Critical Care

Critical Care #

Good References:

Sepsis:

  • First thing to go: Lactate, Cr
  • First thing to get better: Lactate

Rapid Sequence Intubation (RSI) #

  • ETT 7.5
  • Etomidate 20mg (+/- 2-4mg versed IV)
  • Rocuronium: 1mg/kg (OR Vecuronium: 10mg fixed, or Succinylcholine 1.5mg/kg)
  • Checklist:
    • Bag (make sure you can bag before giving paralytic or you’re F-ed)
    • Suction
    • Meds
    • ET Tube (plus spare)
    • Vent/RT

Sedation meds (all given as IV bolus): #

  • Etomidate: 0.15-0.3mg/kg, 20-30mg usually
    • Onset 30-60sec, duration 3-5mins
    • Lowers seizure threshold?
    • Causes release of cortisol, can have rebound hypotension ˜24hrs later
    • Inhibits cortisol, caution in adrenal insufficiency
  • Ketamine: 2mg/kg
    • Onset 1-2min, duration 5-15mins
    • Avoid with increased cranial pressures (closed intracranial trauma, ↑ intraoccular pressure, CAD, HTN)
  • Propofol: 0.5-2mg/kg
    • Onset 9-50sec, duration 3-10mins
    • Can cause hypotension, just bolus with fluids at same time and it’ll be ok
    • Egg and soy allergies

Paralytics #

  • Succinylcholine: 1.5mg/kg
    • Onset 30-60sec, duration 5-15mins
    • Don’t use if hx of malignant hyperthermia or life-threatening hyperkalemia
  • Rocuronium: 1mg/kg
    • Onset 1-2mins, duration 45-70mins

Confirming Placement #

Dr. Amir’s Setup #

  • ETT 7.5 (7-8)
    • good for almost everyone
  • Etomidate 20mg
  • +/- versed 2-4mg
  • Paralytic
    • Make sure you can bag before you give paralytic
      • If not, you are screwed if you give paralytic and can’t intubate
    • Rocuronium: 1mg/kg
    • Vecuronium: 10mg fixed
    • succinylcholine: 1.5mg/kg
      • Careful as can raise K, not great for renal failure Get a PEEP valve on bag mask (helps you get peep when bagging, really need this for ARDS, when you take off HHF sats will tank)

ACLS (Adult) #

Arrest #

ACLS Adult Cardiac Arrest Algorithm

Bradycardia #

  • Eval
    • ABCs
    • O2
    • IV
    • EKG
  • Stable
    • Monitor
  • Unstable
    • Atropine 1mg (q3-5mins, max 3mg)
      • Epinepherine gtt: 2-10mcg/min
      • Dopamine gtt: 5-20mcg/kg/min
    • Transcutaneous pacing

Tachycardia #

  • Eval
    • ABCs
    • O2
    • IV
    • EKG
  • QRS complex width
    • Narrow (<0.12)
      • Stable
        • Vagal maeuvers
        • Adenosine
          • 6mg then 12mg (can go higher in real life)
      • Unstable
        • Sync cardioversion
        • Adenosine
    • Wide (>0.12)
      • Stable
        • Adenosine (only if regular and monomorphic)
        • Procainamide 20-50mg/min (max dose 17mg/kg)
      • Unstable
        • Sync cardioversion

Stroke (CVA) #

  • ABCs, O2 if needed
  • Check glucose
  • CT/MR
  • IV

Goals:

  • Gen assessment: 10 mins
  • Neuro assessment and CT/MR: 20 mins
  • Rads read: 45mins
  • lytics within: 60 mins from ED door
  • lytics within: 3-4.5 hrs of symptom onset
  • EVT (endovascular therapy)
    • LVO: 24 hrs
    • 0-6hrs: CT findings
    • 6-24hrs: penumbral scan
  • Admission to bed: 3 hrs
  • Transfers: 1 hr

AMI #

  • if O2 < 90% → 4L
  • ASA 162-325mg
  • Nitro (careful with RV ischemia, pre-load dependent)
  • Morphine IV (careful with RV ischemia, pre-load dependent)

Goals:

  • Door to balloon: 90 mins
  • Door to needle (lytics): 30 mins

ROSC #

  • Breaths: 10+/min
  • SpO2: 92-98%
  • PaCO2: 35-45 mmHg
  • SBP >90, MAP >65
  • EKG → if STEMI or LBBB cards intervention
  • Follows commands?
    • No
      • TTM (32-36C) x 24hrs
      • CT head
      • EEG
    • Yes
      • ICU management

BLS #

  • Adults:
    • Breaths: 1 every 6 sec
    • 30-2
    • If pregnant to umbilicus, laterally displace uterus
  • Peds:
    • Breaths: 1 every 2-3 sec
    • One rescuer
      • 30-2
      • Leave after 2 mins to get AED
    • Two+ rescuers
      • 15-2

Vent Management #

Three modes to know:

  • VC
    • Good for COPD, asthma since you can control the I:E ratio
  • VC+ (PRVC)
    • Pressure regulated volume control
    • Good general purpose
  • APRV
    • Inverted I:E
  • Oxygenation
    • FiO2
    • PEEP
  • Ventilation (i.e. CO2)
    • tidal volume
    • rate
    • combination of which is your minute ventilation

EMCrit Vent Handout

Changes #

Winter’s formula: $P_{CO_2} = 1.5 * HCO3- + 8 +/- 2$

Then figure your change as CO2 is proportional to rate and tidal volume. $CO2 prop rate * V_T$

Plateau pressures should be <30

tidal volume should be 6-8cc/kg ideal body weight

Sedation on Vent #

  • Important to differentiate between anxiety and delirium, sometimes hard to tell the difference

  • [PADIS 2018 guidelines](’/literature/PADIS 2018 guidelines.pdf')

  • Precedex

    • Awesome med, can be continued post extubation
      • Quick and clean on and off
      • Not a sedative, it’s an anxiolytic
      • Can cause bradycardia/hypotension
        • Not a huge issue, but be aware of it
    • Transition to clonidine if going to be used for more than 7 days

  • Propofol

    • Great for short term (<3-4 days) as is a sedative
      • switch to fentanyl/versed pushes if you need longer
    • Quick on, quick off
    • Has some GABA activity
      • Good choice in EtOH withdrawl and/or seizures
    • Watch for propofol infusion syndrome
      • Looks like shock without a source
        • ↑ CK
        • ↑ lactate (12-14ish)
        • ↑ Chol, LFTs
        • hypotension
        • green urine (boards only really)
      • usually happens to people on high doses (>100/hr) and long durations (>3-4 days)
    • Not great in fat people, gets stored in fat

  • Ketamine

    • Need to learn more here…

  • Always favor narcotic pushes over drips

  • Last resort is benzos

    • Almost never use benzo drips

Paralytics #

Almost always use Cisatracurium.

  • Cleared by Hoffman elimination, not eliminated by kidneys or liver.

Anxiety #

  • Talk to family, ask if pt with history of anxiety
  • Benzos great for anxiety, crappy for delirium (can make it worse)

Delirium #

  • Definition: imparied attention (that’s it!), usually acute onset (vs dementia)
    • Important as is independent risk factor for mortality
    • Evidence to suggest that it’s an inflammatory brain process (from autopsies)
      • Important for healing, not just for making out and RNs lives easier
    • Hyperactive and hypoactive flavors

Treatment #

  • haloperidol (Haldol)
    • 0.5-20mg q15-30mins until calm
  • olanzapine (Zyprexa)
    • 5-10mg IM, max 30mg/day
  • ziprasidone (Geodon)
    • 10mg IM q2h or 20mg q4h, max 40mg/day
    • 20-40mg PO q12h
  • quetiapine (Seroquel)
    • 50mg PO BID, max 400mg/day

Also Qtc prolongers

Watch for serotonin sydrome with above meds: - fever, rigitity - Check CPK,

Central Line #

Nasogastric tube (NG/Dob-hoff) #

ECMO #

  • VV = all on right side
    • Code => normal
  • VA = take from right side, return to arterial side
    • Code => just fix heart
  • Sweep = speed of gas (O2) in exchanger
    • Basically equivalent to minute ventilation (think of it like resp rate on vent)
    • Increase this to take off more CO2
  • FsO2 = just like FiO2
  • Doing good if sweep <2, and FsO2 as low as can go

Acute hypoxia #

  • Causes:
    • Parenchymal => pulm edema, atelectasis/shunt
    • PE
    • Cardiac => MI, arrhythmias
    • Hypercarbia => displaces O2

Chronic hypoxia #

  • Causes:
    • CHF
    • pHTN
    • Lung disease
    • CO2
    • Shunt

Workup #

  • ABG => looking at pCO2, paO2
  • PFTs (full): dlCO, plus underlying lung disease
  • CT => structural lung disease (CXR good quick and dirty look, but can miss a lot)
  • Echo w/ bubble => cardiac causes
  • EKG

Acute Respiratory Distress Syndrome (ARDS) #

  • Acute onset hypoxemia with bilateral radiographic infiltrates (no LA hypertension)
    • Dx needs three things:
      1. Onset within one week of known insult
      2. Bilat opacities on CXR => not effustions, or otherwise explained
      3. Resp failure not from fluid overload or some other cause (i.e. cardiac causes)
    • Decrease in lung compliance
    • Insults usually cause direct lung injury
      • PNA
      • Aspiration
      • Massive rapid transfusion (TRALI)
      • Non-pulm sepsis
      • Severe trauma

Severity #

Severity PaO2/FiO21 Mortality
Mild >200mmHg 27%
Moderate 100-200mmHg 32%
Severe <100mmHg 45%

Evaluation #

  • r/o other causes of sepsis
  • ABG
  • CXR/Chest CT
  • Echo + pBNP (r/o cardiac causes)
  • Bronch

Treatment #

  • Mechanical vent

ARDSnet table #

FiO2 Low PEEP High PEEP
0.3 5 5-14
0.4 5-8 14-16
0.5 8-10 16-20
0.6 10 20
0.7 10-14 20
0.8 14 20-22
0.9 14-18 22
1.0 18-24 22-24

Usually use high PEEP for COVID-19.

Airway Pressure Release Ventiliation (APRV) #

EMCrit explanation article and settings/strategy.

  • Good for reqruitment
  • Not great for "floppy lung" diseases (COPD, asthma)
  • Best for stiff lungs (i.e. ARDS, pneumonia, some ILDs)
  • Typical start
    • P-high: 30-35cm
    • P-low: zero
    • T-high: 5 sec
    • T-low: 0.5 sec
      • reduce if tidal volume >8mL/kg

ABGs #

  • pCO2 normal range:
    • Men: 36-40
    • Premenopausal Women: 34-36 (even lower in pregnancy)
  • pO2 normal range:
    • Denver: 70-80
  • VBG
    • Tells you everything except for oxygenation
    • To “correct” to an ABG
      • Peripheral
        • pH: add 0.02-0.04
        • pCO2: subtract 3-8mmHg
      • Central
        • pH: add 0.03-0.05
        • pCO2: subtract 4-5mmHg
  • SvO2
    • Normal: >65% (normal O2 extraction ≈25-30%)
    • <65% => imparied tissue oxygenation
    • >80%
      • High PaO2
      • Cytotoxic dysoxia
        • severe sepsis
        • cyanide poisoning
        • mitochrondial disease
      • Microcirculatory shunting
        • severe sepsis
        • liver failure
        • hyperthyroidism
      • Left → right shunt

Volume Status #

Assessment of volume status in criticall ill

Septic Shock #

Ferguson&rsquo;s Septic Shock Algorithm

Anaphylactic Shock #

  • Epipen q5min
  • Epi drip with “dirty” epi
    • “Dirty” epi
      • 1mg epi in 1000mL NS
    • Start at 1mL/min
    • Titrate to symptoms and BPs
  • Adjuncts
    • Methylprednisone 125mg IV
    • Diphenphyramine 2mg/kg (50mg max)
    • famotadine 20mg IV (or other H2 blocker)

Pearls #

  • Palpate posterior upper leg for edema in ICU patients (most dependent spot)
  • Every 10 CO2 increase => 1 bicarb increase
  • Sats above 80 are OK! As long as normal WOB, mentating normally.
  • Stress Dose Steroids: Hydrocort 50mg q8h until shock gone
  • Angor animi => medical term for “sense of impending doom”

  1. with PEEP/CPAP > 5cm H20 ↩︎