Critical Care

during CPR as hyperglycemia and hypercalcemia may cause e Clinical presentation can be mistaken as an ACS

neuronal damage. e Pain is sharp and tearing{ ripping

MRI is the diagnostic modality of choice

Advanced Life Support (ALS or ACLS) HTN is treated by esmolol + nitroprusside. Labetolol is

Defibrillation : alternative for monothcrapy

<' DC cardioversion is TOC for pulseless v, tach and Fenoldopam is a recent drug useful in aortic dissection

V-fib

e Recommended energy level for the first shock is 200 joules + Positive ionolropic agents hove 110 role in diastolic heart

for biphasic shocks & 360 joules for monophasic shocks. fail11rr. Diuretic d1uopy cun be co11nterproductive ond lffO)'

further impair \'f!ntricularfilli11g and CO

In children it is2J/kg
+ lntra-oortic balloonco11nlerp11/sali0fl pump (JABP) is ustd i11

seltcted cases o
f Ml witl, cardtogenic sock tlrat is rejructory

Drugs administered during CPR to htmodynamic dn,g support

fl Avoid ET route, as dose of ET drugs are still not

confinned.

o Drugs which can be given via endotracheal routes are-« Central Venous Catheter

atropine, epinephrine, vasopressin, lidocaine e Mic route of central venous catheterization is femoral

� Epinephrine is recommended for most cases of pulseless vein.

cardiac arrest including those d/to asystole, pulseless ECG. e Catheter related sepsis is the m/c complication.

Atropine is adjunct

(} IV Amiodarone is now recommended for cases of V-fib

and pulse less V-tach that are refractory to defibrillation and

vasopressor drugs.

INTUBATION
o IV calcium gluconate is indicated if- there is hypocalccmia,
------·· ----·-
CCB toxicity, and electromechanical dissociation Intubation is difficult in ( Conditions alw

() An increase in end tidal C0 (fEtCOJ is the predictor intubation failure are}··

2

of succesful outcome I. Laryngeal edema

o. Peripheral veins arc preffered to central vein as it do not 2. LTB

require interruption of CPR. Vascular/ Intraosseous route 3. Epiglottitis

is preferred over tracheal route for drug administration.

Orotracheal (endotracheal) intubation

e Common method o
fendotracheai intubation is oro-tracheal

Acute Coronary Syndrome (ACS) approach.

t< Oral I i.v, nitroglycerine is indicated to relieve chest pain � Rough guide to Tube size is

d/to unstable angina or ACS a/w HTN. 2.5 ·- Prctenn

Morphine is the DOC for chest pain that is refractory to 3.5 ••• Full tenn healthy infant

nitroglycerine 4 + Age in years /4) - For children

7.5 to 9 -· in adults

Acute Pulmonary Edema

Nitroglycerine (sub-lingual) is most effective in reducing

pre load. + Armor1red ET tubes are cuffed mbes used in 11euro.su,gery.

e Loop diuretics esp furosemide is being used for years . It

acts by diuresis+ venodilatarion.

e Morphine can help in J..ing COP.

e NPSV (Non-invasive pressure support ventilation) should Contraindications to Nasal Intubation

be considered early. It Les preload & aft:erload and tes c. Severe nasal/midface trauma

intrathoracic pressure. e Basilar skull #

e Patient taking anticoagulants or having h/o coagulopa1hy

Acute aortic dissection

675_
 ROAMS

Rapid sequence intubation (RSI) Important formulae in PALS to select

e Done in full stomach patients. I. ET Suction catheter (Suction of E1T)

e lndications are: == Internal diameter (size) of ElT X 2 FG

I.Trauma patient with GCS 0f� 8 2. Lip to carina length ofETI(Length of ETT)

2. Significant facial trauma with poor airway control == Internal diameter (size) of ETT X 3 cm

3. Bum patient with airway involvement and inevitable 3. Size of ETI in children (Internal diameter)

airway loss == (Age in years/4) +4 mm

4. Respiratory exhaustation e.g. respiratory failure, near·

drowning, COPD with hypoxia, CHF. Hypotension (low BP) is said if

5. Non-fasting state (full stomach) in a patient requiring c Systolic BP is <60 in newborn

intubation. e Systolic BP is< 70 + age x 2 --- in 1 - 1 0 years children

6. Prolonged seizures e Systolic BP is< 90 in >10 years children,

7. Drug overdose with altered mental status. adults

e- Sequence/or normal anaesthesia: In Pediatric assesment

3-4 min pre-oxygenate - llv induction-+ MR-+ BMV e AVPU assessment include - Alertness, Verbal

- Intubate response, response to

o Sequence in fit!/ stomach patients: pain, Unconsciousness

Preoxygenate - llv induction + Sedation - Fast acting c SAMPLE assessment include- Signs/symptoms,allergies,

muscle relaxation (Sch or vecu /rocuronium) - Apply medications, past history,

cricoid pressure (Se\ik's maneuver) - Intubate last meal, exposure to any

Bag and mask ventilation (BMV) is contra- indicated toxins

e Cuffed ET- tube should be used

(' Oind: significant facial edema, distorted laryngeal anatomy ABCD of CPR in adults! children are

( post cancer pt), airway anomaly e Airway

e Drugs used form/s relaxation-Rocuronium >Vecuronium, o Breathing

Sch (scoline). e Circulation

e Defibrillation

o. Emergency intubation is required in :

High spinal injury ABCDE of primary assessment of a ped;atric

patient

Practical Points e, Airway

e, The basilic vein is preferred to cephalic vein for PICC e Breathing

(peripherally inserted central catheters) because it is slightly o Circulation

larger than the cephalic vein c Disability

o Presence of a coagulation disorder is not a contraindication o- Exposure

to placement of central venous catheter.

e Femoral vein is not recommended as a primary site for M/m and Action steps in an unresponsive/

placement of central venous cannulation d/to risk of venous critical child

thrombosis. e Sequence is : Asses - Categorize- Decide - Act

e Peripheral venous catheter should be replaced every 3-4 e General assesment PAT triangle

days - Appearance

- Breathing

- Circulation

Is there any action required (0 inhalation, CPR, BMV etc.)

2

---�PALS GUl�(Lllil;$. _- _ _ . ,
on the basis of general assessment -Act

Pediatric advanced life support (PALS) guidelines are e Do primary assessment ABCDE (C-A-B now a days)

important in m/m of critical children I. Airway -- Is airway maintainable or not - If not

maintainable do head tilt chin lift manueuver (use only

_676
 Critical Care

jaw thrust if cervical spine injury is suspected ), suction D.Dopamine

etc. (Ans. Vasodilator therapy)

2. Breathing --- Check 5 things RR, chest movements,

work of breathing, air entry, any added sounds

3. Circulation ••• Check HR, pulses (both central and :- A40ycaro\dpatient presents withsignsofdecompensated

peripheral), temperature, sP02,CIT, BP. heart failure . He has a recent H/0 myocarditis.

Supportive evidence of circulatory status arc -- skin, 0/E his PCWP is 18 mm Hg, cardiac output is 3llmin, and

kidney and brain perfusion (look for mottling I colour BP is 120 /82 mmHg. Best initial tit for this patient would

of skin, urine output, mental status) be--

4. Disability --- Neurological status by -- A. Diuretics

1. AVPU assessment (alertness, verbal response, pain B. Nitroprusside

response, unconsciousncss)for cortical function C. Dobutamine

2. Pupillary response for cerebellar function D. Dopamine

5. Exposure- Includes complete head to toe examination (Ans. Dobutamine )

Categorize, decide and act on the basis of primary

assessment n A 40 year old patient after an episode of acute Ml presents

a Secondary assessment includes --- SAMPLE (Sign/ with signs of decompensated heart failure.
,s,

symptoms, allergy, medication history, past history, last 0/E his PCWP is 18 Hg, cardiac output is 3Llmin,
�. mm and

meal.exposure to any toxin etc.) BP is 100/ 54 mmHg. Best initial lit for this patient would
ay

Decide and act on the basis of secondary assessment be--

A. Diuretics

B.Nitroprusside

C. Dopamine in a dose 5 µgt kg! min

D.Dopamine in a dose> 10 µgt kg/min

IMPORTANT NEGATIVE POINTS

(Ans. Dopamine in a dose> IO µgl kg! min)
�....,,.-'-'----- j •

e Transtentorial herniation does NOT usually results in

··- lpsitateral hemiparesis g or ti

Clue to the di t are

o NOT useful in management of acute pulmonary edema M/m strategies for decompensaled left sided heart failure

-- Digoxin are based on the BP of patient

e NOTtrucofflai!chest

-- Paradoxical movements may not be seen in consciuos High PCWP, low Bypass_ Vasodilatortftwilh_

patient. CO, High BP . nitroprosside/nitro­

g!y=mo(ICOby
a NOT included in APACHE score --- S. Calcium level

a Adminislration of glucose solution is not prescribed in

-- Hx of unconsciousness.

Acute MI, Dopaminem

puJomonary vasoconstrictofilose(>IO

(Cardiogenic embolism, wdkgfmin}

- - - � CA L VIGNITTES . ___J shock) bypass.viral

myocarditis
r, A 40 year old patient, who underwent bypass surgery for

triple vessel disease 6 hours back , presents with signs of

+ Dlumics are useful i
n chronic heart failure
,.) decompensated heart failure. 0/E his PCWP is 18 mm Hg,
+ Nisiritide is a rerombinanl humon B-rype natriumic pepfw.

cardiac output is 3Umin, and BP is 170/100 mmHg. Best which is a syslemic vasodifator

initial tit for this patient would be--

at
A. Diuretics !3 A 40 year old patient presents with signs of right heart

ly B. Vasodilators failure following an episode of acute Ml.

677 _
C. Dcbutaminc
 ROAMS

0/E his PCWP is 13 mm Hg, and BP is 86146 mm.Hg. Best C. IV fluids and a sample of blood for cross matching

initial tit for this patient would be-- D. Rush to operation theatre

A. Infusion of IV fluids B. Nitroprussidc [All lndi,'09)

C. Dobutaminc D. Dopamine (Ans.C. IV fluids and a sample of blood for cross

(Ans. Infusion of IV fluids) matching)

Tit o
f diastolic/ right sided heart failure following an

episode o
fMl (11s11ally inferior Wall Ml
) isguided b
y PCWP Tit protocol in blunt abdominal trauma

andRVEDV I. Primary survey -- CABDE

2
• If PC\VP i s < 15 or the RVEDV is below 140mU m C = Circulation (establish i.v. line, check pulses,

--- Infuse volume until PCWP or CVP increases by 5 mm CFT, BP, Correct hypovolcmia by crysmlloids)

Hg (reaches 20 mmHg) A .. Airway maintenance (with cervical

2
- IfPC\VPis> 15 orthe RVEDVis 140mUm orhigher-­ immobilization)

start dobutamine @ 5 µgl kg/ min 8 • Assess breathing (ensure adequate ventilation, give

oxygen, look for b/L air entry).·

n A head injured patient, who opens eyes to painful stimulus, D = Disability ( determine neurological status, AVPU

is confused and localizes to pain. What is his Glasgow coma assesment for cortical function, pupillary response

Score? [Al[MS Nov'05] forcerebellar lesion)

A.7 B. 9 C. 11 D.13 E "" Exposure ( Completely expose the patient and

( A ns : C . 1 1 ) examine)

Glassgow coma scale - includes EVM assesmcnt

Eye opening : a In a patient of head trauma with unexplained hypotension

Spontaneous one should look for evaluation of

To speech A. Upper cervical spine

To pain 8. Lower cervical spine

None C. Thoracic spine

D. Lumbar spine

Best Verbal response : (Ans.A. Upper cervical spine )

Oriented [All India '09,AIIMS May'OS, 09)

Cori fused

Inappropriate words � A head injury patient is admitted. On examination he opens

Incomprehensible sounds eyes on giving painful stimuli, there is inappropriate verbal

None response and he is able to localise pain. The Glasgow coma

score for this patients is: [AllMS Nov'09]

Best Motor response : A.8 8.10

Obeys C.12 D. 14

Localizes ( Ao s . 1 0 )

WithdraWal

Abnonnal flexion ,, A patient after THR post op day 2 develops chest pain,

Extensor response hypotension and respiratory distress. ECHO shows right

None ventricular motion abnormalities with TR. Mosr likely

diagnosis is : [AIPGMEE'IO]

A. Pulmonary embolism 8. Myocarditis

'.' A patient who sustained blunt trauma abdomen with C. Acute Ml D. Constrictive pericarditis.

Glasgow coma score 15, pulse rate 120/ mt, BP of 100/80 (Ans.A. Pulmonary embolism)

mmHg, management priority after ensuring breathing and Right ventricular motion abnormalities with TR on ECHO

ventilation include one of the following are suggestive of right ventricular dysfunction most likely

A. Establishment a good airway secondary to pulmonary embolism. Pulmonary embolism

B. Immediate blood transfusion is a known complication after THR.

_678
 Ejection fraction is affected and cardiac involvment is

global in myocarditis and pericarditis.

- A 24 yr old male presents in the casualty with hollow

viscous perforation peritonitis of24 lusduration and shock.

After securing airway and breathing and starting IV fluid

rescucitation, the next most appropriate management strategy

would be··- [AIPGMEE'l 1]

A. Shift the patient in OT and perform exploratory

laparotomy under GA

B. Immediatcly insert abdominal drain under LA and shift

the patient in OT for exploratory laparotcmy

C. Immediately shift in OT for diagnostic laparoscopy and

proceed under GA

0. Stabilize the patient in casualty and correct electrolyt_es

followed by exploratory laparmomy in OT under GA

(Ans. : A. Shift the patient in OT and perform

exploratory laparoromy under GA)

·, In an ICU patient, Right subclavian vein cannulation for

CV line was done. Few hours later, he sudden1y developed

dyspnea, tachycardia, and hypotension. Chest examination

revealed hyper-resonance on percussion, and decreased

breath sounds on auscultation. Left sided breath sounds

were minimally reduced Which of the following is likely

diagnosis? [A1PGMEE'l2]

A.Tension pneumcthorax

9. Traumatic hemothorax

C.Cathe1erfracture

D. Air embolism

[Ans.A. Tension pneumothorax]

Puncture of pleura-Tension pneumothorax is a common

complication of subclavian line placement. Clinical signs

are very much suggestive of pneumothorax.

NQTES

679_