Introduction to Acutely Unwell and Critical care Flashcards
Aims
• Understand and explain the underlying
philosophy of intensive care.
• Describe and explain intensive care unit (ICU)
monitoring of cardiovascular, respiratory and neurological systems.
• Justify the role of physiotherapy within the
multidisciplinary team (MDT) in ICU based on
evidence.
What is NEWS₂?
= National Early Warning Scores.
- Analysis of the observations recorded
- Obs given a score in relation to normal range
- Sum of scores used to determine clinical
management - Allows identification of sick patients and
appropriate escalation of care
see 3mins in to lecture for YouTube video.
What NEWS₂ score ranges are considered:
- Low
- Low-Medium
- Medium
- High
- Low: 0-4
- Low-Medium: 3
- Medium: 5-6
- High: 7+
What is the required response for the different NEWS₂ score ranges?
- Low
- Low-Medium
- Medium
- High
- Low = Ward-based response - Low-Medium = Urgent ward-based response - Medium = Key threshold for urgent response - High = Urgent or emergency response
What to do next after detecting a high or worrying NEWS₂ score?
- Ensure you know what escalation plans are in
place/ceilings of treatment. - Call the appropriate people – you are not
alone! - Have the relevant information ready and
ensure the handover you provide is effective. e.g. SBAR.
What does SBAR stand for?
- Situation
- Background
- Assessment
- Recommendation
Why do we need critical care and what does it typically involve?
- Levels of care 0-3.
- Unable to breathe unassisted.
- Multi organ failure (2 or more).
- Specialist monitoring and treatment of critically
unwell patients. - Intensive nursing / monitoring whilst critically ill.
What should you have in mind during an objective assessment in ICU?
- Systematic approach
- Multi-systems assessment
- Consider implications for physio
- Formulate problem list
- Who else within the MDT needs to be
involved?
What are the 2 main types of multi-systems assessments?
Rapid systems assessment=
ABCDE: Airway, Breathing, Circulation, Disability (AVPU/GCS), Exposure.
Body systems:
- Respiratory
- Cardiovascular
- Neurological
- Renal
- Haematological
- MSK
What should you look for when assessing a patient on a ventilator? pt1
- How much work is the patient doing?
- Patient triggering all their own breathing?
- Patient and ventilator working together?
- Ventilator doing all work?
- What’s their respiratory rate? (normal 12-16)
- What’s their tidal volume? (6ml/kg)
- Their ABG’s vs normal values, either have a note of normal values or revise them.
What should you look for when assessing a patient on a ventilator? pt2
Respiratory Pattern
- Increased work of breathing
- Accessory Muscle Use
- Paradoxical breathing
- Pursed lip breathing
- Cheyne stokes respiration.
Cough and Sputum
- Volume of secretions
- Colour of secretions
- Viscosity of secretions
- Odour??
- Are they clearing their secretions effectively?
- What’s normal for them prior to admission?
Auscultation - Listen to all lobes - Breath sounds? - Bronchial breathing? - Added sounds? - Palpation – expansion, tactile fremitus/ secretions?
Chest Drains - Pneumothorax - Pleural effusion - Cardiac surgery - Look / feel for surgical emphysema
Are they on Respiratory Drugs Bronchodilators - Short acting Beta 2 agonists (salbutamol) - Longer acting anticholinergics (tiotropium) Mucolytics - n-acetylcysteine, carbocystine Pulmonary vasodilators - Nitric Oxide What are they usually on when ‘well’?
Look at their Cardiac rhythm.
Can also look at recent scans CX, CXR.
What should you look for when assessing a patient on a ventilator? pt3
Cardiac Output
- CO = volume of blood pumped by heart in 1
minute.
- CO = SV x HR
- CO = 4-6 litres/min
- Low CO, poor perfusion to tissues → hypoxia.
Cardiovascular Drugs • Inotropes - Dobutamine - Milrinone • Vasopressors - Norepinephrine • Beta blockers -Atenolol, Propranolol • Vasodilators -GTN • Anti-arrhythmics -Amiodarone
What is a Swan Ganz Catheter?
Passes through right atrium, right ventricle
- Sits in pulmonary artery
- Measures Pulmonary Artery Pressure (PAP)
- Normal PAP 10-20mmHg
- Pulmonary Capillary Wedge Pressure (PCWP): 6-15mmHg
What type of mechanical assistance is there for the heart?
- Intra Aortic Balloon Pump (IABP)
- Sits in aorta
- Assists left ventricular function if poor EF
- Balloon inflates on diastole, deflates on
systole. - Vacuum ‘sucks’ blood out of left ventricle and
improves EF - IABP
- Pacemaker
What is involved in a neurological assessment on a ICU?
How awake / alert is the patient?
- Orientation?
- GCS – 15/15?
- PEARL?
- Sensation / tone changes?
- Any sedative drugs?
- Any paralysing agents?
Intracranial Pressure
- ICP <15 mmHg
- Cerebral Perfusion Pressure (CPP) > 70mmHg
- Ensures adequate perfusion of brain
- CPP calculated by MAP – ICP.
Munro-Kellie Doctrine - Brain made up of 5% blood 10% CSF 85 % brain tissue - Skull is a rigid box. - Increase in one component → relative ↓ in others. - If ICP too high → herniation of brain tissue (conning and brain stem death).
