ICU Flashcards
Name the 2 types of blunt injury
Deceleration injury
Compression injury
Name 2 types of penetrating injury
Low-velocity injuries
High-velocity injuries
List 6 lethal injuries
Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac temponade
What is the primary survey provided in ER
ABCDE approach to rescuitation
Lethal 6 injuries
Abdominal injury (identify and manage internal bleeding)
What is the secondary survey for ER
Head to toe evaluation and history taking
Placement of lines and continuation of care from primary survey
Radiological investigations
List 6 hidden injuries
Pulmonary contusion
Myocardial contusion
Traumatic disruption of the aorta
Traumatic diaphragmatic rapture
Tracheobronchial injury
Oesophogeal trauma
Precautions and contraindications related to abdominal injury
Analgesia
Caution with drainage tubes
Caution with manual chest therapy over anterior basal lung segments
Vigorous chest percussions may cause alveolar collapse
Wound support during suction and coughing
Open abdomen - restric head tilt to 25 degrees
If abdominal compartment syndrome develops no turning of patient
What is a TBI
An alteration in brain function or other evidence of brain pathology caused by external force
What categories can TBI be classified based on
Mechanics of injury
Location of injury
Extent of injury
Severity of injury
What is epidural haematoma
Blood accumulates between the skull and dura mater
Arterial bleeding from middle meningeal artery
Temporal or temporo-parietal region often affected
What is subdural haematoma
Blood accumulated between dura mater and arachnoid meninges
Haematoma occurs due to damage occurring cerebral cortex and venous sinus
What is subarachnoid haematoma
Bleeding in the subarachnoid space
Ruptured aneurysms occur here (can be Traumatic or not)
What is intracerebral haematoma
Collection of fluid in the brain tissue
Majority of lesions occur in the frontal and temporal lobes
What is primary head injury
The initial Traumatic force applied to the head that causes neuronal damage due to contusion, damage to blood vessels and axonal injury
What is a secondary head injury
The delayed non-mechanical damage that develops hours and days after the primary injury
The degree of secondary damage depends on duration of cerebral ischemia and intracranial hypertension
What are the factors that lead to ischemia
Hypoxaemia
Systemic hypotension
Cerebral hypo-perfusion
Inflammatory processes
Cerebral oedema
Hypercapnia
Factors that influence outcomes of a patient following a TBI
Severity of primary and secondary injuries
Low GCS findings on presentation
Advanced age
Presence of comorbidities
What is the GCS rating of Severity of TBI
Mild (13,14)
Moderate (9-12)
Severe (3-8)
What is intracranial pressure
Pressure within three cranium
Influenced by :
Blood volume, brain tissue and CSF in rigid skull
Name the ICP monitoring devices
Epidural sensor
Subdural bolt
Subarachnoid bolt
Parenchymal catheter
Intraventricular catheter
Factors that may increase ICP
Suction
Head movements
Turning
Head down positions
MHI
manual techniques
Seizures
Pain
Anxiety
Increased BP and abdominal pressure
Late signs of raised ICP
GCS of 3/10 or 3/15
Abnormal motor response (abnormal posture or flaccidity)
Cushing’s response (hypertension, bradycardia, increased temp and altered respiratory pattern)
What is cerebral perfusion pressure
The BP gradient across the brain
Contraindications for physiotherapy management
Cardiovascular instability
Neurological instability I.e seizures
Non-reactive dialted pupils
Temp above 40 degrees
Nasal suction with base of skull fracture
Haematological instability (platelets lower than 50x10^9L)
Define DIC (Disseminated intravascular coagulation)
A condition in which small blood clots develop throughout the bloodstream blocking small blood vessels due to overactive proteins
What is phase 1 of DIC
Thrombotic phase
Numerous small thrombi and emboli form throughout the microvasculature causing blockage of circulation and ischemic organ damage.
What is phase 2 of DIC
Fibrinolytic phase
The fibrin degradation products suppress thrombin and have an anti-haemostatic effect aggravating bleeding
Risk factors for the development of DIC
Blood transfusion reaction
Cancer
Pancreatitis
Liver disease
Infection of blood
Pregnancy complications
Recent surgery or anesthesia
Signs and symptoms of excessive blood clotting
Chest pain with shirtless of breath (PE)
Pain, swelling and redness if DVT
Headaches, speech changes, paralysis and dizziness (stroke)
Heart attack
Signs and symptoms of internal bleeding
Blood in your urine
Blood in stools (dark, tarry colour)
Headaches, double vision and seizures
Define acute renal failure
Sudden loss of the ability of the kidneys to excrete waste, concentrated urine, conserve electrolytes and maintain fluid balance in the body
Comorbidities associated with development of ARF
Hypertension
Diabetes
Chronic heart failure
Liver disease
Obesity
Chronic infection
Autoimmune disease
Clinical presentation of ARF
Decreased urine output
Swelling of the legs, ankle and feet
Shortness of breath
Fatigue
Fever
Loss of appetite
Arrhythmia
Nausea and vomiting
Confusion
Joint pain
Coma and seizures
Nosebleed
Symptoms of ARDS
cyanosis
Decreased respiratory compliance
Hypoxemia
Acute onset of severe dyspnoea
Risk factors for development of ARDS
Sepsis
Multiple blood transfusions
Pnuemonia
Drug overdose
Near drowning
DIC
multiple trauma
Diabetes
Classification of ARDS
Primary or secondary
Primary ARDS
Failure of lungs alone
Direct pulmonary injury e.g near drowning, gastric Aspiration
Secondary ARDS
Failure of lungs due to systemic disease
Sepsis
Multiple trauma
Multiple transfusions
List the 3 stages of ARDS
Exudative
Poliferative
Fibrotic
Exudative phase
1st week of onset symptoms
Increased pulmonary vascular permeability leading to alveolar oedema
Intrapulmonary shunt causes severe hypoxemia
Surfactant lost due to oedema
Damage to type 1 and 2 pnuemocytes
Decreased lung compliance
Pt presents with dyspnoea and tachypnoea
Poliferative phase
Week 1-2
Activation of type 2 pnuemocytes and fibroblasts
Lung compliance decreased and become heavy
Airway and lung tissue resistance increase
Fibrotic phase
More than 2 weeks
Macroscopically coarse cobble-stoned lungs
Excessive depositions of collagen and diffuse fibrosis
Further decreased lung compliance
Benefits of prone position
Decrease intrapulmonary shunt
Decrease mortality
Decrease the amount of FIO2 needed
Improves oxygenation
No haemodynamic complication
Advantages of negative pressure ventilator
Decreased risk for pnuemonia
Decreased need for sedation
Less decrease in cardiac output
Cheaper than positive pressure ventilation
Comfortable for patient
Easy to wean patient
Disadvantages for negative pressure ventilation
Difficulty to suction pt
Inability to generate high intrapulmonary pressures
Limited access to the pt body
Contraindicated where you cannot maintain upper airway
Pressure sores
Indications for mechanical ventilation
PaO2 less than 60mmHg
Inability to clear secretions independently
Increasing exhaustion of respiratory muscles
Increased confusion and inability to protect airway
Loss of bulbar function
Life threatening disorder of another system
Elective preoperative ventilation
Therapeutic hyperventilation
GCS of 8 or lower with TBI
CNS depression
Burns above 50% BSA OR 40% with inhalation injury
Signs of Tracheal tube obstruction
Patient anxiety
Use of the accessory muscles and possible nasal flaring
Dismissed breathe sounds on auscultation
High PIP and low tidal volume readings
What is the purpose of hemodynamic monitoring ?
To determine the patient’s efficacy of cardiac function and to determine their fluid replacement needs
What are the associated complications associated with Swann-Ganz Catheter
Invasive monitoring (pulmonary artery catheter)
Pulmonary infarction
Perforation Of the pulmonary artery
Ballon can rapture leading to pulmonary embolism
Catheter kink and intra cardiac knotting
Pneumothorax
What’s to remember with cardiac function index
Normal (4.5-6.5l/min)
If less than norm pt may not tolerate techniques increasing demand of myocardium
What to remember with pulmonary occlusion pressure (PAOP)
Normal 6-12 mmHg
If low pt may not be able to tolate positive pressure techniques (MHI, VHI or upright sitting)
What to remember with systemic vascular resistance (SVR)
Normal (700-1600 dyn/s cm3)
If low pt may not tolerate positive pressure interventions
What is hypoxia
Inadequate deliver of oxygen to body tissues (PaO2 less than 60mmHg)
List the pathophysiology Basis of hypoxemia
V/Q mismatch
Hypoventilation
Diffusion limitation
List the different types of hypoxemia
Anaemic hypoxemia
Stagnant hypoxemia
Histotoxic hypoxemia
Hypoxic hypoxemia
Clinical features of hypoxemia
Restlessness
Confusion
Sweating
Tachycardia
Hypertension
Cyanosis
Worsening neurological signs of hypoxemia
Blurred vision
Tunnel vision
Loss of coordination
Impaired judgement
Convulsions
Long-term effects of hypoxemia
Pulmonary hypertension
Death
Cardiac arrthymias
Tissue damage and organ dysfunction
What is non-invasive ventilation
Delivery of mechanical ventilation to the longs with techniques that do not involve the endotracheal airway
Aims of non-invasive ventilation
Improve gas exchange
Optimize lung volumes
Reduce WOB
List non-invasive ventilation
Negative pressure vent
Abdominal displacement vent
Positive pressure vent
Diaphragm pace (stimulate phrenic nerve)
Glassopharyngeal breathing
Explain how does the negative pressure vent works
It’s works by delivery pressure below the atmospheric pressure increasing transpulmonary pressure to increase and the atmospheric pressure in the mouth to inflate the alveolar
Exhalation is passive
Explain how does the abdominal vent work
Patient relies on the displacement of the abdominal visceral organ encourage motion of the diaphragm and ventilation
Explain how does the positive pressure vent work
Delivering of increased pressure of gas (above atmospheric pressure) to the airways causing alveolar distensing pressure therefore inflating the lungs
What is CiPAP
continous positive airway pressure
During both inhalation and Exhalation
Benefits of CPAP
Constant p during inhalation and Exhalation increased FRC
opens collapsed alveolar
Less intrapulmonary shunting occurs
Improved oxygenation
What is BiPAP ?
Cycles between 2 different positive pressures
List the 2 different kinds of BiPAP
Inspiratory PAP
Expiratory PAP
List the short term goal of NIPPV
Reduce work of breathing
Improve or stabilize gas exchange
Optimize pt comfort
Good patient ventilator synchrony
Minimize risk
Avoid intubation where possible
List long term goal of NIPPV
Improve sleep duration quality
Enhance functional status
Prolong survival
List the 3 stages of shock
Preshock
Frank shock
Refractory shock
List the types of shock?
Cardiogenic shock
Hypovolaemic shock
Neurogenic shock
Septic shock
List the classification of ICU acquired Weakness
Critical illness polyneuropathy (CIP)
Critical illness myopathy (CIM)
Critical illness neuromyopathy (CINM)
Name the problems that critically I’ll patients often present with
Increased WOB
decreased lung volume and lung compliance
Decreased mucociliary clearance and secretion retention
Decreased gas exchange
Weakness of extremely and resp muscles
Complications following OHS
post operative pulmonary complications
Cardiovascular instability
Sternal complications
Stroke
Hemorrhage
Myocardial ischemia
List the risk factors for sternal complications (Pre-screen)
Smoking
Diabetes
Obesity
COPD
large chest circumference
Females with large breasts
List pathophysiological basis of hypoxemia
VQ mismatch
Hypoventilation
Diffusion limitation
List the different types of hypoxaemia
Anaemic hypoxemia
Stagnant hypoxemia
Histotoxic hypoxemia
Hypoxic hypoxemia
