ICU care & monitoring + Sepsis + Shock + antibiotic + Burn + DKA 🔥🚨 Flashcards

Question

Types of Branula and flow rate

Answer 1

- National Early Warning Score was developed in 2012, through collaborative work of Royal College of Physicians (RCP) and National Health Service (NHS) Trusts in UK on the basis of there should be a national system for recognising very sick patients whose condition is deteriorating and who need more intensive medical or nursing care. - The NEWS is an adjunct to decision making, used in combination with clinical judgement and communicated across the care pathway **Standardized Communication Tool** * Provides a universal language among: * Nurses * Doctors * Paramedics * ICU teams “A NEWS of 7” means the same across all departments. **Guides Escalation of Care** * Helps staff decide when to: * Call senior clinician * Activate rapid response team * Transfer to higher care (e.g., ICU) Summary: Why NEWS Matters: ⏰ Early warning = early intervention ⚠️ Recognizes subtle deterioration 🔗 Connects teams with common scoring language 📈 Proven to reduce complications and death

Answer 2

🧪 Types of Inotropes **Positive Inotropes (Enhance cardiac contractility)** **1.Beta-Adrenergic Agonists:** * **Dobutamine:** Primarily stimulates β₁-receptors, increasing contractility with modest vasodilation. Commonly used in acute heart failure and cardiogenic shock. * **Dopamine:** Dose-dependent effects; low doses may promote renal perfusion, moderate doses enhance cardiac output via β₁-receptor stimulation, and high doses induce vasoconstriction through α-receptor activation. * **Epinephrine (Adrenaline):** Potent β₁ and α-adrenergic agonist; increases heart rate, contractility, and systemic vascular resistance. Used in cardiac arrest and anaphylactic shock. * **Norepinephrine (Noradrenaline)**: Strong α-adrenergic effects leading to vasoconstriction; also has β₁ activity enhancing contractility. First-line agent in septic shock with hypotension. 🩺**Clinical Indications and Selection Criteria** The choice of an inotrope is guided by the patient’s hemodynamic status, underlying pathology, and specific therapeutic goals. **Cardiogenic Shock:** * **Dobutamine:** Preferred for its inotropic and vasodilatory properties, improving cardiac output. * **Norepinephrine:** Used when hypotension is profound; provides vasoconstriction and modest inotropic support. **Septic Shock:** * **Norepinephrine:** First-line agent to counteract vasodilation and maintain perfusion pressure. * **Dobutamine:** Added if myocardial dysfunction leads to low cardiac output despite adequate perfusion pressure.

Answer 3

Under normal circumstances, the peritoneum is a smooth serous membrane lining the abdominal cavity. Normally, this contains less than 100 ml of sterile, clear fluid with less than 3000 cells / mm3. Once this layergets inflamed, the main peritoneal defence mechanisms, or the ‘physiological’ mechanisms that come into play are: * Absorption of the purulent fluid through the diaphragmatic lymphatics. - Activation of the peritoneal mesothelial cells. * Migration of neutrophils and activation of the peritoneal macrophages. * Exudation of protein and fibrinogen rich fluid into this ‘third space’ to entrap, dilute and localize the infective fluid. The losses seen here may parallel the losses seen and estimated in patient with severe burns. Spread of the infection and transition to the stage of frank peritonitis then ensues, and this is the classical stage of peritonitis, with the patient silent and avoiding movements, with tachycardia, tachypnea and a silent abdomen with ‘board like’ rigidity and rebound.

Answer 4

Burst abdomen refers to the **postoperative separation of the abdominal musculo-aponeurotic layers, leading to partial or complete disruption of the abdominal wall**. This separation can result in the exposure or protrusion of intra-abdominal organs through the surgical incision.

Answer 5

➔ Partial Dehiscence (⚡ skin, fat open — fascia intact) ➔ Complete Dehiscence (⚡⚡ fascia ruptured — organs at risk of coming out)

Answer 6

Classification of wounds Wounds may be classified by their potential for infection: - Clean wound: an operation carried out through clean, non-infected skin under sterile conditions, where the GI tract, genitourinary (GU) tract or respiratory tract are not breached, e.g. hernia repair, varicose vein surgery; risk of wound infection should be <2%. * Clean contaminated wounds: an operation carried out under sterile conditions with breaching of a hollow viscus other than the colon, where contamination is minimal, e.g. uncomplicated lap cholecystectomy, uncomplicated acute appendicitis, hysterectomy; the risk of wound infection should be <10% * Contaminated wound: an operation carried out where contamination has occurred, e.g. by opening the colon ( elective colorectal surgery), an open fracture, or animal or human bites; the risk of wound infection is around 15% -20% * Dirty wounds: an operation carried out in the presence of pus or a perforated viscus, e.g. perforated diverticulitis, perforated gallbladder empyema, perforated appendicitis with pus ,faecal peritonitis; the risk of wound infection is >40%

Answer 7

🎯 **Learning Objectives** Assess critically ill patients with simultaneous resuscitation and examination Apply a systematic ABCDE approach Treat abnormal physiology immediately, even before final diagnosis Create daily management plans for both stable and unstable patients 🩺 **The Three-Stage CCrISP Assessment** 🧱 1. **Immediate Assessment – ABCDE** 🔤 A – Airway Look: Cyanosis, tracheal tug, accessory muscles, see-saw breathing Listen: Gurgling, snoring, stridor Feel: Airflow at nose/mouth Actions: High-flow oxygen via reservoir mask (12–15 L/min) Chin lift, jaw thrust, suction, airway adjuncts (Guedel, NPA) Call anaesthetist if airway unstable 🔤 B – Breathing Look: RR, cyanosis, use of muscles, chest movement Listen: Speech, wheeze, absent sounds Feel: Equal movement, tracheal shift, surgical emphysema Check: SpO₂ (note that it doesn’t detect CO₂) Actions: Sit patient up Treat reversible causes (PTX, bronchospasm, PE) Bag-mask ventilation if tiring 🔤 C – Circulation Look for shock: Cool skin, delayed CRT, tachycardia Assume hypovolaemia until proven otherwise Actions: 16G IV cannula, send bloods (FBC, U&E, Xmatch, lactate) **Fluid bolus:** - 10 mL/kg (normotensive) - 20 mL/kg (hypotensive) - 5 mL/kg (cardiac issues) Identify bleeding & escalate if surgery needed 🔤** D – Disability** Use AVPU scale: Alert / Voice / Pain / Unresponsive Common causes: hypoxia, hypotension, drugs, sepsis, hypoglycaemia Check blood glucose early 🔤 **E – Exposure** Examine full body: bleeding, wounds, rashes Preserve warmth & dignity 🔁 **Always reassess after each step.** Deterioration? Repeat ABCDE. 📝 **2. Full Patient Assessment** 📈 **Chart Review** Focus on trends, not isolated readings Review: RR, HR, BP, SpO₂, temp, UO, drain output, fluid charts 🗣️ **History & Examination** Get info from: patient, staff, notes, family Full top-to-toe exam with focus on surgical site & comorbidities 📊 **Review Results** Bloods: FBC, U&E, ABG, clotting Microbiology: Cultures Radiology: X-ray, CT, US ECG: For cardiac suspicion Use checklists to avoid missed issues 🧭 **3. Decide & Plan** 🔷 **Stable Patient** Normal observations and progressing well Make a daily plan: Labs & imaging Restart oral intake Remove unnecessary lines/drains Prescribe fluids, nutrition, VTE prophylaxis Plan physiotherapy & document clearly 🔶 **Unstable Patient** Needs urgent reassessment & further investigations (CXR, ABG, CT, etc.) Call for help: senior or ICU Document clearly: Who saw patient Interventions done Response Plan & review timing Criteria for escalation

Answer 8

📖 Definitions **Sepsis:** A life-threatening organ dysfunction caused by a dysregulated host response to infection. (Clinically: an increase of ≥2 points in SOFA score from baseline in response to infection.) **Septic Shock:** A subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality. (Clinically: sepsis with persistent hypotension requiring vasopressors to maintain MAP ≥ 65 mmHg and serum lactate > 2 mmol/L despite adequate fluid resuscitation.) **MODS – Multi-Organ Dysfunction Syndrome:** Progressive failure of two or more organ systems in a critically ill patient, often due to uncontrolled sepsis. Indicates a high risk of death and often requires intensive care support. 🎯 **Learning Focus** - Understand sepsis as a clinical emergency requiring immediate treatment. - Prevent progression to septic shock and MODS by rapid intervention. - Manage using structured protocols such as Sepsis 6. - Emphasise source control, appropriate antibiotics, and critical care escalation. 🔬 **Pathophysiology of Sepsis** Infection triggers immune activation → cytokine surge (IL-1, IL-6, TNF-α). Leads to: Widespread vasodilation → hypotension. Capillary leakage → oedema and hypovolaemia. Microvascular thrombosis → impaired oxygen delivery. End result = tissue hypoxia, cellular dysfunction, and organ failure if untreated. ⚠️ **High-Risk Surgical Groups** - Post-abdominal or pelvic surgery patients. - Those with suspected anastomotic leaks, abscesses, or infected wounds. - Patients with central lines, urinary catheters, or surgical drains. - Immunocompromised individuals (steroids, chemotherapy, diabetes). - ICU/HDU patients with new deterioration or signs of infection. 🚨 **Clinical Recognition – Early Clues** - Fever or hypothermia. - Tachycardia, hypotension, and tachypnoea. - Confusion, restlessness, or ↓ GCS. - Oliguria or anuria. - Cool peripheries, mottled skin, prolonged capillary refill. - Elevated serum lactate = sign of tissue hypoperfusion. - Note: Elderly and immunocompromised may have atypical signs. 🛠️ **Initial Management – Sepsis 6 (within 1 hour)** - Administer high-flow oxygen to maintain SpO₂ >(92 or 88% if Chronic lung). - Take blood cultures before antibiotics. - Administer IV broad-spectrum antibiotics immediately. - Give IV fluid bolus. - Check serum lactate. - Insert urinary catheter and measure hourly output. Administer 30 ml/kg crystalloid for hypotension or lactate ≥ 4 mmol/L. These steps aim to stabilise the patient and reverse hypoperfusion. Clinical improvement must be reassessed continuously. 🏥 **If Deterioration Persists – Next Steps** - Start vasopressors (e.g. noradrenaline) if fluid resuscitation fails. Goal: Maintain MAP ≥ 65 mmHg. - **Investigate and treat source of infection:** Drain abscesses surgically or radiologically. Remove infected devices (e.g., central lines). Return to theatre if necessary (e.g., leak, peritonitis). Perform urgent CT or ultrasound to locate infection. Escalate to ICU if vasopressors or organ support are needed. 🧠 **Progression to MODS** As sepsis advances, it can affect multiple organ systems: **Lungs**: ARDS, ↓ PaO₂, need for ventilation. **Kidneys**: oliguria/anuria, rising creatinine. **Brain**: delirium, confusion, coma. **Heart**: persistent hypotension, elevated lactate. **Liver**: jaundice, ↑ LFTs, coagulopathy. **Coagulation**: thrombocytopenia, ↑ INR, DIC. **MODS** has a high mortality and must be managed in a critical care setting. ✅ **Key Takeaways** Sepsis is more than just infection — it is a dangerous systemic response. Early signs (mental status change, hypotension, oliguria) must not be missed. Complete the Sepsis 6 bundle within 1 hour of recognition. Control the infection source — antibiotics alone are not sufficient. If organs are failing or hypotension persists, escalate to ICU early. Monitor response, reassess often, and document clearly.

Answer 9

⚙️ **How PCT Works in Infection:** 🔹 In Healthy People PCT is only produced in thyroid C cells, converted quickly to calcitonin. 🧪 Serum PCT level = very low. 🔥 **In Bacterial Infection / Sepsis** - Bacterial toxins (e.g. endotoxins) and cytokines (e.g. IL-1β, TNF-α, IL-6) stimulate PCT production. - Multiple organs (liver, lungs, kidneys, adipose tissue) begin to produce PCT. - Unlike thyroid production, this PCT is not converted to calcitonin → it accumulates in blood. 🟠 **PCT starts rising within 2–4 hours, peaks at 6–24 hours, and has a half-life of about 24 hours.**

ICU care & monitoring + Sepsis + Shock + antibiotic + Burn + DKA 🔥🚨 Flashcards

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