critically ill patient

1. CARE OF CRITICALLY ILL PATIENTDr Eunice Rabiatu Abdulai
26TH August 2015.
VENUI: ENT DEPARTMENT KOR-BU TEACHING HOSPITAL

2. OUT LINE
• Introduction
• Definition
• Anatomy
• Aetiology/pathogenesis
• Clinical characteristics{signs and
symptoms}
• Investigations
• Treatment
• Conclusion

3. INTRODUCTION
Proper management of a critical ill patient
require
• Early identification of the critical ill
patient
• Identification of the immediate
problem that can kill the patient
• Taking and performing quick
measures to save the persons life.
Some pathology require high index of
suspicion.

4. DEFINITION: (CRITICALLY ILL PATIENTS)
• Patients at high risk for actual or potential life-threatening health problems
• They are
•Highly vulnerable
•Unstable
•Complex
• There by requiring intense and vigilant nursing care in addition to medical and or
surgical care

5. ANATOMY
•ALL systems can be
involved
•CVS
•CHEST
•ABDOMEN
•CNS
•MUSCULOSKELETAL
•HORMONAL

6. AETIOLOGY
• CONGENITAL:
• e.g. ENT
• bilateral choanal atresia,
• bilateral vocal cord paralysis,
• Tracheoesophageal fistula
• ect
• INFECTIONS:
• E.g. ENT
• complicated sinusitis,
• complicated otitis media
• retropharyngeal abscess
• ect
• OTHERS
• typhoid perforation,
• retroperitoneal abscess,
• diabetic foot,
• necrotising fasciitis of scrotum,
• cerebral abscess,
• MI,
• acute renal failure,
• septicaemia,
• septic shock
• ect

7. AETIOLOGY
• TRAUMA:
• laryngeal fracture,
• ruptured spleen,
• multiple abdominal organ rupture,
• poly trauma,
• tension pneumothorax,
• heamothorax,
• head injury,
• neurogenic shock.
• TUMOUR:
• subglottic polyp
• OTHERS:
• aspirated foreign body,
• anaphylactic shock,
• cardiogenic shock,
• hypoglycaemia,
• Hyperglycaemia
• Ruptured ectopic pregnancy
• Thyroid storm

8. AETIOLOGY
•Can be from any system
•CNS,
•CHEST,
•CVS,
•ABDOMEN,
•GENITOURINARY,
•MUSCULOSKELETAL,
•ENDOCRINE

9. PATHOGENESIS
•VARIED , DEPEND ON
THE CAUSE
•Embryonic
•Inflammatory
•Trauma
•Tumour
•Iatrogenic
•Unknown

10. CLINICAL CHARACTERISTICS {SIGNS AND SYMPTOMS}
•Assessment of deranged physiology and immediate
resuscitation must proceed diagnostic consideration
•Initial diagnostic uncertainty and need for immediate
monitoring and physiological support defines critical
care

11. SYMPTOMS
GENERAL: dizziness, headache
CHEST: Difficulty in breathing, cessation of breathing, Chest pain,
CVS: Palpitations, saviour Sharp pain radiating to shoulder, orthopnoea, PND
CNS: Unconscious, Deteriorating consciousness, Confused, Abnormal behaviour
(aggression)
GENETOURINARY: Small urine or cessation of urination
MUSCULOSKELETAL: Ascending paralysis, inability to sit or walk

12. SYMPTOMS(ENT ARRANGEMENT(EXAMINATION
FINDINGS))
• GENERAL
• STATUS LOCALIS (ear, nose and throat and head and neck(lymph nodes and
cranial nerve palsy))
• CNS
• CVS
• CHEST
• ABDOMEN
• GENITOURINARY
• MUSCULOSKELETAL

13. SIGNS(EMMERGENCY(call for help))
• ASSESSMENT AND CLINICAL EXAMINATION::
• A: AIRWAY
(Secretions or blood, falling tongue, loss of denture, recovery position (mind full of
cervical fracture and fix neck collar))
• B: BREATHING
(Chest movement,FAN,ICR,SCR,Trachial tagging, retrosternal in drawing, chest
examination(inspect, palpitation, auscultation) oxygen saturation, blood gasses)
• C: CIRCULATION
Iv line ,sample, pulse(characteristics), heart rate,BP, bleeding points)
• D: DISABILITY
(Fracture(Step formation, chest and pelvic compression tenderness))
• E: EXPOSURE
(Cut through clothes(poly trauma patient))

14. SIGNS (AIR WAY AND BREATHING PROBLEMS)
• AIR WAY PROBLEMS
• Secretions/blood in airway(nasal and oral cavity)
• Vomiting( unconscious patient)
• Noisy breathing(stridor)
• Mouth breathing
• Use of accessory muscles of respiration
• ↑RR,
• Sniffing dog position(acute epiglottitis)
• BREATHING PROBLEMS
• ↓Oxygen saturation
• Absent or ↓chest movement
• Deranged Blood gasses

15. SIGNS OF ADEQUATE INTRAVASCULAR FLUID VOLUME
REPLACEMENT
• CIRCULATION
• Heart rate < 100 beats. min -1
• Pulse pressure > 30 mmHg
• Urine output > 0.5 – 1 ml.kg-1.h-1
• Absence of metabolic acidosis
• Minimal effects of positive pressure
ventilation on blood pressure.

16. INVESTIGATION
• HEAMATOLOGY :
• (FBC, Clotting profile, sickling, HB electrophoresis, Grouping and cross matching,??ESR)
• BIOCHEMISTRY:
• ( Arterial blood gasses, BUNCr electrolyte, LFT,RBS,FBS)
• MICROBIOLOGY:
• (C/S, CSF cell count, Microscopy, ZN-AFB, Gram stain, urine and stool R/E, MP’S)
• BIOPSY:( eg:Therapeutic Excisional biopsy of subglottic polyp)
• IMAGING(X-Ray,U/S,ECHO)
• (Depends on pathology)
• OTHERS :
• (hormonal(eg TFT,))

17. REQUIREMENT OF MANAGEMENT(CRITICALLY ILL PATIENT)
• Immediate availability of
• surgeons/ physicians,
• anesthesiologists,
• nurses
• facilities,
• emergency room,
• theatres,
• ICU beds,
• radiology,
• laboratory,
• blood bank
• 24 hours every day of the year.

18. Requirement of management
1. Airway equipment/devices
Oro/Nasopharyngeal airways,,
orotrachial tube,
nasotrachial tube,
tracheostomy tubes,
esophageal obdurate airway,
crocothyroid tube,
pharyngotrachial lumen tube(PTL)(Combination of esophageal
obturator tube(airway)+endotracheal tube)
- Magill’s forceps
- Laryngoscopes, endotracheal tubes
2. Ambubags
3. Mechanical ventilator.
4. Anesthesia machine
5. Monitoring devices.
6. Blood pumps and primed infusion sets in blood
warmers.
7. Drugs in labelled syringes.
8. Electrical defibrillator.

21. Air way mx

22. cricothyrotomy

23. TREATMENT
GUIDING PRINCIPLES::
• DELIVERY OF OPTIMAL AND APPROPRIATE CARE .
• RELIEF OF DISTRESS
• COMPASSION AND SUPPORT
• DIGNITY
• INFORMATION
• CARE AND SUPPORT OF RELATIVES AND CARE GIVERS

24. TREATMENT (medical,surgical,combined)
• INTENSIVE CARE MEDICINE INVOLVES
1. A :Airway management.
2. B: Ventilation of the lungs.
3. C: I.V administration of potent and rapidly acting drugs.
4. D: Fluid, electrolyte and blood administration including parental
nutrition.
5. Non invasive and invasive monitoring of vital organs

25. A--AIRWAY
• Suction(secretions, blood
foreign body)
• Position(recovery
possition,prop up)
• Airway use(nasopharyngeal
tube, oropharyngeal tube,)
• Intubation or other
alternatives

26. B-- BREATHING
• Chest movement
• Use of accessory muscles of
respiration
• Oxygen saturation
• Arterial Blood gasses
• Give oxygen
• Chest tube
(pneumothorax,heamothorax,
chylothorax,pneumohaemoth
orax,pyothorax)

27. Options of airway
management
• Percutaneous dilatational
tracheostomy
• NPPV(Non invasive positive
pressure ventilation)
• Laryngeal mask airway(LMA)
• Endotracheal intubation
• Trans tracheal needle ventilation
• Cricothyroidotomy
(minitracheostomy/laryngotomy)

28. C--Circulation
• IV line,
• Take sample,
• Intraosose cannulation
• Iv fluids--
(crystalloids(R/L,N/S,D/S),Colloids()
• Blood and blood product
transfusion (whole blood, fresh
blood,RBC concentrate, albumin
concentrates,FFP act.)
• fluid and temp. chart,
• CPR
• Pass urethral catheter
• NG Tube

29. D--DRUGS
• IV antibiotics
• Analgesics
• Steroids
• Naloxines (↑ BP)
• Oxygen radical scavengers(superoxide
dismutase,Allopurinol,vit C)
• Antithrombin III (Prevent further coagulopathy)
• Inotropic Agents(heart failure; dopamine/dobutamine)
• Monoclonal antibodies to TNF,IL-1,IL-6

30. MANAGEMENT OF OTHER ORGAN (status locales)
• ABDOMEN: (Liver failure, peritonitis, peritoneal abscess, pancreatitis Intestinal
obstruction, raptured spleen, feeding tube,)
• GENUTOURINAL: (kidney failure, trauma to kidneys empyema, UTI ( Unconscious
elderly),Testicular necrotising fasciitis)
• PELVIC: (Septic abortion, ectopic pregnancy, postpartum sepsis,PID)
• MUSCULOSKELETAL: ( Diabetic foot gangrene(amputation),prevent bed sore,
physiotherapy)

31. MANAGEMENT OF OTHER ORGAN (status locales):
continuation
• CNS: (SEIZURES, craniotomy(heamatoma,abscess,tumour))
• ENT: ( Retropharyngeal abscess, mastoid abscess, complicated sinusitis,
complicated otitis media, advance head and neck tumours, necrotising fasciitis of
the ear)
• Others: burns, hypovolemia(vomiting, diarrhiour, ),allergic reaction,
immunosuppression,leukemia,carcinoma

32. MANAGEMENT OF CRITICALLY ILL PATIENT:
• COMPLETE MONITORING
• RESPIRATORY CARE
• CARDIO VASCULAR CARE
• VENOUS THROMBOSIS PROPHYLAXIS INFECTION CONTROL
• FLUID, ELECTROLYTE AND GLUCOSE BALANCE
• GASTROINTESTINAL/NUTRITIONAL CARE
• BLADDER CARE
• NEURO MUSCULAR
• COMFORT AND REASSURANCE
• COMMUNICATION WITH THE PATIENT
• SKIN CARE
• GENERAL HYGIENE AND MOUTH CARE
• DRESSING AND WOUND CARE COMMUNICATION WITH RELATIVES

33. 1. COMPLETE MONITORING
• Temperature
• BP
• HEART RATE{HR}
• ECG
• RESPIRATORY RATE{RR}
• OXYGEN SATURATON
• ARTERIAL BLOOD GASSES
• INPUT AND OUTPUT CHART
• RENAL FUNCTION ( BUNCr and Electrolytes(SODIUM,CLORIDE,POTASSIUM))
• HAEMATOLOGY{HB,WBC AND DEFFERENCIALS}

34. EXAMPLES OF ORGAN SYSTEM FAILURE
TREATED IN THE INTENSIVE CARE UNIT
• Acute respiratory failure
• Congestive heart failure
• Sepsis
• Head injury
• Acute renal failure
• Acute hepatic failure
• Malnutrition

35. ACUTE RESPIRATORY FAILURE
• Not a single dx. Entity
• Combination of pathophysiologic derangements that arise from a variety of
etiologic insults.
• Therefore considered as ADULT RESPIRATORY DISTRESS SYNDROME
(ARDS)

36. PATHOPHYSIOLOGY OF ARDS
• Many mediators have implicated in the pathophysiology:
• complement,
• cytokines,
• O2 radicals,
• arachidonic acid products,
• nitric oxide and
• proteases.

37. AETIOLOGY ARDS
1. DIRECT injury to lung –
• aspiration,
• pneumonia,
• pulmonary contusion,
• thermal inhalation,
• amniotic fluid,
• embolism and
• particle inhalation.
2. INDIRECT injury to lung via mediator release
• e.g.
• pancreatitis,
• sepsis,
• bacteremia.
• The presence of multiple insults increases the risk of ARDS

38. • Cardiac dysfunction
Shock (hemorrhage, sepsis)
Congestive heart failure
Post – cardiopulmonary bypass
Central nervous system dysfunction
Hypothalamic injury
Depressant drug overdose
Neuromuscular dysfunction
Myasthenia gravis
Spinal cord transection
Guillain – Barre syndrome
Tetanus
Drugs (muscle relaxants, antibiotics)
Miscellaneous
Massive blood transfusion
Disseminated intravascular coagulation
Morbid obesity
Uremia
Acute pancreatitis
MORTALITY OF ARDS: 40 – 60% in most studies
• FULL ETIOLOGY OF ACUTE
RESPIRATORY FAILURE
• Trauma with associated multiple
organ system failure.
• Pulmonary dysfunction
• Obstructive pulmonary disease
• Restrictive pulmonary disease
• Pneumonia
• Inhaled toxins (gastric fluid, smoke,
meconium)
• Oxygen toxicity
• Emboli (blood, fat, amniotic fluid)
• Lung contusion
• Near – drowning
• Hyaline membrane disease

39. CLINICAL DIAGNOSIS OF ARDS
Acute onset
1. Arterial hypoxemia PaO2 < 60mmHg despite supplemental inhaled O2.
PaO2/FiO2(FRACTION OF INSPIRED OXYGEN) ratio < 200
2. Pulmonary oedema despite pulmonary artery occlusion pressure < 18 OR no
evidence of left atrial hypertension.
3. ↓ Pulmonary compliance
4. Bilateral (patchy, diffuse, homogenous) infiltrates on CXR consistent with
pulmonary oedema.

40. DIFFERENCES BETWEEN ACUTE RESPIRATORY
FAILURE AND CHRONIC RESPIRATORY FAILURE
Relationship of PaCO2 to the pH.
• ARF – Abrupt ↑ in PaCO2 and corresponding ↓ pH.
• CRF – ↑ PaCO2 but pH near normal (compensation by renal reabsorption of HCO3 ions).

41. TREATMENT OF ARDS
Support pulmonary function till lungs can recover from insult.
Usually necessary to intubate and ventilate.
- PEEP (Positive End – Expiratory Pressure) for IPPV(intermittent partial
pressure ventilation) patients.
- CPAP (Continuous Positive Airway Pressure) for spontaneously breathing
patients.
- Inhalation of nitric oxide.
More than 75% of patients dying of ARDS now die of multiple organ system
failure rather than impaired gas exchange.

42. SEPSIS
Hospital acquired infections
- Important cause of death in ICU
Common sources of infection
1. Urinary tract
2. Surgical wounds
3. Pneumonia
4. Intravascular devices
5. Sinusitis ( may be unexplained cause of fever, esp. if Nasotracheal tube is
in place)
6. Leading cause of mortality - PNEUMONIA

43. SEPTIC SHOCK
1. Hypotension (BP< 90mmHg) in presence of peripheral vasodilation
2. Oliguria
Suspect if symptoms occur following operations or instrumentation of the
genitourinary tract.
3. in state of consciousness e.g. contusion and disorientation
- Measure C.O(cardiac output) and S.V.R( systemic vascular resistance) to
confirm diagnosis
- Positive blood culture is diagnostic but not always present.

44. TREATMENT OF SEPTIC SHOCK
1. I.V fluids
2. Dopamine to support cardiac and renal function
3. Antibiotics – 2 usually selected. One ( e.g. Chindamycin) effective
against gm +ve bacteria. The other e.g. aminoglyeoside derivative)
effective against gm –ve bacteria.
4. Steroids ???
5. Surgical intervention may be necessary
6. Ketamine – good induction agent for anaesthesia

45. CONGESTIVE HEART FAILURE
1. ↓ C.O
• Requires pharmacologic treatment with isotropic or vasodilator drugs or both
based on information from pulmonary artery catheter.
• Drug-induced ↑ in C.O are reflected in ↓atrial filling pressures, improved
arterial oxygenation and PVO2.

46. TREATMENT OF CCF
Vasodilator
e.g. - Nitroprusside 0.5 – 5mgKg -1 min -1
Nitroglycemia 0.5 – 5mgKg-1min -1
Hydralazine
Vasodilators increase cardiac output by ↓ impedance to forward ejection
of Lt. ventricular stroke volume.
(*But ↓ BP results in ↓coronary perfusion pressure! Be careful).
2. INOTROPIC drugs (dopamine, dobutamine, ephinephrine) improve C.O
by ↑ myocardial contractility

47. ACUTE RENAL FAILURE (ARF)
• Best treatment is prevention by maintaining optimal I.V fluid volume
and cardiac output.
• Relative fluid overload → pulmonary oedema may be necessary to
prevent oliguria and risks of ARF. Iatrogenic pulmonary oedema
treatable!
• Acute tubular necrosis (ATN) – only treatment is HAEMODIALYSIS.

48. INCREASED RISK OF ACUTE RENAL
FAILURE
Co-existing renal disease
Prolonged renal hypoperfusion (hypovolaemia, hypotension)
High risk surgery (abdominal aneurysm resection, cardiopulmonary
bypass)
Advanced age
Congestive heart failure
Extensive burns
Sepsis and/or jaundice
Treatment with prostaglandin inhibitors

49. TESTS USED FOR EVALUATION OF
RENAL FUNCTION
1. Glomerular filtration rate
Blood, urea, nitrogen
Serum creatinine
Creatinine clearance
Proteinuria
2. Renal tubular function
Rine specific gravity
Urine osmolarity
Urine sodium

50. ACUTE HEPATIC FAILURE (AHF)
Regardless of aetiology, AHF is associated with poor progress.
- Hyperventilation constant feature. Reflects stimulation of ventilation by
ammonia.
- Hypoglycaemia common
- C.O tends to ↑ (due to ↑ arteriovenous shunting)
- Bleeding diathesis resembling DIC.
- Terminal events – renal failure, arterial hypoxaemia, hypotension and
hepatic encephalopathy.
Treatment of AHF – Symptomatic and supportive, Neomycin, lactulose or
both to decrease ammonia production

51. MALNUTRITION
Critically ill patients often experience malnutrition (negative caloric intake) complicated by hypermetabolic
states 2° trauma (multiple fractures energy about 25% and burns by as much as 100%), fever,
(every 1° C increase energy needs by 15%), sepsis and wound healing.
Give enteral nutrition (tube feeding) OR Total Parenteral Nutrition (TPN) usually delivered through a catheter
placed in a central vein e.g. subclavian.
Complications of Total Parenteral Nutrition (TPN)
1. Hyperglycaemia
2. Hypoglycaemia
3. Hyperchloremic metabolic acidosis
4. Increased carbon dioxide production
5. Electrolyte abnormalities
6. Catheter – related sepsis

52. CONCLUSIONS
Every one is involved(doctor and nurse) in given special attention and close
monitoring of the patient.
Patient should be regularly reviewed by doctors
Patient should be in a bed that is easily viewed by Nurse and near emergency
trolley.
Urgency is essential in patient management.
• All the systems should be examined at each review.
• Vital signs should be monitored regularly
• Fluids input and output chart
• Nutrition
• Others : wound care ,physiotherapy, bathing, oral care, nails care

53. Thanks for listenting