Contents Advanced Cardiac Life Support 5 Critical Care Patient Management 15 Critical Care History and Physical Examination 15 Critical Care Physical Examination 15 Admission Check List 16 Critical Care Progress Note 17 Procedure Note 17 Discharge Note 18 Fluids and Electrolytes 18 Blood Component Therapy Fibrillation 36 Hypertensive Emergency 41 Ventricular Arrhythmias 44 Torsades de Pointes 44 Acute Pericarditis 45 Pacemakers 46 Pulmonary Disorders 49 Orotracheal Intubation 49 Nasotracheal Intubation 50 Ventilator Management 51 Inverse Ratio Ventilation 52 Ventilator Weaning 52 Pulmonary Em 69 Pericardiocentesis 69 Hematologic Disorders 71 Transfusion Reactions 71 Disseminated Intravascular Coagulation 72 Thrombolytic-associated Bleeding 73 Infectious Diseases 75 Bacterial Meningitis 75 Pneumonia 79 Pneumocystis Carinii Pneumonia 83 Antiretroviral Therapy and Opportunistic Infections in AIDS 85 Sepsis 87 Peritonitis 91 Gastroenterology 93 Upper Gastrointestinal Bleeding 93 Variceal Bleeding 94 Lower Gastrointestinal Bleeding 96 Acute Pancreatitis 99 Hepatic Encephalopathy 102 Toxicology 105 Poisoning and Drug Overdose 105 Toxicologic Syndromes 106 Acetaminophen Overdose 106 Cocaine Overdose 108 Cyclic Antidepressant Overdose 109 Digoxin Overdose 109 Ethylene Glycol Ingestion 110 Gamma-hydroxybutyrate Ingestion 111 Iron Overdose 111 Isopropyl Alcohol Ingestion 112 Lithium Overdose 112 Methanol Ingestion 113 Salicylate Overdose 113 Theophylline Toxicity 114 Warfarin (Coumadin) Overdose 115 Neurologic Disorders 117 Ischemic Stroke 117 Elevated Intracranial Pressure 120 Status Epilepticus 122 Endocrinologic and Nephrologic Disorders 125 Diabetic Ketoacidosis 125 Acute Renal Failure 127 Hyperkalemia 130 Hypokalemia 133 Hypomagnesemia 134 Hypermagnesemia 135 Disorders of Water and Sodium Balance 136 Hypophosphatemia 140 Hyperphosphatemia 141 Commonly Used Formulas 142 Commonly Used Drug Levels 142 Index 144 Advanced Cardiac Life Support EMERGENCY CARDIAC CARE If wi tnessed arrest, give precord ial thump and check pulse. If absent, continue CP R Assess Re spo nsiveness Unresponsive Call for code team and De fibr illato r Assess breathing (op en the airway, look, liste n an d feel for breathing) If Not Bre ath ing, give two slow b reaths. Assess Cir cula tion PULSE NO PULSE Initia te CPR Give oxygen by bag mask Secure IV access Dete rmine proba ble e tiol ogy of arrest based on histo ry, physical exam, car diac monitor, vital signs, and 12 lead ECG. Ven tricular fibrillation/tach ycardia (VT/VF) p rese nt on monitor? Hypo ten sion /shock, acute p ulmonary edema . Go to fig 8 NO YES Intu bate Confirm tube pla ceme nt Dete rmine rhythm and cause. VT/VF Go to Fig 2 Arrh ythmia Brad ycardia Go to Fig 5 Tachycardia Go to Fig 6 Electrical A ctivity? YES NO Pulseless e lectrical activity Go to Fig 3 Asystole Go to Fig 4 Fig 1 - Algorithm for Adult Emergency Cardiac Care VENTRICULAR FIBRILLATION AND PULSELESS VENTRICULAR TACHYCARDIA Con tinue CPR Persist ent or recurrent V F/VT Epinep hrine 1 mg IV pu sh, re pe at q3 -5min o r 2 m g in 10 ml NS via ET t ube q3 -5min or Vasopressin 40 U I VP x 1 do se o nly Def ibrillate 360 J Amiodarone (Cordarone) 300 mg IV P or Lido ca in e 1. 5 mg /k g IV P, an d repe a t q 3-5 min, u p t o to ta l max o f 3 mg/ kg or Magnesium s ulf at e (if Tors ade de poin te s or hypo ma gn es emic ) 2 gms IV P or Procaina mide (if ab ove are in ef fec tive ) 3 0 mg/min I V inf u sion to ma x 17 mg/kg Continue CPR Secure IV access In tubat e if no respo nse Def ib rillate immediately, u p to 3 times at 20 0 J, 20 0-30 0 J, 36 0 J. Do not de la y defibrillation Return of spo nt ane ou s circulation Pu lseless E lectrical Act ivity Go to Fig 3 Monit or vital sign s Su pp or t a irway Su pp or t b re athing Provide me dications appropriate for bloo d pre ssure, hea rt rate, and rhythm Asse ss Airway, Breath ing, Circulation, Diffe rent ial Diagnosis Ad min ister CPR u ntil d efibrillato r is ready (p recordia l thu mp if witn esse d arrest ) Ve ntricular Fibrillation or Ta chycardia presen t on defibrillator Asyst ole Go to Fig 4 Check pu lse and Rhythm Co nt inue CP R De fibrilla te 36 0 J, 30-60 seconds af te r ea ch dose of me dication Repe at amio daro ne (Cord arone ) 15 0 mg IV P prn (if re urrent VF/ VT) , up to ma x cu mulative do se of 22 00 mg in 24 ho urs Cont in ue CP R. Ad minist er s odium bicarbonate 1 mEq/k g I VP if long arres t period Repe at patt ern o f d rug -sho ck, drug-sho ck Note: Epinephrine, lidocaine, atropine may be given via endotracheal tube at 2-2.5 times the IV dose. Dilute in 10 cc of sa line. After each intraveno us dos e, give 20-30 mL bolus of IV f luid and elevate extremity. Fig 2 - Ventricular Fibrillation and Pulseless Ventricular Tachycardia PULSELESSELECTRICALACTIVITY PulselessElectrical Activity Includes: Electromechanical dissociation (EMD) Pseudo-EMD Idioventricularrhythms Ventricular escaperhythms Bradyasystolic rhythms Postdefibrillation idioventricular rhythms Epinephrine 1.0 mgIVbolus q3-5min, or high dose epinephrine0.1 mg/kg IVpushq3-5min; maygivevia ET tube. Continue CPR If bradycardia (<60beats/min), giveatroprine 1 mgIV, q3-5 min, up to total of 0.04 mg/kg Consider bicarbonate, 1mEq/kg IV(1-2amp, 44 mEq/amp), if hyperkalemiaor other indications. Determine differential diagnosis and treat underlying cause: Hypoxia (ventilate) Hypovolemia (infuse volume) Pericardial tamponade (performpericardiocentesis) Tension pneumothorax (per formneedle decompression) Pulmonary embolism (thrombectomy, thrombolytics) Drug overdose with tricyclics, digoxin, beta, or calciumblockers Hyperkalemia or hypokalemia Acidosis (give bicarbonate) Myocardial infarction (thrombolytics) Hypothemia(active rewarming) Initiate CPR, secure IV access, intubate, assess pulse. Fig 3 - Pulseless Electrical Activity ASYSTOLE Cont inue CPR. Confirmasystoleby repositioning paddl es or by checking 2leads. IntubateandsecureIVaccess. Consider underlyingcause, suchas hypoxia, hyperkalemia, hypokal emia, acidosis, drug overdose, hypothermia. myocardial infarction. Consider transcutaneous pacing(TCP) Atropine1 mgIV, repeat q3-5minuptoatotal of 0.04 mg/kg; maygivevia ETtube. Epinephrine1.0mgIVpush, repeat every 3-5 min; maygi veby ETtube; highdoseepinephrine 0.1 mg/kg IVpushq5min(1:1000sln). Consider bicarbonate1mEq/kg(1-2amp) if hyperkalemia, acidosis, tricyclicoverdose. Consider terminationof efforts. Fig4-Asystole BRADYCARDIA No Yes Ye sNo Assess Airway, Breathing, Circulation, Assess vital signs Differential Diagnosis Reviewhistory Secure airway and give oxygen Perform brief physical exam Secure IVaccess Order 12-lead ECG Attach monitor, pulse oximeter and au tomaticsphygmomanometer Too slow (<60 beats/min) Bradycardia (<60beats/min) Serious Signs or Symptoms? If type II second or 3rd degree heartblock, widecomplex escapebeats, MI/ischemia, denervated heart (transplant),new bundle branch block: Initiate Pacing(transcutanous or venous) If type I second degree heart block, give at ropine 0.5-1. 0mg IV, repeat q5min, then initiatepacing if bradycardia. Dopamine 5-20 :g/kg per min IV infusion Epinephrine 2-10 mcg/ min IV infusion Isoproterenol 2-10 mcg/ min IVinfusion Observe Consider transcutaneouspacing or transvenous pa cing. Type II second degree AV heart blockor third degree AV heart block? Fig 5-Bradycardia (withpatientnot in cardiac arrest). No or borderline Atrial fibr illation Atrial flutter TACHYCARDIA Paroxysmal supraventricular narrow complex tachycardia (PSVT) Wide-complex tachycardia of uncertain type Ventricular tachycardia (VT) Torsade de pointes (polymorphic VT) Determine Etiology: Hypoxia, ischemia, MI, pulmonary embolus, hyperthyroidism, electrolyte abnomality, theophylline, inotropes. If uncertain if V tach, give Adenosine 6 mg rapid IV push over 1-3 sec Amiodarone 150- 300 mg IV over 10- 20 min Adenosine 12 mg, rapid IV push over 1-3 sec (may repeat once in 1-2 min) 1-2 min Adenosine 6 mg, rapid IV push over 1-3 sec 1-2 min Cardioversion of atrial fibrillation to sinus rhythm: If less than 2 days and rate controlled: Procainamide or amiodarone, followed by cardioversion If more than 2 days: Coumadin for 3 weeks; control rate, start antiarrythmic agent, then electrical cardioversion. Control Rate: Diltiazem,verapamil, digoxin esmolol, metoprolol Yes Assess Airway, Breathin g, Circulation, Differential Diagnosis Assess Vitals, Secure Airway Review histo ry and examine patien t. Give 100 % oxygen , secure IV access. Attach ECG monitor, pulse oximeter , blood pressure monitor. Order 12-lead ECG, portable chest x-ray. Correct underlying cause: Hypokal- emia, drug over- dose (tricyc lic, phenothiazine, antiarrhythmic class Ia, Ic, III) UNSTABLE, with serious signs or symptoms? Unstable includes, hypotension, heart failure, chest pain, myocardial infarction, decreased mental status, dyspnea IMMEDIATE CARDIOVERSION Atrial flutter 50 J, paroxysmal supraventricular tachycardia 50 J, atrial fibrillation 100 J, monomorphic ventricular tachycardia100 J, polymorphic V tach 200 J. Premedicate with midazolam (Versed) 2-5 mg IVP when possible. Vagal maneuvers: Carotid sinus massage if no bruits Fig 6 Tachycardia Ad eno s ine 12 m g , ra pid IV p ush o ver 1 -3 se co nd s ( m ay r ep eat o n c e i n 1-2 m i n ); m a x to ta l 30 m g Lidoca ine 1-1 .5 m g/ k g IV pu s h . R ep ea t 0.5 -0. 75 m g /kg IV P q 5-1 0m in to m a x to ta l 3 m g/ kg M ag nesium 2-4 gm IV over 5-1 0 m i n Ove r drive pa cing ( cut an eo us or ve n ou s) Iso pr o te re no l 2 -2 0 m cg/ m in OR Ph e nyto in 15 m g /kg IV at 5 0 mg /m in OR Lidoca i ne 1 .0-1 .5 m g /kg IV P C ard io ve rsio n 20 0 J Pro cainam ide 30 m g /m in IV to m ax to ta l 17 m g /kg Lidoca i ne 1 .0-1 .5 m g /kg IV P Com p lex wid th ? Nar row Wide If W o lf -Pa rkin son -W hit e syn dr om e , give am io da r on e (C or da r on e) 1 5 0-30 0 m g IV over 10- 20 m i n Pr o cain am id e 2 0-30 m g /m in, m a x to ta l 1 7 m g /kg ; fo llow ed b y 2 -4 m g /m in in fu sion If W P W , avo id ade nosine , bet a- b lo cke rs, ca lc iu m -blo cker s, an d digoxin Syn ch ro nize d card io ve rsio n 10 0 J N or m a l or e leva te d press ure Low -un sta ble Ve rap am il 2.5- 5 m g IV 15-30 m in Ve rap am il 5 -1 0 m g IV Con side r Digo xin Be ta b lo cke rs Dilt iaze m Ove rdr ive pacing Fi g 6 - Ta c h y c a r dia Blo od Pressure ? STABLE TACHYCARDIA If ventricular rate is >150 beats/min, prepare for immediate cardioversion. Treatment of Stable Patients is based on Arrhythmia Type: Ventricular Tachycardia: Procainamide (Pronestyl) 30 mg/min IV, up to a total max of 17 mg/kg, or Amiodarone (Cordarone) 150-300 mg IV over 10-20 min, or Lidocaine 0.75 mg/kg. Procainamide should be avoided if ejection fraction is <40%. Paroxysmal Supraventricular Tachycardia: Carotid sinus pressure (if bruits absent), then adenosine 6 mg rapid IVP, followed by 12 mg rapid IVP x 2 doses to max total 30 mg. If no response, verapamil 2.5-5.0 mg IVP; may repeat dose with 5-10 mg IVP if adequate blood pressure; or Esmolol 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion, and titrate up to 200 mcg/kg/min IV infusion. Atrial Fibrillation/Flutter: Ejection fraction $40%: Diltiazem (Cardiazem) 0.25 mg/kg IV over 2 min; may repeat 0.35 mg/kg IV over 2 min prn x 1 to control rate. Then give procainamide (Pronestyl) 30 mg/min IV infusion, up to a total max of 17 mg/kg Ejection fraction <40%: Digoxin 0.5 mg IVP, then 0.25 mg IVP q4h x 2 to control rate. Then give amiodarone (Cordarone) 150-300 mg IV over 10-20 min. Stable tachycardia with serious signs and symptoms related to the tachycardia. Patient not in cardiac arrest. Check oxygen saturation, suction device, intubation equipment. Secure IV access Synchronized cardioversion Atrialflutter 50 J PSVT 50 J Atrial 100 J Monomorphic V-tach 100 J Polymorphic V tach 200 J Premedicate whenever possible with Midazolam (Versed) 2-5 mg IVP or sodium pentothal 2 mg/kg rapid IVP Fig 7 -Stable Tachycardia (not in cardiac arrest) [...]... /kg M or phi ne IV 1- 3 m g N it r o g ly c e r in S L 0 4 m g t a b q 3 -5 m in x 3 O xy g e n B ra d yc a r d ia T a c h y ca r d ia G o t o F ig 5 G o to F ig 6 Diasto lic B P >11 0 mm Hg I f is c h e m ia a n d h yp e rte n s io n : N itr o g ly c e r in 1 0 -2 0 : g /m in IV , an d titr a te to e ffec t a n d /o r N itr o p r u s s id e 0 1 -5 0 : g/k g / m in IV 14 Critical Care History and Physical... a m in e 5 -2 0 : g / kg p e r m in S y s t o li c B P 7 0- 10 0 m m H g D o p a m in e 2 5 - 2 0 : g /k g p e r m in I V ( a d d n o r e p in e p h r in e if d o p a m in e i s > 2 0 : g /k g p e r m in ) Fig 8- Hypotension, Shock, and AcutePulmonaryEdema Systoli c B P >10 0 m m Hg an d dia sto lic BP n orm al D o b u t a m in e 2 0 -2 0 : g / k g p e r m in I V F u r o s e m id e IV 0 5 -1 .0 m g /kg... , an d titr a te to e ffec t a n d /o r N itr o p r u s s id e 0 1 -5 0 : g/k g / m in IV 14 Critical Care History and Physical Examination Critical Care History and Physical Examination 15 Critical Care Patient Management T Scott Gallacher, MD, MS Critical Care History and Physical Examination Chief complaint: Reason for admission to the ICU History of present illness: This section should included... ECG, diagnostic studies 6 Discuss case with resident, attending, and family Critical Care Progress Note 17 Critical Care Progress Note ICU Day Number: Antibiotic Day Number: Subjective: Patient is awake and alert Note any events that occurred overnight Objective: Temperature, maximum temperature, pulse, respiratory rate, BP, 2 4- hr input and output, pulmonary artery pressure, pulmonary capillary wedge... Medications: Dose and frequency Use of nitroglycerine, beta-agonist, steroids Allergies: Penicillin, contrast dye, aspirin; describe the specific reaction (eg, anaphylaxis, wheezing, rash, hypotension) Social history: Tobacco use, alcohol consumption, intravenous drug use Review of systems: Review symptoms related to each organ system Critical Care Physical Examination Vital signs: Temperature, pulse,... regurgitation) Cardiac murmurs: 1/ 6 = faint; 2/6 = clear; 3/6 - loud; 4/6 = palpable; 5/6 = heard with stethoscope off the chest; 6/6 = heard without stethoscope Abdomen: Bowel sounds normoactive, abdomen soft and nontender Extremities: Cyanosis, clubbing, edema, peripheral pulses 2+ Skin: Capillary refill, skin turgor Neuro Deficits in strength, sensation Deep tendon reflexes: 0 = absent; 1 = diminished; 2 =... EDEMA  Signs and symptoms of congestiveheart failure, acute pulmonary edema Assess ABCD's, secure airway, administer oxygen; secureIVaccess Monitor ECG, pulse oximeter, bloodpressure, order 12 -lead ECG, portable chest X-ray Check vital signs, review history, and examine patient Determine differential diagnosis D e t e r m in e u n d e r ly in g c a u s e A d m in is te r F lu id s, B lo o d C o n s id... Disease: Plans for antibiotic therapy; antibiotic day number, culture results Endocrine/Nutrition: Serum glucose control, parenteral or enteral nutrition, diet Admission Check List 1 Call and request old chart, ECG, and x-rays 2 Stat labs: CBC, chem 7, cardiac enzymes (myoglobin, troponin, CPK), INR, PTT, C&S, ABG, UA, cardiac enzymes (myoglobin, troponin, CPK) 3 Labs: Toxicology screens and drug levels... diminished; 2 = normal; 3 = brisk; 4 = hyperactive clonus Motor Strength: 0 = no contractility; 1 = contractility but no joint motion; 2 = motion without gravity; 3 = motion against gravity; 4 = motion against some resistance; 5 = motion against full resistance (normal) Labs: CBC, INR/PTT; chem 7, chem 12 , Mg, pH/pCO2/pO2 CXR, ECG, impedance cardiography, other diagnostic studies Impression/Problem... output Lungs: Clear bilaterally Cardiac: Regular rate and rhythm, no murmur, no rubs Abdomen: Bowel sounds normoactive, soft-nontender Neuro: No local deficits in strength, sensation Extremities: No cyanosis, clubbing, edema, peripheral pulses 2+ Labs: CBC, ABG, chem 7 ECG: Chest x-ray: Impression and Plan: Give an overall impression, and then discuss impression and plan by organ system: Cardiovascular: . Ingestion 11 1 Iron Overdose 11 1 Isopropyl Alcohol Ingestion 11 2 Lithium Overdose 11 2 Methanol Ingestion 11 3 Salicylate Overdose 11 3 Theophylline Toxicity 11 4 Warfarin (Coumadin) Overdose 11 5. over 1- 3 sec Amiodarone 15 0- 300 mg IV over 1 0- 20 min Adenosine 12 mg, rapid IV push over 1- 3 sec (may repeat once in 1- 2 min) 1- 2 min Adenosine 6 mg, rapid IV push over 1- 3 sec 1- 2 . Support 5 Critical Care Patient Management 15 Critical Care History and Physical Examination 15 Critical Care Physical Examination 15 Admission Check List 16 Critical Care Progress Note 17 Procedure