with cardiogenic shock not responding to above measures Tell:+252-63-7423353 10/1/2024 17 Email:[email protected] MANAGEMENT OF COMMON VASCULAR DISORDERS 18 10/1/2024 BY Mr Nour M.Ahmed  SEPTIC SHOCK Definition: Sepsis associated hypotension (SBP < 90 mmHg or a reduction of more than 40mmHg from baseline) and perfusion abnormalities or the requirement for vasoactive drugs despite adequate fluid resuscitation in the absence of other causes for hypotension. Causes Any primarly or secondarly generalized infection can lead to septic shock but the most common causative agents of septicaemia in a previously healthy individual: - E.coli - Pneumococcus - Staphylococcus aureus - Meningococcus - Group A beta-haemolytic streptococcus Note: In-patients with symptoms from the urinary tract, E. coli, Klebsiella species and enterococci are the most common causes of urosepsis. Tell:+252-63-7423353 10/1/2024 19 Email:[email protected]  clinical manifestation - Low blood pressure but the patient’s skin is warm (“warm hypotension”) - General malaise, chills - Fatigue, weakness, pain - Nausea and vomiting - Skin signs (often petechiae, haematoma) - Confusion - Unexplained worsening of an underlying illness Tell:+252-63-7423353 10/1/2024 20 Email:[email protected]  Investigations - CBC - Urea, creatinine and electrolytes - Blood sugar - Blood and body fluid culture - Liver function tests - Coagulation tests - Chest X-ray - ABG Tell:+252-63-7423353 10/1/2024 21 Email:[email protected]  Management - General management Commence resuscitation measures immediately the patient is seen Start empirically broad-spectrum antibiotics after obtaining samples for appropriate cultures within 1 hour : → Cefriaxone 1 g IV once daily OR Benzyl penicillin 4 mega units IV every 6 hours → PLUS Gentamycin 80 mg 12 hourly with adequate fluid replacement and close monitoring of urea, creatinine and electrolytes → PLUS Metronidazole 500 mg IV 8 hourly → PLUS Hydrocortisone 100 mg 8 hourly for 24-48 hours: only to septic shock patients after it has been confirmed that their blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy Tell:+252-63-7423353 10/1/2024 22 Email:[email protected]  CONT…… - Vasopressor: Dopamine and Noradrenaline are the first line vasopressors. Target a MAP>65mmHg. In case of inadequate cardiac output, consider Dobutamine or Adrenaline infusions - Oxygenotherapy and Mechanical ventilation (High PEEP and permissive hyparcapnia in case of ARDS) under sedation/ analgesia - Start oral medication once the required course of IV antibiotics is completed. Choice of antibiotics depends on the source of infection, and culture and sensitivity results. Note: Always anticipate the onset of disseminated intravascular coagulopathy Prevention of stress gastric ulcers if critically ill in ICU: Ranitidine or Omeprazole Prevention of DVT with LMWH (e.g: Heparin 40mg SC OD) Other supportive therapy accordingly: Hemodialysis Tell:+252-63-7423353 10/1/2024 23 Email:[email protected]  cont.….. - Recommendation - Refer if complicated; especially if urinary output starts failing, serum urea, creatinine and potassium start rising, or if there is evidence of any other organ failure despite attention to adequate hydration with prompt attention to electrolyte balance and antimicrobial administration Tell:+252-63-7423353 10/1/2024 24 Email:[email protected]  Complications - Myocardial depression - Acute Respiratory Distress Syndrome: (ARDS) - Acute Kidney Disease - Disseminated Intravascular Coagulopathy (DIC) - Liver failure Tell:+252-63-7423353 10/1/2024 25 Email:[email protected] MANAGEMENT OF COMMON VASCULAR DISORDERS 26 10/1/2024 BY Mr Nour M.Ahmed  Anaphylactic shock Definition: is a life-threatening serious allergic reaction often involving respiratory difficulties and circulation failure. Causes - Foods Nuts (tree nuts and peanuts), fish, seafood, celery, kiwi, egg, milk, avocado, carrot and bananas - Drugs Antibiotics (especially penicillins, sulphonamides, muscle relaxants) Analgesics (opioids, NSAIDs) Tell:+252-63-7423353 ACE inhibitors 10/1/2024 27 Email:[email protected]  Cont…. - Vaccines and serum - Insect stings Wasp, bee, mosquito, snake bites - Radiographic contrast media, blood products, allergenic products used in examinations and treatment. - Natural rubber (Latex allergy) Gloves, catheters, condoms, balloons - Physical exercise (eating wheat followed by physical exercise as a rare phenomenon), shaking, cold. Tell:+252-63-7423353 10/1/2024 28 Email:[email protected]  clinical manifestation - Erythema - Angioedema - Rash - Urticaria - Bronchospasm - Cardiovascular collapse - severe hypotension Tell:+252-63-7423353 10/1/2024 29 Email:[email protected]  Management - Check CABD and stop the administration of any potential trigger, particularly IV agents. - Call for help - Maintain airway and give O2 100% - Elevate the legs - Give Adrenaline in 50µg IV increments at a rate of 100µg/min until blood pressure or bronchospasm improves (Alternative: Adrenaline 0.5mg-1mg IM to be repeated 10min after if necessary) - Give IV fluid (Crystalloid) Complication - Circulatory and respiratory arrest Tell:+252-63-7423353 10/1/2024 30 Email:[email protected] MANAGEMENT OF COMMON VASCULAR DISORDERS 31 10/1/2024 BY Mr Nour M.Ahmed