Staying Balanced Spring 2008 1
Mar 14, 2016
Staying BalancedSpring 2008
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“Universal solvent”60% of body’s weightCells “haf to have it.”
▪ –Arnold Schwarzenegger
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154# person x .60 (60%) = 92# Water is approx 8# per gallon 11 ½ gallons water (Obese people/ less) (Thin people/ more) Infants Elders
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The fundamental unitRequires:
Cell membrane Enzymes Internal membranes Genetic material
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EpithelialConnectiveMuscleNervous
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All metabolic reactions occurThe precise regulation of volume and
composition of body fluid is essential to health.
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Intracellular Fluid - ICFExtracellular Fluid – ECF
Intravascular Fluid- Plasma Interstitial Fluid
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Fluid in all body cells75% of the water (60%)
31.50 L (70 kg adult)40% of total body weight
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20% of water (60%)10.50 L (70 kg adult))
Includes intravascular and interstitial compartments
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Intravascular
4% of (60%)
▪ 7.5 L
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Interstitial 16% of (60%)
▪ 17.5 LFluid between cells and outside
the vascular bed Connective tissue, cartilage, bone,
CSF, intraocular fluid
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Water – Universal Solvent
Intake & Output (I&O)
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HomeostasisThe body’s need for balance
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Newborns – TBW ~ 80%Children – TBW ~ 60-65%Elders – TBW < ~ 60%
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Food - 1200 mlDrink - 1000 mlMetabolic
sources - 300 ml
= 2,500 ml
Lungs - 400 mlKidneys - 1500 mlSkin - 400 ml Intestine (Feces) -
200 ml
= 2,500 ml
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Osmoreceptors - anterior hypothalamus
Baroreceptors - carotid sinus, aortic arch, kidneys High and low blood pressure
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Anti-diuretic hormone (ADH) If tide goes out Pituitary Gland Excretes
Tide comes in!!!▪ Re-absorb from kidneys▪ Decrease urine
Thirst also regulates
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Abnormal decrease in TBW
Thus the weigh-in at fires
Rarely involves only water lossElectrolyte loss
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Signs and symptoms?
Treatment?
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GI losses N/V/D
Insensible losses Normal losses + with fever Hyperventilation High Environmental Temps
Increased sweating
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Internal losses “Third” spacing
▪ Peritonitis▪ Pancreatitis▪ Malnourished
▪No protein to retain water
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Plasma Losses Burns Surgical Drains Open Wounds
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Signs of shockSkin changes (turgor)Orthostatic hypotensionThirst Increased pulse rateFurrowed tongue
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Decreased BP Dry mucosa Infants: Anterior fontanelle sunken
▪ Dry diapers▪ Absent tears▪ Cap refill > 2 seconds▪ Dry mucosa
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O2ABCsFluids
Flavor?Consider PASGECG
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EdemaPeripheral vs. central (more later…)
Aggressive treatment if Pulmonary Edema
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ABCsO2Consider ETTMeds:
NTG. Lasix M.S.
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Medical causes Diabetes Heat
Emergencies Blood Loss
Traumatic causes Blood loss
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In H2O dissociate into ionsCations = positiveAnions = negative
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Sodium (Na+) Prevalent in ECF
▪ “Water follows it” Nerve impulses Hyper/ Hyponatremia
Potassium (K+) Prevalent in ICF Nerve impulses Hypo/ Hyperkalemia
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Calcium (Ca++) Prevalent in ICF Muscle contraction Nerve impulse Hypo/hypercalcemia
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Magnesium (Mg++) Present in ICF
Necessary for many processes Found in some:
Antacids Laxatives
Most associated with phosphate Renal Functions
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Chloride (Cl-) Present in ECF Balances cations Fluid balance Renal function Usually found hanging around sodium
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Bicarbonate (HCO3-)
Found in ECF
The Buffer Neutralizes Acidic (H+)
Tx for acidosis
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Phosphate (HPO4--)
Found in ICF - buffer Energy stores Mg++ in renal function
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Electrolytes - mEq/LNon-Electrolytes -
Glucose
Urea
Proteins
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OsmosisDiffusionActive TransportFacilitated Diffusion
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IsotonicHypertonicHypotonicOsomotic gradient - difference in
concentration
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Movement of
water
(solvent) Semi-
permeable
membrane
Towards
higher solute
concentration39
Movement of solutes Across membrane
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•Towards Towards lesser lesser solutesolute concentrationconcentration
Movement of solutesAcross membrane
Against osmotic gradientRequires energy (ATP)
Sodium-potassium pump
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Helper proteins Insulin
Open gateGlucose
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Governs movement of water and solutes across cell membrane
Pressure exerted by concentration of solutes
Pulls from other side of membrane
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Colloid osmotic pressure Plasma
Hydrostatic pressure Blood pressure
▪ Filtration
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Localized Site of injury Organ systems - brain, lungs, heart,
abdomen
Generalized Dependent edema
▪ Pitting edema48
Body water in interstitial spaces not available for metabolism
Relative dehydration
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Decrease in production of plasma proteins Liver disorder Burns Open wounds
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Increase in hydrostatic pressure Venous obstruction Salt and water retention Thrombophlebitis Liver obstruction Tight clothing Prolonged standing
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Increased capillary permeability - plasma proteins escape Inflammation and immune response Allergic reactions Burns Trauma Cancer
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Lymphatic channel obstruction Infection Surgery
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Blood transfusions
Plasma Formed Elements
Leukocytes (WBCs)Erythrocytes (RBCs) >99%Thrombocytes
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Mostly Water (92%)
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Monocytes (Big eaters, chronic)
Neutrophils (bacteria)
Basophils (inflamation)
Eosinophils (allergies, parasites)
Lymphocytes (intracellular)
Indicate Combat Readiness
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•State of the union
State of the union
Transports oxygen40-45% Hematocrit
After specimen is spun
Hemoglobin - Iron-based compound;
binds with oxygen
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Major role in blood clotting
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Determined by ratio of plasma to formed elements
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AntigensBlood type proteins
AntibodiesResistance (in serum)
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A A Antigen B Antibody
B B Antigen A Antibody
AB A & B Antigen No Antibodies “Universal Recipient”
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ONo AntigensA & B Antibodies (serum)
“Universal Donor”
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Measured in + or –+ = Anti-Rh antibodies present
- = Ok.- = No Anti-Rh antibodies pres.
- = Ok + = Sensitization ++ = Severe reaction / death
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Blood type Volume infused Time
Packed Cells:Preferred method
250-350 ml 2 – 3 hours
Whole blood: 550 ml 2 – 3 hours
Leukopoor RBCs:Prevents febrile non-hemolytic reactions
250 – 500 ml 2 – 3 hours
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Blood type Volume infused TimeIrradiated RBCs Used in immunodeficient clients
250 – 350 ml 2 – 3 hours
Fresh frozen plasma:Has most coagulation factorsUsed in DIC, liver disease
200 – 250 ml 1 hour
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Physician’s order Check type and cross-match; verify with
partner Check blood bag for bubbles, cloudiness,
dark color, sediment Check patients vital signs
Temperature BP Pulse Respirations
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Rotate blood bag gently Pull back tabs on blood unit bag,
expose port. Spike blood bag port carefully and hang
unit. (Be sure clamp is closed). Open clamp and fill drip chamber. Make
sure filter is submerged in blood. Open clamp on tubing, carefully run
blood through tubing, and place needle on end of tubing.
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Check primary IV solution – Never use dextrose solutions!
Attach blood tubing into IV port and tape into place.
Shut off primary IV and begin transfusion.
Administer blood slowly for first 15 minutes, ~ 20 gtts/min. ALLOWS TIME TO OBSERVE FOR
ADVERSE REACTION
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When blood bag is empty, clamp off tubing to bag, open clamp to normal saline bag, and flush line.
Close all clamps and remove blood tubing from injection port.
Monitor patient for s/s of transfusion reaction.
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S/SSudden increase in temperature (may be 105o)HypotensionDry, flushed skinAbdominal painHeadacheLumbar painSudden chillUrticariaRespiratory wheezing, laryngeal edema
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Stop transfusion immediately Change tubing Observe for shock Monitor vitals every 15 minutes until
stable Keep blood tubing and bag for ED staff. Control hyperthermia Consider antihistamine if allergic
reaction
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A 40 y/o male driver involved in a head-on collision at ~ 40 mph. Pt is seat belted with a lap belt only. Pt is CAO PPTE on arrival, c/o acute abd. Pain and SOB. P – rapid, thready BP – unable to auscultate RR – rapid
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DDX?Why?TX?Why?
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This patient is 82 y/o, and calls you at 0030, c/o feeling ill.
Pt is CAO PPTE, but slow to respond B/P 120/76 P 94, irreg. RR 24 Skin cool, dry, pale Mucous membranes dry with
furrowed tongue and sunken eyes75
DDX?Why?Tx?Why?
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You are called to a 60 year old male c/o SOB, chest pain. His sx started ~ 2 hrs ago while painting the garage. He says the chest pain went away almost immediately, but he’s increasingly short of breath.
PMH: Pulmonary edema, Angina, HTN, recent URI
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Pt is CAO PPTE, anxious, in tripod position. BBS decreased with coarse crackles in the
bases BP 130/60 HR 126, sl irreg. RR 36, shallow Skin pale, cool, dry with poor turger, dry
mucous membranes, furrowed tongue78
DDX?Why?Tx?Why?
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