Staying Balanced Spring 2008 1. “Universal solvent” 60% of body’s weight Cells “haf to have it.” ▪–Arnold Schwarzenegger 2.

Staying Balanced

Spring 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 loss

Electrolyte 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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O2

ABCsFluids

Flavor?Consider PASGECG

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EdemaPeripheral vs. central (more later…)

Aggressive treatment if Pulmonary Edema

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ABCsO2

Consider 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

spunHemoglobin -

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 Time

Irradiated RBCs

Used in immunodeficient clients

250 – 350 ml 2 – 3 hours

Fresh frozen plasma:

Has most coagulation factors

Used 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)

Hypotension

Dry, flushed skin

Abdominal pain

Headache

Lumbar pain

Sudden chill

Urticaria

Respiratory 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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