Lost í börnum

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Lost brnum. Einar Bjrnsson Seminar 25. Aprl 2005. Lost. Lfelisfrilegt stand sem verur vegna skeringu blflis til vefja lkamans, og .a.l. minni srefnisflutningur til vefjana. Ef ekki er gripi inn egar loststandi er enn afturkrft, veldur srefnisskorturinn v a: - PowerPoint PPT Presentation

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  • Lost brnumEinar BjrnssonSeminar25. Aprl 2005.

  • LostLfelisfrilegt stand sem verur vegna skeringu blflis til vefja lkamans, og .a.l. minni srefnisflutningur til vefjana.Ef ekki er gripi inn egar loststandi er enn afturkrft, veldur srefnisskorturinn v a:Jnagng htta a starfaBjgur verur inn frumunniLkkun pHFrumudaua

  • LostEf etta er ekki leirtt tka t verur...Skai lffrum.San...Skai lffrakerfum (MOF)Og a lokum...Daui

  • Hva stjrnar O2 flutningi?Cardiac output (CO)HjartslttartniSlagrmml (stroke volume)Preload fylling slegla dastluVirkni hjartavvans (contractility)Afterload mtstaa vi blfli fr hjarta (slagarstingur)Systemic vascular resistance (SVR)EykstVi lengd ar ykkt bls (Hematocrit)Og verml arSrefnismagn slagMagn hemoglobnsSrefnismettun hemoglobns

  • FlokkunHypovolemicVkvatapBlingDistributive (Vasodilatory)SepticAnaphylacticNeurogenicCardiogenicCardiomyopathiesArrhythmiasMechanicalObstructiveCompensatory

  • Hypovolemskt lostAlgengasta losti brnum heiminum.Mortalitet undir 10% vesturlndum.

    Lgt preload=> SV=> COCompensera me hjartslttartni SVRSkipt tvo flokka: 1)Vkvatap 2)Bling

  • Hypovolemskt lostVkvatapNiurgangurUppkstHitakramparOsmotsk duresaBruniAdrenal insufficiencyThird spacingNephrotic syndromeIntestinal obstruktionAscitesDiabetes insipidus

  • Hypovolemskt lostBlingTraumaGastrointestinal blingAgerirSickle cell crisis

  • Distributive (Vasodilatory)Minnkaur SVRelileg dreifing blfli og lkamsvkvaSrefnisflutningur of ltill til mikilvgari vefjaFunctional hypovolemia minnka preloadCO mist lti, elilegt ea htt. gegndrpi hraSkipt : 1)Septic 2)Anaphylactic 3)Neurogenic

  • Distributive (Vasodilatory)Septic kjlfar Sepsis/severe sepsisSystemic inflammationVasodilatation gegndrpi hraCytokine og hvt blkornEinkenni blflisskeringar me ea n blrstingsfallsSking annahvort sstemsk (septicemia) ea stabundin20-70% blrktana jkvarBakteriur, toxin, veirur og sveppirAlgengi USA 0,56/1000 (5,16/1000 ungbrnum, 0,2/1000 10-14 ra)Dnartni1960s 97%, 1980s 60%, 1999 9% (fullornir 27%)

  • Distributive (Vasodilatory)httuhpar fyrir septskt lostMjg ung brnAlvarleg og/ea langvinn veikindiInniliggjandi hld (t.d. aleggir)nmisbling/galliSplenectomiaAgerirBrunarVannringMikil skllyfjanotkun

  • Distributive (Vasodilatory)AnaphylacticIgE medieraVirkjun mast frumum og basophilumMikil losun mediatorum sem hefur hrif HinandunarfriHjarta- og akerfimeltingarfriAnaphylactoidNonantigen/antibodySmu hrif og IgE

  • Distributive (Vasodilatory)Helstu ofnmisvaldarLyfBlusetningarContrastColloid vkvarSermiGammaglobinLatexMaturSkordrabit/stungur

  • Distributive (Vasodilatory)Neurogenic kjlfar akt skaa mitaugakerfiHfuhggSpinal ShockGengur yfirleitt tilbakaTap sympatskum tonusatvkkunMinnka SVRMinnka preload og afterloadelileg dreifing blfliHypoxic/ischemic injuryHypotension n reflex tachycardiu og vasoconstriction

  • CardiogenicHjartavvinn gefur sig COVeldur reflex vasoconstriction sem afterloadSem mti CO afterload => veggspennu hjartavvans => blfli kransarVtahringuralgengt brnum mia vi algengi fullornum

  • CardiogenicCardiomyopathiurFamilialSkingarInfiltrativeIdiopathicMyocardial skaiLangvarandi ischemiaCardiopulmonary bypassSepsis

  • CardiogenicArrhythmiurAtrial og ventricular uppruniTachycardiurOf mikil hjartslttartni preload => SVBradycardiurOf ltil hjartslttartniElilegt SVAlgengustu sturMefddir hjartagallar, Lyf/eitun, hypothermia

  • CardiogenicMechanskir gallarHtt afterload ea preloadHjarta hefur ekki eftir til langs tmaEndar lostiHelstu sturMefddir gallarCoarctationTumorAortic stenosaFebris Rheumatica

  • CardiogenicObstructiveExtracardiac mtstaa gegn dluvirkni hjartansGetur presentera sem hypovolemia eftir astum/orsakavaldi (preload)Helstu orsakir:Massive pulmonary embolism, tensions pneumothorax, constrictivur pericardit, tamponade, mikill lungnahrstingur

  • Stig LostsCompensera lostHomeostatskir mechanismar compenseraTachycardiaVasoconstrictionElilegur blrstingurHeilbrigt barn sem hefur misst 10% blrmmls getur veri nr elilegtDecompensera lostNr ekki a compensera allt stefnir niur viHypotensionEinkenni lffraskemmda koma fram25-30% minnkun blrmmliCardiac index
  • BlrstingurBirth (12 h,
  • BlrstingurNeri fimmta percentile systoliskum blrstingiNewborn - 60 mm HgInfant (1 mo to 1 y) - 70 mm Hg Child (>1 y) - 70 + 2 X age (in y)

  • PlsElilegur pls mia vi aldur1 = 120-1802 = 120-1607 = 100-14015 = 90-140

    Harriett Lane Handbook of Pediatrics

  • SagaFinna etiologiuForeldrar, heilsufarsupplsingarOfnmiLyf/lyfjabreytingar/eitranirFyrri sjkdmarAkt og krnsktFyrri kvartanir og einkenninmisblingStorkubrenglanirSlys og eli essFu- og vkvainntakatskilnaur

  • EinkenniSameiginleg einkenniHypotensionKemur seint brnum vegna betri algunarhfniOftast mia vi 5. percentile fyrir aldurHbreytingarVasoconstriction perifertCool & clammy, fl, marmoriseruMinnka capillary refill >2 sekVasodilationFlushed, hyperemia, roiEarly distributiveLangt gengi irreversible lostMjg hratt capiller refill (flash)

  • EinkenniBreyting peripher plsumMinnkair peripher plsarBounding peripher plsarMinnkaur vagtskilnaur
  • EinkenniSeptic ShockSnemmaSVR, CO plsrstingurHeitir og urrir tlimirToxskir, tachycard, tachypnea, bounding pulse, el capillary refill og hiti.rigors, grunting, mental confusion or irritability, og diarrhea.petechiae, purpura, ea gulaLokastigMikil hypotension, SVR, CO, minnku ndun/ndunarbilun, cyanosa, kaldir tlimir, minnkkair plsar, skert mevitund, coma.

  • EinkenniHypovolemiskt lost vegna blingarClass I 15% bltap, minimal einkenniClass II 15-30%, mild tachycardia og tachypnea, rngur plsrstingur, vgt hg hrafylling, minnkaur vagtskilnaur og vgur kvi Class III 30-40%, tachycardia, tachypnea, hypotension, hg hrafylling, skertur mental status, og oliguria Class IV - >40%, augljslega losti, kaldur, hvtur, mevitundarskertur, mikil tachypnea og tachycardia, anuria.

  • EinkenniHypovolemiskt lost vegna vkvatapsTengt vkvatapireyta, orsti, vvakrampar, stusvimi, h og slmhir.San kviverkir, skert mevitundEftir tegund vkva sem tapastExtracellular vkvi isosmotisktBara vatn hypernatremia (diabetes insipidus, insensible losses)ElektrolytatruflanirVvaslappleiki vegna hypokalemiu ea alvarlegrar hyperkalemiuPolyuria og polydipsia vegna hyperglycemiuSvefnhfgi, rugl, krampar og coma vegna hyponatremiu ea mikla hyperosmolalitet vegna hypernatremiu ea hyperglycemiuDehydration er reiknu t fr hlutfallslegu tapi lkamsyngdMild er 10%

  • SkounHr skoun fyrst, san almenn egar sjklingur er orin stabllHEENT conjunctiva (urrkur, gula, anemia), tr, slmhir, sokkin augu, pupillur, augnhreyfingar, fontanellur.Hls JVP, eitlar, hnakkastfleiki.Lungu Tachypnea, grunn ndun, nghlj, slmhlj, stridor, minnku ndunarhlj, rub.Cardiovaskuler EKG, S3 gallop, broddslttur, heave, hlj, fjarlg hlj, rub, pulsus paradoxus, Kussmauls sign.

  • SkounKviur harur, aninn, aumur, peritoneal erting, garnahlj, fyrirferir, hepatosplenomegaly, ascites.Rectal skoun tonus, bl.tlimir plsar, hrafylling, cyanosa, bjgur, blrstingsmunur.Taugakerfi fokal einkenni, lamanir, krampar, agitation, rugl, delerium, sambandsleysi, mevitundarleysi, coma.H kld, sveitt, heit, rau, tbrot, petechiae, purpura, urticaria, cellulitis.

  • Rannsknir leit a orskPrognostiskthrif lffriMonitoring

  • RannsknirBlprufur:Status, Diff, Na, K, Cl, Krea, Urea, iCa, Mg, Kolsra, phosphat, Glksi, CRP, Lifrarprufur, Amylasi og Lipasi, lactate, Albumin, Fibrinogen, D-dimer, blingarprf, hjartaensm, skjaldkirtilsprf, cortisol.Astrup PO2, PCO2, pH, base deficit, bikarbonat.vagstatusRktanirMyndrannsknir rtg. lungu, hjarta og/ea abdomen, Hjartamun, CT.EKG og Monitor, mettun og blrstingur (noninvasift, arteria, central venu, pulmonary art)

    Hypoxia vs ischemiaLengd + ykkt ekki mjg breytilegtEn verml mjg dynamsktDysentery veldur bltapiTNF-a IL 1,2,6 coagulation, complement, bradykininNO myndun v/iNOSHraleki, third spacingDirect skai hjartaThe mortality rate increased progressively along the continuum: 7 percent with SIRS alone, 16 percent with sepsis, 20 percent with severe sepsis, and 46 percent with septic shock.Spinal shock fyrir ofan T levelMinnka mtvgi vi parasymp mti kemur einnig pulmonary edemaVinstri vs. Hgri hjartabilun fullornum er alg kransasjdShuntVolume overload ea rstingsmtstaaPO2/FiO2 ratio Serum creatinine Platelet count Glasgow coma score (show table 2A-2B) Serum bilirubin Mean arterial blood pressure Serum lactate Oft erfitt a f sguMottled extremities, lethargy, poor feeding, a bulging or sunken fontanelle, decreased tone, and hypoglycemia may be noted in neonates and infants