Management of the Critically Ill Patient

Question 1

What is ABC

Answer 1

Airway, breathing, Circulation

Question 2

MEDB?

Answer 2

Minium Emergency Database

Question 3

How to Triage?

Answer 3

• Prioritizing
• Key biody systems
• Bring diagnostics to the patient POC
• Criteria: bleeding, resp, CRt, wounds/ fract
• MEDB
• Other POC tests: ECG, BP, oximetry
• Serial analysis!

Question 4

What tends to be our MEDB?

Answer 4

• PCV
• TSP
• BUN
• Glucose
• Blood lactate
• Blood smear
• Potassium

Question 5

How do we go about stabilisation?

Answer 5

• give oxygen
• Place IV cath
• Stop any obvious bleeding- CCPR?
• Analgesics and other drugs
• MEB, POCUS?

Question 6

Describe the Secondary survery

Answer 6

• After primary survey and initial stabilisation
• Nose-to-tail exam
• Further diagnostics if stable
• Make sure owner on board with £££

Question 7

What is SIRS ?

Answer 7

Systemic inflammatory response syndrome -> inflammatory mediators enter circulation - progression same for each disease

Question 8

How happens as a result of SIRS?

Answer 8

• Peripheral vaso-dilation
• Micro-capillary blood shunting
• Inc capillary permeability
• Depressed cardiac function
• Multiple organ dysfunction

Question 9

What is MODS

Answer 9

Multiple Organ Dysfunction (Syndrome)

Question 10

What does MODS affct?

Answer 10

• Respiratory
• CV
• Renal ysfunction
• Haematological ysfunction
• GI dysfunction
• Liver
• Nervosu system dysfunction

Question 11

What prophylactic monitoring/tx can we do against MODS

Answer 11

• Peripheral vasodilation
• Inc capillary permeability
• Depressed cardiac function
• Target organ dysfunction

Question 12

What is Kirby’s rule of 20 ?

Answer 12

All parameters to monitor in critically ill patients

Question 13

What to think about for Fluid Balance?

Answer 13

• Is it indicated?
• What type of fluids?
• Ho much?
• Rate?
• How to monitor (CRT, HR, MM, Temp, PCV …)

Question 14

When should we be cautious with when admin of fluids?

Answer 14

• Respiratory distress (can get oedema)
• Head trauma
• Bleeding (can be triggered)
• Heart dx (volume overload)
• False impressions

Question 15

Recap of Fluid Therapy basics

Answer 15

• Fluid require= Replacement + Maintenance + Ongoing losses
• Replacement = BW x dehydration x 10= ml rq
• Maintenance = (BWx30) + 70 = ml rq

Question 16

What are signs of circulatory overload?

Answer 16

• Restlessness
• Shivering
• Tahcypnoea
• Crackles
• Coughing
• Oedema

Question 17

How to monitor Oxygenation & ventilation?

Answer 17

• CLinical exam
• Blood gas eval
• Pulse oximetry
• Supplement oxygen (mask, cage, flow by)

Question 18

BP= … x ….

Answer 18

BP = CO x VR (with CO= HRxSV)

Question 19

What should MAP be?

Answer 19

above 60mmHg ; Systolic > 80mmHg

Question 20

What are different BP measurement options ?

Answer 20

• doppler -> systolic BP only
• Oscillometric machine -> systolic, diastolic, MAP
• Invasive monitoring -> catheter in dorsal pedal artery measures arterial pressure

Question 21

Normal glucose?

Answer 21

3.3-5.5 mmol/L

Question 22

If low blood glucose how would you supplement glucose?

Answer 22

• 50% dextrose at 0.5-1ml/ kg
• Dilute with sterile water to prevent hemolysis
• Add to drip fluid as CRI (to not get an immediate drop after bolus)

Question 23

What causes of dec blood glucose?

Answer 23

• sepsis (SIRS, MODS)
• Puppies and kittens
• certain toxins (xylitol)
• Paraneoplasti hypoglycaemia
• Insulinoma
• Insulin overdose
• Working dogs

Question 24

What causes of INC blood glucose?

Answer 24

• Stress
• Diabetes mellitus
• Oer supplementation
• Cranial trauma
• Severe pancreatitis

Question 25

What are the two types of Hypothermia?

Answer 25

Primary - exposure
Secondary - (SIRS etc)

Question 26

Describe Hyperthermia

Answer 26

• temp > 41°C
• Do not cool febrile patients if under 41
• Always cool heat stroke patients
• Seizures & muscle activity can cause this
• Dont go below 39°C

Question 27

Role of albumin?

Answer 27

Oncotic pull, carrier protein, tissue healing (>70% of oncotic pressure)

• Maintain > 20g/L

Question 28

Persistent hypoalbuminemia associated with ….

Answer 28

poor prognosis

Question 29

How can we make up for low albumin ?

Answer 29

• Plasma transfusion
• Albumin transfusions
• Synthetic colloids

Question 30

What electrolyte disorders commonly found in critically ill patients?

Answer 30

• Hypokalaemia & hypocalcemia
• Refeeding syndrome: hypoG, hypoK, hypoP, hypo Mg
• Diabetic ketoacidosis= hypoK & hypoPhos
• Renal failure: hyperphos & hyper- or hypokalaemia

Question 31

Most important electrolyte to monitor for?

Answer 31

Potassium ->important in vomiting / anorexic patients

Add to fluids! Max rate 0.5 mEq/kg/hr

Question 32

Describe evaluation of mentation?

Answer 32

• Level of consciousness
• Aware of surroundings
• Coma scale
• Seizures
  -hypoglycaemia
• IC pressure
• Oxygen

Question 33

Role of Nutrition in CIPs?

Answer 33

• Higher metbaolic needs
• GIt barrier breakdown and malabsoprtion
• dec immunity
• Disrupted microflora
• Dec organ function
• delayed wound healing
• dec muscle strength

Question 34

What is Refeeing syndrome ?

Answer 34

• Rapid reintroduction of food after prolonged undernourishment
• Intracellular shifting of electrolytes and glucose that can be fatal

Question 35

Describe normal ranges of urine output

Answer 35

Normal = 1-2ml/kg/h
Oliguria = <0.5-1ml/kg/h
Polyuria = >2ml/kg/h

Question 36

Coagulation considerations?

Answer 36

• Hyper-coagulable
• Hypo-coagulable
• DIC
• Loss of clotting factors or platelets

Tx: vit K and/or Plasma