Intensive Care - Short Cases Flashcards
- Describe the CT appearance.
- What is a normal range of values for Intra-cranial pressure (ICP)?
- How are ICP, Mean Arterial Pressure (MAP) and Cerebral Perfusion Pressure (CPP) related?
- Why is there a need to maintain targets for ICP and CPP in these patients and what are the
recommended targets? - What 5 patient factors predict a poor outcome in TBI?
What 5 conditions must be met before formal brain stem testing can be performed?
Case – End of Days
Mr Simpson is a 35yo man who was riding a motor bike without a helmet and crashed into a tree at high speed while attempting to dodge a stray dog that had run onto the road. He suffered a massive traumatic brain injury, and the surgeons are unable to offer any therapy. He was intubated at the scene by ambulance officers with a GCS of 3 and now 24 hours later is in your intensive care unit with a pulse of 40, BP of 200/100 and fixed dilated pupils.
What are the 3 components of clinical brain stem testing?
Examination
After this four-hour period, clinical testing is carried out by two medical practitioners of specific experience and qualifications. No fixed interval of time is recommended between the two clinical tests.
https://www.anzics.com.au/wp-content/uploads/2022/04/ANZICS-Statement-on-Death-and-Organ-Donation.pdf
What 4 investigations can be performed to diagnose brain death when clinical testing cannot be
performed?
Case Scenario - Lying Around
A 28yo man is brought in by ambulance after a friend found him collapsed on the floor. He was surrounded by empty medicine bottles and the ingested substances were mainly benzodiazepines, quetiapine and sodium valproate. He was last seen 2 days previously so the time of ingestion is unknown. His initial obs in ED are a GCS of 5, Temp 33.4, PR 120 BP 85/55 and RR 8. The toxicologist review him and after some initial investigations advise no specific therapies for the overdose other than supportive care. He is intubated for airway protection and admitted to intensive care. You note he is anuric and his initial blood tests on 50% oxygen show:
Describe the acid base and electrolyte abnormalities and give the most likely diagnosis?
List 8 causes of rhabdomyolysis and the common clinical features.
4 Main points for the management of Rhabdomyolysis?
What are the likely causes of this lady’s presentation?
(List 7)
Describe her arterial blood gas and list the diagnostic criteria for ARDS (4).
Her initial ABG shows as acidaemia. There is a metabolic acidosis with appropriate respiratory compensation: predicted CO2 = (1.5x HCO3) + 8 mmHg
What are the methods available of improving oxygenation in ventilated patients? (7)
The methods available for improving oxygenation in mechanically ventilated patients are:
1. Increase the FiO2.
2. Physiotherapy and suctioning
3. Increase the mean airway pressure, primarily by increasing PEEP.
4. Change ventilation mode (consider using modes that reduce expiratory times Eg. inverse ratio ventilation, APRV and HFOV)
5. Change patient positioning (consider prone position)
6. Inhaled NO
7. Negative fluid balance and restrictive fluid strategies viii) cardiopulmonary bypass (ECMO)
What are the causes of ARDS?
- 5 Common Intra-pulmonary Causes?
- 7 Common Extra-pulmonary Causes?
The causes of ARDS are multiple and varied. It is often divided into Intra-Pulmonary and Extra- Pulmonary as the intrapulmonary causes seem to have less compliant lungs that have more oxygenation difficulties and poor responsiveness to increased PEEP.
Case scenario - Yellow
A 30yo lady is brought to the emergency department 30 weeks pregnant by her husband feeling unwell. This is her 1st pregnancy and had been progressing uneventfully. The husband had noted that for about a week she had a yellowish tinge to her skin and eyes. She was due to see her obstetrician tomorrow so they were going to mention it then. Today she was drowsy when she woke up and has been confused and unsteady on her feet. When you first see her she is agitated and disorientated to time and place. She is overtly jaundiced and has a tender right upper quadrant with hepatomegaly. Her initial blood tests show:
What are 7 causes of acute liver failure and which 3 are specifically related to pregnancy?
- What is the definition of acute liver failure?
- What clinical signs would you look for to suggest chronic liver disease as opposed to acute
liver failure?
Acute Liver Failure: Evidence of liver necrosis associated with:
a. Jaundice
b. Coagulopathy (INR>1.5)
c. Encephalopathy of any grade
The time to onset of encephalopathy after the onset of jaundiced is further used to subclassify it into hyperacute (<7 days), acute (7-21 days) and subacute (3-26 weeks) but these are of little use clinically as they do not affect outcome.
What is the cause of the altered mental state in patients with acute liver failure?
Altered mental state in acute liver failure is multifactorial but an important component of it is the high plasma ammonia level due to impaired hepatic function being unable to process it.
Case - A 60-year-old unidentified male is found in a park with a reduced level of consciousness. There is no obvious sign of injury. He is bought into the emergency department where further diagnosis and management of his condition is continued and supportive care provided.
Q1 - Provide a diagnostic approach to a patient with a reduced conscious state.
This question is testing
a) Knowledge
BUT ALSO
b) The way ones structures it
By structuring it, a mechanism is used to maximise your answer which is good for marks, but more importantly is good for patients!
What are the 4 types of intracranial haemorrhages?
Different types of intracranial haemorrhages
1. Parenchymal
2. Subdural
3. Epidural
4. Subarachnoid
SAH with hyperdensity in subarachnoid space and enlarged temporal horns
Describe this Head CT.
Mass effects = Midline shift towards the patients left & Effacement of the ventricles
Left subdural with a previous SD
Right ventricular dilatation
Loss of sulci/gyri
Characterise this ABG.
This patient has an uncompensated respiratory acidosis, is hypoxaemic and has mild hyperlactaemia.
The patient does not open his eyes and makes only incomprehensible noises to painful stimuli. His Glasgow Coma Scale (GCS) score is 7. What is the motor component of this score? What is the significance of the GCS in this case?
E = 1
V = 2
M = 4 = Withdrawal from pain
Implication: GCS – not protecting his airway, needs to be ventilated.
Outline 3 indications and 7 contraindications for non-invasive ventilation.
Indications for NIV
1. COPD exacerbations
2. Acute pulmonary oedema - the increased PEEP reduces the Left ventricular afterload so it actual helps the left ventricle to do less work
3. Hypoxic respiratory failure (less so)
Contraindications for NIV
1. Coma, seizures, severe neurological disturbances
2. Inability to protect airway
3. Unstable haemodynamics
4. Upper GI bleed
5. Recent facial surgery/trauma/#s
6. Undrained pneumothorax
7. Vomiting/excessive secretions
A patient with an intracranial haemorrhage proceeds to theatre and returns with an intracranial pressure monitor. Describe the components of his neurological intensive care management and their rationale.
FAST HUGS IN BED
Neuroprotective measures
CPP = MAP – ICP
A patient is extubated on D5 post EVD insertion for intracranial haemorrhage and is discharged to the ward a few days later. He is making a good neurological recovery. He undergoes a rapid response call after hours. He appears distressed and his vital observations are as follows:
- RR 28/min
- BP 74/45
- HR 107/min
- Temp 36.5ºC
- Sats 96% on 2L nasal prong oxygen.
Outline your approach. Comment on his ECG.
“I am concerned about this patient and feel this is a critical situation given how hypotension he is so I would conduct a simultaneous assessment an management using an A to E approach.”
ECG - ST elevation in the anterior leads (V1-V4) with reciprocal changes in the inferior leads (II, III, aVF) - LAD most likely affected.
- Initiate ALS & Call Cath lab
What are the 2 shockable rhythms - what do they look like on ECG? What % of cardiac arrests do they make up?
What is the mechanism of shock that results from his condition - pulseless VT?
= Cardiogenic Shock
- “a life-threatening, generalised form of acute circulatory failure resulting in inadequate oxygen utilisation by the cells.
- Cellular dysoxia results (loss of adequate O2 delivery for the cell’s oxygen consumption)
Compare the clinical features of cardiogenic and distributive shock.
A patient who has had an incranial bleed & post-op MI/VT. With good management in ICU, he makes a recovery over the following three days. His U & E results, which were normal on hospital admission, are now as follows.
- Characterise his acute kidney injury.
- Describe your management of his AKI.
Principles of Management
1. Treat & Reverse underlying cause
2. Optimize intravascular volume status.
- DO NOT allow hypovolaemia!
3. Optimize cardiac output / BP - MAP >70mmHg (usually >65 but they need good renal perfusion + usually these patients are slightly hypertensive anyway so they can cope)
4. Avoid nephrotoxins.
5. Dialysis if required = supportive only
