Critical Care

Question 1

What is ARDS?

Answer 1

Acute Respiratory Distress Syndrome
also known as Acute Lung Injury
Reaction of the lungs to direct and indirect injury (usually sepsis)

Question 2

What are the features of ARDS?

Answer 2

Respiratory distress
Stiff lungs (requiring high inhalation pressures)
New pulmonary infiltrates on chest radiograph - PULMONARY OEDEMA w/o cardiac cause
No apparent cause of pulmonary oedema (pulmonary obstruction pressure <18mmHg)
Gas exchange problems
Pleural effusions also common

Question 3

What percentage of patients with sepsis will develop ARDS? Why is it concerning?

Answer 3

20-40%

It is concerning in and of itself but also is considered as a warning factor for later MSOF

Question 4

What happens to pulmonary pressures during ARDS?

Answer 4

There is often a pulmonary hypertension that can lead to right ventricular failure

Question 5

Why do the lungs become stiff in ARDS?

Answer 5

Within days of the lung injury fibroblasts start to collect within the lung tissue leading to lung fibrosis

Question 6

How does ARDS present clinically?

Answer 6

Tachypnoea
Hypoxaemia and central cyanosis
FINE CRACKLES (particularly at lung bases)

Question 7

How should ARDS be managed?

Answer 7

Artificial ventilation 
Fluid restriction
Use of diuretics 
Haemofiltration
Change in position 
Inhaled NO

Question 8

What is the difference between T1RF and T2RF?

Answer 8

Type 1 - hypoxaemia

Type 2 - hypoxaemia with co2 retention

Question 9

What are some cause of T1 and T2RF?

Answer 9

T1 - Asthma attacks, cariogenic pulmonary oedema, acute lung injury, lung fibrosis
T2 - COPD (change in ventilatory shift) + reps wall weakness (Guillain Barré)

Question 10

What are some clinical features that someone might be in resp failure?

Answer 10

Remember lots of these are also consequences of their conditions that have caused the RF
Tachypnoea, Dyspnoea, incr RR, Cyanosis, Accessory muscle use, tripoding, IC recession, pulses paradoxus, Agitation

Question 11

What is classed as acute and severe resp failure?

Answer 11

RR > 40, unable to speak, exhausted, confused

Question 12

can patients refuse CPR?

Answer 12

Patients CAN REFUSE CPR

However cannot request (deny DNACPR) it if Drs think it will be futile

Question 13

What do you do if you are called to see patient who has died?

Answer 13

Go ASAP

1. Check resuscitations status (if no DNACPR then commence CPR via ALS algorithm)
2. Read notes and ask nurses what happened
3. Ask is there family present at the moment?

Question 14

Who must be present when talking to patients family about organ donation?

Answer 14

a SNOD (specialist nurse for organ donation)

Question 15

What are the two types of cadaveric organ donation

Answer 15

1. Donors after brainstem death (coning, hypoxia, CVA)

2. Donors after circulatory death

Question 16

Describe the sequence of events for donors after brainstem death vs. donors after circulatory death.

Answer 16

Involve family and SNOD

1. Donors after brainstem death
   - diagnose brainstem death (absent cranial nerve reflexes, apnoea tests)
   - optimise (cardio, resp, endocrine, electrolytes, coag)
   - get team to take to surgery
   - organ retrieval
2. Donors after circulatory death
   - get team ready in theatre
   - stop support (and let family say goodbyes)
   - diagnose death
   - organ retrieval (laporotomy within 10 mins)

Question 17

Factors we consider when admitting to ITU

Answer 17

• Comorbidity (are they palliative)
• Functional status
• Reversibility(e.g. not pulmonary fibrosis deterioration)
• Diagnosis
• Patient’s wishes
• Parent team
Is it something that the ICU will fix? Can it be reversed?

Question 18

Indications for non invasive ventilation?

Answer 18

Indications for non invasive ventilation

• requiring FiO2 of 60% +
• ABG shows type 2 resp
• clinically deteriorating

Question 19

What are some examples of NIV?

What situations would you give each option?

Answer 19

Examples
-high flow nasal oxygen (60L/min), CPAP and BiPAP

CPAP

• pressure is continuous
• EPAP (expiratory positive airway pressure)

BiPAP
-different inspiratory and expiratory pressures)

When to give what?
CPAP for type 1 RF (pulmonary odema)
BiPAP for type 2 RF (e.g. COPD)

Question 20

Whats the calculation for minute ventilation

Answer 20

Minute ventilation (ml/min)=Tidal volume (500ml) X resp rate

Question 21

equation for Cardiac output

equation for systolic BP

Answer 21

CO=SVxHR

SBP=CO x SVR (systemic vascular resistance)