GENERAL ICU
12/8/10
Venkatesh, B et al (2003) “Data Interpretation in Critical Care Medicine” Elsevier
Alex Pirides Notes
PY Mindmaps
FANZCA Part II Notes
Adrenal Crisis
Hyponatraemia
Hypotension
Hypoglycaemia
On steroids
Priorties:
A, B, C, D, E
Correct electrolyes
Glucose
Hydrocortisone 100mg Q6hours
Fludrocortisone 0.1mg QID
HDU/ICU
Endocrine
Agitation
Diagnose cause and management
A, B, C, D, E
COMMON
Pain
Urinary retention
Drug effects
Hypoxia
Hypercarbia
UNCOMMON
Aspiration
MI
CVA
Drug allergy
Electrolyte
Airway Assessment
History – chart review
Examination – habitus, face, neck
Investigations – nasal endoscopy, CXR, CT
Airway Fire
Priorities
1. Extinguish fire
2. Ventilate patient
3. Quantify damage
4. Staff safety
Turn off O2
Disconnect patient from circuit
Remove ETT
Flood field with H2O
Ventilate patient with air
Perform laryngoscopy +/- bronchoscopy
Retintubate patient
Airway Obstruction
Priorities
1. open airway
2. oxygenation
Open and examine airway (foreign bodies)
FiO2 1.0
Ventilate and intubate if required
Amniotic Fluid Embolism
Priorites:
1. Prompt recognition
2. Prompt resuscitation (ACLS protocol)
3. Prepare for massive bleeding and coaguloapathy
4. Early delivery of fetus
Anaphylaxis
Stop trigger!
Optimise and manage A, B, C
FiO2 1.0 and verify
Head down/elevate legs
IVF
Adrenaline 50mcg boluses (adult), 10mcg/kg boluses (children) IV -> 0.1-1mcg/kg/min
Hydrocortisone 250mg IV
Promethazine 25mg IV
Ranitidine 150mg IV
Approach to an ICU Management Problem (REAC)
Resuscitate
Electrolytes + Acid-Base abnormalities
Antidotes
Causes
ARDS Ventilation
- controlled ventilation
- TV 6mL/kg
- plateau pressure < 30cmH2O
- PEEP titration 5-24
- oxygenation target: SpO2 > 90, PaO2 > 60mmHg
- permissive hypercapnia
- other strategies: prone, iNO, inhaled prostacycline, ECMO
Aspiration
Priorities
1. Minimise further aspiration
2. Airway protection
3. Oxygenation
4. Management of complications
Head down
Left lateral position
Suction
Intubation (may have to intubate oesophagus first to isolate)
Suction of ETT until debris clears
Lung protective ventilation
Management of circulatory compromise (fluids, inotropes, CPR)
Empty stomach
Bronchoscopy +/- lavage
CXR
ICU
Chest physio
Atrial Fibrillation
Priorities
1. Assess for need for emergency cardioversion (shock, CHF, collapse, CP) – chemical or electrical
2. Rate control
3. Rhythm control
4. Risk stratification for anti-coagulation
Auto-triggering
H2O in circuit
Sensitivity too high
Circuit leak
Cardiac oscillations
Patient actually breathing!
Bradycardia
Priorties
1. diagnose and treat cause
2. maintenance of end organ perfusion
3. support circulation
DIC
Stop all vagal stimulation
Look for and treat cause – hypoxia, drugs, myocardial, metabolic, surgical (CEA)
Assess A, B, C
Atropine 0.6mg IV (maximum 3mg)
Ephedrine 9mg IV
Adrenaline 10mcg boluses -> infusion
Pacing (external, wire, pacemaker)
Breathing Systems
Aims of a Breathing System
1. Remove CO2
2. Supply adequate amounts of O2
3. Allow delivery of anaesthetic gases
Classification
Non-rebreathing systems
Mapelson
A + Lack + Magills
B
C
D + Bain
E
F + Jackson Ree’s Modification of an Ayers T-Peice
Circle systems + CO2 absorber
Bronchospasm
Priorities
1. treat cause
2. maintain oxygenation
3. lung protective ventilation
Disconnect from ventilator and bag
FiO2 1.0 and verify
A – for patency and position
B – trachea, SpO2, ETCO2, chest movement and compliance, percussion and AE
C – review haemodynamics, rhythm
Ventilation
- don’t worry about peak pressure (measure plateau -> inspiratory hold, < 30cmH2O)
- long I:E ratio
- measure auto PEEP (expiratory hold)
- use PEEP (not higher than intrinsic PEEP)
- use volume control
- if using pressure watch TV
- slower rate
Established Treatments
O2
Salbutamol IV – loading dose 15mcg/kg -> 0.1-1mcg/kg/min
Anti-cholinergics – ipratropium bromide 500mcg Q2-6 hrly NEB
Hydrocortisone 100mg IV Q6
Aminophylline 5mg/kg IV -> 0.1-0.7mg/kg/hr
NIV
Non-established Treatments
MgSO4 10mmol IV
Adrenaline 10mcg boluses IV -> 0.1-1mcg/kg/min
Ketamine 0.5mg-2mg/kg/hr IV
Heliox
Iso or Sevo
Cardiac Arrest
ACLS protocol
Priorities =
1. early defibrillation
2. high quality, uninterrupted CPR
3. support of circulation (fluid, adrenaline, antiarrhythmics, praecordial thump)
4. intubation + O2
5. treatment of cause (MI, arrhythmia, 5 H’s and 4 T’s)
6. post resuscitation care
Cardiogenic Pulmonary Oedema
Goals
1. maintain oxygenation
2. minimise myocardial work
A, B, C approach
FiO2 1.0
PEEP
Decrease Preload – diuretics, GTN, PEEP, morphine
Decrease Afterload – GTN, PEEP
Increase contractility – inodilator (milrinone)
Chest drain principles
First – drain fluid
Second – underwater seal drain
Third – apply suction
Coagulopathy
Assess circulation (pulse, BP, blood loss, urine output, colour, CVP)
Assess haemostasis (Hb, platelets, coag’s, fibrinogen)
Treat cause (dilution, acidosis, hypothermia)
Give volume
Appropriate products – RBC’s, PLT’s, FFP, Cryo
Anti-fibrinolytics – TXA
Compliant Against Myself
Duty to patient (go and see)
Duty to myself (support and advice)
Duty to my department (inform senior colleague and HOD if required)
Duty to my hospital
Duty to Medical Council and CICM
Death on the Table
Control scene and patient
Ask senior colleague to confirm death
Duty to Coroner
Duty to Family
Duty to staff (M+M)
Duty to myself
Duty to future patients (quarantine OT)
Document
Decreased LOC
COMMON
V/Q inequality – hypoxia, hypercarbia
Decreased Q – hypotension
Drug effect – sedatives, paralysis, analgesia, anti-emetics (droperidol)
Hypothermia
Hypoglycaemia
UNCOMMON
CVA
Increased ICP
Encephalopathy
Electrolyte abnormality
Mechanism
1. Bilateral hemispheric damage
2. Brainstem pathology
3. Diffuse depression/damage
Assess patient
Review and support - A, B (ABG), C (rhythm, BP, SpO2), D (pupils, GCS, BSL), E (temp)
Reverse drugs (naloxone 40mcg IV, flumazenil 100mcg IV, neostigmine 50mcg/kg, atropine 25mcg/kg)
Coma drugs (dextrose 20mL 50%, thiamine 100mg IV, antibiotics/antivirals, mannitol 0.25mg/kg)
Bloods – U+E, Ca2+, PO4, Mg
CT head
Wait
Decreased Urea:Creatinine Ratio (i am a SIMPLe SR)
Severe liver dysfunction
Intrinsic renal damage
Malnutrition
Pregnancy
Low protein diet
SIADH
Rhabdomyolysis
Difficult Intubation
Priorities = oxygenation and minimisation of airway trauma
Identify and prevent!
Consider waking up
BMV + adjuncts
Optimise position
* Tricks if time (McCoy, Chicaine, fast track, asleep fibre optic intubation)*
LMA
Surgical cricothyroidotomy
Distributive Shock
Sepsis
Anaphylaxis
Liver failure
Adrenal failure
Spinal
Haemophagocytic syndrome
DKA
Goals:
1. rehydration (prevention of cerebral oedema)
2. clear ketoacidosis
3. electrolyte supplementation
4. treat precipitant
- IV bolus rehydration for hypotension (use a balanced salt solution) -> maintenance (80% normal)
- IV actrapid (start @ 1U/kg/hr) + start 10% dextrose once BSL < 15mmoL/L (keep running until ketones in urine clear)
- K+ supplementation (need large amounts)
- measure urine output
Donation Post Cardiac Death (6 P’s)
Preconditions
Preparation
Process
Post donation time
Preparation for possible unsuccessful donation
Possibility of consent withdrawal
Drug Error
Causes:
1. Slips and Lapses (unintended errors)
2. Mistakes due to lack of knowledge or experience (intended errors)
3. Communication failures
4. Systems errors
Unfortunate mistake
Apologise
Open disclosure
Allow questions
Offer support
Document
Risk manage
MPS (if required)
Protect doctor
Incident form (AIMS)
M+M review
Eclampsia
Goals
1. treatment of seizure (and prevention)
2. prevention of complications
A - jaw thrust -> ETT
B - FiO2 1.0, bag-mask, SpO2
C - left lateral position (prevent aorto-caval compression), IV, BP
D - 4g MgSO4 IV over 5min -> infusion of 1g/hr for 24 hrs (theraputic level = 2-4mmoL)
Stablilse situation
Assess fetal well being & decide on when delivery appropriate
Status Epilepticus -> ?propfolol/thiopentone
Anti hypertensive treatments (aim SBP 140-160mmHg) -> hyrdralazine, labetalol, nifidepine
Electrical Safety
Macroshock = large amount of current flow that produces harm or death
Microshock = small current @ high density close to myocardium -> VF
0.1mA - to myocardium -> VF
<0.1mA – nothing
10mA – skeletal muscle spasm
100mA – VF
1000mA – muscular burn
General measures
Class of equipment (1, 2 and 3)
Type of equipment (B, BF and CF)
Equipotentiality
RCD’s (circuit breakers)
Line isolation monitors
Isolating transforms
Diathermy
Area classification (body and cardiac)
Emergency Management (DIC)
Declare emergency
Inform the team
Call for help
Equipment Template (IUD Method Of Contraception)
Item name
Uses
Description
Method of Insertion and/or use
Other information
Complications
Functions of the Vagus Nerve (B-Saphenous Vein Graft)
Branchial Motor
Secretomotor
Visceral Sensory
General Sensory
High AWP
Cause
1. Machine and circuit (supply, machine, ventilator, valves, filter)
2. ETT
3. Patient
Disconnect patient from machine
FiO2 via bag-mask
Airway for patency and position
Breathing (aspiration, bronchospasm, surgery related, increased abdominal pressure, inadequate relaxation, MH)
Circulation review
Keep patient asleep with IV hypnotic
High Anion Gap Metabolic Acidosis (LTKR)
Lactate
Toxins
Ketones
Renal Failure
High Anion Gap + High Osmolar Gap (MADE SP)
Methanol
Alcoholic ketoacidosis
DKA
Ethylene glycol
Salicyclic acid poisoning
Pyroglutamic acidosis
High Frequency Oscillation Ventilation – mechanisms of gas transport (PAT the Cat)
Pendelluft mixing
Augmented diffusion
Taylor dispersion
Co-axial flow patterns
Hypercalaemia (BIO)
Bone
Intake
Others
Hypermetabolic Syndromes
Thyroid storm
Phaemochromocytoma
MH
Sepsis
Liver failure
Serotonin syndrome
Cocaine toxicity
NMS
Hypercarbia
Causes
1. Measurement error
2. Increased production or administration – MH, sepsis, phaeochromocytoma, thyroid storm, NMS, laparoscopy, tourniquet, CO2 gas insufflation or CO2 laser
3. Decreased removal – hypoventilation, V/Q inequality, CO2 absorber, circuit issue
Isolate patient (bag)
Check patient – A, B (ABG), C, D, E
Check monitoring
Check machine
Hyperkalaemia
Urgent situation
Diagnose and Treat cause
A, B, C, D, E
Ca2+ gluconate 10% 10mL
NaHCO3 8.4% 1mmol/kg
Insulin-dextrose bolus – 50mL of 50% glucose + 10U actrapid -> infusion
Salbutamol IV/Neb
Dialysis
Hypertension
COMMON
- pain
- depth of anaesthesia
- hypoxia
- hypercarbia
- drug error
- fever
- clamping of aorta
UNCOMMON
- disease specific - rebleed with SAH, PET, increased ICP, autonomic dysreflexia, pre-existing
- weird stuff – MH, phaechromocytoma, thyroid storm, aortic dissection, NMS, serotonin syndrome
Treat cause and prevent complications
Agents that lower BP (volatile, opioids, hypnotic)
Vasodilators – GTN 50mcg IV -> 0.1-2mcg/kg/min, hydralazine 5-10mg IV, SNP 0.1-4mcg/kg/min
Betablockers – esmolol 10mg IV
Ca2+ channel blockers – nifedipine 5-10mg SL, verapamil
Hyperthermia
COMMON
Iatrogenic – FAW on high
Measurement error
Sepsis
Blood transfusion
UNCOMMON
Drugs – MH, NMS, MAOI’s, cocaine
Endocrine – phaechromocytoma, thyroid crisis
Treat cause
Stop or expedite surgery
Cool – IVF, FAW on cold, expose, ICE, cold fluid to cavities, paracetamol/NSAIDS
Hypocapnia
Causes
1. measurement error
2. decreased production –> hypothermia, dying
3. decreased Q -> hypoperfusion
4. increased removal –> ventilation
Isolate patient (bag)
Review – A, B, C, D, E
Treat cause
Hypotension
In this context the most likely causes = …
Goals
1. Oxygenation
2. Maintenance of end-organ perfusion
3. Optimise preload, contractilty and afterload
Head down
Legs up
Review and support A, B, C
FiO2 1.0 and verify
Review P, BP and rhythm
Administer fluid bolus + vasopressor/inotrope
Causes
1. Measurement error
2. Drug infusion issues
3. Hypovolaemic – bleeding, dehydration
4. Cardiogenic – MI, arrhythmia
5. Distributive – anaphylaxis, epidural
6. Obstructive – PE, TP, tamponade
Hypothermia
-> associated with increased perioperative morbidity
CVS – increased -> decreased Q, arrhythmias, increased MI
RESP – increased laryngospasm and O2 demand
CNS – decreased response to hypoxia and hypercarbia, increased sensitivity to sedatives and opioids, decreased LOC
NEUROMUSCULAR – increased duration of action of NMBD, volatiles and opioids, shivering
GU – polyuria
HAEM – decreased haemostasis, increased risk of DVT, increased wound infections
METABOLIC – hyperglycaemia, acidosis from poor peripheral perfusion
SKIN – slow healing
Priorities
1. Minimise heat distribution
2. Cutaneous warming
3. Internal warming
Methods
Anaesthetic - wrap head, FAW, humidification of gases, warm fluids
Surgical - minimise exposure and surgical time, minimise bleeding, warm irrigation
Environmental - keep patient warm prior to OT, warm OT, minimise drafts, discourage opening of door intraoperatively
Hypocalcaemia (Detectives from CIB)
Drugs
Chelation
Intake
Bone
Hypokalaemia (Dr from MIT)
Decreased K+ Intake
Magnesium depletion -> increases renal potassium loss
Increased Loss
Transcellular Shift
Hypokalaemic Alkalosis
Vomiting/high NG losses
Frusemide therapy
Refeeding syndrome
Villous adenoma of rectum
Steroid therapy, Cushings syndrome, Conn’s syndrome
Laxative abuse
Hypomagnesaemia (RRID)
Reduced intake – malnutrition, alcoholism
Redistribution – insulin, hungry bone syndrome
Increased loss – diuretics, diarrhoea,
Drugs – amphotericin B, cisplatin
Hyponatraemia
Hyposomolar
- hypovolaemic -> renal vs extra renal causes
- euvolaemic – SIADH, hypotonic IVF, psychogenic polydipsia
- hypervolaemic – CHF, nephrotic syndrome, cirrhosis, hypothyroidism
Isoosmolar – elevated proteins or lipids, TURP/hysteroscopy syndrome, *advanced renal disease
Hyperosmolar – glucose, mannitol, sorbitol, radiocontrast, *advanced renal disease
Hypophosphataemia (RICE)
Renal losses
Inadequate intake/absorption
Cells – redistribution into
Extreme catabolic states
Hypoventilation
Causes
1. Airway obstruction – blood, pack, laryngospasm, oedema, nerve injury
2. V/Q inequality
3. Neuromuscular problem
4. CNS depression
5. Equipment – inadequate ventilation
Assess and manage accordingly
Disconnect from ventilation
A – patency
B – FiO2 1.0 and verify, ETCO2, WOB, PNS
C – P, BP, perfusion
D – LOC, BSL, pupils, lateralising signs, signs of drug toxicity
E – temperature
Hypoxia
Causes
1. Inadequate supply (O2 supply, machine, ventilation, filter, airway)
2. Inadequate Q
3. V/Q inequality
4. Measurement error
Disconnect from machine -> BMV
Assess and optimise A, B, C
FiO2 1.0 and verify
Increased Urea:Creatinine Ratio – (Dane’s Can use GPS)
Dehydration/prerenal failure
Corticosteroids
GIH
Protein diet
Severe catabolic state
Intraoperative Fluids
Crystalloid – hypertonic (dextrose, hypertonic saline), hypotonic (dextrose), isotonic (N/S, Hartmans, Plasmalyte)
Colloids – dextrans, starches, gelatins
Blood products – RBC’s 10mL/kg, FFP 15mL/kg, Platelets 10mL/kg, Cryo 5mL/kg, albumin 10mL/kg
Investigations
Bed side
Laboratory
Radiological
Special tests
Ketoacidosis
Starvation ketosis
Alcoholic ketoacidosis
DKA
Lactic Acidosis (Cohen and Woods Classification)
A – Inadequate O2 delivery
(i) anaerobic muscular activity
(ii) tissue hypoperfusion
(iii) reduced tissue oxygen delivery or utilisation
B – Adequate O2 delivery
B1 – underlying diseases (lukes, tips and failures)
B2 – drugs and toxins
B3 – inborn errors of metabolism
Lactate Acidosis in the patient with Multi-organ failure
Lactate over production
- catecholamines
- low cardiac output state with global hypoperfusion
- organ ischaemia (bowel)
- sepsis with mitochondrial dysfunction
Decreased lactate catabolism
- liver failure
- renal failure
Laryngospasm
Priorities
1. Oxygenation
2. Relieve obstruction
Remove foreign bodies (throat pack)
Open airway
FiO2 1.0
CPAP
Deep anaesthesia (propofol)
Suxamethonium 1mg/kg IV (+ atropine 25mg/kg)
*** My emergency drug for laryngospasm in children =
100mg suxamethonium (2mL) + 0.12mg atropine (1mL) =
33mg/mL of sux + 0.4mg/mL of atropine