Critical Care, TARMS Flashcards
What are the different levels of care provided by critical care?
Level 0 - needs can be met through normal ward
Level 1 - at risk of deteriorating; needs met with support from critical care team
Level 2 - patients requiring more detailed observation/interventions; a single failing organ system; post-operative care
Level 3 - advanced respiratory support; support of at least 2 organ systems; support for multi-organ failure
What are type 1 and type 2 respiratory failure?
Type 1 = Hypoxaemia
- PO2 < 8kPa on air
- PCO2 < 6kPa
Type 2 = Hypoxaemia + hypercapnia
- PO2 < 8kPa on air
- PCO2 > 6kPa
What causes a type 1 respiratory failure?
V/Q mismatch
- Reduced ventilation but normal perfusion e.g. pulmonary oedema, bronchoconstriction
- Reduced perfusion but normal ventilation e.g. PE
Name 4 categories of causes of type 2 respiratory failure
- Increased resistance due to airway obstruction e.g. COPD
- Reduced compliance of lung tissue/chest wall e.g. rib fractures, obesity
- Reduced strength of respiratory muscles e.g. MND, Guillan-Barré
- Drugs acting on respiratory centre e.g. opiates
What are the indications for a CPAP machine?
Type 1 respiratory failure
- Pulmonary oedema
- Fluid overload
- Atelectasis
- Pneumonia
Severe obstructive sleep apnoea
What does CPAP do?
A fixed low positive pressure is delivered throughout inspiration and expiration
It assists spontaneous ventilation
It splints the airway open and so prevents airway collapse and loss of lung volume
What complications can arise from CPAP?
Pneumothorax
Hypotension
What does BiPAP stand for?
Biphasic Positive Airway Pressure
How does BiPAP work?
Delivers positive pressure throughout inspiration and expiration
The inspiratory positive airways pressure is higher than the expiratory positive airways pressure so ventilation is provided by iPAP
ePAP recruits collapsed alveoli (keeps them open for longer) for better gas exchange and removal of exhaled gas
What does positive airway pressure mean?
The pressure outside the lungs is greater than the pressure inside the lungs, which results in air being forced into the lungs (requiring less respiratory effort) and increasing the forced residual capacity of the lungs
What part of breathing requires the most energy?
Normally, bronchioles and alveoli collapse at the end of expiration
Overcoming the pressures required to re-expand collapsed parts of the lungs requires the most energy
What are the indications for BiPAP?
- Type 2 respiratory failure
- COPD with a respiratory acidosis
- Secondary to chest wall deformity
- Secondary to neuromuscular disease - Weaning of tracheal intubation
What are some contraindications to CPAP/BiPAP?
Definite contraindications:
- Facial burns/trauma
- Vomiting/excess secretions - risk of aspiration
Potential contraindications:
- Confusion/agitation
- Impaired consciousness
- Bowel obstruction
- Recent facial/upper airway surgery
- Undrained pneumothorax
What happens if the iPAP is too high on a BiPAP machine?
Hypotension due to reduced venous return
Can cause the mask to leak
Can lead to stomach inflation with risk of vomiting and aspiration
Define death
Irreversible loss of capacity for consciousness combined with irreversible loss of capacity to breathe
Where is the brainstem and what is it comprised of?
Brainstem is in the posterior part of the brain and is continuous with the spinal cord
It includes the midbrain, the pons and the medulla oblongata
What does the brainstem control?
Consciousness
Awareness
Breathing
Ability to regulate heart rate and blood pressure
What are some potentially reversible causes of brainstem death?
i. Baclofen overdose
ii. Organophosphate toxicity
iii. Lignocaine toxicity
iv. C spine injury
v. Electrolyte or glucose abnormalities – particularly hypophosphataemia
vi. Thyroid storm
vii. Addisonian crisis
viii. Hypothermia
ix. Hypotension
What brainstem reflexes are tested when confirming brainstem death?
- Pupillary reactions – fixed and dilated
- Corneal reflex – absent (difficult in facial weakness)
- Gag reflex absent
- Pain response by applying pressure to supraorbital ridges absent
- Caloric testing – ice water irrigated into external auditory canal
What are the steps taken to confirm brainstem death?
- Identify the cause and exclude potentially reversible causes
- Complete neurological examination
- Test brainstem reflexes
- Apnoea testing
What does apnoea testing involve?
An increase in arterial CO2 causes metabolic acidosis and should stimulate increased respiration by stimulating the medullary respiratory centres
Where is interosseous access most commonly obtained?
Proximal tibia
Can also use the distal femur and humeral head
What does ABCDE stand for in trauma?
A = Airway and cervical spine control
B = Breathing and ventilation (oxygenation)
C = Circulation with haemorrhage control
D = Disability and neurological status
E = Exposure and environmental control
How do you examine for airway compromise?
Look for:
- Facial fractures or facial burns
- Head injury
- Neck wounds
- Epistaxis/vomiting/blood/soot in mouth
- Obtundation or cyanosis
- Paradoxical chest movements/retractions/accessory muscles
Listen for:
- Audible breath sounds
- Voice quality
- Stridor/gurgling/snoring
Feel for:
- Tracheal deviation
- Laryngeal crepitus
How do you size a cervical collar?
Use your fingers to measure from top of patient’s trapezius to point of chin
This measurement is then used against the sizing posts on the cervical collar
What is the definition of a definitive airway?
A cuffed tube secured in the trachea
What are the indications for a definitive airway in trauma care?
Failure of airway maintenance or protection
Failure of oxygenation or ventilation
Anticipated clinical course
What general situations can compromise ventilation?
Airway obstruction
CNS depression
Altered ventilatory mechanics i.e. thoracic or cervical spinal cord function
How do you assess thoracic function?
Look for signs of ventilatory compromise
- Inadequate/asymmetrical chest rise and fall
- Laboured breathing
- Decreased or absent air entry
Look for injuries which could compromise ventilation
Look for signs suggestive of thoracic injury
- Abnormal O2 sats/RR
- Tracheal deviation
- Chest wall bruising/wounds
- Fractures
- Abnormal air entry
What thoracic conditions do you need to look for in the B assessment of the primary survey in trauma cases?
ATOM FC (life threatening thoracic injuries)
Airway obstruction
Tension pneumothorax
Open chest wound
Massive haemothorax
Flail chest
Cardiac tamponade
Broadly, how do you manage a severe penetrating thoracic injury?
Manage inadequate ventilation immediately by:
- Optimising oxygenation (this includes considering the need for intubation)
- Needle/tube thoracocentesis or pericardiocentesis
- Resuscitative thoracotomy
- Definitive treatments
What is pulmonary contusion and what is its effect?
A bruise of the lung caused by chest trauma
Blood and other fluids accumulate in the lung tissue as a result of damage to capillaries
The excess fluid interferes with gas exchange, potentially leading to hypoxia
What are the anatomical landmarks for a chest drain?
5th intercostal space in the mid-axillary line
Safe triangle:
- Superiorly = base of axilla
- Anteriorly = lateral border of pectoralis major
- Laterally = lateral border of latissimus dorsi
- Inferiorly = 5th intercostal space
What steps should be taken to fluid resuscitate a trauma patient?
2 x large bore cannulae
Bloods sent for crossmatch, FBC, U&E, LFT, Amylase, Coagulation, VBG
Pelvic binder
Warm crystalloid fluid whilst waiting for O-negative blood plus platelets + FFP
Tranexamic acid stat bolus if haemorrhaging
Consider activation of massive transfusion protocol
What are the main sites of haemorrhage?
On the floor and 4 more
External wounds (i.e. on the floor)
Chest cavity (lungs + cardiac tamponade)
Abdominal cavity (incl. retroperitoneal)
Pelvic cavity
Long-bone fractures
In the context of head trauma, what can you immediately do to help prevent neurodisability?
Optimise oxygenation Immobilise C-spine Maintain cerebral perfusion (BP>90) Avoid hypoglycaemia Avoid pyrexia Do imaging then treat
What technique is used to move a trauma patient?
Log-roll - it allows the posterior of the patient to be examined without their active movement
It requires 5 people: 1 to stabilise neck, 3 to roll patient, 1 to examine the back/spine and perform DRE
What are some signs of spinal injury?
Diaphragmatic breathing
Evidence of neurogenic shock
Responds to pain only above the clavicles
Priapism (persistent + painful erection of penis)
Flexed posture of upper limbs
Flaccid areflexia
Patient complains of loss of sensation or function
Spinal tenderness, bruising or swelling
In which part of ABCDE should pelvic fractures be considered and why?
In C due to their potential for massive blood loss
What should be put in place if there is any risk of a pelvic fracture?
Pelvic binder - it aims to stabilise a fractured pelvis to prevent movement and disruption of haematoma in the pelvic cavity
Where is the pelvic binder place?
It is placed at the level of the greater trochanters
