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careofcriticalillpatient-151005215606-lva1-app6891.pdf

  1. 1. CARE OF CRITICALLY ILL PATIENT Dr Eunice Rabiatu Abdulai 26TH August 2015. VENUI: ENT DEPARTMENT KOR-BU TEACHING HOSPITAL
  2. 2. OUT LINE • Introduction • Definition • Anatomy • Aetiology/pathogenesis • Clinical characteristics{signs and symptoms} • Investigations • Treatment • Conclusion
  3. 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. 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. 5. ANATOMY •ALL systems can be involved •CVS •CHEST •ABDOMEN •CNS •MUSCULOSKELETAL •HORMONAL
  6. 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. 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. 8. AETIOLOGY •Can be from any system •CNS, •CHEST, •CVS, •ABDOMEN, •GENITOURINARY, •MUSCULOSKELETAL, •ENDOCRINE
  9. 9. PATHOGENESIS •VARIED , DEPEND ON THE CAUSE •Embryonic •Inflammatory •Trauma •Tumour •Iatrogenic •Unknown
  10. 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. 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. 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. 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. 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. 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. 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. 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. 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.
  19. 19. Air way mx
  20. 20. cricothyrotomy
  21. 21. 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
  22. 22. 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
  23. 23. A--AIRWAY • Suction(secretions, blood foreign body) • Position(recovery possition,prop up) • Airway use(nasopharyngeal tube, oropharyngeal tube,) • Intubation or other alternatives
  24. 24. 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)
  25. 25. 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)
  26. 26. 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
  27. 27. 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
  28. 28. 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)
  29. 29. 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
  30. 30. 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
  31. 31. 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}
  32. 32. 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
  33. 33. 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)
  34. 34. PATHOPHYSIOLOGY OF ARDS • Many mediators have implicated in the pathophysiology: • complement, • cytokines, • O2 radicals, • arachidonic acid products, • nitric oxide and • proteases.
  35. 35. 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
  36. 36. • 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
  37. 37. 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.
  38. 38. 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).
  39. 39. 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.
  40. 40. 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
  41. 41. 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.
  42. 42. 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
  43. 43. 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.
  44. 44. 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
  45. 45. 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.
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. Thanks for listenting

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