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104 Cards in this Set
- Front
- Back
What represents one of the leading causes of death in children less than 5 years of age throughout the world?
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Diarrhea
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What causes diarrhea?
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Abnormal intestinal water and electrolyte transport
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What causes acute diarrhea?
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Viral, bacterial, and parasitic infections
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What causes chronic diarrhea?
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Malabsorption syndrome, inflammatory bowel disease, immunodeficiency, food allergy, lactose intolerance, chronic nonspecific diarrhea (CNSD), or result from inadequate management of acute infectious diarrhea
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What causes secretory diarrhea?
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Bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cell, the principal secretory cells of the small intestines
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What are the characteristics of cytotoxic diarrhea?
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1. Viral destruction of the mucosal cells of the ville of the small intestine
2. A smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption |
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What is osmotic diarrhea?
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A malabsorption syndrome, such as lactose intolerance, in which the intestines cannot absorb nutrients and electrolytes
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What is dysenteric diarrhea?
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1. An inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms
2. Edema, mucosal bleeding, and leukocyte infiltration occur |
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What might acute diarrhea be associated with?
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Upper respiratory or urinary tract infections
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How long does acute diarrhea usally last?
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Less than 14 days
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What are the major consequences of diarrhea?
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Dehydration and malnutrition
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Who are at high risk for the development of dehydration and malnutrition?
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Infants and young children
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How is diarrhea acquired or spread?
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1. Fecal-oral route through contaminated food or water
2. From person-to-person, especially where there is close contact (e.g. daycare centers) 3. Lack of clean water 4. Crowding 5. Poor hygiene 6. Nutritional deficiency 7. Poor sanitation |
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What is the most common pathogen identified as the cause of diarrhea and dehydration in hospitalized young children?
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Rotavirus
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What are the non-microorganism causes of diarrhea?
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1. HIV infection
2. Ingestion of laxatives 3. Excessive ingestion of sorbitol and fructose in common foods such as apple juice or in gum or candy |
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What does excessive ingestion of sorbitol and fructose cause?
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Osmotic dietary diarrhea from the poorly absorbed carbohydrate
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How does antibiotics cause diarrhea?
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By altering the normal intestinal flora, allowing pathogenic ones to grow (such as Clostridium difficile)
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What are the most serious consequences of acute diarrhea?
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1. Dehydration
2. Electrolyte disturbances 3. Malnutrition 4. Metabolic acidosis |
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What type of stool suggests sugar intolerance?
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Watery, explosive stools
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What type of stool suggests fat malabsorption?
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Foul-smelling, greasing, bulky stools
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What does diarrhea that develops after the introduction of cow's milk, fruits, or cereals suggest?
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An enzyme deficiency or protein intolerance
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What does the presence of neutrophils or red blood cells in the stool indicate?
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Bacterial gastroenteritis or inflammatory bowel disease
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What does the presence of eosinophils in the stool suggest?
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Protein intolerance or parasitic infection
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What may indicate carbohydrate intolerance or secondary lactase deficiency?
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A stool pH of less than 6 and the presence of reducing substances
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What are the major goals in management of acute diarrhea?
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1. Assessment of the fluid and electrolyte imbalance
2. Rehydration 3. Maintenance fluid therapy 4. Reintroduction of adequate diet |
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What should be treated first in infants and children with acute diarrhea?
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Oral rehydration therapy
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Why is oral rehydration therapy (ORT) preferred over IV rehydration?
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1. Effective and safer
2. Less painful 3. Less costly |
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What is required for severe dehydration and vomiting?
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Intravenous fluids - a saline solution containing 5% dextrose in water is usually given. The initial volume should be 20 to 30 ml/kg and should be administered as a bolus. Therapy during the remainder of the first 24 hours should be aimed at completely correcting the remaining fluid and sodium deficits and replacing ongoing abnormal losses
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Why are antidiarrheal drugs contraindicated in infants and young children?
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Toxicity and adverse effects, such as worsening of the diarrhea because of the slowing of motility and ileus or decrease in diarrhea with continuing fluid losses and dehydration, may occur
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What physical assessments should be made for diarrhea?
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1. Dehydration, such as decreased urinary output and weight
2. Dry mucous membranes 3. Poor skin turgor 4. Sunken fontanel in the infant 5. Pale, cool, dry skin |
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What may indicate impending shock with more severe dehydration?
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1. Increased pulse and respiration
2. Decreased BP 3. Prolonged capillary refill time (>2 seconds) |
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What early practices are now discouraged for treating diarrhea?
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1. Withholding feedings
2. Providing clear liquids (juices, broth, or gelatin) 3. Providing a BRAT (Bananas, Rice, Applesauce, and Tea) diet |
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What strict assessments must be documented for hospitalized children with diarrhea?
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1. Hydration status
2. Daily weights 3. Measurement of intake and output 4. Urine specific gravity 5. Stools examined for blood, pH, and reducing substances |
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Why is extra care needed for children with diarrhea?
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Because diarrheal stools are highly irritating and the skin in the perianal area needs to be protected from becoming excoriated
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What is the definition of chronic diarrhea?
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An increase in stool frequency and increased water content with a duration of more than 14 days
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What is intractable diarrhea of infancy?
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A syndrome defined as diarrhea that occurs in the first few months of life, persists for longer than 2 weeks with no recognized pathogens, and is refractory to treatment
(no relief) |
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What is the most common cause of intractable diarrhea of infancy?
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Acute infectious diarrhea that was not managed adequately in terms of nutrition
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What causes diarrhea to become intractable?
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Combination of secondary consequences:
1. Malnutrition deprives the infant of essential nutrients necessary for mucosal regeneration 2. The villi of the small intestine atrophy 3. Secondary digestive and absorptive disorders develop as a result of malnutrition, dysmotility, and overgrowth of bacteria |
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What age group is commonly affected by chronic nonspecific diarrhea (CNSD)?
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Children between 6 and 54 months of age
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What are the potential causes of chronic nonspecific diarrhea (CNSD)?
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1. Disordered small intestine motility
2. Excessive fluid intake 3. Dietary fat restriction 4. Carbohydrate malabsorption |
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What might children with chronic nonspecific diarrhea (CNSD) have?
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Impaired intestinal motility, which causes rapid intestinal transit and impaired fluid absorption
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How is chronic nonspecific diarrhea (CNSD) diagnosed?
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Only by exclusion - a history of prior illnesses and antibiotic use should be obtained. A dietary history, including fluid intake and quantities of fruit and fruit juice ingested, is important.
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What is the therapeutic management of chronic nonspecific diarrhea (CNSD)?
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1. Avoidance of foods and liquids containing sorbitol and fructose (prunes, prune juice, pears, pear juice, peaches, apple juice, sugar-free gum and candy)
2. Increased fiber in the diet 3. Increased fat content in the diet 4. Limitation of fluid intake (use fluid maintenance - do not overhydrate) |
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What is vomiting?
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Forceful ejection of gastric contents through the mouth
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What is regurgitation?
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Simpler, more passive, and effortless phenomenon of spitting up
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What complications can occur in children who have persistent vomiting?
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1. Dehydration
2. Electrolyte disturbances 3. Malnutrition 4. Aspiration 5. Mallory-Weiss syndrome (small tears in the distal esophageal mucosa) |
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What is Mallory-Weiss syndrome?
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Small tears in the distal esophageal mucosa caused by persistent vomiting
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What does green, bilious vomit suggest?
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Bowel obstruction
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What does curdled stomach contents, mucus, or fatty foods that are vomited suggest?
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Poor gastric emptying or high intestinal obstruction
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What does fever and diarrhea accompanying vomiting suggest?
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Infection
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What does constipation associated with vomiting suggest?
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An anatomical or functional obstruction
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What does localized abdominal pain and vomiting suggest?
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1. Appendicitis
2. Panreatitis 3. Peptic ulcer disease (PUD) |
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What does a change in level of consciousness or a headache associated with vomiting suggest?
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A central nervous system or metabolic disorder
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What is forceful vomiting assoicated with?
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Pyloric stenosis
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What part of the brain controls vomiting?
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The medulla (with secondary impulses from the chemoreceptor trigger zone)
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What is nausea?
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A desire to vomit, with discomfort felt in the throat or abdomen
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What autonomic symptoms are associated with nausea?
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Salivation, pallor, sweating, and tachycardia
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What is retching?
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A series of spasmodic movements during inspiration, creating a negative intrathoracic pressure, and contraction of the abdominal muscles
(May occur with or without vomiting) |
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What does projectile vomiting accompany?
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Vigorous peristaltic waves
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What is evaluated when vomiting occurs?
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Behavior, symptoms, analysis for urine protein or blood, serum electrolytes, radiographic studies, etc.
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What is important to consider regarding vomiting?
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Maintaining hydration or preventing dehydration
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What is shock?
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Circulatory failure, a complex clinical syndrome characterized by tissue perfusion that is inadequate to meet the metabolic demands of the body
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What does shock result in?
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Cellular dysfunction and eventual organ failure
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What are the physiologic consequences of shock?
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1. Hypotension
2. Tissue hypoxia 3. Metabolic acidosis |
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What is the most common type of circulatory failure in children?
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Hypovolemic shock
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What is hypovolemic shock?
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A reduction in circulating blood volume related to blood loss, plasma losses, or extracellular fluid losses beyond the child's physiologic ability to compensate
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What does cardiogenic shock result from?
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Impaired cardiac muscle function that leads to decreased cardiac output
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What is distributive shock?
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Vasogenic shock, which results from a vascular abnormality that produces maldistribution of blood supply throughout the body
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What are the types of distributive shock?
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1. Neurogenic shock
2. Anaphylactic shock 3. Septic shock |
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What is neurogenic shock?
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Distributive shock characterized by massive vasodilation resulting from loss of sympathetic nervous system tone, which can occur with spinal injuries
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What is anaphylactic shock?
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Distributive shock characterized by a hypersensitivity reaction that causes massive vasodilation and capillary leak and may occur with drug or latex allergy, insect stings, or blood transfusion
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What is septic shock?
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Distributive shock characterized by a decreased cardiac output and derangements in the peripheral circulation in response to a severe, overwhelming infection
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What are the stages of shock?
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1. Compensated
2. Decompensated 3. Irreversible |
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What are the principal differentiating signs at all stages of shock?
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1. Degree of tachycardia and perfusion to extremities
2. Level of consciousness 3. Blood pressure |
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What is compensated shock?
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When vital organ function is maintained by intrinsic mechanisms in reaction to shock
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How does the body respond during compensated shock?
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1. Cardiac output and systemic arterial BP are usually normal or increased
2. Blood flow generally uneven or maldistributed in the microcirculation |
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What are the early clinical signs of compensated shock?
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1. Apprehension
2. Irritability 3. Normal BP 4. Narrowing pulse pressure 5. Thirst 6. Pallor 7. Diminished urinary output |
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What are the signs of decompensated shock?
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1. Tachypnea
2. Moderate metabolic acidosis 3. Oliguria 4. Cool, pale extremities with decreased skin turgor and poor capillary filling |
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What are the outcomes of circulatory failure due to decompensated shock?
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1. Tissue hypoxia
2. Metabolic acidosis 3. Eventual dysfunction of all organ systems |
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What is irreversible shock?
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Terminal shock that implies damage to vital organs of such magnitude that the entire system is disrupted regardless of therapeutic intervention
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What are the signs of irreversible shock?
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1. Systemic vasoconstriction
2. Hypoxia of visceral and cutaneous circulations 3. Hypotension 4. Acidosis 5. Lethargy or coma 6. Oliguria or anuria 7. Thready, weak pulse 8. Periodic breathing or apnea 9. Possibly death |
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What are signs of impending cardiopulmonary arrest?
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Stupor or coma
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What laboratory tests assist in assessment of shock?
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1. Blood gas measurements
2. pH 3. Sometimes liver function tests 4. Coagulation status (PTT, partial thromboplastin time, platelet count, fibrinogen, fibrin) |
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What are the treatments of shock?
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1. Ventilation
2. Fluid administration 3. Improvement of the pumping action of the heart (vasopressor support) |
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What is the priority of treating shock?
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1. Establish an airway and administer oxygen
2. Circulatory stabilization 3. Placement of one or more multilumen central lines, preferably above the diaphragm |
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Which organ in most sensitive to shock?
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Lungs
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How is ventilatory support provided?
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Via endotracheal intubation with positive-pressure ventilation and supplemental oxygen
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What is monitored frequently during ventilation treatment for shock?
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1. Blood gases
2. O2 saturation 3. pH |
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What is therapy directed at in patients experiencing shock?
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Maintaining normal arterial blood gas measurements, normal acid-base balance, and circulation. Efforts are made to remove fluid and prevent accumulation by increasing oncotic pressure and decreasing microvascular hydrostatic pressure.
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How is elevated oncotic pressure promoted?
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By diuresis with furomeside or mannitol, colloid administration, or both
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What is the first choice for fluid replacement?
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An isotonic crystalloid solution (NS or lactated Ringer's solution)
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How is the crystalloid solution administered?
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In intravenous boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary
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What are colloids?
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Protein-containing fluids that are often administered to children in shock
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What is the most common colloid?
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Albumin
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Why is albumin commonly used?
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Because it is a protein solution, it stays in the vascular space much longer than crystalloid fluids
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What agents are principally used to improve cardiac output and circulation during shock?
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1. Exogenous catecholamines, administered by constant infusion pump
2. Dopamine, which also improves renal perfusion 3. Other agents (dobutamine, isoproterenol, epinephrine) may be used to improve cardiac output |
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What other therapies are a priority when treating shock?
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Prevention of infection
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What position is most beneficial to children experiencing shock?
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Head-down position, which tends to increase ICP, decrease diaphragmatic excursion and lung volume, and decrease venous return to the heart because of the altered thoracic pressure
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What is the emergency treatment of shock?
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1. Ventilation - establish airway; be prepared for intubation; administer O2, usually 100% by mask
2. Fluid administration - restore blood or fluid volume as ordered 3. Cardiovascular Support - administer vasopressors (epinephrine 1:1000, 0.01 mg/kg subQ; max dose of 0.5mg; may repeat if needed) 4. General support - keep child flat with legs raised above level of heart; keep child warm and calm |
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What is the first stage of septic shock?
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Chills, fever, and vasodilation with increased cardiac output, which results in warm, flushed skin that reflects vascular tone abnormalities and hyperdynamic, warm, or hyperdynamic-compensated responses
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What is the second stage of septic shock?
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Skin is cool, but pulses and BP are normal, urinary output diminshes, mental state is depressed
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What is the third stage of septic shock?
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Hypothermia, cold extremities, weak pulses, hypotension, and oliguria or anuria; patient is severely lethargic or comatose; multiorgan failure is common
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In which stage does the patient has the best chance of survival?
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First stage of septic shock
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Which is the most dangerous stage of septic shock?
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Third stage
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