GENERAL ICU
12/8/10
Venkatesh, B et al (2003) “Data Interpretation in Critical Care Medicine” Elsevier
Alex Pirides Notes
PY Mindmaps
FANZCA Part II Notes
Adrenal Crisis
Hyponatraemia
Hypotension
Hypoglycaemia
On steroids
Priorties:
A, B, C, D, E
Correct electrolyes
Glucose
Hydrocortisone 100mg Q6hours
Fludrocortisone 0.1mg QID
HDU/ICU
Endocrine
Agitation
Diagnose cause and management
A, B, C, D, E
COMMON
Pain
Urinary retention
Drug effects
Hypoxia
Hypercarbia
UNCOMMON
Aspiration
MI
CVA
Drug allergy
Electrolyte
Airway Assessment
History – chart review
Examination – habitus, face, neck
Investigations – nasal endoscopy, CXR, CT
Jeremy Fernando (2011)
Airway Fire
Priorities
1.
2.
3.
4.
Extinguish fire
Ventilate patient
Quantify damage
Staff safety
Turn off O2
Disconnect patient from circuit
Remove ETT
Flood field with H2O
Ventilate patient with air
Perform laryngoscopy +/- bronchoscopy
Retintubate patient
Airway Obstruction
Priorities
1. open airway
2. oxygenation
Open and examine airway (foreign bodies)
FiO2 1.0
Ventilate and intubate if required
Amniotic Fluid Embolism
Priorites:
1.
2.
3.
4.
Prompt recognition
Prompt resuscitation (ACLS protocol)
Prepare for massive bleeding and coaguloapathy
Early delivery of fetus
Anaphylaxis
Stop trigger!
Optimise and manage A, B, C
FiO2 1.0 and verify
Head down/elevate legs
IVF
Adrenaline 50mcg boluses (adult), 10mcg/kg boluses (children) IV -> 0.1-1mcg/kg/min
Hydrocortisone 250mg IV
Promethazine 25mg IV
Ranitidine 150mg IV
Approach to an ICU Management Problem (REAC)
Resuscitate
Jeremy Fernando (2011)
Electrolytes + Acid-Base abnormalities
Antidotes
Causes
ARDS Ventilation
-
controlled ventilation
TV 6mL/kg
plateau pressure < 30cmH2O
PEEP titration 5-24
oxygenation target: SpO2 > 90, PaO2 > 60mmHg
permissive hypercapnia
other strategies: prone, iNO, inhaled prostacycline, ECMO
Aspiration
Priorities
1.
2.
3.
4.
Minimise further aspiration
Airway protection
Oxygenation
Management of complications
Head down
Left lateral position
Suction
Intubation (may have to intubate oesophagus first to isolate)
Suction of ETT until debris clears
Lung protective ventilation
Management of circulatory compromise (fluids, inotropes, CPR)
Empty stomach
Bronchoscopy +/- lavage
CXR
ICU
Chest physio
Atrial Fibrillation
Priorities
1. Assess for need for emergency cardioversion (shock, CHF, collapse, CP) – chemical or
electrical
2. Rate control
3. Rhythm control
4. Risk stratification for anti-coagulation
Auto-triggering
H2O in circuit
Sensitivity too high
Circuit leak
Cardiac oscillations
Jeremy Fernando (2011)
Patient actually breathing!
Bradycardia
Priorties
1. diagnose and treat cause
2. maintenance of end organ perfusion
3. support circulation
DIC
Stop all vagal stimulation
Look for and treat cause – hypoxia, drugs, myocardial, metabolic, surgical (CEA)
Assess A, B, C
Atropine 0.6mg IV (maximum 3mg)
Ephedrine 9mg IV
Adrenaline 10mcg boluses -> infusion
Pacing (external, wire, pacemaker)
Breathing Systems
Aims of a Breathing System
1. Remove CO2
2. Supply adequate amounts of O2
3. Allow delivery of anaesthetic gases
Classification
Non-rebreathing systems
Mapelson
A + Lack + Magills
B
C
D + Bain
E
F + Jackson Ree’s Modification of an Ayers T-Peice
Circle systems + CO2 absorber
Bronchospasm
Priorities
1. treat cause
2. maintain oxygenation
3. lung protective ventilation
Disconnect from ventilator and bag
FiO2 1.0 and verify
Jeremy Fernando (2011)
A – for patency and position
B – trachea, SpO2, ETCO2, chest movement and compliance, percussion and AE
C – review haemodynamics, rhythm
Ventilation
-
don’t worry about peak pressure (measure plateau -> inspiratory hold, < 30cmH2O)
long I:E ratio
measure auto PEEP (expiratory hold)
use PEEP (not higher than intrinsic PEEP)
use volume control
if using pressure watch TV
slower rate
Established Treatments
O2
Salbutamol IV – loading dose 15mcg/kg -> 0.1-1mcg/kg/min
Anti-cholinergics – ipratropium bromide 500mcg Q2-6 hrly NEB
Hydrocortisone 100mg IV Q6
Aminophylline 5mg/kg IV -> 0.1-0.7mg/kg/hr
NIV
Non-established Treatments
MgSO4 10mmol IV
Adrenaline 10mcg boluses IV -> 0.1-1mcg/kg/min
Ketamine 0.5mg-2mg/kg/hr IV
Heliox
Iso or Sevo
Cardiac Arrest
ACLS protocol
Priorities =
1.
2.
3.
4.
5.
6.
early defibrillation
high quality, uninterrupted CPR
support of circulation (fluid, adrenaline, antiarrhythmics, praecordial thump)
intubation + O2
treatment of cause (MI, arrhythmia, 5 H’s and 4 T’s)
post resuscitation care
Cardiogenic Pulmonary Oedema
Goals
1. maintain oxygenation
2. minimise myocardial work
A, B, C approach
FiO2 1.0
Jeremy Fernando (2011)
PEEP
Decrease Preload – diuretics, GTN, PEEP, morphine
Decrease Afterload – GTN, PEEP
Increase contractility – inodilator (milrinone)
Chest drain principles
First – drain fluid
Second – underwater seal drain
Third – apply suction
Coagulopathy
Assess circulation (pulse, BP, blood loss, urine output, colour, CVP)
Assess haemostasis (Hb, platelets, coag’s, fibrinogen)
Treat cause (dilution, acidosis, hypothermia)
Give volume
Appropriate products – RBC’s, PLT’s, FFP, Cryo
Anti-fibrinolytics – TXA
Compliant Against Myself
Duty
Duty
Duty
Duty
Duty
to
to
to
to
to
patient (go and see)
myself (support and advice)
my department (inform senior colleague and HOD if required)
my hospital
Medical Council and CICM
Death on the Table
Control scene and patient
Ask senior colleague to confirm death
Duty to Coroner
Duty to Family
Duty to staff (M+M)
Duty to myself
Duty to future patients (quarantine OT)
Document
Decreased LOC
COMMON
V/Q inequality – hypoxia, hypercarbia
Decreased Q – hypotension
Drug effect – sedatives, paralysis, analgesia, anti-emetics (droperidol)
Hypothermia
Hypoglycaemia
UNCOMMON
CVA
Jeremy Fernando (2011)
Increased ICP
Encephalopathy
Electrolyte abnormality
Mechanism
1. Bilateral hemispheric damage
2. Brainstem pathology
3. Diffuse depression/damage
Assess patient
Review and support - A, B (ABG), C (rhythm, BP, SpO2), D (pupils, GCS, BSL), E (temp)
Reverse drugs (naloxone 40mcg IV, flumazenil 100mcg IV, neostigmine 50mcg/kg, atropine
25mcg/kg)
Coma drugs (dextrose 20mL 50%, thiamine 100mg IV, antibiotics/antivirals, mannitol
0.25mg/kg)
Bloods – U+E, Ca2+, PO4, Mg
CT head
Wait
Decreased Urea:Creatinine Ratio (i am a SIMPLe SR)
Severe liver dysfunction
Intrinsic renal damage
Malnutrition
Pregnancy
Low protein diet
SIADH
Rhabdomyolysis
Difficult Intubation
Priorities = oxygenation and minimisation of airway trauma
Identify and prevent!
Consider waking up
BMV + adjuncts
Optimise position
* Tricks if time (McCoy, Chicaine, fast track, asleep fibre optic intubation)*
LMA
Surgical cricothyroidotomy
Distributive Shock
Sepsis
Anaphylaxis
Liver failure
Adrenal failure
Spinal
Haemophagocytic syndrome
DKA
Goals:
Jeremy Fernando (2011)
1.
2.
3.
4.
rehydration (prevention of cerebral oedema)
clear ketoacidosis
electrolyte supplementation
treat precipitant
- IV bolus rehydration for hypotension (use a balanced salt solution) -> maintenance (80%
normal)
- IV actrapid (start @ 1U/kg/hr) + start 10% dextrose once BSL < 15mmoL/L (keep running
until ketones in urine clear)
- K+ supplementation (need large amounts)
- measure urine output
Donation Post Cardiac Death (6 P’s)
Preconditions
Preparation
Process
Post donation time
Preparation for possible unsuccessful donation
Possibility of consent withdrawal
Drug Error
Causes:
1.
2.
3.
4.
Slips and Lapses (unintended errors)
Mistakes due to lack of knowledge or experience (intended errors)
Communication failures
Systems errors
Unfortunate mistake
Apologise
Open disclosure
Allow questions
Offer support
Document
Risk manage
MPS (if required)
Protect doctor
Incident form (AIMS)
M+M review
Eclampsia
Goals
1. treatment of seizure (and prevention)
2. prevention of complications
A - jaw thrust -> ETT
B - FiO2 1.0, bag-mask, SpO2
C - left lateral position (prevent aorto-caval compression), IV, BP
D - 4g MgSO4 IV over 5min -> infusion of 1g/hr for 24 hrs (theraputic level = 2-4mmoL)
Jeremy Fernando (2011)
Stablilse situation
Assess fetal well being & decide on when delivery appropriate
Status Epilepticus -> ?propfolol/thiopentone
Anti hypertensive treatments (aim SBP 140-160mmHg) -> hyrdralazine, labetalol, nifidepine
Electrical Safety
Macroshock = large amount of current flow that produces harm or death
Microshock = small current @ high density close to myocardium -> VF
0.1mA - to myocardium -> VF
<0.1mA – nothing
10mA – skeletal muscle spasm
100mA – VF
1000mA – muscular burn
General measures
Class of equipment (1, 2 and 3)
Type of equipment (B, BF and CF)
Equipotentiality
RCD’s (circuit breakers)
Line isolation monitors
Isolating transforms
Diathermy
Area classification (body and cardiac)
Emergency Management (DIC)
Declare emergency
Inform the team
Call for help
Equipment Template (IUD Method Of Contraception)
Item name
Uses
Description
Method of Insertion and/or use
Other information
Complications
Functions of the Vagus Nerve (B-Saphenous Vein Graft)
Branchial Motor
Secretomotor
Visceral Sensory
General Sensory
High AWP
Cause
Jeremy Fernando (2011)
1. Machine and circuit (supply, machine, ventilator, valves, filter)
2. ETT
3. Patient
Disconnect patient from machine
FiO2 via bag-mask
Airway for patency and position
Breathing (aspiration, bronchospasm, surgery related, increased abdominal pressure,
inadequate relaxation, MH)
Circulation review
Keep patient asleep with IV hypnotic
High Anion Gap Metabolic Acidosis (LTKR)
Lactate
Toxins
Ketones
Renal Failure
High Anion Gap + High Osmolar Gap (MADE SP)
Methanol
Alcoholic ketoacidosis
DKA
Ethylene glycol
Salicyclic acid poisoning
Pyroglutamic acidosis
High Frequency Oscillation Ventilation – mechanisms of gas transport (PAT the
Cat)
Pendelluft mixing
Augmented diffusion
Taylor dispersion
Co-axial flow patterns
Hypercalaemia (BIO)
Bone
Intake
Others
Hypermetabolic Syndromes
Thyroid storm
Phaemochromocytoma
MH
Sepsis
Liver failure
Serotonin syndrome
Jeremy Fernando (2011)
Cocaine toxicity
NMS
Hypercarbia
Causes
1. Measurement error
2. Increased production or administration – MH, sepsis, phaeochromocytoma, thyroid storm,
NMS, laparoscopy, tourniquet, CO2 gas insufflation or CO2 laser
3. Decreased removal – hypoventilation, V/Q inequality, CO2 absorber, circuit issue
Isolate patient (bag)
Check patient – A, B (ABG), C, D, E
Check monitoring
Check machine
Hyperkalaemia
Urgent situation
Diagnose and Treat cause
A, B, C, D, E
Ca2+ gluconate 10% 10mL
NaHCO3 8.4% 1mmol/kg
Insulin-dextrose bolus – 50mL of 50% glucose + 10U actrapid -> infusion
Salbutamol IV/Neb
Dialysis
Hypertension
COMMON
-
pain
depth of anaesthesia
hypoxia
hypercarbia
drug error
fever
clamping of aorta
UNCOMMON
- disease specific - rebleed with SAH, PET, increased ICP, autonomic dysreflexia, pre-existing
- weird stuff – MH, phaechromocytoma, thyroid storm, aortic dissection, NMS, serotonin
syndrome
Treat cause and prevent complications
Agents that lower BP (volatile, opioids, hypnotic)
Vasodilators – GTN 50mcg IV -> 0.1-2mcg/kg/min, hydralazine 5-10mg IV, SNP 0.14mcg/kg/min
Betablockers – esmolol 10mg IV
Ca2+ channel blockers – nifedipine 5-10mg SL, verapamil
Jeremy Fernando (2011)
Hyperthermia
COMMON
Iatrogenic – FAW on high
Measurement error
Sepsis
Blood transfusion
UNCOMMON
Drugs – MH, NMS, MAOI’s, cocaine
Endocrine – phaechromocytoma, thyroid crisis
Treat cause
Stop or expedite surgery
Cool – IVF, FAW on cold, expose, ICE, cold fluid to cavities, paracetamol/NSAIDS
Hypocapnia
Causes
1.
2.
3.
4.
measurement error
decreased production –> hypothermia, dying
decreased Q -> hypoperfusion
increased removal –> ventilation
Isolate patient (bag)
Review – A, B, C, D, E
Treat cause
Hypotension
In this context the most likely causes = …
Goals
1. Oxygenation
2. Maintenance of end-organ perfusion
3. Optimise preload, contractilty and afterload
Head down
Legs up
Review and support A, B, C
FiO2 1.0 and verify
Review P, BP and rhythm
Administer fluid bolus + vasopressor/inotrope
Causes
1.
2.
3.
4.
5.
Measurement error
Drug infusion issues
Hypovolaemic – bleeding, dehydration
Cardiogenic – MI, arrhythmia
Distributive – anaphylaxis, epidural
Jeremy Fernando (2011)
6. Obstructive – PE, TP, tamponade
Hypothermia
-> associated with increased perioperative morbidity
CVS – increased -> decreased Q, arrhythmias, increased MI
RESP – increased laryngospasm and O2 demand
CNS – decreased response to hypoxia and hypercarbia, increased sensitivity to sedatives and
opioids, decreased LOC
NEUROMUSCULAR – increased duration of action of NMBD, volatiles and opioids, shivering
GU – polyuria
HAEM – decreased haemostasis, increased risk of DVT, increased wound infections
METABOLIC – hyperglycaemia, acidosis from poor peripheral perfusion
SKIN – slow healing
Priorities
1. Minimise heat distribution
2. Cutaneous warming
3. Internal warming
Methods
Anaesthetic - wrap head, FAW, humidification of gases, warm fluids
Surgical - minimise exposure and surgical time, minimise bleeding, warm irrigation
Environmental - keep patient warm prior to OT, warm OT, minimise drafts, discourage
opening of door intraoperatively
Hypocalcaemia (Detectives from CIB)
Drugs
Chelation
Intake
Bone
Hypokalaemia (Dr from MIT)
Decreased K+ Intake
Magnesium depletion -> increases renal potassium loss
Increased Loss
Transcellular Shift
Hypokalaemic Alkalosis
Vomiting/high NG losses
Frusemide therapy
Refeeding syndrome
Villous adenoma of rectum
Steroid therapy, Cushings syndrome, Conn’s syndrome
Laxative abuse
Jeremy Fernando (2011)
Hypomagnesaemia (RRID)
Reduced intake – malnutrition, alcoholism
Redistribution – insulin, hungry bone syndrome
Increased loss – diuretics, diarrhoea,
Drugs – amphotericin B, cisplatin
Hyponatraemia
Hyposomolar
- hypovolaemic -> renal vs extra renal causes
- euvolaemic – SIADH, hypotonic IVF, psychogenic polydipsia
- hypervolaemic – CHF, nephrotic syndrome, cirrhosis, hypothyroidism
Isoosmolar – elevated proteins or lipids, TURP/hysteroscopy syndrome, *advanced renal
disease
Hyperosmolar – glucose, mannitol, sorbitol, radiocontrast, *advanced renal disease
Hypophosphataemia (RICE)
Renal losses
Inadequate intake/absorption
Cells – redistribution into
Extreme catabolic states
Hypoventilation
Causes
1.
2.
3.
4.
5.
Airway obstruction – blood, pack, laryngospasm, oedema, nerve injury
V/Q inequality
Neuromuscular problem
CNS depression
Equipment – inadequate ventilation
Assess and manage accordingly
Disconnect from ventilation
A – patency
B – FiO2 1.0 and verify, ETCO2, WOB, PNS
C – P, BP, perfusion
D – LOC, BSL, pupils, lateralising signs, signs of drug toxicity
E – temperature
Hypoxia
Causes
1. Inadequate supply (O2 supply, machine, ventilation, filter, airway)
2. Inadequate Q
3. V/Q inequality
Jeremy Fernando (2011)
4. Measurement error
Disconnect from machine -> BMV
Assess and optimise A, B, C
FiO2 1.0 and verify
Increased Urea:Creatinine Ratio – (Dane’s Can use GPS)
Dehydration/prerenal failure
Corticosteroids
GIH
Protein diet
Severe catabolic state
Intraoperative Fluids
Crystalloid – hypertonic (dextrose, hypertonic saline), hypotonic (dextrose), isotonic (N/S,
Hartmans, Plasmalyte)
Colloids – dextrans, starches, gelatins
Blood products – RBC’s 10mL/kg, FFP 15mL/kg, Platelets 10mL/kg, Cryo 5mL/kg, albumin
10mL/kg
Investigations
Bed side
Laboratory
Radiological
Special tests
Ketoacidosis
Starvation ketosis
Alcoholic ketoacidosis
DKA
Lactic Acidosis (Cohen and Woods Classification)
A – Inadequate O2 delivery
(i) anaerobic muscular activity
(ii) tissue hypoperfusion
(iii) reduced tissue oxygen delivery or utilisation
B – Adequate O2 delivery
B1 – underlying diseases (lukes, tips and failures)
B2 – drugs and toxins
B3 – inborn errors of metabolism
Jeremy Fernando (2011)
Lactate Acidosis in the patient with Multi-organ failure
Lactate over production
-
catecholamines
low cardiac output state with global hypoperfusion
organ ischaemia (bowel)
sepsis with mitochondrial dysfunction
Decreased lactate catabolism
- liver failure
- renal failure
Laryngospasm
Priorities
1. Oxygenation
2. Relieve obstruction
Remove foreign bodies (throat pack)
Open airway
FiO2 1.0
CPAP
Deep anaesthesia (propofol)
Suxamethonium 1mg/kg IV (+ atropine 25mg/kg)
*** My emergency drug for laryngospasm in children =
100mg suxamethonium (2mL) + 0.12mg atropine (1mL) =
33mg/mL of sux + 0.4mg/mL of atropine
Give 1mL IM for every 10kg of body weight (3mg/kg sux + 40mcg/kg atropine)
Give 0.5mL IV for every 10kg of body weight (1.5mg/kg sux + 20mcg/kg
atropine)
LA Toxicity
Priorities
1.
2.
3.
4.
Limit exposure
Prolonged supportive care (ACLS protocol)
Intralipid administration
Prevention of acidosis
Intralipid 20% - 1mL/kg Q 3min x 3 -> 0.25mL/kg/min
A – intubate
B – FiO2 1.0, hyperventilation
C – access, defibrillation, CPR, fluid, adrenaline 10mcg/kg, vasopressors, antiarrhythmics
(amiodarone 5mg/kg, NaHCO3 1mmol/kg, bretylium 5-10mg/kg -> 1-2mg/min)
D – anti-convulsants (phenytoin 15mg/kg LD), BSL, sedation (midazolam) and paralysis
Jeremy Fernando (2011)
Lactic Acidosis and Hypoglycaemia
Liver failure
Seizures
Alcohol intoxification
Metformin OD (severe)
Low Anion Gap (< 8)
High – Li, Br, Ca2+, Mg2+, globulins
Low – hypoalbuminaemia
Long Stay ICU Patient
- multi-system approach
A – tracheostomy
B – respiratory wean, prevention of VAP
C – cardiovascular optimization
D – analgesia, sedation, depression
E – nosocomial infection surveillance
F – fluid balance, feeding
G – ulcer prophylaxs, find bore N/G, constipation cares
L – lines (minimization)
L – standard -> twice weekly bloods
M – medication review (conversion to N/G agents)
FASTHUG
F – family liaison and support
Machine Check
Level 1-3
Level 2 Check: Service Label, High pressure, Low pressure, Circuit, Suction, Ventilator, Drugs
and Infusions, Monitors, Scavenging, Bag-mask
Safety Assessment (essential, relative and other)
Major Bleeding
Goals
1.
2.
3.
4.
Stop bleeding
Defend BP
Defend Blood volume
Defend Blood constituents
Assess – P, BP, capillary refill, perfusion, mentation, urine output
2 large bore IV
Titrated IVF boluses
Haemostatic Resuscitation & Damage control surgery (in Trauma)
Specific treatments for anti-coagulants and anti-platelet drugs
Jeremy Fernando (2011)
Malignant Hyperthermia
Priorities
1.
2.
3.
4.
Stop trigger
Dantrolene
Cool
Support A, B, C, D, E
Notify team
Call for help
Discontinue agent
A - ETT
B - 100% O2, hyperventilate
C - support
D - Dantrolene 2.5mg\kg -> until physiological response, keep asleep with TIVA
Cooling - cold IVF, ice, cold fluid to bladder and stomach
Monitoring
U+E - correct hyperkalaemia and acidosis
Convert to a safe anaesthetic
Treat DIC
Acidosis -> NaHCO3 (will need increased in MV)
Post event follow up (medic alert, referral for IVCT, family counselling)
Metabolic Acidosis
DIC
Simultaneous diagnosis and management
Treat cause
Anion/Non anion Gap (LTKR and CAGE)
Myocardial Ischaemia
Optimise myocardial O2 supply and demand
Review A, B, C
Goals
1. increase blood O2 content (FiO2, V/Q mismatch, SpO2, Hb)
2. increase coronary blood flow (adequate Q and MAP, normal HR, consider MI as cause - >
anti-platelets, GTN, heparin, statin, thrombolysis or PCI)
3. decrease O2 demand – slow heart, vasodilate if hypertensive, decrease contractility
Metabolic Acidosis with Ionized Hypocalcaemia (HEATAR)
Hydrofluric acid OD
Ethylene glycol OD
Acute pancreatitis
ACIDOSIS
HYPOCALCAEMIA
Fluoride
Lactate, oxalate, glycolate
Lactate
Ca2+ precip. ->soft tissue
Ca2+ oxalate -> urine
Ca2+ precipitation
Jeremy Fernando (2011)
Tumour lysis syndrome
ARF
Rhabdomyolysis
Lactate, SO43-, PO43-, Urate
Hyperphosphataemia
See TLS
See TLS
Metabolic Alkalosis
Diuretics
Volume contraction
Upper GI losses
Steroids
Initiating Process
- gain of alkali in the ECF (endogenous/exogenous)
- loss of H+ from ECF (kidney or GI)
Maintenance
- chloride depletion (diuretics, loss of gastric juice)
- potassium depletion (primary hyperaldosteronism, Cushing’s Syndrome, severe K+
depletion, Bartter’s syndrome))
- reduced GFR
- ECF volume depletion
Myxoedema Coma
Hyponatraemia
Hypoglycaemia
Hypercholesterolaemia
Needle Stick Injury
First Aid
Quantify risk
Post-exposure prophylaxis
Occupational Health review (protection of self, staff and other patients)
Neonatal Resuscitation
Insure safety of mother
Dry
Stimulate
Keep warm
Open airway
Assess for meconium -> if present and baby obtunded -> ETT and suction
If baby vigorous -> FiO2 1.0, IPPV (5 effective breaths), neopuff
P <60 CPR (3:1)
Adrenaline 10mcg/kg (0.1mL/kg of 1:10,000) IV or IO
Naloxone 100mcg/kg IV
ETT MEDS = LANE
Jeremy Fernando (2011)
Lignocaine
Atropine
Naloxone
Epinephine
Neuroleptic Malignant Syndrome
Goals
1. early recognition
2. withdrawal of precipitants
3. supportive care
Hydration
Nutrition
Cooling
DVT prophylaxis
Bromocriptine or Amantidine
Dantrolene
NMBD are effective at relieving rigidity
Normal Anion Gap Metabolic Acidosis (CAGE)
Chloride
Addisons/Acetazolamide
GI – diarrhoea, vomiting, fistulae (pancreatic, ureteric, billary, small bowel, ileostomy)
Extras - RTA
Obstructive Shock
PE
Tension pneumothorax
Tamponade
Oesophageal Doppler
Semi-invasive cardiac output monitor -> measures velocity of blood in descending aorta
Q = SV x HR
SV dependent on preload, afterload and contractility
Q – minute distance
SV – interpretation of stroke distance x aortic root diameter
Preload – measured by FTc
Afterload – measured by interpretation of FTc and PV
Contractility – measured by PV
Evidence
Q – accurate
Preload – accurate
Rest not so
Better inter-operator variability than PAC
Jeremy Fernando (2011)
Good for guiding fluid management
Decreases post op stay, time to BM, time to first diet
Open Lung Biopsy
Infection (viral, bacterial, parasitic…)
Malignancy
Vasculitis
BOOP
ARDS
Oxygen Cylinders
- black and white shoulders
- 1400kPa
- sizes = C (170L) to J (6800L)
Oxygen Storage -> OT
VIE (1000kPa)
Piping + regulators (414kPa)
Wall outlet (400kPa)
Machine (determined by APL valve)
Peripheral Nerve Stimulators Modes
Single Twitch – paralysed or not
TOF – resolution of block
DBS – tactile appreciation
PTc – resolution of dense block
Porphyric Crisis
Goals
1. stop precipitating agent
2. reverse factors that increase haem production (ALA synthase activity)
Call for help
Stop administering precipitent
Haem arginate 3mg/kg IV OD for 4/7
Analgesia - opioids
Beta-blockers (manage haemodynamics + decreases activity of ALA)
Plasmapheresis
Supportive care
Give glucose
Monitor
Prone
Physiological – CVS changes, improved V/Q matching, impaired RESP, hypotension
Jeremy Fernando (2011)
Pathological – airway access, PPP, bleeding, dealing with emergency, staff safety when
moving, blindness
Procedure Stations - Generic Approach
Contraindications
Explain
Consent
Monitoring
Assistance
Drugs
Equipment
Position
Landmarks
Insertion
End point
Things to avoid
Dressing
Check position
Regional Block (CIMPLE)
-
Consent & Contraindications
IV
Monitoring
Positioning
Landmarks
End-points and Evaluate the Block
Remote Anaesthesia (REMOTE-P)
-
Risks with anaesthesia & remote location (consent)
Equipment and Ergonomics
Monitoring
O2 + back up
Transport
Environment (hostile)
Personnel (unfamiliar)
-
Physical – cold, distance, dark, delivery
Procedure – anaesthetic, procedure, safety
Patient – co-morbidity, specific problems
Machine + Monitoring
Man power
Magic potions
Method plan
Respiratory Alkalosis
Hyperventilation (spontaneous or induced)
Septic encephalopathy
Asthma
Jeremy Fernando (2011)
Pneumonia
Rhabdomyolysis (HIMED)
Hypermetabolic
Ischaemic
Myopathic
Electrolytes
Drugs
Shock
Hypovolaemia
Distributive
Cardiogenic
Obstructive
Endocrine
Electrolytes
Technical
SIADH Causes (PAM tHe COD)
Pulmonary disease
ACH secretion (ectopic)
Major surgery
Hormone deficiency
CNS disease
Others
Drugs
Starting TPN
General principles
Nutritional assessment (caloric requirements)
Nutritional requirements
Monitoring and management of complications
Serotonin Syndrome
Supportive
Benzodiazepine
Cyprohepatidine - antihistamine with anti-serotonergic action.
Usually subsides over 24 hrs but deaths have been reported.
Sinus Tachycardia
- anxiety
- thyrotoxicosis
- acute blood loss
Jeremy Fernando (2011)
- anaemia
- heart failure
Sickle Cell Crisis
-
lumbar spine, femur, knee, sternum & abdomen pain
rest
rehydration
antibiotics
O2
warm
opioids or regional
blood transfusions (consult haematologist)
exchange transfusions (consult haematologist)
- consult haematologist prior to surgery regarding: blood transfusion triggers, exchange
transfusions, optimization (re: HbS level < 30% decreases complication ?controversial)
- send GH & antibody screening
Status Epilepticus
Goals
1. Terminate seizure
2. Supportive
A, B, C, D, E
Lorazepam 0.1mg/kg (up to 4mg)
Phenytoin 15mg/kg
GA with propfol or thiopentone
Phenobarbitone 15mg/kg
BSL
Bloods
Toxicology screen
Consider infective cause
CK for rhabdo
Stridor
Airway emergency!
Determine level of obstruction (supraglottic & laryngeal, mid tracheal, lower tracheal and
bronchial)
Determine severity and course
Thorough airway assessment – including possible nasal endoscopy
Allow to adopt comfortable position
O2
Dexamethasone 0.1mg/kg
Adrenaline nebulisers
Supraglottic & Laryngeal Airway Obstruction
Options:
Jeremy Fernando (2011)
1. Gas induction
2. Awake tracheostomy
Gas induction
2 anaesthetists
IV access
LA to pharynx
Slow
NP airway if needed
Don’t bag
Get deep
Laryngoscopy (x 2 only)
Asleep tracheostomy
Airway Obstruction: LMA, rigid bronchoscopy, emergency tracheostomy
Awake tracheostomy
No sedation
Helium/O2 mix
Prepare in sitting position
Insert and verify with ETCO2
Mid Tracheal Airway Obstruction
Thorough airway assessment
Ensure patient can be intubated below obstruction
A standard induction may be acceptable
Otherwise AFOI or Gas induction
Lower Tracheal and Bronchial Obstruction
Rigid bronchoscope
Cardio-pulmonary bypass
Systematic Approach to the ICU Patient – On a Ward Round
Housekeeping – FASTHUG
Feeding
Analgesia
Sedation
Thromboprophylaxis
Head up
Ulcer prophylaxis
Glucose control
THEN
Jeremy Fernando (2011)
New Residents Can Get Killed, Even Surgeons Live In Danger
Neuro, Resp, CVS, GI, Kidneys, Endocine, Skin, Labs, ID, Devices
OR
A – airway
B – respiratory
C – cardiovascular
D – neurology
E – temperature and infection (nosocomial)
F – feeding and fluid balance (renal function)
G – gastrointestinal
Lines
Lab’s
Medications
FASTHUG
Family
Tachycardia
May be an emergency, I would note it and investigate cause
Common
Hypoxia
Hypercarbia
Pain
Inadequate depth of anaesthesia
Blood loss
Fever
Arrhythmia
Drug error
Equipment (ie. CVL in RA)
Electrolyte abnormalities
Uncommon
Anaphylaxis
Myocardial ischaemia
PE
Aspiration
Metabolic acidosis (anion or non-anion gap) – MH, phaechromocytoma, thyroid storm
DIC
A, B, C, D, E approach
Treat cause
Tamponade
Priorities
1. support of circulation
2. urgent decompression
Jeremy Fernando (2011)
ACLS protocol
Needle pericardiocentesis or re-sternotomy
Temperature Monitoring
Electrical – resistance, thermistor, infrared
Non-electrical – mercury, alcohol, bourdon’s gauge
Thyroid Storm
Supportive
-
IVF (glucose)
cooling cares
paracetamol (no NSAIDS or aspirin -> displaces thyroxine from proteins)
propanolol increments (1mg IV) or esmolol boluses -> infusion (50-100mcg/kg/min)
Specific
- hydrocortisone 200mg IV QID (adrenal insufficiency + decreases T4 release and
conversion)
- propylthiouracil (1g load PO -> 250mg QID to inhibit thyroid hormone release and decrease
peripheral conversion from T4-T3)
- after blockade by propylthiouracil give sodium iodide or potassium iodide or Lugol’s iodine
5-10 drops NG
Topicalisation for Nasal AFOI
5 sprays of co-phenylcaine (each nostril)
10 sprays of 10% lignocaine to oropharynx and base of tongue
4mL 4% lignocaine via crico-thyroid puncture
Total Body H2O Distribution
ICF = 55%
ECF = 45% (interstitial 22.5%, intravascular 7.5%, CT 7.5%, bone 7.5%, transcellular 2.5%)
Total Spinal
Supportive care
A - ETT
B - ventilate
C - fluids, inotropes
Recovery may take many hours
TURP Syndrome
Supportive: stop surgery -> ABCDE
Specific: diuretics, fluid restriction, hypertonic saline
Jeremy Fernando (2011)
Unresolved Septic Syndrome (CCDHB)
Collection
Complication – iatrogenic, nosocomial
Drug – right antibiotic
Host – immunosuppressed
Bacteria - MDRO
Upper Airway Obstruction (COMET-Failure)
Call for help
Optimise treatment
Monitoring
Equipment and Drugs
Technique
Failure – plan for failed intubation
Vapourises
1.
2.
3.
4.
5.
regulation of output concentration (variable bypass, measured flow)
method of vapourisation (flow, bubble through, injection)
agent specific or not
low resistance/high resistance
temperature compensation (manual, automatic or supplied)
Venous Air Embolism
Goals
1. minimise further air entrainment
2. support ventilation and haemodynamics
Flood surgical field with saline
Compression of proximal veins (ie. neck)
Left lateral position + head down
Aspirate CVL if in RA
FiO2 1.0
Fluids
Inotropes
ACLS protocol
Jeremy Fernando (2011)