When you see “IV fluids” among answer choices in any question, immediately look at the blood pressure and heart rate. If BP is low (SBP ≤ 90), heart rate is >90/min and/or there are other features of volume depletion (e.g., dry oral mucosa, orthostatic drop in BP), then IV fluid resuscitation is always the right answer.
IV dextrose can precipitate acute thiamine deficiency (due to increased consumption of thiamine). This is more likely to occur in patients with low thiamine levels (e.g., alcoholism, severe malnutrition).
NSIM volume resuscitation a
bIn early septic shock, inflammatory cytokines lead to primary vasodilation (low TPR/SVR) and compensatory increase in cardiac output (increased cardiac index) → increased blood flow and velocity → decreased oxygen extraction by tissues → normal or high Mean Venous Oxygen content.
cIn neurogenic shock (e.g., cervical or high thoracic spinal cord injury), there is sudden loss of sympathetic stimulation, which leads to primary vasodilation and a decrease in preload and cardiac contractility → low cardiac output → decreased velocity of blood flow → increased extraction of oxygen by tissues → low MVO2.
Abbreviations: MVO2 content, mean venous oxygen content; NSIDx, next step in diagnosis; PCWP, pulmonary capillary wedge pressure (which is an indirect measurement of left heart pressure); SVR/ TPR, systemic vascular resistance (a.k.a. total peripheral resistance).
Right ventricular failure a
Inotropic vasopressors (dobutamine, dopamine) and if refractory, IABPb
bIABP = intra-aortic balloon pump. IABP is timed to inflate during diastole to augment coronary perfusion (primary mechanism of action) and deflate during systole, which increases the forward flow by creating a vacuum effect. IABP is contraindicated in patients with severe acute aortic regurgitation.
Right atrial pressure (normal is 2-6)a
RV pressure (normal is <25/8)a
PCWP (normal is <12-15)b
dThe more hours have passed the less the benefits of activated charcoal. It is not effective in situations where absorption is considered complete. This depends on what poison, drug, or chemical was ingested.
Patients with hx of caustic ingestion can present years later with mechanical dysphagia due to formation of peptic stricture related to scar tissue. Also, this scar tissue can predispose to squamous cell carcinoma of esophagus.
Gastric lavage: It includes placement of a large-bore orogastric tube, followed by repeated fluid instillation and aspiration. This is rarely used nowadays because evidence shows limited benefit and potential risk. It can however be performed in instances when a large amount of toxin has been known to be ingested within 1 hour.
Organophosphate or carbamate poisoninga
Atropine and other anticholinergicsb
For treatment of poisoning, avoid further exposure by removing the clothes and washing the body thoroughly. If ingested, administer activated charcoal within 1 hour. Give pralidoxime, if evidence of cholinergic toxicity.