SHA24/050004

Haemodynamics Made Easy

Case Discussion Gurmeet Kaur Gurdav Singh RN,CCRN,BSc,MSc

Case scenario 1  Ali, 3 year old presented with vomiting and loose bowel motion for 2 days with complain of drowsiness  • • • • •

On examination: Airway is patent Eyes are sunken Mucosa is dry Peripherals – cold & clammy Capillary refill > 4 seconds

 • • •

Vital signs H/Rate :130bpm R/Rate: 32bpm Blood Pressure : 68/40(53)mmhg

Management What is the clinical status of Ali?  Hypotensive What is the likely cause?  Hypovolemia (Volume Deficit) Treatment ?  Replace volume with crystalloid and reassess  Continue volume resuscitation to target endpoints

Measurable Elements • Mental status • Blood Pressure • Heart Rate • Urine Output • Central Venous Pressure (CVP)

ECHO Image Normal Heart

Hypovolemic Heart

Case scenario 2  Maria, 16 year old has abrasion & contusion over chest and abdomen with small cuts on face  • • • •

On arrival Complain of drowsiness Airway is patent with severe breathlessness Equal breath sound Capillary refill > 5 seconds

 • • • •

Vital Signs H/Rate : 120bpm R/Rate : 38bpm Blood Pressure : 78/45 (56) mmhg Saturation : 93%

Management What is the clinical status of Maria?  Hypotensive with Respiratory Distress Treatment ?  Started on Oxygen  Administered Fluid Boluses

Reassessment Vital signs on Arrival

Vital Sign after Volume & Oxygen

H/Rate : 120bpm

H/Rate : 135bpm

R/Rate : 38bpm

R/Rate : 34bpm

B/P: 78/45 (56)mmhg

B/P: 75/43 (52)mmhg

Saturation : 93%

Saturation : 94%

No improvement in Clinical Status ďƒ˜ 2nd IV fluid bolus administered ďƒ˜ Peripheral Arterial Line inserted and started ABP monitoring

Reassessment 150 bpm 88%

76/45 (55)

Tachycardia Oxygen Demand Pulsus Paradoxus

Possible causes?

ECHO Image

Cardiac Tamponade

Cardiac Tamponade Accumulation of Fluid in pericardium space Prevent Ventricles to expand fully Reducing Ventricular Filling Deprived Systematic Circulation

Treatment : Pericardiocentesis

Case Scenario 3 Wong ,71 year old, present to A&E with acute episode shortness of breath,orthopnoeic Past Medical History •Hypertension •Type II Diabetes Mellitus •Ischemic Heart Disease

Vital Signs •Blood Pressure: 160/95 •HR: 120bpm •RR: 28 •SaO2: 86% •Temp: 36.8

Clinical Observation •noticeable swelling of the ankles •speaking in short sentences •JVP: raised •Chest- crepitus upon auscultation

Management What is the clinical status of Wong?  Hypertensive with Respiratory Distress Treatment  Oxygen therapy  Antihypertensive medication Investigation  CXR  Bloods

Investigation?

Bloods Full Blood Picture (FBC) :Normal Glucose: 6.2 Troponin: Normal K+: 4.8 (3.5-5.0) Na+: 132 (135-145) Urea: 7.5 (2.5-8.0) Creatinine: 118 (70-120)

Chest X-Ray Wong’s CXR

Cardiomegaly Congested

Normal CXR

Immediate Management

ďƒ˜ Diuresis - Intravenous Furosemide ďƒ˜ Vasodilation- Nitrate Glycerine Trinitrate Reduction central Blood Pressure Reduce Preload + Afterload Reduce Congestion

Further Investigation

ECHO - Global dysfunction with an ejection fraction of 23%

CHD (Congestive Heart Failure)

Congestive Heart Failure

CHD Goal Restore oxygenation Restore adequate perfusion to organs Restore fluid balance status

References Howard, P., K., Steinmann, R.,A., editors (2010).

Sheehy’s Emergency Nursing: Principles and Practice, 6 th Edition, Mosby Elsevier, USA: St Louis

Manoach, S., Weingart, S.,D., Charchaflieh, J.,(2012).

The evolution and current use of invasive hemodynamic monitoring for predicting volume responsiveness during resuscitation, perioperative, and critical care.

Journal of Clinical Anesthesia 24, pp 242–250.

Available from: http://ac.els-cdn.com/S0952818012000694/1-s2.0-S09528180

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Hemodynamics Made Easy

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