CRITICAL CARE, March 2020
CRITICAL CARE, March 2020
RESUSCITATION LECTURES:
INTRODUCTION TO ACUTE CARE:
EMERGENCY MEDICINE,
ANAESTHESIA,
CRITICAL CARE
• ED: Emergencies,
• ICU: Intensive care units
• OT: High-risk patients before and after major surgery.
• HDU: High-dependency units offer a level of care intermediate between the general
ward and that provided in an ICU.
• WARDS: Monitoring and support for patients at risk of developing organ failure…
• ANYWHERE & ANYTIME: ??????
• COGNITIVE DOMAIN
• PSYCHOMOTOR DOMAIN
• AFFECTIVE DOMAIN
RESUSCITATION SKILLS
?
EM MED. Observe:-
PATIENT’S S/S
PROCEDURE
MONITORING
TECHNIQUES
ANAESTHESIA POSTING
4. AVOID MEDICAL
ERRORS-
NEVER EVER………..
PATIENT
SAFETY
THERE WILL ALWAYS BE HISTORY,
SYMPTOMS AND SIGNS BEFORE A
PATIENT BECOMES CRITICAL !!!!
SIGNS HAD
STARTED HERE
8 HRS EARLIER
How different?
•
•
Crisis Environment
Time Restriction
3
• Changing Clinical Environment
• Team Work
• Inter-professional Learning
• Clinical governance MEDICO-
LEGAL
• Professional Accountability
CASE
• Professional Regulation
• Patient Safety
• ? NO HISTORY
• ? LIMITED EXAMINATION
• ? NO INVESTIGATION
• ? UNSURE DIAGNOSIS
✓ TREAT & MANAGE
5
SHOCK
Def:
A complex clinical syndrome
that results when tissue
oxygenation or nutrient
delivery are insufficient to
maintain the metabolic
needs of the cell
CLASSIFICATION AND DIFFERENCIATION OF SHOCK
TYPE CAUSE PATHO SYMPTOMS SIGNS VITAL SIGNS
PHYSIOLOGY PR/ECG RR SKIN SPO2 GCS BP
1 HYPOVOLUMIC LOSS OF REDUCED VOLUME, GIDDINESS, LETHARGY, PALLOR COOL,
BLOOD, VENOUS RETURN, ANXIOUS, AMS,LOC SWEATING, COLD,
FLUIDS CARDIAC OUTPUT, BP ANXIOUS CHILL,
RESTLESS PEA CLAMMY,
MOTTLED
2 CARDIOGENIC MI,VALVE PUMP FAILURE CARDIAC CHEST PAIN, ANXIOUS,
FAILURE, VALVE FAILURE DIZZINESS, LETHARGY
TAMPONAD DIAPHORESIS,
E, DRUGS NAUSEA, VOMITING, ARRHYTHMA
PALPITATIONS,
5 NEUROGENIC CERVICAL SPINAL CORD INJURY, TRAUMA, UNABLE TO PARALYSIS, N EARLY WARM, N N
INJURY, SYMPATHETIC DAMAGE, MOVE, NUMBNESS, PARAESTHESIA LATE COOL
SPINAL VASODILATION, POOLING TINGLING, ,WARM PINK
DRUGS OF BLOOD REDUCED NECK PAIN, UNABLE P.,PRIAPISM,
VENOUS RETURN & BP TO BREATH, INCONTINENC BRADYCARDIA
E, REDUCED
TONE COPYRIGHT- Dr AAli
CLASSIFICATION OF HAEMORRHAGIC SHOCK
NO SIGNS CLASS I CLASS II CLASS III CLASS VI
1 Blood Loss:
Percentage < 15% 15 – 30% 30-40 % ➢ 40%
Volume < 750 ml 750 – 1500 ml 1500-2000 ml ➢ 2000 ml
2 Blood Pressure:
Systolic Unchanged Normal Reduced Very Low
Diastole Unchanged Raised Reduced Unrecordable
3 Pulse Rate 100 bpm 100-120 bpm > 120 bpm ➢ 120 bpm
➢ thready
4 Capillary Refill Normal Slow Slow Undetectable
10 9
• Starling’s law of the capillaries is that the volume of fluid & solutes
reabsorbed is almost as large as the volume filtered
Tortora & Grabowski 9/e ©2000 JWS 21-22
Arterioles
• Small arteries delivering blood to
capillaries
– tunica media containing few layers
of muscle
• Metarterioles form branches into
capillary bed
– to bypass capillary bed, precapillary
sphincters close & blood flows out
of bed in thoroughfare channel
– vasomotion is intermittent
contraction & relaxation of
sphincters that allow filling of
capillary bed 5-10 times/minute
Figure 15.5
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
What is the Pathogenesis of Hypoperfusion ?
How do you interpret the Symptoms & Signs ?
NO
VITAL SIGNS VALUE RANGE REMARKS
1 PULSE RATE
Infants <160 bpm
7 VITAL SIGNS
Preschool <140 bpm
School <120 bpm
Adult <100 bpm 60 – 80 bpm Volume?
2 RESPIRATION Rate, TV
Infant 25 – 50 bpm
School 15 – 30 bpm
Adult 12 – 20 bpm 12 - 30 bpm <10 , >30
3 TEMPERATURE 37C >38.5C Cool, Cold, Chill,
Warm, Hot Clammy, Mottled
4 GLASGOW COMA SCALE 3 - 15
5 OXYGEN SAT % > 97% <95% , <90%
6 BLOOD PRESSURE
Infant 70 mm Hg
School 80 (2 age in years)
Adult 120/80 mmHg MAP?
7 PAIN SCALE 0 - 10
OTHER SIGNS VALUE
1 SKIN Pale, Cool, Cold, Clammy, Mottled
CAPILLARY REFILL < 2 sec
2 CARDIAC RHYTHM
3 CVP / VEINS 4 – 10 cm H2O pr
4 ABG Metabolic Acidosis: <pH, n/<PaCO2, >Base def, < Bicarb.
5 URINARY OUTPUT 0.5 – 1 ml / kg / hr
6 PAWP 6 – 12 cm H2O pr
7 ARTERIAL PRESSURE
8 JUGULAR/NECK VEINS
9 PUPILS
10 CYANOSIS
11 EYE MOVEMENT
12 SPEECH
13 SPECIFIC SIGNS
FLOW DIAGRAM FOR MANAGEMENT OF UNDIFFERENTIATED SHOCK
HISTORY THINK
1 Trauma? Haemorrhagic Sh.
Tension Pneumothorax
Cardiac Tamponade
2 GIT haemorrhage, Diarrhea, Vomiting? Volume Resus
3 Fever?Hypothermia? Sepsis syndrome
4Infection?
TFT
4 ECG / s/sACS? MI ? Cardiogenic Sh.
Pulm Embolism
5 Bradycardia / Hypotension? Drug injestion-Neg inotrops
TFT
Addisonian Crisis
6 Hypoxemia? Pulm. Embolism
7 Abdominal/Low Backpain? Volume Resus
Abd U/S
8 Wheezing / Hives? Anaphylaxis Sh.
https://www.rcplondon.ac.uk/projects/outputs/natio
nal-early-warning-score-news-2
Dec 19, 2017 - NEWS2 is the latest version of the
National Early Warning Score (NEWS), first
produced in 2012 and updated in December 2017
58 Year-old male HT, with a Crushing chest pain.
What are you going to do?
RESPIRATORY DISTRESS
• Tachycardia
• Increased respiratory effort
• Inadequate respiratory effort
• Abnormal airway sounds
• Tachycardia
• Pale, cool skin (warm, red, diaphoretic)
• Agitation/Changes in level of consciousness
• Use of Abdominal muscles to assist in breathing
RESPIRATORY FAILURE
• Marked tachypnoea
• Bradypnoea, Apnoea
• Increased/Decreased/
• No respiratory effort
• Poor distal lung air movement
• Tachycardia (early)
• Bradycardia (late)
• Cyanosis
• Stupor/Coma (late)
RESPIRATORY ARREST
• Absence of breathing
• Gasping <6/min, No chest movement
39
Mx RESPIRATORY ARREST – BLS/ALS
• Giving supplementary Oxygen
• Opening the airway
• Providing basic ventilation-MM,MM,BVM
• Using basic airway adjuncts-OPA,NPA
• Suctioning
• Assess and Fix
BASIC AIRWAY SKILLS
• Head tilt- Chin lift
• Jaw thrust without head extension
• Mouth-to-mouth ventilation
• Mouth-to-nose ventilation
• Mouth-to-barrier device ventilation
• Bag-mask ventilation
ADVANCED AIRWAY DEVICE
• Laryngeal mask airway
• Laryngeal tube
• Esophageal-tracheal tube
• Endotracheal tube
◼ Preparation
– Team Assembly
– Equipment Check
◼ Triage
– Sort patients by level of acuity
◼ Primary Survey
– Designed to identify injuries that are
immediately life threatening and to treat them
as they are identified
◼ Resuscitation
– Rapid procedures and treatment to treat
injuries found in primary survey before
completing the secondary survey
◼ Secondary Survey
1. Resuscitation techniques,
2. Management of multiple injured patients.
3. Principles of management of different shock syndromes.
4. Understand the principles of preoperative assessment of patients posted for elective surgery, basic monitoring,
conduct of different anaesthetic techniques, post op management in PACU, acute and chronic pain management.
5. Principles of management of acute abdominal pain.
6. Common respiratory emergencies like bronchial asthma, acute exacerbation of COPD and respiratory failure.
7. Acute poisoning.
8. Emergency wound management
9. Management of Acute coronary syndrome.
10. Transport of critically patient.
11. Disaster preparedness.
12. Common endocrine emergencies
13. Fluid and electrolyte management.
14. Arterial blood gas analysis
15. Management of sepsis and Septic shock
16. Management of anaphylaxis.
TEACHING AND LEARNING ACTIVITIES: