CriticalCareEssentialsfortheRuralIntensiveCare( Unit · CriticalCareEssentialsfortheRuralIntensiveCare(Unit (AKnowledge Guide(forPhysiciansandNurses ((Version1.0 (2013(((((Editors:(HariPrabhakar(Dr.NandakumarMenon

Critical Care Essentials for the Rural Intensive Care Unit

A Knowledge Guide for Physicians and Nurses

Version 1.0 2013

Editors: Hari Prabhakar Dr. Nandakumar Menon

ATMA Intensive Care Unit Gudalur Adivasi Hospital

Tamil Nadu, India

Disclaimer:

This manual is NOT created for commercial purposes and should not be distributed as such. It has been created to provide a basic knowledge base for critical care for physicians/nurses working in rural intensive care. It is not meant as a comprehensive reference or skills guide. Material has been integrated from multiple sources, including Critical Care Nursing Made Incredibly Easy (Wolters Kluwer 2008). For any suggestions/edits, please call [email protected].

Table of Contents

Heading Section Intensive Care Unit Overview 1

Basic Care of Patient 2

Introduction to Critical Care Nursing 3

Basics of Pulse Oxymetry and Patient Monitoring 4

Introduction to Defibrillation 5

Intravenous Infusions and the Infusion Pump 6

Introduction to the Crash Cart 7

Intensive Care Pain Management 8

Intensive Care Neurology 9

Intensive Care Cardiology 10

Pulmonary Critical Care 11

Intensive Care Gastroenterology 12

Intensive Care Endocrinology 13

Intensive Care Hematology/Oncology 14

Multisystem Disorder Management 15

Pediatric Critical Care 16

Adult Basic and Advanced Cardiac Life Support 17

Imaging in the Intensive Care Unit 18

mailto:[email protected]

Section 1

Intensive Care Unit Overview

1. ICU Definition (Taken from College of Intensive Care Medicine-‐Australia/New Zealand)

An Intensive Care Unit (ICU) is a specially staffed and equipped, separate and self-‐contained area of a hospital dedicated to the management of patients with life-‐threatening illnesses, injuries and complications, and monitoring of potentially life-‐threatening conditions. It provides special expertise and facilities for support of vital functions and uses the skills of medical, nursing and other personnel experienced in the management of these problems. In many units, ICU staff are required to provide services outside of the ICU such as emergency response (eg rapid response teams) and outreach services. Where applicable the hospital must provide adequate resources for these activities. 2. ATMA ICU Overview

The ATMA ICU is a joint initiative of the Gudalur Adivasi Hospital and the American Tamil Medical Association to provide high-‐quality critical care to the Gudalur Valley. This rural ICU is currently attended by the hospital physicians and nursing staff.

The aim of the ATMA ICU is to function as a Level 1 Intensive Care Unit. The definition of a Level 1 Intensive Care Unit is defined below, as per the College of Intensive Care Medicine of Australia and New Zealand:

A Level I ICU should be capable of providing immediate resuscitation and short term cardio-‐respiratory support for critically ill ents. It

must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours. The patients most likely to benefit from Level I care include: a) Patients with uncomplicated myocardial ischemia. b) Post-‐surgical patients requiring special observations and care. c) Unstable medical patients requiring special observations and care beyond the scope of a conventional ward, and d) Patients requiring short term mechanical ventilation. Level I ICUs should have an established referral relationship with a Level II or Level III unit that should include mutual transfer and back transfer policies and an established joint review process. Provision of mechanical ventilation and simple invasive cardiovascular monitoring for more than 24 hours is acceptable when the treating specialist is a trained intensivist. In circumstances where the treating specialist is not an intensivist, this should only occur within the context of ongoing daily discussion with the referral Level II or Level III unit, such as that available in Coimbatore or Calicut Medical College. All patients admitted to a Level I unit must be referred to the specialist taking responsibility for the unit at the time of admission. 3. The following clinical skills are recommended for physicians/nurses working in a rural intensive care unit (University of Calgary):

Intubation Arterial line Placement Central line Placement Chest tube Placement Intravenous access ECG interpretation Chest x-‐ray interpretation CPR (Cardiopulmonary Resuscitation) Cardioversion ATLS (Advanced Trauma Life Support) ACLS (Advanced Cardiac Life Support)

Section 2

Basic Care of Patients in the ICU

1. Arrival of the patient

On arrival of the patient, the following critical information will be collected and recorded on the dedicated ICU register and the vital signs data sheet:

a)

b) Reason for admission into the ICU

c) Blood type

d) Temperature

e) Heart rate, pulse, blood pressure, oxygen saturation as determined by pulse oxymetry

2. Patient monitoring

Vital signs & I/Os (Ins and Outs)

The patient will have their vital signs monitored at least every hour while remaining on continuous pulse oxymetry, or as per the dedicated ICU input/output and

medication administration sheet.

Medications

The patient will have their medications logged in the dedicated ICU medication sheet with the amounts and time the medication was administered.

Laboratory Results

The patient will have their laboratory results entered into the dedicated laboratory results form which will accessible at the patient bedside.

Section 3

Introduction to the Intensive Care Unit and Intensive Care Nursing

Intensive Care Nursing

1. Intensive care nursing is the delivery of specialized to very ill patients. Many times, the illness can be life-‐threatening 2. The patient is often very unstable, which is why the intensive care nurse must keep a watchful eye at all time

Types of Patients in the Intensive Care Unit

Severe wounds and accidents (trauma) Shock caused loss of fluid, infection, or heart failure Heart problems like heart failure, heart attack Patients who have had long or complicated surgeries like bowel surAgery Severe lung diseases like respiratory failure and pulmonary embolism (clot in the lungs) Gastrointestinal and liver disorders like bleeding in the gastrointestinal tract, liver failure, and inflammation of the pancreas

(pancreatitis) Kidney failure Cancers of the lung, stomach, and esophagus Blood electrolyte problems like hyponatremia or hyperkalemia

Responsibly of the Nurse Working in the Intensive Care Unit

Watching the patient for changes in condition and monitoring all the equipment attached to the patient Developing a plan pain, heart problems, skin problems, lack of

fluids in the body Implementing a plan of action including controlling pain, positioning the patient in proper condition, adjusting the IV

pumps, providing care for wounds, helping the patient do breathing exercises

Holistic Care

The intensive care nurse must provide support to the patient and the family. Oftentimes, the family is very afraid when they have to come to the ICU

Just providing medical care is not enough. The ICU nurse also has to attend to the physical, emotional, social, and spiritual aspects of patient care

Equipment in the Intensive Care Unit

Because patients can be very sick in the ICU, there are lots of medications and equipment that are used Equipment includes IV infusion pumps, patient monitors, mechanical ventilators, tubes that are placed in the patient to

provide food/medications Medications include pain medications, anti-‐seizure medications, antibiotics, heart rate and rhythm medications, steroids (to

prevent inflammation ) Many of these medications can cause large side effects like dizziness, seizures, sleepiness, agitation

Example of an Intensive Care Unit Patient and Equipment

Equipment Use

Oscilloscope flow through arteries/veins

IV Fluids Deliver medications and fluids to the patient

Intracranial Pressure Line (ICP Line) Measures pressure in the skull

Respirator/endoctracheal tube Helps the patient breathe if they cannot breathe on their own

Nasogastric tube Deliver food to the stomach/intestine

EKG electrodes Monitors electrical signals in the heart

Foley catheter Drains urine from the patient

Arterial line Measures the arterial blood pressure more accurately than a BP cuff, particularly when exact measurement of blood pressure is needed

Chest tube collapsed lung (pneumothorax)

Suction Apparatus airways

Section 4

Introduction to Pulse Oxymetry

Important Terms: Bradycardia: Heart rate that is too low for the patient <60/min Cyanosis: Blue appearance of the skin due to low oxygen levels in the blood Hemoglobin: The part of the blood cell that carries oxygen Hypotension: Abnormally low blood pressure<90mmHg systolic Shock <60 Hypothermia: Low body temperature (less than 36°C) Hypoxia: Abnormally low levels of oxygen in the body Pulse: A measure of heart rate, defined in beats per minute What is a Pulse Oxymeter?

It measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen. An early warning device that tells you about low oxygen levels or high/low heart rates Can detect a signal in a finger or toe and can calculate the amount of oxygenated hemoglobin and the pulse rate Consists of the monitor containing the batteries and display, and the probe that senses the pulse (fits on the finger) More advanced units (called patient monitors) can also measure blood pressure and ECG

Normal Values: Pulse Rate: Heart rate in beats per minute Normal pulse rate for adults: 60-‐100 Normal pulse rate for 2-‐10 years old: 60-‐140 Normal pulse rate for newborn-‐2 years: 100-‐180 Oxygen Saturation (SP02): Percentage of blood that is carrying oxygen Normal values should be between 95%-‐100% < 90% saturation is hypoxemia

What Can Cause a High or Low Heart Rate?

High heart rate: Light anesthesia Pain Medications (atropine/ketamine) Low blood volume Fever Irregular heart rate Exercise

Low heart rate: Deep anesthesia Medications (beta blockers) Highly trained athletes Stimulation of nerves which slow heart rate Heart block What can cause a low oxygen saturation?

Airway: Obstructions, vomit, improperly placed tubes Breathing: Anesthesia, pneumonias, lung collapse, asthma Circulation: Irregular heart beat, heart failure, congenital heart disease Drugs: Anesthesia, bupenophrine, diazepam Equipment: Problem with pulse oxymeter, empty oxygen tank

Effect of Decreased Oxygen Saturation:

85% and above-‐ No evidence of impairment 65% and less-‐Impaired mental function on average 55% and less-‐Loss of consciousness on average

Parts of the Pulse Oxymeter:

1. Oxygen saturation (SpO2) measurement value 2. SpO 2 high and low alarm limit settings, adjustable 3. Pulse rate measurement value 4. Pulse rate high and low alarm limit settings which you can set 5. Plethysmographic pulse bar (tells the strength of the heart beat) 6. Alarm Light 7. Alarm Silence button 8. Knob for changing monitor settings 9. Display area for on-‐screen control symbols 10. Battery indicator 11. Power button and external power LED

Section 4a

Overview of the Patient Monitor (Enter Demo Code: 5188)

Important Terms: ECG: A machine that measures and displays the electrical signals in the heart NIBP: Non-‐invasive blood pressure monitoring. This includes using a normal BP cuff IBP: Invasive blood pressure monitoring. This involves inserting a line into the artery, which helps to measure blood pressure more accurately Respiration Waveform: An approximation of the strength/volume of the breaths Sp02 Plethysmography: Measures the change in blood volume (strength and volume of the pulse) to a specific part of the body

Use of the Patient Monitor: The patient monitor is an essential piece of equipment in the intensive care unit. This is because it can monitor many

different parts of the patient at one time, and alert ICU staff when something is wrong The patient monitor is very good for very sick patients, especially those with severe heart and lung problems The patient monitor provides information on 5 major factors: ECG, Respiratory Status, Oxygen Saturation, Non-‐Invasive

Blood Pressure, and Temperature The patient monitor operates on electrical power and also on battery power. The battery needs to charged regularly The exact information displayed on the patient monitor is displayed below:

Parameter Specific Information Displayed on Monitor Parts Included ECG Heart rate

ECG Waveform ST Segment Analysis (Helps to see if

Irregular heart rhythm (arrythmia)

5 ECG Leads

Respiratory Status Respiratory rate Respiratory waveform

2 ECG Leads (Red and Green)

Oxygen Saturation Oxygen saturation Sp02 Plethysmogram

Pulse Oxymeter Probe

Non-‐Invasive Blood Pressure Systolic, diastolic, and mean pressure Blood Pressure Cuff Temperature Body temperature Temperature probe

Example of Sp02 Plethysmogram

Example of Respiratory Waveforms

Placement of 5 ECG Leads on Patient (The White V Lead Goes in the V1 Position)

RA=Red, LA=Yellow, RL=Black, LL=Green V=White

Temperature Probe (Place on patient s arm and tape down)

Vital Sign Ranges for Adults and Children:

ADULT

PEDIATRIC

Section 5

Introduction to Defibrillation Important Terms: Arrhythmia: An irregular heart beat which can be due to many different factors Fibrillations: Rapid, irregular, and unsynchronized contraction of the heart Cardiac Arrest: Failure of heart to pump, thus leading to no blood circulation in the body (ESPECIALLY THE BRAIN!) Cardio Pulmonary Resuscitation (CPR): Emergency procedure with chest compressions and breaths to help restore blood circulation and breathing. Goal is to preserve brain function Electrocardiogram: A device with electrodes that is used to record and display the pattern of electrical signals in the heart A heart can have an irregular rate (too fast/slow) or rhythm (time between beats is not standard) Electric Signal Flow in the Heart:

Electrical signals are created at certain points of the heart (NODES) and then are sent to other parts of the heart These electrical signals tell the parts of the heart (including the atria and ventricles) when to contract and how fast the

heart should beat When the electrical signals stop or are not sent to other parts of the heart properly, heart can start to twitch (fibrillate) and

not pump properly

What is a Defibrillator and When is it Used?

An electronic machine that sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and to restore the normal heart rhythm

To correct life-‐threatening fibrillations of the heart, which could result in cardiac arrest Should be performed immediately after identifying that the patient is experiencing a major cardiac emergency, has no

pulse, and is not responding to anything Should NOT be performed on a patient who has a pulse or is alert, as this could cause cardiac arrest

Preparation for Defibrillation: 1) Cardiopulmonary resuscitation (CPR) is started until the defibrillator is set up 2) Electrocardiogram leads are attached to the patient's chest 3) Gel is applied to the defibrillator paddles 4) The doctor verifies a lack of a pulse 5) Pa

Process of Defibrillation:

ANNOUNCE TO EVERYONE TO STAND AWAY AND NOT TO TOUCH THE PATIENT BEFORE SHOCKING Initial Defibrillation Series: 1st Counter shock-‐ Use 200 joules Reassess the patient. If patient is converted out of Ventricular Fibrillation, stop defibrillation. If pulselessness persists, continue CPR while recharging the defibrillator. Minimize time between counter shock. 2nd Counter shock-‐ Use 300 joules Reassess the patient. If patient is converted out of Ventricular Fibrillation. If pulselessness persists, continue CPR while recharging the defibrillator. Minimize time between counter shock. 3rd Counter shock-‐ 360 joules Reassess the patient. If patient is converted out of Ventricular Fibrillation. If pulselessness persists, continue CPR, if not already done apply monitoring leads. Patient Care after Defibrillation

The patient's cardiac status, breathing, and vital signs are monitored until he or she is stable An electrocardiogram and chest x ray are taken The patient's skin is cleansed to remove gel or paste, and, if necessary, ointment is applied to burns An intravenous line provides additional medication, as needed

Complications:

Watch for skin burns, injury to heart muscle, clotting after defibrillation The SUCCESS of defibrillation depends on how fast the patient receives it Longer period of heart fibrillation damages the heart further, as more oxygen is used by the heart muscle

Section 6

Intravenous Infusions and the IV Infusion Pump

Important Terms: Intravenous: Inside a vein Enteral: Within the intestine Parenteral: Any route other than the mouth Catheter: Thin tube that can be inserted into a patient Infusion: Injecting something inside someone/something Solution: Fluids in Our Body:

Water makes up approximately 60% of our body weight Our body gains and loses solutions/fluid We can also lose a large amount of flood through diarrhea , vomiting, or hemorrhage In the hospital setting, sometimes fluids are given intravenously and there are many types of fluids to give

Isotonic Fluids:

Isotonic means having the same concentration of particles as our body fluids 0.9% sodium chloride (0.9% NaCl), lactated Ringer's solution, 5% dextrose in water (D5W), and Ringer's solution are all

isotonic .9% NaCl (saline) used in hemorrhage, vomiting, severe diarrhea Lactated Ringers in burns, hemorrhage, trauma D5W (Dextrose and water) often used for high sodium levels (hypernatremia)

Hypertonic Fluids:

Higher concentration of particles than what we have in our body fluids 3% NaCl, 5% NaCl, D10W, Mannitol, are hypertonic fluids Often used for very low sodium levels (hyponatremia) Sometimes used in cerebral edema (lot of swelling in the brain)

Hypotonic Fluids:

Lower concentration of particles than what we have in our body

.45% sodium chloride (0.45% NaCl), 0.33% sodium chloride, 0.2% sodium chloride, and 2.5% dextrose in water are all hypotonic fluids

Help maintain daily body fluid requirements and can also be used when person has very high sugar levels in the blood How Much Maintenance Fluid Per Hour? Weight-‐based calculations can be helpful 4:2:1 rule

For the first 10 kgs, 4ml/kg/hour For next 10 kgs, 2 ml/kg/hour For every 1 kg above that, 1 ml/kg/hour

Example: 50 kg patient: (4*10) + (2*10)+(30*1) = 90 ml/hour of fluid OR 1st 10 Kg-‐ 100ml/Kg/day 2nd 10 Kg-‐ 50ml/Kg/day 3rd 10 Kg-‐ 20 ml/Kg/day Infusion Pumps:

Electronic machine used to give (infuse) fluid to a patient at a specific rate Connected to the IV bag Fluid can include medications mixed with other solutions Settings can be entered into the computer on the infusion pump The one at our hospital is called the SK-‐600II

Dopamine Infusion Example: Dopamine 200mg in 250ml D5W gives a concentration of 800 mcg/ml (60microdrops or 13 mcg/drop) A 50 kg man who needs 2mcg/kg/min needs 100mcg/min or 7-‐8 drops/min(1/8ml) Complications:

Watch for air bubbles in the tube! Too much fluid can be bad in a person with heart failure or kidney failure Too much fluid can accumulate in the lungs Check often to see if the patient has too much or too little fluid Watch for air bubbles in the infusion machine as air bubbles in the blood are bad

Section 7

Introduction to the Crash Cart

Definitions Crash Cart: Trolley for storing lifesaving drugs and equipment for use in an emergency, particularly cardiopulmonary arrest BLS (Basic Life Support): Emergency care (CPR/defibrilator) often given before a patient receives full care at the hospital ALS (Advanced Life Support):

and to open the airway ACLS (Advanced Cardiac Life Support): Advanced clinical procedures to help patients in cardiac arrest Intubation: Placement of tube into airway (trachea) to keep it open and to allow air to flow in the body CABs: Circulation, airway, breathing

Purpose of the Crash Cart

Newborn, pediatric, and adult carts available Saves time during emergency medical situations All lifesaving drugs and equipment are in one place Helps teams respond to emergency situations easier Often found in the intensive care unit, patient wards, and emergency departments, where patients can be unstable

Crash Cart Drugs

Amiodorone

Reason for Use When Not to Use Delivery Method Emergency Dose

Antiarrythmic (helps correct an irregular heart beat)

Pregnancy, certain heart

lidocaine

Oral and intravenous 300 mg in 20-‐30cc 5% Dextrose solution (D5W) for cardiac arrest. 150 mg can be given additionally IV, along with IV infusion of 900 mg over 24 hours.

Atropine (Drug class: Anticholinergic)


Restore heart rate and blood pressure when the heart rate is low

Glaucoma Subcutaneous, intramuscular, intravenous

200 mcg/kg. Maximum 600 mcg per dose.

Calcium Gluconate


Low calcium (hypocalcemia) in the blood or high potassium (hyperkalemia) in the blood

Ventricular fibrillation (when the ventricle is quivering this can be seen on EKG)

Intravenous Hypocalcemia: 1-‐2 g slow IV injection

Dextrose


Low blood sugar (hypoglycemia)

Intracranial hemorrhage (blood inside in the cranial vault)

Intravenous 0.5 g/kg of body weight/hour

Diazepam (Drug class: Benzodiazepines)


Seizures, anxiety, alcohol withdrawal (hallucinations, tremors)

Allergy to benzodiazepines or glaucoma

Intravenous or intramuscular

200-‐300 mcg/kg, repeated once after 10 minutes as necessary

Diphenhydramine (Drug class: Antihistamines)


Allergic reactions, particularly to blood and plasma

Newborns, nursing mothers, allergic reaction

Intravenous or deep intramuscular

10 mg IV or by deep IM injection; Required up to 4 doses in 24 hours

Dopamine (Drug class: Pressors)


Shock due to heart attack, renal failure, trauma, sepsis

Pheochromocytoma (tumor that elevates blood pressure)

Intravenous drip Titrated to needs of patient, but normally 2-‐5 mcg/kg/min infusion

Digoxin (Drug class: Cardiac glycosides)


Atrial fibrillation, atrial flutter, heart failure

Low potassium (hypokalemia) or taking verapamil, epinephrine, amiodorone, erythromycin

Intravenous or oral .5 mg STAT, .25 mg Q2H till rate 80-‐90 min, then .25mg-‐.5 mg maintenance

Epinephrine (Drug class: Pressors)


Allergic reactions to drugs, serum, allergens, acute asthmatic attacks (to prevent bronchospasm)

Allergy to drug, glaucoma Intravenous Cardiopulmonary resuscitation: 1 mg (10 ml) of 1/10,000

Anaphylaxis:

IM: .5 ml of 1/1000 (1 mg/ml)

IV: 50 mcg slow infusion

Furosemide


Edema (swelling) associated with congestive heart failure, cirrhosis of the liver, and renal disease

Allergy Intravenous or intramuscular 20 40 mg given as an IV or IM single dose over 1-‐2 minutes, increased by 50 mg every 2 hours. Max of 1.5g/day.

Lidocaine


Ventricular arrhythmia (irregular beating of heart), particularly after heart attack

Allergy Intramuscular and intravenous

50 100 mg administered IV at a rate of 25 50 mg/min and under ECG monitoring. Follow with 4 mg/minute for 30 mins, 2mg/minute for 2 hours, and 1 mg/minute. Monitor EKG

Magnesium Sulfate


Ventricular tachycardia (rapid contraction of ventricle), low magnesium, seizures during pregnancy,

2 hours prior to delivery for patients with preeclampsia

Intravenous and intramuscular

Eclampsia: 4 g IV over 5-‐15 minutes, followed by 1 g/hour over 24 hours after seizure or delivery

Midazolam (Drug class: Benzodiazepine)


Preoperative sedation, reduction of anxiety prior to surgery

Allergy, glaucoma Intravenous and intramuscular

IV: 2 mg/minute, 5-‐10 minutes before procedure, initially 2-‐2.5 mg

Phenytoin


Control of seizures, prophylaxis from seizures for patients with traumatic brain injury

Allergy Oral and intravenous IV loading dose of 18 mg/kg, dissolved in normal saline, and infused at a rate no faster than 50 mg/min (1-‐3 mg/kg/min), then 2 mg/kg (100 mg) Q8H

Sodium Bicarbonate


High acid level in the blood (metabolic acidosis) due to renal failure, low blood circulation, diabetic ketoacidosis

Vomiting and when patients are losing chloride

Intravenous Slow IV injection up to 8.4% concentration

Vasopressin (Drug class: Pressors)


Diabetes insipidus (low ADH level causes loss of water from body), control of variceal bleeding

Allergy, coronary artery disease

Intravenous, intramuscular Diabetes insipidus (sub Q/IM): 5-‐20 units/4 hours

Variceal bleeding: IV 20 units over 15 minutes

Section 8

Intensive Care Pain Management

2 Types of Pain

3.

4. Chronic Pain: Pain that lasts 6 months or longer (pain from arthritis, back pain, cancer pain)

Pain Assessment

1. Where is the pain?

2. How bad is the pain?

3. Is the pain sharp/dull/burning?

4. When did the pain start?

5. What makes the pain better or worse?

6. Any other problems with pain like nausea and vomiting?

Pain Scale

The Wong-‐Baker Scale can help to tell how much pain the patient has. You can ask the patient to point to the face that best represents their pain. It is important to frequently ask the patient how severe their pain is.

Signs and Symptoms of Pain

High heart rate, rapid breathing, dilated pupils, increased/decreased blood pressure, nausea, vomiting, fear, lack of sleep

Pain, Sleep, and Delirium

1. In the intensive

2. distracted. This is called ICU delirium

3. ICU delirium can be treated by helping a patient get lots of rest, and moving/walking

Pain Management

1. 3 classes of pain medication include non-‐opiods, opioids, and adjuvant analgesics.

2. Non-‐opioids are the first option for managing mild pain. They include paracetamol, non-‐steroidal anti-‐inflammatory drugs (NSAIDS), aspirin, tramadol, and lidocaine

3. Opioids include morphine, fentanyl, oxycodone, codeine, pentazocine(fortwin), buprenorphine. Naloxone and naltrexone can reverse the effect of the opioid. Too much opioids can cause a person to stop breathing, and so it is best to use opioids only when necessary.

4. Buprenorphine is an example of a mixed opioid and often has less side effects than a pure opioid

5. Adjuvant analgesics are drugs which can also have the side-‐effect of reducing pain. They include anticonvulstants (like carbamezapine and gabapentin), tricyclic antidepressants like amitriptyline, benzodiazepines like alprazolam, and corticosteroids like dextamethasone.

World Health Organization Analgesic Ladder

The World Health Organization has come up with a way to figure out what pain medication is best is which situation:

Step Type of Pain Type of Medication Example

1 Pain is just beginning Non-‐opioids +/-‐ adjuvant Paracetamol, aspirin

2 Mild to moderate pain which keeps increasing Opioid +/-‐ nonopioid +/-‐ adjuvant

Codeine. hydrocodone

3 Moderate to severe pain Stronger opioid Pentazocine (fortwin), buprenorphine, Morphine, oxycodone, hydromorphone

Adminstration of Pain Management

1. Pain medication is medication can also be given orally, but usually acts slower on the body because it needs to be digested

2. Using pain medication in small amounts throughout the day helps to control levels of pain

3. Sometimes, the patient can self-‐administer a set amount of pain medication using something called a patient-‐controlled anesthesia (PCA) pump.

Non-‐Medical Pain Management

Non-‐medical therapy included application of heat (thermotherapy), cold therapy (ice), massage therapy.

Section 9

Intensive Care Neurology

Anatomy

1. The nervous system comprises of the brain, spinal cord, and peripheral nervous system 2. The brain and the spinal cord are classified as the central nervous system 3. The brain has three parts: cerebellum, brain stem, cerebrum 4. Different parts of the nervous system control different parts of motion, sensation, and vital function

Basic Neurological Examination

Mental status (consciousness, speech, ability to think/remember properly) Cranial nerves (can they hear, smell, speak, smile, feel on their face, move their tongue and see properly?) Sensory examination (can they feel touch, vibration, pain, and position) Motor exam (Do they have good strength, can they walk and stand properly)

Glasgow Coma Scale

7 indicate severe damage

Types of Imaging

CT scanning and MRI can show pictures of the brain, problems with blood flow, and structural deficiencies Angiography can show blood flow in the brain using dye Lumbar puncture looks for blood/infection in the cerebrospinal fluid

Types of Medications/Surgery

Analgesics (pain medications), anticonvulsants (prevent/stop seizure), anticoagulants (prevent clots in the blood), barbiturates (anesthetic to put someone in a coma to reduce brain swelling), benzodiazepines (anesthetic), calcium channel blockers (vasodilators-‐prevent vessels from closing), diuretics (reduce swelling in brain), thrombolytics (break clots in the brain), corticosteroids (reducing inflammation in brain)

Craniotomy (opening the skull), aneurysm repair (repairing or tying off a swollen artery so it does not burst)

Disorders and Treatment

Spinal Cord Injury 1. Spinal cord injury is often caused by trauma to head or neck (falls/vehicle accidents/diving) 2. Watch for low heart rate, low blood pressure, inability to move, and loss of movement/sensation 3. X-‐Ray/CT/MRI can help detect spinal cord injury 4. Immobilize spine, give high dose of IV steroids, put on pulse oxymeter, check heart and lung sounds, insert foley catheter, give oxygen Encephalitis 1. Inflammation of the brain with fever, headache, vomiting 2. CSF study with lumbar puncture can help make the diagnosis 3. Give antiviral, anticonvulsants, corticosteroids (to reduce edema), diuretics+mannitol to reduce swelling in head Head Injury 1. Open or closed injury 2. Can cause increase in pressure in head (intracranial pressure), infection, lower breathing rate, pushing of brain down (coning) 3. X-‐ray/CT/MRI can show areas of injury and pooling of blood 4. Cleaning of wound, anticonvulsants like phenytoin, corticosteroids (to reduce edema), diuretics +mannitol to reduce swelling in head and surgery if there is an intracranial blood clot, 5. Check vital signs and level of consciousness frequently, and use paracetamol to reduce headache Meningitis 1. Infection of brain and spinal cord by bacteria or virus 2. Fevers, chills, headache, stiff neck, vomiting 3. Antibiotic therapy for 2 weeks + mannitol/anticonvulsant/paracetamol 4. Do neurological exam often and watch for seizures 5. Do not give too much fluid as it may cause increased pressure in the head Seizures 1. Brain cells discharge electrical signals without control in one side or both sides of the brain

3. Anticonvulsants, oxygen, and glucose (if seizure caused by low blood sugar)

Stroke 1. Low blood flow to part of brain due to clot, rupture of blood vessel causing bleeding, embolism from blood clots in the heart . Low oxygen levels to part of brain 2. Can cause weakness, loss of speech, loss of consciousness, vision loss 3. Immediately check airway, breathing, circulation and put in IV 3. CT/MRI can tell where stroke has happened in brain 4. Within 60 minutes of stroke, give TpA 5. Aspirin, anticonvulsants, antihypertensives, steroids, pain medication, stool softener (or high fiber diet) 6. Check patient frequently 7. Administer oxygen to maintain saturation over 90%, place patient on patient monitor Increased Intracranial Pressure (Increased pressure in the head) 1. Often due to trauma or bleeding or low blood sodium (hyponatremia) or meningitis/encephalitis 2. Level of consciousness is less, pupils are unequal, weakness, abnormal breathing, low heart rate 3. Treat with steroids, diuretic + mannitol, IV saline for hyponatremia

Section 10

Intensive Care Cardiology

Anatomy

1. The cardiac system comprises of the heart and blood vessels. Blood is important for carrying oxygen, nutrients, and hormones, while removing metabolic waste.

2. The heart has many layers and has 4 chambers (RA, LA, RV, LV). The ventricles have thicker muscles as they pump blood forcefully into the arteries. Valves in the heart keep blood flowing in one direction.

3. The coronary arteries supply blood to the heart itself. The sinoatrial node on the right side of the heart sends electrical signals to establish the rhythm.

4. Electrical signals then pass through the heart the stimulate contraction of the heart 5. Systole refers to contraction of the ventricles, while diastole refers to filling of the ventricles. If the heart rate is too high,

the ventricles cannot fill properly

Cardiovascular Assessment

1. Patients with heart problems often come with chest pain, irregular heartbeat, shortness of breath, cough, weakness, weight changes, swelling of extremities, dizziness, headache, and skin changes

2. Make sure that you ask where the pain is located, how severe is the pain, and when does it start/stop 3. The 3 main parts of examining the cardiovascular system are inspection of the chest, touching(palpate) the chest, and

listening to the hear sounds (auscultate). 4. Abnormal findings on the chest include odd skin color (blue or very red), abnormal shape, or abnormal curving 5. lub-‐

closing. The normal heart rate is 60-‐100 beats per minute 6. -‐ 7. portant. Very strong or very weak pulses can signify

problems 8. When the patient is at a 45-‐degree angle, checking the neck veins on the right side of the neck can help to tell if the heart is

overloaded (if the veins really stick out)

Diagnostic Tests Th

mean problems with electrical signaling in the heart, and this can be seen on the EKG. It can help tell if the person is having a heart attack

Cardiac markers (proteins in the heart that are released during a heart attack) like troponins and CK-‐MB can help to tell if the person had a heart attack

Echocardiography can look at the structure of the heart and is very much like ultrasound. It can find out if there is any valve leak or abnormal connection in congenital heart disease

Cardiac catheterization means placing a catheter on the right or left side of the heart to look at the arteries/valves and to measure blood pressures/amount of blood the heart is pumping

The normal cardiac output (amount of blood pumped by the heart in 1 minute) is 4-‐8 L Cardiac Drugs

There are many types of drugs to improve cardiac function, including cardiac glycosides, phosphodiesterase inhibitors, antiarrythmics, antianginals, antihypertensives, diuretics, adrenegenics, and beta blockers

Cardiac glycosides and phosphodiesterase inhibitors increase the force of contraction on the heart (make it pump harder) Name of Drug Class of Drug Use Notes Digoxin Cardiac glycoside Heart failure, arrhythmia

(irregular heartbeat) Can cause nausea, vomiting, pain, headache,

Milnirone Phosphodiesterase inhibitor Heart failure that does not

respond to Digoxin, diuretics, or vasodilators

after a heart attack

Antiarrhythmic drugs are used to treat a variety of kinds of irregular heartbeats. There are a number of classes of

antiarrhythmics Name of Drug Class of Drug Use Notes Amiodorone Antiarrythmic Life threatening irregular

heart beats Can affect the lungs

Diltiazem/Verapamil Antiarrythmic Irregular heart beat not caused by the ventricles

Adenosine Antiarrythmic Rapid heart beat caused by problem in the atria

Can cause flushing of the skin

Angina is chest pain due to inadequate oxygen to the heart when the heart is working too hard. The goal of treatment is to reduce the work of the heart and conserve more oxygen

Nitrates, beta blockers, and calcium channel blockers are all used to treat angina

Name of Drug Class of Drug Use Notes Nitrates Nitrates Relief and prevention of

angina Check blood pressure before and after

Beta blockers (atenolol, metoprolol, propanalol)

Beta blockers Long-‐term prevention of angina, hypertension, stable heart failure

Can cause problems with breathing

Amlodipine Calcium channel blockers Long-‐term prevention, hypertension

Watch heart rate and rhythm

There are many kinds of drugs to treat high blood pressure, and they are called antihypertensives Name of Drug Class of Drug Use Notes Hydrochlorthiazide Thiazide diuretic First-‐line treatment of

hypertension Watch for gout, high blood sugar

Beta blockers (atenolol, metoprolol, propanalol)

Beta blockers Long-‐term prevention of angina, hypertension, stable heart failure

Can cause problems with breathing

Enalapril ACE Inhibitor Hypertension/heart failure Watch for cough/Check blood pressure before and after

Losartan Angiotensin receptor blocker Hypertension, and heart failure resistant to ACE Inhibitor

Watch blood pressure before and after

Amlodipine Calcium channel blockers Long-‐term prevention, hypertension


Clonidine, Doxazosin, Labetalol

Sympatholytic drugs (affects the central nervous system)

Emergency control of hypertension

Check blood pressure before and after

Hydralazine Vasodilator Moderate to severe hypertension

Check blood pressure before and after

Diuretics help remove water from the kidneys and can be used in a variety of conditions like hypertension and edema (too

much fluid) Different kinds of diuretics include, loop diuretics, and potassium-‐sparing diuretics, and hydrochlorothiazide. They act on

different parts of the kidney Diuretics can often change the concentrations of electrolytes (sodium, potassium, chloride, bicarb) in the body and so this

must be monitored Too much diuretic will cause a person to lose too much fluid and become hypotensive Anticoagulants are used to reduce the ability of blood to clot and can be used for patients with cardiovascular problems.

The main anticoagulants include heparin, warfarin, and aspirin/clopidogrel Name of Drug Class of Drug Use Notes Heparin

Anticoagulant Prevention of deep vein thrombosis or clot

Prevention of complications after heart attack

Watch for signs of bleeding Can be reversed with Protamine Sulfate

Warfarin Anticoagulant Prevention of deep vein thrombosis

Prevention of complications of valves

Irregular atrial beats

Watch for signs of bleeding Can be reversed with Vitamin K

Aspirin/Clopidogrel Antiplatelet drug Decreased risk of death after heart attack

Reduces risk of heart attack

Watch for signs of bleeding, low platelets

Thrombolytics are used to dissolve a pre-‐existing clot, for example a clot in the brain. The most common thrombolytic drugs are streptokinase and alteplase

Adrenergic drugs can be used to help the heart and blood pressure. The most important ones are, dopamine, dobutamine and epinephrine

Name of Drug Class of Drug Use Notes Dobutamine Catecholamine Increase the cardiac output

temporarily when the heart is failing

Give the drug on a drip

Make sure the patient has enough fluid in the body before giving dobutamine


Dopamine Catecholamine Shock, low blood pressure, low cardiac output

Same as above

Epinephrine (Adrenalin) Catecholamine Severe allergic reaction

Restoring cardiac rhythm after cardiac arrest

Prevent closing of airways

Same as above

Norepinephrine Catecholamines Maintain blood pressure in low BP states

Same as above

Ephedrine Non-‐catecholamine Maintain BP in low BP states, particularly in spinal anesthesia

Same as above

Phenylephrine Non-‐catecholamine Maintain BP in low BP states, particularly in spinal anesthesia

Same as above

Mephenteramine Anti-‐hypotensive Maintain BP in low BP states

Same as above

There are also drugs that can be used to reduce heart activity, and these are called adrenergic blocking drugs. The most common are beta blockers and alpha blockers Name of Drug Class of Drug Use Notes Prazosin Alpha blocker High blood pressure Watch heart rate and

rhythm Labetalol, Propanalol, Atenolol, Metoprolol

Beta blocker High blood pressure, prevention of complications after heart attack

May change levels of insulin needed in diabetic patients

High levels of fat/cholesterol in the blood can lead to heart disease, as the fat/cholesterol can build up in the vessels There are many drugs that can be given to patients to reduce levels of fat/cholesterol in the body. These must be

accompanied by lifestyle changes, however!

The most common drugs for treating high fat/cholesterol are statinse

Cardiac Surgeries

Major surgeries to help the heart heal include coronary artery bypass grafts (CABG), heart transplantation, valve surgery, vascular repair, and ventricular assist device

Name of Surgery Procedure Description Purpose Coronary artery bypass Bypass a blocked coronary artery by

attaching another blood vessel to the heart

Relieve angina pain due to low blood flow to the heart

Heart transplant heart

Uncontrolled severe heart problems

Valve surgery Replace a valve in the heart (Mitral, aortic, pulmonary, or tricuspid)

Open blocked valves and correct broken valves which allow blood to flow backwards

Vascular repair Removing clots, bypassing a damaged vessel, inserting a filter to prevent blood clots, fixing a swollen artery that may burst

Fix or go around damaged or clotted vessels

Ventricular assist device Made of a blood pump, cannula, and small computer

Helps failing heart pump blood

Balloon catheter Inserting a balloon in the heart which inflates and deflates

Opens the coronary arteries, helps blood flow into the coronaries and rest of the body

Electrical Treatment for the Heart

The heart runs on electrical signals, and when those signals are not proper, the heart can beat improperly The types of electrical therapy include cardioversion, defibrillation, pacemaker

heart. Name of Therapy When to Use

Cardioversion Irregular heartbeat that does not respond to drugs

Defibrillation When the heart begins to quiver, with or without a pulse (use EKG to tell if heart is quivering)

and irregular heartbeat

Pacemaker Patient has low heart rate, heart disease, or electrical problem that caused irregular pacing of the heart

Common Heart Disorders Requiring Intensive Care Acute Coronary Syndrome (Angina) 1. Caused by blocking of the coronary vessel, which feeds blood to the heart muscle heart muscle can often die 2. Patient often has an immediate crushing/squeezing feeling on the chest, that sometimes goes to the jaw + nausea/vomiting, shortness of breath 3. EKG can help show lack of oxygen to the heart, as can coronary angiography (shooting dye in the heart to visualize a clot) 4. Levels of heart proteins in blood (CK-‐MB, troponin) can help indicate a heart attack

5. Give nitrates, morphine to reduce pain, b-‐blockers to slow heart, aspirin+heparin to reduce clotting, statins to reduce fat levels in the future

heart rate and rhythm closely by EKG, watch urine output 7. Listen to heart and listen for fluid in the lungs 8. Make sure patient gets plenty of rest Aortic Aneurysm 1. Swelling of the aorta (main large artery) due to weakening of the wall 2. Depending on where the aortic aneurysm is, there are many symptoms that the patient can have 3. Symptoms include hoarse voice, trouble breathing, abdominal pain/feeling full, low blood pressure (with ruptured aneurysm), lower back pain 4. If the aneurysm ruptures, there can be a reduction in hemoglobin/hematocrit 5. Ways to see an aortic aneurysm are ultrasonography, echocardiography, CT, MRI, Aortography 6. Aneurysms may require resection (cutting it out) or fixing the walls, and medications to control BP, anxiety, and pain 7. In an emergency, where the aneurysm has ruptured, give fluids, blood, IV Nitroprusside to keep BP between 90-‐100 systolic (top number), pain medication, urine catheter, and arterial line to measure BP properly

gns very carefully, and prepare for emergency surgery

Cardiac Arrhythmias 1. Cardiac arrhythmias are irregular electrical signals in the heart which cause the heart to beat abrnomally 2. Arrhythmias can sometimes cause death or inadequate blood flow in the body 3. Patients can be pale, have low BP, low urine, chest pain, dizziness, tiredness, shortness of breath 4. An EKG can tell if there is abnormal electrical signaling in the heart 5. Treatment includes antiarrhythmic drugs, electrical treatment (cardioversion/defib), pacemakers, surgical removal of bad piece of heart 6. Be sure to give oxygen, pain medications Cardiac Tamponade 1. Cardiac tamponade is when fluids compresses the heart and reduces blood pressure and causes backup of blood 2. Can cause anxiety, shortness of breath, swollen veins on neck 3. Can detect cardiac tamponade on echocardiography, CT, MRI 4. Needle can be used to remove fluid from around the heart 5. Give oxygen, drugs like dobutamine to maintain BP 6. Give blood products if ne Cardiogenic Shock 1. Caused by the heart failing to pump, often after heart attack 2. Patients are often pale, high heart rate, crackles in lungs, low blood pressure, low oxygen 3. EKG and monitoring of the BP can help to tell if there is cardiogenic shock 4. To treat, give fluid, drugs like IV dopamine, phenylephrine, norepinephrine, or dobutamine. Also give oxygen and monitor the patient on the pulse oxymeter

5. Make sure that patient does not get too much fluid, and if they do, give a diuretic like furosemide to help drain fluid Cardiomyopathy 1. Cardiomyopathy is when the heart muscle either grows or hardens so much that the heart is unable to pump and fill Properly 2. A chest x-‐ray, echocardiography, and EKG can help with making the diagnosis 3. Goal of treatment is to help heart pump better, remove all abnormal beats, prevent blood clots from forming 4. Patient may also need additional oxygen Heart Failure 1. When the heart cannot pump (systolic failure) and fill with blood properly (diastolic failure) 2. Patients can have difficulty breathing, tiredness, cough, cool skin, weight gain, swelling 3. EKG, chest X-‐ray, and blood tests (BNP) can help to find out whether there is heart failure 4. To treat, use diuretics to remove fluid from body and lungs, beta blockers, digoxin to help heart pump, limit sodium in patient diet

Hypertensive Crisis 1. Very fast elevation of blood pressure above baseline , where BP is greater than 220/120 2. This high blood pressure can hurt the brain/organs, and patients will often have headache, vomiting, trouble seeing 3. Check BP numerous times to confirm high blood pressure 4. Treatment is focused on reducing blood pressure by IV labetolol/nitroglycerin 5. Provide basic medications for headache and watch how much urine the patient is passing Pericarditis 1. Pericarditis is inflammation of the heart, which can be due to infecirregularly or stop pumping 2. An EKG/Echocardiogram can often indicate if there is pericarditis, and blood tests can tell if an infection is causing the heart inflammation 3.Non-‐steroidal anti-‐inflammatory drugs can be used to reduce pain, bedrest, and oxygen Heart Valve Disease 1. The heart has 4 main valves (aortic, pulmonic, mitral, and tricuspid), and these valves can become broken or hardened 2. Patients often have shortness of breath, chest pain, fainting, cough 3. Chest x-‐rays, EKG, and echocardiography can indicate problems with valves 4. To treat, food with little sodium, oxygen, anticoagulants (to prevent clots), beta blockers to correct heart rate, antibiotics to prevent infection of the valve, oxygen in case of emergency 5. Watch patient vital signs, place patient on EKG

Section 11

Respiratory Intensive Care

Anatomy

1. The respiratory system comprises of the airways, lungs, ribcage, and respiratory muscles 2. The purpose of the respiratory system is to provide oxygen to the blood and to remove carbon dioxide

larynx(voicebox). 4. The lower airways include the trachea (windpipe) and lungs.The lungs are made up of alveoli which inflate and deflate and provide oxygen to the blood 5. Respiratory muscles include the diapragm and intercostals muscles which on contraction help the chest expand and allow us to take air in (inspiration) When these muscles relax air comes out (expiration) Respiratory Assessment

9. Patients with heart problems often have shortness of breath, cough, wheezing, chest pain, difficulty sleeping 10. Make sure that you ask when the patient has difficulty breathing, what makes it worse, what makes it better, and if there is

any pain involved 11. The 3 main parts of examining the respiratory system are inspection of the chest (shape, movement, rate of breathing),

palpation(touching the chest), percussion(tapping the chest) to see if there is any fluid, and auscultation(listening to the chest) with a stethoscope for abnormal sounds.

12. Abnormal findings on the chest include odd skin color (blue-‐cyanosis or very red), abnormal shape, or abnormal movement.

13. Count the number of breaths per minute. The normal rate is 12-‐20 breaths per minute. Very slow breathing(<12/min) or very rapid breathing(>20) can be a problem.

14. In an emergency, you need to see if the patient is anxious, having difficulty breathing, looks pale 15. Abnormal sounds in the lungs include crackles and wheezes. Make sure you listen in all parts of the both lungs.

Diagnostic Tests

Pulse oxymetry can tell how much of the red blood cell is bound to oxygen (saturated) Looking at the levels of oxygen and CO2 in arterial blood is called arterial blood gas analysis. The ABG can also tell if the

blood if high in acid or base Sputum from a deep cough can be analyzed (Gram stain or cultured) for infection Chest X-‐ay can help see fluids, cancers, size of the lungs, lung collapse or hardening

blood CT Scan be used to see a 3D view of the lung

Respiratory Drugs

There are many types of respiratory drugs in the ICU, including anti-‐inflammatory agents, bronchodilators (open the airways), sedatives (make people go to sleep), and neuromuscular blocking agents (stop the muscles from working)

Anti-‐inflammatory agents are used to reduce inflammation in the airways and to help open up the airways Name of Drug Class of Drug Use Notes Dexamethasone, methylprednisolone, prednisone

Systemic steroids Respiratory failure, COPD, severe asthma

Watch blood pressure and blood sugar

Beclomethasone, fluticasone, budesonide

Inhaled Long-‐term control of asthma for mild asthma attacks Look for fungal (candida) infection of mouth)

Bronchodilators are used to keep the airways open and help people breath better. They can be used for asthma or

bronchospasm (closing of airways) Name of Drug Class of Drug Use Notes Salbutamol, Albuterol Beta agonist Short term relief of asthma Watch respiratory status Epinephrine Beta agonist Used in acute asthma, severe

allergic reaction atients with

glaucoma Ipratropium Anticholinergic Reduce airway problems with

bronchitis and COPD Watch respiratory status

Neuromuscular blocking agents are used for patients on a mechanical ventilator in order to prevent a person from attempting to breath on their own. Most common neuromuscular blocking agents include succinylcholine and pancuronium/vecuronium. These do not make the patient unconscious, so you have to give a sedative as well.

Sedatives are used for a variety of purposes including s Name of Drug Class of Drug Use Notes Diazepam, Lorazepam Benzodiazepines Anxiety, continued seizures,

before operation

Midazolam Benzodiazepines short acting

Before surgery, before minor procedures, drip for ventilated patients

breathing rate

Propofol Starting anesthesia Watch blood pressure and breathing rate. Do not mix with other fluids.

Respiratory Surgeries Major surgeries to help the lungs heal include tracheotomy, chest tube insertion, thoracotomy, and lung transplant Name of Surgery Procedure Description Purpose Tracheostomy Creating an opening into the windpipe

(trachea) to put in a tube Keeping the airway open if there is swelling, foreign body obstruction. This can be done at the bedside

Chest tube Tube inserted near the lung Reinflate lung, remove blood or other fluid in lung

Thoracotomy Cutting into the chest Remove parts of lung, remove blood or other materials from chest

Lung transplantation Taking a lung from a donor and putting it in the patient

Severe lung diseases

Mechanical Ventilation (Respirator) Machine that helps patient breathe Used for patients that cannot breath on their own

Oxygen therapy Different kinds of oxygen mask Used for patients who need additional oxygen

Respiratory Disorders The most common respiratory problems found in the ICU include ARDS (acute respiratory distress syndrome), COPD, pneumonia, pneumothorax, pulmonary embolism, pulmonary hypertension, status asthmaticus Acute respiratory distress syndrome (ARDS)

1. ARDS is fluid in in the lungs due to the lung being hurt (injured) 2. 3. Checking the arterial oxygen shows very low oxygen even after giving oxygen, and chest X-‐ray shows lots of patches 4. To treat, provide oxygen, diuretics to remove additional fluid, mechanical ventilation (breathing machine -‐ ventilator)

sometimes needed, turning patient face down (prone), antibiotics

Acute respiratory failure 1. When the lungs fail to give enough oxygen to the blood, and can be caused by pneumonia, asthma or COPD, pleural

effusion, clots (embolus), collapse of lung, 2. Patient may have signs of low oxygen including blue lips, pale skin, confused, agitated, inability to respond/think properly,

high heart rate, high breathing rate, 3. Can tell if there is respiratory failure by looking at pulse oxymeter, arterial levels of low O2 (ABG), chest x-‐ray

4. Treat with oxygen, antibiotics if infection, corticosteroids to reduce inflammation, bronchodilators (salbutamol/albuterol) to open airways, diuretics to reduce fluid, and dopamine/phenylephrine to keep up the blood pressure, and mechanical ventilator if needed

Chronic Obstructive Pulmonary Disease 1.Damage to lungs which cause air to be trapped in the lung and for the chest to balloon, caused by smoking, infection 2. If patient comes in with COPD who is having a major problem breathing, then give oxygen, albuterol to open airways, IV steroids to reduce inflammation, antibiotics like Doxycycline, Azithromycin

Pneumonia:

e 2. Patient can have chest pain, cough, and fever, and there could be phlegm or no phlegm 3. Chest x-‐ray can show if there is pneumonia, white blood cell count in blood could be higher, and pulse oxymetry could show lower level of oxygen in blood 4. Culture of the phlegm can show if it is a bacterial cause, and then antibiotics can be given 5. Other treatment includes cough therapy, bed rest, pain medication, and make sure that the patient coughs and breaths deeply Pneumothorax: 1. Pneumothorax is a collapsed lung, as air in the chest causes the lung to shrink down 2. Patients may often have a sharp chest pain and shortness of breath 3. Breath sounds may not be heard on the side of the collapsed lung 4. Severe pneumothorax can also cause high heart rate and hypotension (tension pneumothorax) and this is an emergency 5. Chest x-‐ray can show the collapsed lung 6. Treatment is chest tube between 3rd and 4th ribs, or a needle between the 2nd and 3rd ribs if the lung collapse is severe

reathing as mechanical ventilator (respirator) may be needed if patient can breathe properly Status asthmaticus: 1. Severe asthma attack which can cause a person to go into respiratory failure 2. Asthma is caused by inflammation in the airways and release of certain chemicals which make the airways get smaller 3. In patient, see increased heart rate, increased respiratory rate, inability to think/speak properly 4. When listening to lungs, will hear wheezing 5. Treatment includes oxygen, bronchodilators, epinephrine, corticosteroids, and possibly placement on the ventilator

asthma becomes very severe Pulmonary Embolism 1. Pulmonary embolism is a clot that enters the pulmonary artery and prevents blood from going to the lungs and filling up with oxygen 2. Patients can have high heart rate, shortness of breath, chest pain, crackles in lungs. Sometimes a fat clot from a fractured bone can cause confusion, shortness of breath, 3. Pulmonary angiography/CT, EKG, and chest X-‐ray can help to tell if there is a pulmonary embolus 4. To treat, given oxygen, streptokinase if clot causes very low blood pressure, heparin, and then warfarin for 3-‐6 months Pulmonary Hypertension: 1. Elevated pulmonary arterial pressure over 30 mm hg, and can cause high heart rate, shortness of breath 2. Blood oxygen levels will be low, ECG can show increased size of right ventricle, pulmonary angiography can show blocks in lung 3. To treat, oxygen, lower fluid intake, albuterol, beta blockers, digoxin to help heart contract better

Section 12

Intensive Care Gastroenterology (GI)

Anatomy

1. The gastrointestinal system includes the gastrointestinal tract from the mouth to the anus, and the additional organs of digestion (liver, gallbladder, pancreas) 2. The purpose of the GI system is to break down food, digestion, and excretion of waste 3. The alimentary canal is the hollow tube from mouth to the anus, which includes the mouth, esophagus, stomach, small intestine, large intestine, anus 4. The purpose of the liver is to make as well as break down fats, proteins, carbohydrates, and to remove toxins from body. The liver also regulates levels of blood glucose and secretes bile which is stored in the gallbladder 5. Pancreas releases insulin and glucagon hormones to regulate glucose levels in the body and also secretes enzymes into the duodenum to help digest food

Gastrointestinal Assessment 1. Patients with GI plike aspirin, sulfonamides, NSAIDs 2. Assess the mouth for any irregularities, feel the abdomen for any tenderness/pain, and listen to the abdomen with the stethoscope for bowel sounds (tinkling). Increased bowel sounds could be due to a block in the intestines (intestinal obstruction) 3. Check to see if the liver or the spleen is enlarged Diagnostic Tests

Endoscopy includes colonoscopy, where a tube(used to see bleeding, tumors in the lower GI system

OGD (oesophophagigastroduodenoscopy) is insertion of a tube(gastroscope) to see the esophagus, stomach, and part of duodenum

OGD can also be used to remove foreign bodies Laboratory Tests

Studies of stool can help to see if there is infection, blood, problem with the shape/size of the intestines Liver biopsy where a small piece of the liver is taken using a special needle and sent for pathological examination to see if

there is cancer etc Fluid in the abdomen (ascites) can be analysed (abdominal paracentesis) can help to tell if there is an infection or cancer in

the abdomen, Radiographic Tests

Tests to look at the gastrointestinal system include abdominal x-‐rays (to see stones, gas collection, tumors), CT scan (can see abscesses, cysts, blood collections, tumors)

Gastrointestinal Treatments

Some of the most common drugs for GI in the ICU include antacids (reduce acidity), antiemetics (reduce nausea), antidiuretic hormone, antihistamines, proton pump inhibitor & H2 blockers

Drug Class Purpose Additional Notes Lactulose Detoxicant Removing ammonia from

body when liver is not functioning

levels

Calcium Carbonate Antacids Treating heartburn (stomach acid in the esophagus)

Vasopressin Antidiuretic hormone Used for gastrointestinal hemorrhage after peptic ulcer rupture

Injected IV or intra-‐arterially into the superior mesenteric artery

Ondansetron Anti-‐emetics Reducing nausea after surgery, during cancer therapy

Watch liver function

Metoclopramide Anti-‐emetics Treatment when the stomach is not emptying fast enough

Famotidine/Ranitidine Anti-‐histamines Treatment and prevention of gastric ulcers

Omeprazole Proton pump inhibitor Treating of duodenal and gastric ulcers, prevention of stress ulcer

Gastric lavage is used in emergencis placed in the stomach, fluid is injected, and is then sucked out to remove all the stomach contents

Nasoenteric compression tubes are used to remove materials from the intestine and correct any blockage

Patients can also be given enteral (via the small intestine) and parenteral (via intravenous) nutrition. Enteral nutrition is given by a feeding tube, especially for those who cannot take food by mouth

Parenteral nutrition (intravenous) is given to patients who cannot digest food by their intestine over 10 days Gastrointestinal Disorders

The main abdominal problems seen in the ICU include GI bleeding, pancreatitis (inflammation of the pancreas), lack of oxygen to the intestine (bowel infarction), cirrhosis (destruction of the liver), liver failure, and intestinal obstuction

Gastrointestinal Bleeding 1. Upper GI bleeding includes blood from a ulcer in the stomach, inflammation of the esophagus, tears between the esophagus/stomach, rupture of a vessel in the esophagus (esophageal varices) 2. Lower GI bleeding causes including inflammation of colon, cancers, polyps, inflammation of the intestine in pockets (diverticulitis) 3. Bleeding in the GI tract can be seen by color of vomit (red or coffee coloured ), bright red stool, or black stools (which means blood is coming from the upper GI tract) 4. Patients will often come in with pallor, high heart rate, low blood pressure, fainting 5. Upper GI endoscopy, abdominal x-‐ray (can see if an ulcer has perforated), angiography, and levels of clotting factors in the blood can indicate signs of bleeding 6. Treatment includes giving iv fluids, gastric lavage, proton-‐pump inhibitors and antihistamines 7. Make sure patient has two 16G or 18G large bore needles, additional oxygen, check hemoglobin/hematocrit Acute Pancreatitis 1. Inflammation of pancreas due to gallstones, alcohol, drugs, trauma, infection, high cholesterol 2. Patient says pain is in the stomach area and goes to the back 3. On exam, you may see vomiting, swelling of abdomen, high heart rate, sweating, fever 4. Tests may include high serum amylase and lipase , increased white blood cell count, low calcium, low potassium

5. For treatment, provide fluid and proteins, pain medications, nasogastric tube to remove contents, draining of abscesses Bowel Infarction 1. Decreased blood flow to the major vessels in the intestine, often caused by clot, sickle cell disease, low blood pressure, liver problems 2. Patients may often have abdominal pain, vomiting, bloody diarrhea, weight loss, no bowel sounds, low blood pressure 3. Abdominal X-‐rays show enlarged loops of bowel, angiography can show areas of low blood blow, sigmoidoscopy (tube up the sigmoid) can show bowel with little oxygen 4. Treatment includes fluids, dopamine for low BP, pain medications, antibiotics for infection Cirrhosis 1. Destruction and hardening of the liver, causing liver to stop functioning properly 2. Patients often have nausea, vomiting, jaundice, white stools, anemia, itching, enlarged liver, swelling, fluid in lungs 3. Liver biopsy can show cirrhosis, and can also check ammonia, bilirubin, PT/INR 4. Treat with high calorie and high protein diet (unless patient seems confused), low sodium, paracentesis to remove fluid from abdomen 5. Surgery if necessary 6. Watch for hepatic encephalopathy , which can be seen by differences in behavior/personality and tremors of hands Hepatic encephalopathy 1. Hepatic encephalopathy is a disorder caused by the central nervous system when the liver cannot clean the toxins from the system, and the toxins go to the brain 2. Patients have personality changes, confusion, sometimes comatose 3. Liver function tests are increased, serum albumin (protein) level is decreased (liver produces albumin) , brain waves (electroencephalogram) is not normal 4. Treatment includes neomycin (antibiotic), which is used to destroy ammonia-‐producing bacteria in gut, lactulose to reduce ammonia in blood, and reducing dietary protein 5. Watch vital signs and mental status closely Intra-‐abdominal hypertension 1. Elevation of pressure in the abdomen, over 12 mm Hg, which can lead to death if not treated 2. Elevation of pressure can be caused by trauma, hemorrhage, ruptured aneurysm, shock, surgery, too much fluid given 3. Patients will often have a tense abdominal wall, small breaths, high heart rate, low blood pressure 4. Treat with diuretics to reduce swelling, albumin, mechanical ventilation, surgery to lower pressures, restrict fluid intake but give IV fluids to help with blood flow, NG tube to remove air/fluid from intestine

Section 13

Intensive Care Endocrinology

Anatomy

1. The endocrine system regulates the bodies energy-‐driven activities, and includes glands, hormones, and receptors 2. Glands secrete chemicals into the blood to regulate body functions, hormones are chemical substances secreted by the glands, and receptor are things that bind to hormones and make them work on the body 3. The major glands in the body are the pituitary, thyroid, parathyroid, adrenal, pancreas, thymus, pineal gland, and gonads 4. The hormones that these glands secrete include growth hormone (GH), thyroid stimulating hormone (TSH), FSH, LH, T3, T4, PTH, aldosterone. They all have different functions on the body.

Endocrine Assessment 1. Patients with endocrine problems often come in with tiredness, weakness, weight changes, mental status changes, increased urine, increased thirst 2. Look at skin color, amount of hair, nail shape, face color and shape, tongue size and shape, eye shape and size, shape of neck, shape of chest. Look at breast size and any liquids from the nipple in both males and females 3. Look at the arms and legs for tremors and muscle mass 4. Feel the thyroid gland on the neck and look for any lumps or bumps. If the thyroid gland is enlarged, you can listen to it with a stethoscope Endocrine Testing 1. Levels of hormone can be determined by a blood test or a urine test 2. CT/MRI can also show the shape and size of a gland 3. X-‐rays can show if the bones are affected by the glands 4. Nuclear medicine scans use a certain chemical to see how active a particular gland is Treatment

Common treatment for endocrine problems includes medicines, surgery, and transplantation of certain organs like the pancreas

Drugs include insulin, antithyroid medications, corticosteroids, ADH, and additional thyroid hormone Drug Class Purpose Additional Notes Glipizide/Glyburide/Glimiperide Sulfonylureas Type 2 diabetes (reduce blood

glucose) Watch glucose levels in blood

Metformin Biguanides Type 2 diabetes (reduce blood glucose)

Watch for kidney problems and acid in blood

Pioglitazone/Rosiglitazone Thiazolidinediones Type 2 diabetes (reduce blood glucose)

Watch for liver problems

Insulin Insulin All kinds of diabetes (reduce blood sugar)

Watch blood glucose levels

Propylthiouracil Antithyroid Reduce high thyroid levels Test thyroid levels often Levothyroxine Thyroid replacement Low thyroid (hypothyroid) Check thyroid hormone

levels often Hydrocortisone Corticosteroids Adrenal crises (low blood sugar,

low blood pressure) Watch for hypertension, low potassium

Treatment Type Purpose Additional Notes Diabetes meal planning Non-‐surgical

sugar under control with a proper blanket

Hyperthermia-‐hypothermia blanket

Non-‐surgical Help reduce body temperature in high fever, surgery

Use only paracetamol,

work Pancreas transplantation Surgery Replacement of pancreas,

especially with severe Type 1 diabetes (where pancreas has been damaged)

Many surgical complications possible

Endocrine Disorders Diabetes Mellitus 1. Disease were insulin is not made by pancreas (type 1 diabetes) or the body does not respond to insulin (type 2 diabetes), which allows glucose to enter cells and be used 2. Patient may have high urine, heavy thirst, weight loss, tiredness, dry skin 3. Fasting glucose level is greater than 126 mg/dl, or 2 hour glucose test is greater than 200 mg/dl with 75g of carbs, or nonfasting glucose is greater than 200 mg/dl 4. Treatment includes diet and lifestyle changes (less rice/weight loss), insulin for type 1 diabetes, oral glucose controllers like metformin and glipizide 5. Watch for low blood sugar level below 50 mg/dl, and if patient becomes hypoglycemic, then give a sweet drink Syndrome of inappropriate antidiuretic hormone 1. Common complication of critical illness, cancer, stroke, medications 2. Excessive secretion of ADH hormone, causing too much water to be reabsorbed 3. Patients have increased thirst, headache, high heart rate, low sodium levels 4. Blood tests show low sodium concentration in blood, increased ADH, increased sodium in urine 5. Treatment is restricting fluid to ½ or 1 liter a day. If very low sodium, then 200-‐300 ml of 3% sodium chloride Thyroid storm 1. Emergency situation where too much thyroid in the body

3. Increased T3/T4 thyroid hormone levels in blood, and EKG may show irregular heart rate Adrenal Failure 1. Failure of the adrenal glands (located on the kidneys) to produce hormones called aldosterone and cortisol 2. Combination of low blood sugar and low blood pressure leads to brain death 3. This disorder can happen after infection of the adrenal glands (like tb), trauma, cancer, or stopping hormone therapy 4. Patient will have low blood pressure, low fluid, nausea/vomiting, low blood sugar, high potassium, high heart rate 5. Treatment is immediately giving 100 mg of hyrdocortisone followed by lots of fluid (normal saline), IV dextrose to control blood glucose, vasopressors (like norepinephrine or epinephrine) to keep blood pressure up Diabetes Insipidus 1. A disease caused by the lack of ADH, which is a hormone that allows water to be taken up by the body again after it is filtered by the kidneys 2. Either ADH is not being produced, or the kidney is not responding to ADH by keeping water in the body 3. Patient will have increased urine output (4 to 16L), extreme thirst, weakness, low blood pressure, high heart rate 4. Urine can show colorless urine, blood sodium levels very high (from loss of water) 5. Fluids to replace all the water lost, give subcutaneous or intramuscular (IM) vasopressin (ADH 6. Watch blood pressure very closely as vasopressin can increase blood pressure Diabetic ketoacidosis (DKA) 1. Life-‐threatening disorder amongst diabetic patients due to very high levels of blood sugar 2. DKA can be caused by infection, illness, surgery, stress 3. Patient is severely dehydrated, rapid breathing, infections, abdominal cramps, lots of urine, drinking lots of water 4. Serum glucose is between 200 and 800 mg/dl, urine has a material called ketones, high potassium 5. Arterial blood tests show acidic blood 6. Treatment is with fluids, then IV insulin, then potassium and other electrolytes as needed 7. Below blood sugar levels of 250 mg/dl, start adding dextrose to the fluids Hyperosmolar hyperglycemic nonketotic syndrome 1. Almost the same as DKA, but no ketones in urine, and primarily in patients with Type 2 diabetes 2. Blood glucose levels can be between 800 and 2000 mg/dl 3. Treat with fluids, IV insulin, and below sugar level of 250 mg/dl, start adding dextrose Myxedema Coma 1. Very low levels of thyroid hormone in body (T3/T4) 2. Leads to swelling around eyes, flaky skin, dry tongue, slurred speech, hoarseness, cannot think properly 3. Also see low blood pressure, low blood sugar 3. For treatment, give IV hydrocortisone and IV levothyroxine (thyroid hormone) 4. Treatment is give beta blocker like labetalol, propylthiouracil to prevent making of thyroid hormone, cooling with blanket, corticosteroids (as they can block conversion of thyroid hormone to active form)

Section 14

Intensive Care Hematology

Anatomy

1. The hematologic system is made of the blood and bone marrow (which makes blood cells), as well as the immune system, which fights off infection 2. The purpose of the hematologic system is to transport nutrients, remove wastes, and respond to harmful organisms 3. The main components of the blood include the red blood cells, platelets (help clotting), white blood cells (respond to infection/inflammation 4. The main blood groups in people are A, B, AB, and O. O is the universal donor (can donate blood to any group), while AB is universal recipient (can receive blood from any group). Other types need matches with their own blood type. 5. The immune system, comprising mainly of T-‐cells, B-‐cells, and macrophages helps to fight infection

Hematology Assessment 1. Patients with hematologic problems often come in with abnormal bleeding, bone/joint pain, fatigue, fever, chills, night

check if there is any family history of any blood disorders 2. Check heart rate, blood pressure, oxygen saturation (pulse oxymeter) 3. Check skin, nails, liver size, spleen size, and any problems in the mouth 3. Check for any lumps or bumps in liver, spleen, or in any other of the major lymph nodes in the body (on the neck, under the armpits, near the abdomen) 4. Feel the thyroid gland on the neck and look for any lumps or bumps. If the thyroid gland is enlarged, you can listen to it with a stethoscope Diagnostic Testing 1. ABO blood typing can tell what type of blood (A, B, AB,O) a person has. Before a blood transfusion, it is important to find out the type of donor blood and to mix it with the recipient blood to make sure it is ok (crossmatching) 2. D-‐dimer test looks for clot parts in the blood, which means that there might be clotting in the body 3. Hemoglobin/Hematocrit look at concentrations of blood. Normal hematocrit is 42% to 52%, and 36% to 48% 4. PTT (partial thromboplastin) time and PT (plasma thrombin time) are 2 indicators of how well the blood is clotting. The higher these numbers are, the longer it takes for blood to clot, which means a person may bleed more 5. Platelet counts measure the number of platelets, which are important for clotting 6. A biopsy is a method of removing a small sample of tissue for testing from the bone marrow (site of blood cell production)

Treatment Common treatment for hematologic and immune disorders are drug therapy, transfusions, and corticosteroids to reduce

inflammation

Drug Class Purpose Additional Notes Heparin Anticoagulants Post op prevention of pulmonary

embolism, deep vein thrombosis Watch for bleeding, fever, chills

Warfarin Anticoagulants Treatment of pulmonary embolism, treatment of MI

Monitor Prothrombin Time (2-‐3) to make sure enough warfarin is in system

Serum albumin Blood parts Shock and low protein Watch blood pressure and swelling

Plasma protein Blood parts Shock and low protein Watch blood pressure and swelling

Ferrous Sulfate Iron supplement Iron deficiency Give tablets with juice

There are several drugs for treating HIV/AIDS (Human Immunodeficiency Virus). They include nucleoside analogs, protease inhibitors, non-‐nucleoside reverse transcriptase inhibitors. They all suppress production of cells in the patient, which can have many side effects

Immunosuppressants like cyclosporine are used to prevent complications when a organ/tissue as transplated. The normal response is for the body to reject something that is foreign, but immunosuppressants can help prevent rejection

Clotting factors, which are proteins which help the body clot, can also be given to patients who have a problem clotting properly

Hematologic Disorders Acute Leukemia 1. Leukemia is uncontrolled growth of white blood cells, which cause problems with other cell functioning and production 2. There are many types of leukemia. Acute leukemia happens quickly and often include things like high fever, sweats at night, bleeding 3. Blood tests include aspiration of bone marrow to look for uncontrolled cell growth, complete blood count shows anemia and low platelets 4. Treatment includes chemotherapy and watch for signs of infection Anaphylaxis

3. Treat with injection of epinephrine every 15-‐20 minutes. Also make sure person can breath, provide fluids. 4. Treat low blood pressure with norepinephrine and dopamine 5. Patient may need diphenhydramine and corticosteroids later Disseminated Intravascular Coagulation 1. A disorder where there is lots of clotting, leading to reduction in clotting factors, and then massive bleeding 2. Conditions include infection, shock, heart attack, snake venom

4. Lab tests show decreased platelets (less than 100,000), low fibrinogen, and increased PT/PTT values, and decreased urine oupit 5. Treat with oxygen, heparin, blood transfusion, fresh frozen plasma, platelets HIV Infection (Human Immunodeficiency Virus) 1. HIV is a virus that kills our immune system, so we cannot respond to infection 2. Patients often come in with cough, diarrhea, weight loss, sweats 3. Several tests for HIV including ELISA (enzyme-‐linked immunosorbent assay) and Western Blot 4. No cure yet, but an give antiretroviral therapy that helps to suppress the virus

Idiopathic Thrombocytopenic Purpura 1. When the body destroys its own platelets, which makes clotting difficult 2. Often happens after a virus, and can see bleeding from the mouth, nose, or GI tract 3. Platelet count of less than 20,000 4. Treat with corticosteroids, IV Gamma Globulin, watch heart rate and blood pressure

Section 15

Multisystem Disorders in the Intensive Care Unit

Overview

1. Multisystem disorders are problems with various organ systems or parts of the body at one time. For example, a patient may have head trauma, but also problems with his lungs and kidneys. Overview of Drugs for Multisystem Disorder Drug Class Purpose Dexamethasone Steroid Inflammation Dopamine/Mephenteramine/Phenylephrine Vasopressors Hypotension/shock Ceftriaxone, ciprofloxacin Antibiotics Infection of the lower respiratory tract,

bone/joint/skin infections, blood infection

In a transfusion, whole blood, packed red blood cells, platelets, fresh frozen plasma (full of clotting factors), and protein can

be given. If blood is not properly typed and cross-‐matched, the patient can have a very severe reaction that may lead to severe fever

and low blood pressure Fluid Replacement

Giving the appropriate fluid is important in patients with multi-‐system disorders Fluid Concentration Purpose Additional Notes Dextrose 5% in Water Same as blood Hypernatremia (high

sodium)

Normal Saline Same as blood Shock or hypotension, before starting blood transfusions, dehydration, high calcium

Same as blood Dehydration, burns, acute blood loss

Half Normal Saline Less than blood Water replacement, reduced sodium and chloride

Dextrose 5% in Normal saline Greater than blood Dehydration with low-‐concentration blood sodium

Burn Management

Burns are due to chemical, electrical, or fire sources First, second, and third degree burns are based on how much of the skin is burned. Third degree burns go all the way down

through the fat to the bone and are usually painless In order to treat burns effectively, the percentage of the body burned must be calculated, based on the rule of 9s:

Treatment of burns included oxygen, making sure the airway is open and the patient can breathe, pain medications (pentazocine/morphine/fentanyl), anti-‐microbial cream, surgical removal of burned tissue

Continue listening to heart and lungs, and pour water over chemical burns Amount of lactated ringers fluid (RL) in 24 hours to give is 4 ml/kg weight X % of body burned Give first half of fluid in 8 hours, other half in the remaining 16 hours

Hypovolemic Shock

Low blood pressure due to over 20% loss of blood Low hematocrit, decreased urine output, elevated potassium, creatinine, BUN levels Monitor airways, breathing (provide oxygen), blood pressure/heart rate + insert a catheter to monitor urine output closely Provide IV fluids/blood and dopamine/dobutamine to provide blood flow to kidneys-‐ Aim for over 80 mm Hg blood

pressure and urine output >30ml/hr Septic Shock

Low blood pressure (systolic below 60) due to infection by bacteria, viruses, and some other organisms Often see increased cardiac output, inability to concentrate, reduced urine output, rapid pulses Blood cultures may show infection, and CT scan may show reason for infection To treat, remove the source of infection such as lines, antimicrobial therapy (antibiotics), culture urine/wounds and start

antibiotic therapy Give fluids and vasopressors like dopamine, norepinephrine, or vasopressin

Trauma:

The things to check in trauma patients are airway (can the patient breathe?), breathing (is the patient breathing?),

circulation (does the patient have a pulse and blood pressure), disability (mental assessment) Look from head to toe for any signs of injury ..sometimes, extra scans like x-‐ e needed Keep spine immobilized if there is suspected injury to the area Provide oxygen as necessary, insert two large-‐bore IV catheters into veins for fluids, check blood type and crossmatch for

potential blood transfusion

Section 16

Pediatric Life Support Prepared by Dr. Fran Flanagan

Cardiorespiratory arrest is very different in children compared to adults. It is much less common in children than in adults Cardiopulmonary arrest is usually cardiac in origin in adults but in children it is generally due to respiratory failure +/-‐ shock

in children CPR is conducted differently in children with more respirations i.e. CPR rate of 15:2 (cardiac compressions:breath) rather

than 30:2 in adults. The initiation and overall procedure remains the same DR ABC as adults (danger, airway, breathing, circulation). Diagram taken from resuscitation council of the UK.

No reaction to gentle stimulation or speech

Look, Listen, Feel x 10 seconds

Head tilt, chin lift

The following is the sequence that should be followed by those with a duty to respond to pediatric emergencies (usually healthcare professional teams): 1. Ensure the safety of rescuer and child.

Do not shake infants, or children with suspected cervical spine injuries.

3A. If the child responds by answering or moving:

Leave the child in the position in which you find him (provided he is not in further danger). Check his condition and get help if needed. Reassess him regularly.

3B. If the child does not respond:

Shout for help. Turn the child onto his back and open the airway using head tilt and chin lift: Place your hand on his forehead and gently tilt his head back. chin. Do not push on the soft tissues under the chin as this may block the airway.

If you still have difficulty in opening the airway, try the jaw thrust

forward. Have a low threshold for suspecting injury to the neck. If you suspect this, try to open the airway using chin lift or jaw thrust alone. If this is unsuccessful, add head tilt a small amount at a time until the airway is open. Establishing an open airway takes priority over concerns about the cervical spine.

oking along the chest:

Look for chest movements. Listen Feel for air movement on your cheek.

In the first few minutes after cardiac arrest a child may be taking infrequent, noisy gasps. Do not confuse this with normal breathing. Look, listen, and feel for no more than 10 s before deciding if you have any doubts whether breathing is normal, act as if it is not normal. 5A. If the child is breathing normally:

Turn the child onto his side into the recovery position (see below). Send or go for help call the relevant emergency number. Only leave the child if no other way of obtaining help is possible. Check for continued normal breathing.

5B. If the breathing is not normal or absent:

Carefully remove any obvious airway obstruction. Give 5 initial rescue breaths. While performing the rescue breaths note any gag or cough response to your action. These responses, or their absence, will

Rescue breaths for a child over 1 year:

Ensure head tilt and chin lift. Pinch the soft part of his nose closed with the index finger and thumb of your hand on his forehead. Open his mouth a little, but maintain the chin lift. Take a breath and place your lips around his mouth, making sure that you have a good seal. Blow steadily into his mouth over about 1-‐1.5 s sufficient to make the chest rise visibly.

Maintaining head tilt and chin lift, take your mouth away and watch for his chest to fall as air comes out. hest has

risen and fallen in a similar fashion to the movement produced by a normal breath. Rescue breaths for an infant (baby < 1year old):

Ensure a neutral position of the head (sniffing position) and apply chin lift. Take a breath and cover the mouth and nasal apertures of the infant with your mouth, making sure you have a good seal. If

mouth with his mouth (if the nose is used, close the lips to prevent air escape). -‐1.5 s sufficient to make the chest rise visibly. Maintain head position and chin lift, take your mouth away, and watch for his chest to fall as air comes out. Take another breath and repeat this sequence four more times.

For both infants and children, if you have difficulty achieving an effective breath, the airway may be obstructed:

r sweep. Ensure that there is adequate head tilt and chin lift but also that the neck is not over extended. If head tilt and chin lift has not opened the airway, try the jaw thrust method. Make up to 5 attempts to achieve effective breaths. If still unsuccessful, move on to chest compression.

Take no more than 10 s to: Look for signs of life. These include any movement, coughing, or normal breathing (not abnormal gasps or infrequent,

irregular breaths). If you check the pulse take no more than 10 s: In a child aged over 1 year feel for the carotid pulse in the neck. In an infant feel for the brachial pulse on the inner aspect of the upper arm. For both infants and children the femoral pulse in the groin (mid way between the anterior superior iliac spine and the symphysis pubis) can also be used.

7A. If you are confident that you can detect signs of a circulation within 10 s:

Continue rescue breathing, if necessary, until the child starts breathing effectively on his own. Turn the child onto his side (into the recovery position) if he starts breathing effectively but remains unconscious.

Re-‐assess the child frequently. 7B. If there are no signs of life, unless you are CERTAIN that you can feel a definite pulse of greater than 60 min-‐1 within 10 s

Start chest compression. Combine rescue breathing and chest compression.

For all children, compress the lower half of the sternum:

To avoid compressing the upper abdomen, locate the xiphisternum by finding the angle where the lowest ribs join in the

Compression should be sufficient to depress the sternum by at least one third of the depth of the chest. Release the pressure completely, then repeat at a rate of 100 -‐ 120 min-‐1 After 15 compressions, tilt the head, lift the chin, and give two effective breaths. Continue compressions and breaths in a ratio of 15:2.

The best method for compression varies slightly between infants and children. Chest compression in infants:

The lone rescuer should compress the sternum with the tips of two fingers. If there are two or more rescuers, use the encircling technique: Place both thumbs flat, side by side, on head.

f ack.

Press down on the lower sternum with your two thumbs to depress it at least one-‐ Chest compression in children aged over 1 year:

Place the heel of one hand over the lower half of the sternum (as above). Lift P

least one-‐third of the depth of the chest. In larger children, or for small rescuers, this may be achieved most easily by using both hands with the fingers interlocked.

Continue resuscitation until:

The child shows signs of life (normal breathing, cough, movement or definite pulse of greater than 60 min-‐1). Further qualified help arrives. You become exhausted.

Advanced Pediatric Life Support APLS is a continuation of paediatric life support (effective CPR alone can be life saving). In any case of cardiopulmonary arrest whether an adult or child, a defibrillator should immediately be attached to the patient if available. Unfortunately most children have pulmonary arrests, which cause worsening hypoxia leading to eventual asystole, which is not a shockable rhythm. Children with underlying congenital heart disease often have cardiac arrest (ventricular fibrillation), hence the importance of attaching a defibrillator. The main drug used is adrenaline at a dose of 0.1-‐0.3mg/kg of 1/10,000 (adrenaline in GAH is 1/1000 therefore all adrenaline should be diluted x 10, prior to administration). Adrenaline is used every 3-‐5mins in both shockable and non shockable cardiopulmonary arrests. Immediately after administering adrenaline a flush of 5-‐10mls is administered to deliver the adrenaline through the blood stream to the heart. The most important aspect of APLS is effective CPR, hence it should be continued throughtout the resuscitation with maximum breaks of 10 seconds to allow for a pulse check. Some reversible causes of cardiopulmonary arrest include 4 Hs & 4 Ts Hypoxia outrule by using a bag and mask connected to oxygen 100% Hypovolaemia outrule by administering IV fluid bolus of normal saline at 10ml/kg (often 2-‐3 boluses required) Hypo/hyperkalaemia if electrolytes can be checked rapidly, the problem can be rectified by using KCL/normal saline, salbutamol, calcium gluconate etc Hypothermia out-‐rule by checking an axillary temperature wherever possible the patient should be covered during the resuscitation. Tension pneumothorax out-‐ruled by auscultation of the chest treated by needle decompression Tamponade out-‐ruled by auscultation of the chest treated with needle aspiration Toxins out-‐ruled by careful history taking from patient and bystanders. Thromboembolism consider if any risk factors Diagram taken from the resuscitation council of UK

Section 17

Adult Basic Life Support and Advanced Cardiac Life Support

Basic Life Support (Diagram taken from CyberJaya University)

The purpose of basic life support is to provide air and blood flow throughout the body when a person becomes unconscious due to a severe illness. This can happen often in the ICU.

Advanced Cardiac Life Support (ACLS)

First check to see if the person is breathing and has a pulse. If the patient is not breathing, give rescue breaths using the bag If patient is breathing, then continue giving air to the patient using the bag If the patient does not have a pulse, start CPR as in basic life support, and also attach the defibrillator Compressions should be fast (>100/minute)

Section 18

Imaging in the Intensive Care Unit

Overview

There are many kinds of imaging done in the intensive care unit to look for problems. They include X-‐Rays, CT, MRI, angiography, ultrasound, nuclear imaging. The following provides some imaging for common ICU conditions in each body system. Some types of imaging may not available in a rural hospital. Cardiac Imaging Aortic Aneurysm (X-‐Ray)

Congestive Heart Failure (X-‐Ray)

Pericardial Effusion (X-‐ray)

Pulmonary/Respiratory Imaging: Pneumonia (X-‐ray)

Acute Respiratory Distress Syndrome (X-‐ray)

Pleural Effusion (X-‐ray)

Pulmonary Embolism (CT)

Pneumothorax (X-‐ray)

Kidney Imaging: Kidney stone (Intravenous pyelogram IVP)

Pyelonephritis (CT)

Hematology Imaging: Lytic (punched-‐out) lesions of skull due to cancer (X-‐ray)

Lung cancer (X-‐ray)

Endocrinology Imaging: Thyroid nodule (Ultrasound)

Gastroenterology Imaging: Perforated intestine (X-‐ray)

Bowel obstruction (X-‐ray)

Neurology Imaging: Ischemic stroke (CT)

Hemorrhagic stroke (CT)

Documents

CriticalCareEssentialsfortheRuralIntensiveCare( Unit · CriticalCareEssentialsfortheRuralIntensiveCare(Unit (AKnowledge Guide(forPhysiciansandNurses ((Version1.0 (2013(((((Editors:(HariPrabhakar(Dr.NandakumarMenon