Intensive Care

Question 1

DO2 = CO x [1.39 x Hb x SaO2 + (0.003 x PaO2)]

What here is crossed out and why?
What would reduce in anaemia/resp problems? How to compensate this?

Answer 1

(0.003 x PaO2) bc minimal contribution

Hb x SaO2 reduce in anemia/resp problems

The only way to compensate when Hb and SaO2 are low is an increase in CO

Question 2

What happens with inadequate DO2 (shock)?

Answer 2

Dysoxia → ANAEROBIC RESP
Glycolysis
2 ATP only bc no CTA or ETC
= CO2, lactate and H+

Causes:
↑ HR
↓ BP
Resp rate change
Urine output change

Question 3

Approach to a sick patient

Answer 3

ABCDE

Airway and Oxygenation
Breathing and Ventilation
Circulation and Management of Shock
Disability due to neurological deterioration
Exposure and examination

Allows for rapid interventions while reassessing the patient
(O2, IV access and fluids ± specific treatment)
Can be repeated as many time as possible
Should not take more than 5 minutes

Question 4

A: Airway and oxygenation

Answer 4

Is the airway patent?
Can the patient talk?
Does the patient sound distressed?
Short sentences sign of high RR?

Talk about signs of airway compromise- look, listen, feel
Talk about putting on oxygen!

Question 5

B: Breathing and ventilation

Answer 5

Respiratory Rate is one of the most important signs of clinical deterioration

Normal 12-20
Low usually drug related or due to neuro conditions
High >20 is a very important sign for the recognition of a sick patient.

Is the chest clear
Is the ventilation bilateral and equal?
Cyanosis?
SaO2? >94% on how much oxygen?
If below <94% give some oxygen

Question 6

Management of breathing

Answer 6

You have given oxygen

Treat as you find:
Nebulisers for wheeze (steroids, magnesium)
? Decompression for pneumothorax, haemothorax etc)
NIV (non invasive ventilation) for hypercarbic respiratory failure?

Question 7

C: Circulation and Management of Shock

Answer 7

HR (60-90) and what is normal for the patient?
BP? What is the normal blood pressure?
Capillary refill time (< 2 sec normal)
Temperature of limbs
Heart sounds?
Urine Output?
Oedema?

Question 8

Management of circulation

Answer 8

IV access (large bore) x ?
Bloods (FBC, UE, CRP, LFTS, Coag, BC, VBG etc)
Fluid challenge eg if low volume

Question 9

Fluid challenge

Answer 9

A positive response is an increase in cardiac output in response to the increased volume.

• Heart rate decreases
• Mean arterial pressure increases
• Arterial pulse pressure increases
• Urine output increases
• Lactate clearance increases
• Cardiac output or stroke volume increase

Question 10

D: Disability due to neurological deterioration

Answer 10

Glasgow Coma Scale
AVPU scale
BM? 4.4 to 6.1 mmol/L (79,2 to 119 mg/dL)
don’t ever forget glucose

Question 11

Glasgow coma scale (eye, verbal, motor)

Answer 11

Question 12

AVPU

Answer 12

Is the patient:

Alert
Voice
Pain*
Unresponsive*

*severe concern

Question 13

E: Exposure and Examination

Answer 13

Temperature, rest of the physical examination

Question 14

Steps after ABCDE assessment

Answer 14

History
Background (comorbid state, how much is new)
Obs chart (trends)
Drug Chart
ABG
pH
pCO2  		(high but also low is bad)
pO2 		(on how much oxygen)
BE
HCO3
Lactate 		(normal < 2 mmol/L)
Imaging eg X ray, portable

Question 15

How to communicate your findings?

Answer 15

SBAR
S=Situation (a concise statement of the problem)
B=Background (pertinent and brief information related to the situation)
A=Assessment (analysis and considerations of options — what you found/think)
R=Recommendation (action requested/recommended — what you want)

A is also for action appropriate to your skill mix and location!!