Common problems w/ critically ill
-nutrition (who, what, when, how to feed)
-anxiety
-pain
-impaired communication
-sensory-perceptual problems
-sleep problems
Ethical Decisions:
-id problem
-define ethical issue
-gather info
-delineate decision maker
-examine ethical/moral principles
-explore options
-implement
-evaluate
Pain Medsmorphine- opiod; fast onset & half life, constipation,
nausea, *resp depression; s/e-hypotension
fentanyl-synthetic opiod; very potent; rapid onset &
peak; dispose in sharps; s/e-bradycardia, chest wall
rigidity
hydromorphone (Dilaudid)- semi-synthetic; more
potent than morphine w/ similar onset; needs good renal
& liver fxn;
Meperidine (Demerol)- less potent opiod (weakest,
given in lg doses); s/e-CNS toxic , delirium
Codeine- rarest used, longer onset;
Methadone-
Over- immobility, pressure ulcer, longer extubation
time, muscle weakness, falls, constipation, pneumonia,
thrombo-emboli, hypotensive, inc'd length of stay
Sedation Meds
Analgesics for pain
Sedative (DO NOT relieve pain)-benzo- versed (best for short, fast acting sedationpreop); ativan (better for pts needing longer sedation);
*Romazicon- benzo reversal
Anesthetic-propofol (Diprivan)-short half life (2-4min)
fully awake w/in 30min of d/c; not good for amnesiac
effect; lipid- can only hang for 12hrs (good breading
ground for bacteria); long term needs to be in ICU for
airway maintenance
Neuroleptic: haldol- half life 15-20 hrs
Alpha-adrenic receptor agonists- dexmedetomidine short term vent pt
Neuromuscular blockades (paralytic)- vercuronium;
assess w/ Train of 4 (shock w/ electrode to see if face or
hand twitches)- need ventilator support
Sedation vacation- shut off all analgesics & sedation to
assess status; daily vacation--> less s/e & shorter stay
Emergency Severity Index
Sleep aid:
Hypnotics:
-temazepam, flurazepam- quick onset, long acting; s/erebound insomnia
-zolpidem (Ambien)-rapid, short acting; s/ehallucinations
Richmond Agitation Sedation Score (RASS)
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10
seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye
contact)
-4 Deep sedation No response to voice, but movement or eye opening
to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Sedation Complications
Under- pull lines, self-extubation, anxiety, ischemia
(inc'd demand), inc'd vitals, pain, unpleasant recall of
hospitalization
Primary Survey:
A-airway
B-breathing
C-circulation
D-disability (LOC)
Secondary Survey
E-exposure/environmental control
Full vitals & 5 interventions: ECG, SpO2, Indwelling
catheter, oro- or naso-gastric tube, blood for lab
Facilitate family presence
Give comfort
History & head to toe
Inspect posterior
Eval tetanus prophylaxis, ongoing monitoring, prepare
for transport
Triage
Emergent- life, limb, eye threatening; needs immediate
attention; ie: CP, cardiac arrest, severe resp distress,
chemicals in eyes, limb amputation, acute neuro deficits
Urgent- needs tx in 20min-2hrs; ie: fever >104 (40),
diastolic BP >130, kidney stone, simple fracture, abd
pain, asthma/no resp distress
Nonurgent- can wait hrs or days; ie: sprain, minor
laceration, cold symptoms, rash, simple HA
Mass Casualty Incident- Triage in 15 sec:
Heat exhaustion/ stroke
Etiology-lack of aclitimzation, prolonged exposure,
physical exertion, head/spine injury, dehydration,
thyrotoxicosis, diabetes, phenothiazines, tricyclic
antidepressants, diuretics, cocaine, ethanol,
antihistamines, CV diseas, CNS disorders, alcoholism
S/S-severe muscle contractions, thirst; pale, ashen;
fatigue, weakness; profuse sweating (skin becomes dry
w/ heat stroke); altered mental status; hypotension;
tachycardia; weak, thread pulse; temp 100-104oF (37.840.0oC) for exhaustion, >104oF (40oC) for heat stroke
Interventions
- initial: manage & maintain ABC’s; high flow O2 w/
non-rebreather or bag-mask; establish IV & fluid
replacement; cool environment; rapid cooling measures
for heat stroke (remove clothing, wet sheets, fan, ice
bath, cool IV fluids, lavage w/ cool fluids); ECG; blood
for electrolytes & CBC; urinary catheter
-ongoing-monitor ABC’s, VS, LOC, cardiac rhythm,
SpO2, electrolytes, urinary output, devel’t of
myoglobinuria, clotting studies (for DIC)
Hypothermia
Etiology- prolonged exposure/submersion, inadequate
clothing, hypoglycemia, hypothyroidism, cold IV fluids,
blood admin, inadequate warming in ED or surgery,
admin of neuromuscular blocking agents,
phenothiazines, barbiturates, alcohol, trauma, shock
S/S- core body temp: mild 90-95oF (32.2-35oC), mod 8790oF (30.6-32.2oC), profound <87oF (<30.6oC);
shivering (diminished or absent w/ temp <92oF or
33.3oC); hypoventilations, hypotension, altered mental
status; areflexia; pale, cyanotic; blue, white or frozen
extremities; arrhythmias (brady, a-fib, v-fib, asystole);
fixed, dilated pupils
Interventions-initial- remove from cold environment; manage &
maintain ABC’s; high flow O2 NRB or BMV; anticipate
intubation for diminished or absent gag reflex; rewarm
pt (passive- remove wet & apply dry clothing, warm
blankets, admin warm fluids; active external- body-tobody contact, heating devices or radiant light; active
core warming- warmed IV fluids, heated humidified O2,
peritoneal/gastric/colonic lavage w/ warmed fluids);
anticipate hemodialysis or cardiopulm bypass; warm
cental trunk first in pts w/ profound hypothermia to
avoid aftershock; IV access w/ 2 lg-bore catheters for
fluid resuscitation; assess for other injuries; keep pt’s
head covered w/ warm, dry towels or stocking cap to
limit heat loss; tx gently to avoid inc’d cardiac
irritability
-ongoing-monitor ABC’s, LOC, temp, VS, SpO2, cardiac
rhythm, electrolytes, glucose
Anthrax (bacillus antrhacis)- inhalation (most deadly),
cutaneous (most common) or GI
Manifestations- incubate 1-2days up to 6 wks; abrupt
onset; dyspnea; diaphoresis; fever; cough; CP;
septicemia; shock; meningitis; resp fail; widened
mediastinum on x-ray
Transmission- direct contact, no person-to-person,
spores dormant until enter living host
Tx- ATB effective only if tx’d early; Cipro is tx of
choice; also use PCN, doxycycline; post expure
prophylaxis for 30 days if vaccine avail, 60 days if no
vaccine; vaccine has limited availability
Small pox (varioloa major & minor viruses)
Manifestations- incubation 7-17 days; sudden onset of
symptoms- fever, HA, myalgia, lesions that progress
from macules to papules to pustular vesicles, malaise,
back pain
Transmission- highly contagious, direct person-toperson, air droplets, handling contaminated materials
Tx- no known care, Cidofovir (Vistide) under testing;
isolation for containment; vaccine