Emergency medicine clinics of North America
-
Sepsis and septic shock remain all too frequent syndromes in modern medicine with unacceptably high mortality rates. Physicians must be aware of the many ways in which sepsis and septic shock may present and the multiple differential diagnoses. ⋯ Our current limited understanding of the pathophysiology of sepsis and septic shock significantly limits our ability to treat this syndrome effectively and thus substantively alter mortality. New developments in immunology and metabolism seem promising in furthering our understanding and improving our therapy of this complex multisystem disorder.
-
Emerg. Med. Clin. North Am. · Nov 1986
Review Comparative StudyResuscitation of the critically ill patient. Use of branched-chain decision trees to improve outcome.
The algorithm approach provides criteria based on decision rules for expeditious monitoring, diagnostic and therapeutic decisions; algorithms are particularly useful in crisis situations, in which time is of great importance, for example, in the resuscitation of emergency patients. Because of its objectivity and usefulness as a teaching tool, this algorithmic approach is of practical benefit in the training of residents and students in teaching hospitals, as well as in the community hospital where less experienced physicians manage hypotensive emergency patients more infrequently. In a few instances there has been some reluctance to use the algorithm, but most often it was found to be useful in organizing the work-up and establishing therapeutic priorities. ⋯ The underlying premise under these conditions was to evaluate increments of volume therapy without exceeding safe CVP pressures (less than 18 mm Hg) in order to obviate fluid overloading. A third algorithm for ICU patients with pulmonary artery catheters was developed from decision rules based on objective physiologic, heuristic, survival data as the criteria for post-trauma and postoperative patients who were critically ill despite apparent success with the initial resuscitation and CVP algorithms. The improved mortality in prospective studies supports the hypothesis that compensatory responses of the survivors are the major determinants of outcome.
-
A basic understanding of respiratory physiology and ventilator-patient interaction is critical for the initiation of ventilatory support and management of the ventilated patient. A brief review of these subjects is incorporated in this outline of the approach to the patient requiring mechanical ventilation.
-
Physiologic data obtained from infants and children in shock indicate that there is a high frequency of abnormalities that can only be discovered with pulmonary artery catheters. Cardiogenic shock is a low-output, high-resistance condition, and septic shock is a relatively high-output, low-resistance condition. The use of pulmonary artery catheter data demonstrates that optimal therapeutic goals can be estimated and basic pathophysiologic abnormalities can be discovered.