The Critically Ill Patient Flashcards
ABCDE: What signs can we see with ‘Airway’?
- Ability to speak?
- Difficulty with breathing?
- Noisy/silent breathing? → stridor, wheezing, gurgling, snoring
- ‘See-saw’ breathing pattern?
Theatre recovery is a classic place where people develop airway obstruction, where pts may not have protected airways and are recovering from anaesthesia - shows a ‘see saw’ pattern
ABCDE: What treatment can be administered for airway?
- Airway opening → head tilt-chin lift
- Removing foreign object
- Suctioning
- Simple adjuncts → OP, NP airways
- Adanced airway → LMA, intubation
ABCDE: What signs do we look for in B (breathing)?
- Respiratory rate
- Work of breathing → accessory muscles, distress
- Lung sounds → rales, creps, wheezing
- Oxygenation → cyanosis, SpO2
ABCDE: What treatment can we give for B?
- Oxygen
- Treating cause eg. draining PTX
- Assisting ventilation → NIV (eg CPAP)
- Nebs
Why is resp rate important?
- One of the most important signs of clinical deterioration
- Normal 12-20/min
- Low → usually drug related or due to neurological conditions
- High → v important sign for recognition of sick pt
ABCDE: What signs do we look for in C?
- Pulse → HR, volume
- BP
- HF signs → neck veins, oedema, creps
- Perfusion → LoC, diuresis, CRT
- Bleeding, fluid loss
- ECG: rhythm analysis
- ABG/VBG → lactate
ABCDE: What treatment can be given for ‘C’?
- IV access, blood tests
- Fluid
- Monitor
- Electric cardioversion
- Bleeding control → vasopressors, noradrenaline
What are the three ‘windows’ of shock, in regards to the influence of reduced perfusion on the body?
- Peripheral window → skin that is cold, clammy and blue, pale or discoloured
- Renal window → decreased urine output 0.5 mL/kg/h
- Neurologic window → altered mental characterised by obtundation, disorientation and confusion
ABCDE: What signs fo we look for in ‘D’?
- AVPU or GCS
- Pupils
- Blood sugar (BM)
- Fast neurologic assessment
ABCDE: What treatment can we give for ‘D’?
- IV glucose - BM <3 mmol/l
- IV thiamine
How do you score GCS?
What is AVPU?
- Alert
- Voice
- Pain
- Unresponsive
ABCDE: What signs do we look for in ‘E’?
- Remove clothes to enable thorough examination (maintain dignity)
- Detailed history
- Medications
- Allergies
- Temperature
ABCDE: What treatment can we give for ‘E’?
- Take temperature
- Avoid heat loss
What is the formula for cardiac output?
- CO = HR x SV
- SV: preload, afterload and contractility
- preload → end-diastolic volume
- afterload → resistance that ventricle is working against (eg LV wall thickness)
Afterload is difficult to deal with acutely, maybe dealing with vascular resistance such as dilating vessels, but preload is easier to tweak
Starling’s law states that the more the heart fills the harder it will contract therefore the bigger the stroke volume (up to a point)
Which factors affect stroke volume?
What does the Frank-Starling curve look like?
- X axis - cardiac preload
- Y axis - stroke volume
What is a positive response to a fluid challenge?
- A positive response is an increase in CO in response to 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
What is the origin of shock?
- Decrease in venous return due to loss of circulating volume → due to internal or external loss of fluids
- Failure of heart pump function results from loss of contractility → ischaemia, infarction, myopathy, myocarditis or a major arrhythmia
- Obstruction → PE, T.PTX, cardiac tamponade
- Loss of vascular tone results in maldistribution of blood flow → sepsis, anaphylaxis, or spinal injury
What are the levels of critical care for adult patients, in accordance with the Intensive Care Society (2009)?
- Level 0 → pts needs met through normal acute ward care
- Level 1 → risk of condition deteriorating, or those recently relocated from higher levels, needs can be met on acute ward w/ additional advice and support from critical care team
- Level 2 → requiring more detailed care incl support for a single failing organ, post op care and those ‘stepping down’ from higher levels
- Level 3 → requiring advanced resp support alone or basic resp support together with support for at least 2 organ systems - this level includes all complex pts requiring support for multi-organ failure
