General ICU

Question 1

RASS

Answer 1

RASS - +4 to -5

• 1 = eye contact > 10 secs
• 2 = eye contact < 10 secs
• 3 = no eye contact

Question 2

CAM-ICU

Answer 2

1 - Is there an acute change in mental status?
2 - Test for inattention
Then one of either:
3 - Altered consciousness (RASS)
4 - Disorganised thinking (questions) and Commands (2 stage)

Question 3

Delirium

Answer 3

Acute change in consciousness and awareness that fluctuates of time - generally in response to physiological consequences of a general medical condition.

Thought to be a neurotransmitter imbalance.

RFs:
1 - Patent factors - Age, co-morbidity, baseline cognitive impairment, ETOH
2 - Acute illness factors - High APACHE, sepsis, hypoxia, metabolic derangement
3 - Iatrogenic - disturbed sleep/sedative meds

Reduce risk:
ABCDE - Awake and breathing, Choice of sedation, Coordination, Delirium monitoring, Early mobilisation

Question 4

Modified Rankin Score

Answer 4

0 = no symptoms
1 = Can carry out all activities with some symptoms
2 = Can look after self without assistance but unable to carry out all previous activities
3 = Requires some help but can walk unassisted
4 = Required assistance for ADLs
5 = Requires nursing care or bedridden
6 = Death

Question 5

Intubation

Answer 5

Prep-prep-prep!

Prepare Pt - consent, positioning, pre-O2, gastric emptying
Prepare personnel - roles
Prepare environment 
Prepare drugs 
Prepare equipment

Question 6

Nutrition

Answer 6

25-30 kcal/kg/day

Protein = 1-2g/kg/day
Carbs = 60% of non-protein calories
Lipids = 40% of non-protein calories

Water = 30mls/kg/day
Na = 1-2mmol/kg/day
K = 1
Ca = 0.1
Mg = 0.1
Phos = 0.4

Question 7

Never Events

Answer 7

Listed by NHS England - wholly preventable by guidance and safety systems. All have potential to cause serious harm or death. All must be investigated a serious incident.

Surgical:
1 - Wrong site
2 - Wrong implant
3 - Retained objects

Drugs:
1 - Mis-selection of strong K 
2 - Wrong route of administration
3 - Overdose insulin
4 - Overdose of methotrexate
5 - Mis-selection of high dose midazolam

General:
1 - Fall from windows
2 - Chest/neck entrapment in bed
3 - ABO incompatible blood
4 - NG misplacement
5 - Scalding
6 - Patient on air when should be oxygen

Question 8

Ethics - capacity

Answer 8

Consent - Should be informed and person has capacity

Capacity - two stages
1 - Is there a disorder of brain or mind? Temporary or permanent
2 - Can the patient understand, retain, weigh up and communicate decision?

Capacity is assumed in an adult
Is decision specific and time specific

Mental Capacity Act 2005

• Assumed capacity
• support to make decision
• unwise decision allowed
• best interests
• least restrictive option

Advanced directive - can only cover refusal of treatment, must be specific, must be in writing, signed and witnessed. Can not refuse actions to maintain comfort.
Appoint a lasting power of attorney.

Ascertaining persons likely wishes

IMCA - substitute for family members, represent patients best interests and help decision making
—- used when important decision need to be made without AD/LPA/family , when it is believed a family are not acting in the patients best interests or a conflict between family members.

Question 9

DNACPR

Answer 9

Requested by patient
When CPR would not be successful
When CPR may work but the harms/burdens of doing so outweigh any possible benefit

Inform:
Patient (unless undue suffering), NOK and other healthcare professionals

Difficult situation when patient/family insist on CPR

• Not a withdrawal of support or treatment
• PALS support
• second opinion
• advocate for patient
• case conference
• ultimately Court of Protection

Question 10

Sedation

Answer 10

Why use sedation:
1 - Manage anxiety and agitation
2 - Manage pain
3 - Allow mechanical ventilation 
4 - Control ICP
5 - Modify the PTSD response
6 - Patient safety 

Cont infusion, boluses, enterally

Propofol - GABA potentiation (