Critical Care Flashcards
What is ARDS?
Acute Respiratory Distress Syndrome
also known as Acute Lung Injury
Reaction of the lungs to direct and indirect injury (usually sepsis)
What are the features of ARDS?
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
What percentage of patients with sepsis will develop ARDS? Why is it concerning?
20-40%
It is concerning in and of itself but also is considered as a warning factor for later MSOF
What happens to pulmonary pressures during ARDS?
There is often a pulmonary hypertension that can lead to right ventricular failure
Why do the lungs become stiff in ARDS?
Within days of the lung injury fibroblasts start to collect within the lung tissue leading to lung fibrosis
How does ARDS present clinically?
Tachypnoea
Hypoxaemia and central cyanosis
FINE CRACKLES (particularly at lung bases)
How should ARDS be managed?
Artificial ventilation Fluid restriction Use of diuretics Haemofiltration Change in position Inhaled NO
What is the difference between T1RF and T2RF?
Type 1 - hypoxaemia
Type 2 - hypoxaemia with co2 retention
What are some cause of T1 and T2RF?
T1 - Asthma attacks, cariogenic pulmonary oedema, acute lung injury, lung fibrosis
T2 - COPD (change in ventilatory shift) + reps wall weakness (Guillain Barré)
What are some clinical features that someone might be in resp failure?
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
What is classed as acute and severe resp failure?
RR > 40, unable to speak, exhausted, confused
can patients refuse CPR?
Patients CAN REFUSE CPR
However cannot request (deny DNACPR) it if Drs think it will be futile
What do you do if you are called to see patient who has died?
Go ASAP
- Check resuscitations status (if no DNACPR then commence CPR via ALS algorithm)
- Read notes and ask nurses what happened
- Ask is there family present at the moment?
Who must be present when talking to patients family about organ donation?
a SNOD (specialist nurse for organ donation)
What are the two types of cadaveric organ donation
- Donors after brainstem death (coning, hypoxia, CVA)
2. Donors after circulatory death
Describe the sequence of events for donors after brainstem death vs. donors after circulatory death.
Involve family and SNOD
- 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 - Donors after circulatory death
- get team ready in theatre
- stop support (and let family say goodbyes)
- diagnose death
- organ retrieval (laporotomy within 10 mins)
Factors we consider when admitting to ITU
• 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?
Indications for non invasive ventilation?
Indications for non invasive ventilation
- requiring FiO2 of 60% +
- ABG shows type 2 resp
- clinically deteriorating
What are some examples of NIV?
What situations would you give each option?
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)
Whats the calculation for minute ventilation
Minute ventilation (ml/min)=Tidal volume (500ml) X resp rate
equation for Cardiac output
equation for systolic BP
CO=SVxHR
SBP=CO x SVR (systemic vascular resistance)
