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).
How can you measure ICP?
- Pupils
- Reverse Jugular (RJ)
sats: 65-75% - ICP bolt
How can you monitor ICP?
• Extra ventricular drains
(EVD)
• Need to turn off prior to
moving / treating patient
• Bone Flap (looks like a cyber man thing fucking crazy shit honestly)
• Don’t lie patient on side
of bone flap
What do you need to be aware of for a renal system assessment?
- Maintenance of fluid balance
- Too much vs too little
- Urine output = 1 ml/kg/hr
- Anuric = no urine output
- Oliguric = low U OP
- Polyuric = High U OP
What do you need to be aware of for a Haematological system assessment?
• Temperature 36-37°c • >37.5°c – pyrexia • White cell count (WCC) 4-11 x 10/1 • Haemoglobin (Hb) 11-16 g / 100ml women; 14-18 g / 100ml men • < 8 g anaemic
Clotting • Platelets – 150-400 x 10/1 Electrolytes • Na 135-145 mmol/litre • K 3.5-5 mmol/litre • Cl 97-107 mEq/L
What do you need to be aware of for a MSK system assessment?
• Assessing ROM – usually done passively
• Any resistance to movement?
• Any reduction in range?
• TA length – at risk of losing range rapidly
• Positioning / splinting required?
• Any contraindications or precautions to
movement e.g. trauma / fracture?
What are Aerosol Generating Procedures?
Aerosol Generating Procedures AGPs create an airborne risk of transmission of COVID-19. - AGPs include: • Intubation • Extubation • Bronchoscopy • High flow nasal oxygen
- Use
• Non-invasive ventilation
• Tracheostomy
• CPR prior to intubation
‘Many respiratory
physiotherapy interventions
are potentially aerosol
generating procedures. While there are insufficient
investigations confirming the AGPs of various
physiotherapy interventions the combination with cough
for airway clearance makes all techniques potentially AGPs’
Just a Covid thing
What do you need to be thinking of when making a problem list?
What are the patient’s problems?
- What problems are amenable to physio?
- Are there any contraindications to
treatment? - Treatment plan?
- Outcome measures?
Role of the Physio in Critical Care?
- Traditionally sputum clearance
- Rehabilitation now a big part of role
- Weaning from ventilation, extubation,
decannulation. - Handover and onwards referrals
- ICU follow up clinics
