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Intensive Care - Coggle Diagram

- - - - Arrhythmia, swings in BP, urinary retention, paralytic ileus, hyperhydriasis
- - - - Uncouples intracellular oxidative phosphorylation which inhibits electron flow
        
        Free fatty acids (fuel for cardiac and skeletal myocytes) cant be metabolised and levels rise, causing arrhythmia and cardiac dysfunction
        
        Cardiac and skeletal myocytes deprived of nutrition start to necrose
  - - - Coved ST elevation V1-3
      - AF or VF
      - SVT, bundle branch blocks, bradycardia, asytole
- - - - Multiorgan failure, increased risk with duration
      - Prolonged mechanical ventilation & bed rest
      - Severe sepsis/septic shock
      - Hyperglycaemia
    - - Severity of illness
      - Hypoalbuminaemia
      - Female
      - Hyperosmalality
      - Increased age
      - Parentral nutrition
      - RRT
      - Vasopressors
      - Steroids
      - NMBs
  - - - Reduced amplitude of sensory nerve potentials (SNAPs) and compound motor action potentials (CMAPs)
      - Normal conduction speed
    - - Normal conduction velocity, SNAP normal, CMAP reduced
- - - - Diuresis of dilute urine
  - - - Polyuria and dehydration due to urinary Na loss
      - Hyponatraemia and serum osmolarity <280 mOsm/kg
    - - Na <135 mmol/L, serum osmol <280 mOsm/kg
    - - Not usually polyuric
      - Na < 135, Serum osmol <280
- - - - Thrombus in leg veins - can support Dx if present
    - - Thrombus in PA - highly sensitive and specific, caution in renal failure
    - - Hypovascularity, wedge shaped consolidation, non specific
    - - Thrombus in PA - not as good as CT
    - - Tachycardia, AF, S1Q3T3, poorly sensitive/specific
    - - Acute R heart strain - useful bedside test for unstable patient
    - - Low PO2&CO2, non specific
    - - Invasive - rarely used for Dx
    - - Non specific
  - - - 100% O2, intubate if needed
      - Mx depends on clinical situation
      - IV access - fluid (cautious) and inotropes - phenylephrine or adrenaline
      - Prepare for arrest - likely PEA - prolonged CPR once thrombolysis given
    - - Thrombolysis with alteplase
      - Unfractionated heparin to follow
      - Based on clinical findings - do not delay
      - Invasive techniques (thrombus fragmentation + IVC filter) if available
- - - - Improved wound healing
      - Improved rehab
      - Better immune function
      - Reduced ITU stay & mortality
      - Weaning from ventilator (reduced infection risk, better muscle strength)
  - - - Low BMI with unintentional weight loss
      - Poor recent nutritional intake
      - Low serum K/Mg/PO4
      - ETOH abuse
      - Drugs (chemo, insulin, antacids & diuretics)
    - - On refeeding, insulin driven uptake of glucose to cells with electrolytes
        
        Causes precipitous drop in serum levels
    - - On refeeding, circulating volume increases due to glucose driven osmolality
        
        Risk of heart failure
    - - Unable to cope with increased CO2 production from carbohydrate diet (carbs 1.0, protein 0.9, fat 0.7)
        
        Arrhythmia, seizures, respiratory failure, cardiac failure, coma, death
  - - - Cheap
      - Avoids line infections
      - Reduced risk of stress ulcer
      - Lower risk of hyperglycaemia
      - Reduced risk of abnormal liver function, metabolic derangement, uraemia etc
    - - May not be absorbed
      - Risk of aspiration/pneumonia
      - Necrosis/damage to nose or small bowel due to tube
- - - - Supplement O2
      - NIV/PPV due to ARDS/splinting
    - - Enteric nutrition (jejenal as gastric not tolerated)
      - Stress ulcer prophylaxis
    - - Targeted fluid therapy
      - Inotropic support as needed
    - - Sedation for IPPV
      - Pain control
    - - Glucose Mx
    - - VTE risk benefit
    - - Antimicrobials if necrosis suspected
    - - Minimise AKI
    - - ERCP if gallstone cause
      - Necrosectomy if infected necrosed areas
  - - - No organ failure
      - No local/systemic complications
    - - Organ failure that resolves after 48h
      - Local/systemic complications
    - - Organ failure > 48h
- - - - Moderate < 26.6 kPa
      - Severe < 13.3 kPa
      - Mild < 39.9 kPa
  - - - PEEP
      - Accept PaO2 adequate to oxygenate tissues
      - Permissive hypercapnia
      - Peak pressure <30
      - TV 6ml/kg
      - Minimse peak pressure-PEEP difference
      - Recruitment
      - Prone
    - - Physio (remove secretions, improve GE)
      - early entral feeding
      - Conservative fluid
      - Ventilator care bundle
      - Mx underlying cause
      - ECMO
- - - - GCS <12 or abnormal AVPU
      - Sats <92% OA
      - SBP <90mmHg
      - HR >100 or <60
    - - Venous/arterial pH <7.0
      - Hypokalaemia <3.5mmol/l
      - Bicarbonate <5mmol/l
      - Anion gap >16 ([Na+K]-[Cl+HCO3])
      - Ketones >6mmol/l
  - - - Monitor RR and sats
      - Auscultate ?infection ?CCF
    - - Full monitoring
      - Large bore access
      - Fluid
        
        500ml NSaline/15min if SBP <90
        
        Repeat if SBP <90
        
        Once SBP >90
        
        1L over 1h
      - Give K+ if K below upper limit of normal - if hypokalaemia - senior assistance
    - - Assess GCS
    - - Full examination ?underlying cause
      - Check temperature
    - - Fixed rate 0.1 units/kg/h
    - - 15L NRBM
      - Tube for low GCS or resp difficulties
    - - U&Es
      - VBG
      - Capillary glucose
      - FBC
      - Ketones
      - Cultures
      - ECG
      - CXR/urine/pregnancy test if appropriate
- - - - Haemomediastinum
      - Surgical emphysema
      - Pneumomediastinum
      - Atelectasis/inadequate ventilation
      - Haemothorax
      - Aspiration
      - Pneumothorax
    - - Cuff up with speaking valve
      - Ventilator circuit blocked/disconnected
      - Cuff puncture/deflation/herniation over end of tube
      - Inappropriate vent settings
      - Dislodged tube
      - Inappropriate FiO2
      - Trache blocked (secretions or blood)
  - - - Give 2 ventilated breaths
        
        Unsuccessful remove inner tube and suction and debris
        
        Unsuccessful - deflate cuff and see if pt able to breath (can then reinflate as may have been herniated cuff)
    - - Start 2 person FMV (or via stoma)
    - - Review ease of larygoscopy/tracheostomy and make airway plan
    - - SAD
      - Intubate stoma with size 6 COETT
      - Oral intubation
- - - - Metabolic acidosis
      - Rapid urea/creatinine raise
      - Hyperkalaemia, non responsive to medical Mx
      - Symptomatic uraemia (encephalopathy, pericarditis, bleeding)
      - Refractory fluid overload
      - Oligouria/anuria
    - - Aspirin, ethylene glycol, lithium, methanol, procainamide, theophylline, vancomycin, carbamazepine
  - - - Continuous venovenous haemofiltration [CVVHF]
      - Continuous venovenous haemodialysis [CVVD]
      - Continuous venovenous haemodiafiltration [CVVHDF]
    - - Used if patient already using this form (can cause diaphragmatic splinting in ventilated pts)
  - - - Solutes move via con gradient (Fick's law of diffusion)
      - Diasylate flows in countercurrent to maintain conc gradient
      - Blood pumped through extracorporeal circuit that incorporates dialyser (semiperm membrane which separates blood and dialysate)
    - - Hydrostatic pressure drives plasma water across membrane - ultrafiltration
      - Small molecules (<50kDa) are dragged across membrane by convection
      - Blood pumped through extracorporeal circuit with semiperm membrane
      - Ultrafiltrate discarded and replacement fluid added according to desired FB
- - - - Unstable cspine
      - Severe local infection of front of neck
      - Pt refusal
      - Uncontrolled coagulopathy
    - - High PEEP/FiO2
      - Difficult anatomy
      - Proximity to extensive burns or surgical site
      - Haemodynamic instability
      - Radiotherapy to neck
  - - - A
        
        Loss of airway and risk of hypoxia & death
        
        Airway damage
        
        Obstruction (due to blood/secretions)
      - B
        
        Derecuitment
        
        Surgical emphysema
        
        Pneumothorax
      - C
        
        Bleeding from neck vessels
      - D
        
        Damage to recurrent laryngeal nerve
    - - A
        
        Displaced/blocked tube causing loss of airway
        
        Tracheal stenosis and scarring
        
        Tracheomalacia
      - C
        
        Erosion into blood vessel causing bleeding
      - Infection
      - Scarring/permanent stoma
- - - - Subglottic suction
      - Tapered cuff
      - Antimicrobial coating
    - - Nurse 30degree head up
      - Sedation holds
      - H2 R block
      - Thromboprophylaxis
      - Oral hygiene and chlorhex mouthwash
      - Cuff pressure check (20-30 cmH2O)
- - - - Methypred
      - Insulin
      - DDAVP or vasopressin if polyuric
    - - Physical and pharm VTE prophylaxis
    - - CVC & Aline
      - CO and u/o monitors for directed fluid Mx
      - Vasopressin inf rather than catecholamines
      - Dopamine or dobutamine if targets not achieved by vasopressin
    - - Normothermia
    - - Recruitment
      - 30-45 head up
      - Lung protective ventilation
        
        PEEP 5-10, TV 6-8ml/kg, Peak insp <25
- - - - 15l/min
      - RSI if airway concerns
    - - Large bore access
      - ECG monitoring, A line
    - - ABG/glucose/FBC/AED levels
  - - - A
        
        Soft tissue/dental damage
        
        Obstruction
      - B
        
        Aspiration/pneumonia/resp failure
      - C
        
        MI/hyper/hypotension/arrhythmia/arrest
      - D
        
        Cerebral hypoxia/oedema/haemorrhage
      - Haem
        
        DIC
      - MSK
        
        Fracutres & rhabdo
      - Renal
        
        AKI
      - Metabolic
        
        Hyponat/hyperkal/hypoglycaemia/metabolic acidosis/hyperthermia
- - - - 15L NRB, intubate if unable to maintain or falling GCS
    - - Sats monitoring, assess ventialtion
    - - Large bore access, ECG
      - ?A line
    - - Monitor GCS
    - - Full examination
      - Check glucose
    - - Ascertain poison
        
        Quantity, over what period, alcohol etc
      - Comorbidities
    - - ABG, FBC, U&Es, LFTs, PCM & salicylate (4h)
    - - Specific management
  - - - Na channel blockade
        
        Cardiac depression, reduced CO, arrhythmia, seizures
      - Alpha blockade
        
        Hypotension
      - Anticholinergic effects
        
        Mydriasis, tachycardia, hypotension, ileus, seizures, coma, urinary retention, warm dry skin
      - Reduced serotonin & NA reuptake
        
        Hypotension
    - - Respiratory depression
        
        Intubate & ventilate
      - Seizures
        
        Benzos, GA
      - Acidosis and prolonged QRS
        
        Sodium bicarbonate (increases Na to counter blockade and alkalinises blood to reduce TCA affinity)
      - Arrhythmia
        
        Mg, lidocaine, Mx acidosis
      - Hypotension
        
        IVF, alpha agonists, glucagon
      - Arrest
        
        ALS
      - Rx resistant neuro or cardiac Sx
        
        Intralipid, ECMO
      - Pyrexia
        
        Pt cooling
- - - - Surgery
      - MI
      - Pregnancy
      - GI bleeding
      - Infection
      - DKA
- - - - Can increase elimination - consider if >300mg/L
- - - - Is there acute change of mental status from baseline or fluctuation in past 24h?
    - - Squeeze hands on SAVEHAART if >2 errors then fails
    - - RASS score if not zero then delerium present, if zero then move on
    - - Command (hold up 2 fingers) and show + additional ('add one more'. Error 0-1 the no delerium