EKG Waves

Heart Auscultation

Aortic area: Right sternal border, 2nd intercostal space. S2 is louder than S1.

Pulmonic area: Left sternal border, 2nd intercostal space.

Erb's point: Left sternal border, 3rd intercostal space.

Tricuspid area: Left lower sternal border, 4th intercostal space, not always audible.

Mitral (Apex) area: Left midclavicular line, 5th intercostal space. The S1 is loudest in this area. S3 and S4 are heard here.

Multiple Organ Dysfunction Syndrome

MODS. . .results from perfusion abnormalities and/or altered oxygen uptake by cells during sepsis and SIRS. MODS is considered a syndrome because the s/s are multiple and progressive. Organ systems are considered dysfunctional when they cannot maintain homeostasis or when they require supportive therapies to maintain homeostasis. The degree of organ dysfunction is a continuum that includes the possibility of return to normal function. The major organ systems affected in MODS are the pulmonary, renal, hepatic, cardiovascular, and CNS.

Disseminated Intravascular Coagulation

DIC. . .a result of unregulated clotting and thrombolysis stimulated by cytokine and/or pathogen toxin injury to the vascular endothelium during sepsis and SIRS.

Septic Shock

Affect on hemodynamic variables:

1. HR: Tachycardia in response to fever and hypermetabolism and as a compensatory response for the low SVR and low preload.
2. BP: Hypotension is related to low SVR, low intravascular volume, and/or inadequate EF. The degree of diastolic hypotension correlates with the low SVR.
3. Preload: Cardiac filling pressures, CVP and PAOP are low before IV fluid resuscitation because of vasodilation, peripheral vascular shunt formation, and the increased third spacing of intravascular fluid secondary to severe capillary leak.
4. CO: Typically elevated to compensate for low SVR and increased metabolic needs related to sepsis. Occasionally, patients with septic shock present with low CO and biventricular hypokinesis on echocardiogram. This low-CO state is thought to be caused by thy cytokine myocardial depressant factor, which is released during sepsis. This type of cardiac dysfunction is completely reversible and usually lasts 2 to 4 days.
5. SVR: Low because of vasodilation and increased peripheral vascular shunt formation casued by the cytokine and inflammatory response.

Cosyntropin Stim Test

Cosyntropin Stimulation. . .Detects adrenal insufficiency after cortisone stimulation. Cosyntropin and Cortrosyn are synthetic subunits of Adrenocorticotropin Hormone (ACTH) that exhibits the full corticosteroid-stimulating effect of ACTH in healthy persons. Failure to respond is an indication of adrenal insufficiency.

Normal value: Cortisol: >20 ug/dL (>552 nmol/L) rise after Cosyntropin/Cortrosyn administration.

4mL fasting venous blood sample before administration of stim drug. 4mL sample at 30 and 60 minutes after administration.

Absence or blunted response to stim: Addison's dis, hypopituitarism, adrenal ca, adrenal insufficiency - possible sepsis picture.
Response to stim: adrenal hyperplasma.

Measuring Lactate

Lactate Dehydrogenase (LD, LDH). . .an intracellular enzyme that is widely distributed in the tissues of the body, particularly in the kidney, heart, skeletal muscle, brain, liver, and lungs. Increases in the value usually indicate cellular death and leakage of the enzyme from the cell.

Elevated LDH levels are nonspecific, but useful in confirming Myocardial Infarct or Pulmonary Infarct when viewed in relation to other test findings. For example, LDH remains elevated longer than CK, in MI. Can be broken down into five isoenzymes, but when values are reported or quoted, total LDH is meant.

Normal adult: 140-280 U/L

5mL venous blood sample. Serum is used.

Increased levels: 36-55 hrs after MI, 24 hrs within pain onset in pulmonary infarct, CHF, liver dis, malignancies, hypothyroidism, lung disease, muscular dystrophy, anemias, DTs, shock, hyperthermia, renal infart, CNS dis, pancreatitis, fractures, intestinal obstruction.
Decreased levels: good response to cancer therapy.