Shocks in Adults

Types:
1. Hypovolemic - decreased preload due to volume loss
2. Cardiogenic - cardiac pump failure
3. Distributive (vasodilatory) - severely decreased SVR
4. Combined - ex. septic shock

Types	Preload	Pump Function	Afterload	Tissue Perfusion
Measurement	PCWP	CO	SVR	SvO2
Hypovolemic	↓	↓	↑	↓
Cardiogenic	↑	↓	↑	↓
Distributive	↓/↔	↑	↓	↑

Stages of Shock:

1. Preshock

2. Shock

3. End-organ dysfunction

Septic Shock

Mortality: 20~50%

Goals:
1. Early initiation of supportive care to correct physiologic abnormalities, ex. hypotension/hypoxemia.
2. Distinguishing sepsis from SIRS to treat infections ASAP

Management
1. Stabilize respiration
   A. Supplemental Oxygen + monitor w/ pulse oximetry
       a. Intubation/mechanical ventilation
       b. CXR + ABG

2. Assess Perfusion
   A. Inadequate perfusion
       a. Hypotension: SBP <90 mmHg, MAP <70 mmHg,  ↓ SBP >40 mmHg
           a)  Causes: loss of plasma volume into the interstitial space, decreased vascular tone, and myocardial depression.
       b. S/S:  cool, vasoconstricted skin, HR>90/min, obtundation/restlessness, and oliguria/anuria, serum lactate >1 mmol/L
       c. If BP labile --> A-line

Notes (備忘) - 2

1. Anion Gap Metabolic Acidosis
     A. Anion-gap = [Na+] - ([Cl-] + [HCO3-])
    MUDPILES
     M. Methanol intoxication
     U. Uremia
     D. Diabetic or alcoholic ketoacidosis
     P. Paraldehyde
     I. Isoniazid/Iron overdose
     L. Lactic acid
     E. Ethylene glycol intoxication
     S. Salicylate intoxication

    Non-Anion Gap Metabolic Acidosis
    HARDUP
     H. Hyperalimentation/hyperventilation
     A. Acetazolamide
     R. RTA
     D. Diarrhea
     U. Ureteroenteric fistula
     P. Pancreatic fistula/parenteral saline

2. Dialysis Indications:
    AEIOU
    A. Acid-base problems (severe acidosis or alkalosis)
    E. Electrolyte problems (hyperkalemia)
    I. Intoxications
    O. Overload, fluid
    U. Uremic symptoms

Notes (備忘) - 1

1. Glasgow coma scale (GCS)

GCS	Response
Eye	Open Spontaneously	4
	Open to Verbal Command	3
	Open to Pain Stimulus	2
	No Response	1
Verbal	Talk Spontaneously	5
	Confused, Disoriented Speech	4
	Inappropriated words	3
	Incomprehensive words	2
	None	1
Motor	Obeys	6
	Localizes to Pain	5
	Withdraws from Pain	4
	Abnormal flexion, decorticate posture	3
	Extensor response, decerebrate posture	2
	None	1
Total	3 to 15	???

2. White and Grey Matter 

	Outside	Inside
Brain	Grey	White
Spinal Cord	White	Grey

3. Mean Arterial Pressure (MAP)

(From wikipedia)

Chronic Complications of Spinal Cord Injury (SCI)

Life Expectancy:
1. Mortality rates highest during 1st year
2. >1 yr, then ~90% of normal

Cardiovascular Complications:
1. Autonomic dysreflexia: SCI>T6 due to uninhibited sympathetic responses
      A. Occurs in 20~70%, >1 m to <1 yr
      B. Not Below T6 b/c intact splanchnic innervation allows for compensatory dilatation of the splanchnic vascular bed.
      C. Prevent stimuli, ex. bladder distention, bowel impaction, pressure sores, bone fracture, or occult visceral disturbances
      D: S/S: HA, diaphoresis, HTN, flushing, piloerection, blurred vision, nasal obstruction, and nausea.
             a. profound bradycardia, OHCA, ICH, seizures
      E. Tx:
           a. Measure BP
           b. Sitting the patient upright to orthostatically lower BP
           c. Search for noxious stimuli
           d. BP meds: nitrates, nifedepine, sublingual captopril, IV hydralazine, IV labetalol
2. CAD
      A. Risk factors:  decreased muscle mass, increased fat, and inactivity, 3~10X more likely. Esp. >T5 level
      B. Tx same as non-SCI pts
3. Orthostatic hypotension
     A: More common in 1st several months of SCI, but can still occur due to excessive bed rest+ low fluid intake
4. Bradycardia (>T6)
     A: baseline pressure reduced

Acute Traumatic Spinal Cord Injury (TSCI)

Incidence:
40 million persons per year

Causes of TSCI:
●Motor vehicle accidents: 47 percent
●Falls: 23 percent
●Violence (especially gunshot wounds): 14 percent
●Sports accidents: 9 percent
●Other: 7 percent

S/S:  Based on severity, assess by American Spinal Injury Association Scale (ASIA):
1. Complete cord injury (ASIA grade A): reduced S+M at the level below, then no sensory + motor at all
        Acute: reflex (-), flaccid muscle tone, plantar stimulation (-), bulbocavernosus reflex (-), anal sensation (-), urinary retention, bladder distension, (priapism)

2. Incomplete cord injury (ASIA grades B through D): S+M partially preserved below the level of injury.               
        1. S preserved>M b/c more peripheral
        2. bulbocavernosus reflex, anal sensation (+)      

3. Central cord syndrome: preexisting cervical spondylosis + mild trauma
        1. M impairment > S in upper ext. than lower ext.
        2. Bladder dysfunction
        3. Sensory loss below level of lesion      
      *esp. hyperextension injury

4. Anterior Cord Syndrome: usu. anterior spinal a. injury by bone fragments
        1. Weakness and reflex changes
        2. Bilateral loss of pain and temperature sensation
        3. Urinary incontinence
        4.  Tactile, position, and vibratory sensation are normal (Dorsal column spared)

Spinal shock: hrs ~ wks
        Immediately after injury, loss of all spinal cord function caudal to level of injury
             ●Bradycardia, hypotension, flaccid paralysis, anesthesia, bowel and bladder control (-), reflex (-),                  (priapism)
        Mechanism: reduced axonal transmission due to K+ loss in cells of the cord

Neck, Shoulder and Arm Pain

Differential Diagnosis

Origin	Pain Location	Exacerbation	Physical Examination	Diseases
Cervical Spine	Back of neck/head + shoulder/upper arm	Neck movements	1. Limitation of neck motion 2. Tenderness to palpation over the cervical spine	OA, Osteophytes, Cervical disc herniation, RA, Trama, Whiplash injury, cervical spondylosis, thoracic outlet syndrome
Brachial Plexus	Supraclavicular region/ axilla/shoulder	Arm and neck movements/maneuvers (ex. external rotation)	Palpable abnormality above the clavicle	Brachial neuritis, metastatic infiltration, radiation damage to the plexus
Shoulder	Shoulder + (arm)	Shoulder motion	Tenderness and limitation of movement (internal/external rotation/abduction) sensorimotor and reflex changes (-)	Rotator cuff injury/tear, subacromial/subdeltoid bursitis, periarthritis or capsulitis (frozen shoulder), tendonitis, and arthritis, MI, Sudeck atrophy or Sudeck-Leriche syndrome

*Whiplash injury: If NE (+), consider brain, spinal cord injury, or carotid or vertebral artery dissection

Disc Herniation

Definition: tear in outer ring, annulus fibrosis (AF), and bulging of nucleus pulposus (NC). Usu. posterolateral

Most common: 30 ~40 y/o

                                b/c NC still gelatin-like. 

                        >40 y/o

                                NC dehydrated, reduced risk of herniation