~Teachingcenter的醫學筆記~

休克和休克時的處置
Shock and the Management of Shock

可以一併參考：
http://teachingcenter1.pixnet.net/blog/post/345161474

心因性休克Cardiogenic shock
= 可能成因：AMI, cardiac tamponade, etc
= 建議檢驗和檢查：
--- CK, CKMB, TnI, EKG, CXR
--- 建議推一台超音波來排除cardiac tamponade的可能
= 建議的處置：
--- 中央靜脈導管(On CVC)
--- 給藥：Dopamine +/- dobutamine
--- 聯絡主治醫師、心臟血管外科醫師：IABP, ECMO, emergent cath, etc.

分佈性休克Distributive shock
= 可能成因：septic shock, adrenal insufficiency, anaphylactic shock, neurogenic shock (神經性的休克表現與成因有些不同，有時會獨立出去討論)
= 建議檢驗和檢查：
--- 血液培養兩套、尿檢尿液培養、視情況痰液培養、CSF培養
--- 肝腎功能、檢視病歷決定是否檢驗cortisol
--- 找感染源：CXR, abdominal echo, etc.
= 建議的處置：
--- 中央靜脈導管(On CVC)
--- 給藥：Levophed +/- Pitressin、Antibiotics
--- 嚴重敗血症須小心DIC，考慮輸pRBC, FP，加給dobutamine

低血容性休克Hypovolemic shock
= 可能成因：dehydration, GI bleeding, internal bleeding, etc.
= 建議檢驗和檢查：
--- 凝血功能(PT/aPTT)、肝腎功能
--- 糞便與嘔吐物潛血檢驗
= 建議的處置：
--- 中央靜脈導管(On CVC)，並且至少每八小時監測CVP
--- Give crystalloid (N/S 500ml ivd st) or colloid (albumin or plasmanate 1BT ivd st)
--- 懷疑上下消化道出血時須安排內視鏡

阻塞性休克Obstructive shock
= 可能成因：massive pulmonary embolism, mechanical valve dysfunction, AS, etc.
= 建議檢驗和檢查：
--- D dimer, cardiac echo, CXR
= 建議的處置：Correct underlying cause、照會心血管外科醫師

心搏過速Tachycardia
* Vital sign, consciousness
* Cause of tachycardia? Eg. Hypovolemia, stress, pain sepsis, hyperthyroid, anemia tamponade, AMI with VT?→ treat underlying disease
* 12 lead complete EKG, EKG monitor
* check CBC, BUN/Cr, TSH/free T4, K, Ca, Mg, one touch, CK/CKMB/TnI, ABG
* Narrow or wide complex?
= Narrow – regular – PSVT or sinus tachycardia or atrial flutter
--- carotid massage (若為中風高危險群則不建議執行頸動脈竇按摩) → no effect → adenosine 6mg rapid iv push, immediate N/S 10ml IV flush → no effect→     adenosine 12mg rapid iv push, immediate N/S 10ml IV flush → no effect →     adenosine 18mg rapid iv push, immediate N/S 10ml IV flush
※ Peripheral line：adenosine 6→12→18mg
※ Central line：3→6→9mg
--- Herbesser 1# TID or Verapamil (Isoptin) 1# TID or 1amp IV push
--- Inderol (10) 1# TID or amiodarone 1amp in D5W100ml IVD ST
--- 情況危急：電同步50~100J
= Sinus tachycardia
--- 以治療潛在疾病為主
= Narrow irregular: Atrial fibrillation / Paroxysmal atrial tachycardi?
--- 1) if patient has history of WPW syndrome, give amiodarone as above
---※Don’t give beta blocker/CCB/digoxin in patients with WPW
--- 2) not WPW → rate control優先於 rhythm control
可以一併參考：
http://teachingcenter1.pixnet.net/blog/post/351508043
http://teachingcenter1.pixnet.net/blog/post/351865745
…..A. LVEF>40% or baseline可爬兩樓樓梯不喘 (4MET) → Herbesser 1# tid, or Isoptin 1# tid, or Inderol (10) 1# tid
…..B. LVEF<40% or baseline爬兩樓樓梯會喘、orthopnea、PND → Amiodarone 1amp in D5W 100ml IVD ST then 6amp in D5W 500ml IVD run 34ml/hr for 8hr, then run 17ml/hr. Alternative: → Digoxin (0.5) 1/4amp IVD ST and Q6H for 3 times, then 1/4amp IVD QD (avoid in renal failure). 如果情況危急：電非同步120~200J
= Wide complex tachycardia: pacemaker, VT, VF, hyperkalemia?
--- 校正潛在成因
(如高血鉀的治療可參考http://teachingcenter1.pixnet.net/blog/post/345791096)
--- 情況危急：電同步100J
--- 單純治療症狀和ECG可以考慮使用amiodarone，但對整體預後無幫助

心搏過緩Bradycardia
* Vital sign, conscious; if BP drop or pulse not palpable, call CR!
* complete EKG, EKG monitor
* check K, Mg, Ca, VBG, cardiac enzymes if chest pain (+)
* review drug, hold digoxin, beta blocker, CCB
* if vital sign stable with sinus brady, or 1st degree AV block, or Morbitz I AV block, OBS
* if vital sign unstable with Morbitz II AV block, CAVB, junctional rhythm, call CV1 for pacemaker
* may give dopamine premix run 5ml/hr with titration