Intensive Care - practice •2 weeks‘ lecture •You need: white coat, ID Card, (shoe to change) Practical Info •Final Test – (20 questions, each has 5 answers) •Exams – oral (2 sections) •Evaluation forms 1) ALS 2) Managing unstable patient 3) Oral Case Presentation 4) Assesing ABG + Organ Dysfunction + ECG + X-rays and CT scans What you should know after the practise? Day of the week Time 10:15-11:00 SimMan – simulation 11:00-11:45 Training ALS skills 11:45 - 12:30 Bed-side practical lecture – oral case presentation 10:15-11:00 11:00-11:45 11:45 - 12:30 KDAR FN Brno Children's Hospital (Černopolní 9, Brno)10:15-12:30 Oxygenation failure -diagnostic approach to dyspnea, oxygenotherapy + ARDS Ventilation failure - non-invasive ventilation, basics of arteficial ventilation, COPD+Severe Asthma Bed-side practical lecture Bed-side practical lecture Public Holiday 1st week Friday Topic ALS+4H+4T+ (postresuscitation care: sedation, hypothermia) MondayWednesdayThursdayTuesday 10:15-12:30 Intensive Care - introduction, history, ABCD approach, late critical care) Grouprotation Day of the week Time 10:15-11:00 11:00-11:45 11:45 - 12:30 10:15-11:00 11:00-11:45 11:45 - 12:30 10:15-11:00 11:00-11:45 11:45 - 12:30 10:15-11:00 11:00-11:45 11:45 - 12:30 Severe Trauma + Major Bleeding + Haemotherapy Brain Trauma - Brain Oedema-Intracranial Hypertension-Brain Death and Organ Donation Bed-side practical lecture Sepsis+MODS (Hospital-acquired infections) Palliative Care + End-of-Life Decissions, Life-Sustaining Treatment) Discussion, credits and TEST Grouprotation SimMan – simulation Topic Acute Liver Failure+Delirium Acute Kidney Injury Bed-side practical lecture 2nd week FridayThursday 10:15-12:30 Testing ALS skills Bed-side practical lecture – Testing Student's skills TuesdayWednesdayMonday Shock patient (Haemodynamic, monitoring, fluids, vasoactive drugs) Acid-Base Disorders+Sodium and Potassium Disorders Bed-side practical lecture WHAT IS INTENSIVE CARE? Mortality 90% April 26, 1952 dr. Bjorn Ibsen performed a tracheotomy to a 12-year-old girl with poliomyelitis Introduced cannula with cuff and connected to the system with positive pressure ventilation A total of 315 patients requiring ventilatory support 1,500 medical students, a total of 165,000 hours, shifts per 6 hours 2-3 months to restore breathing Mortality declined from 90% to 25% Monitoring of ventilation: •periodic samples of arterial blood •pH, using new electrodes for total CO2 measurement by Van Slyke •pCO2 was calculated from the HendersonHasselbalch equation Then the students were given instructions how to change the frequency and intensity of breathing! Carl-Gunnar Engström Mechanical Students http://www.uphs.upenn.edu/paharc/collections/g allery/departments/ICU.html 1967 – first ICU monitor in Japan http://www.nihonkohden.com/company/history/1960s.html FAST HUGS BID • Feeding/fluids • Analgesia • Sedation • Thromboprophylaxis • Head up position • Ulcer prophylaxis • Glycemic control • Spontaneous breathing trial • Bowel care • Indwelling catheter removal • Deescalation of antibiotics Vincent WR 3rd, Hatton KW. Critically ill patients need “FAST HUGS BID” (an updated mnemonic). Crit Care Med. 2009 Jul;37(7):2326-7 ABCD-approach A – airway B – breathing C – circulation D – disabilities E – electrolytes F – fluids G – gut, glycaemic control H – hematology I – infections L – lines M –medication N – nutrition O – others R – renal • https://youtu.be/KNqo XboSVUI ABC of late critical care • AWAKENING • BREATHING • COORDINATING/CHOICE • DELIRIUM MONITORING/MANAGEMENT • EARLY MOBILITY/EXERCISE Basic Life Support & Automated External Defibrillation BACKGROUND • Approximately 700,000 cardiac arrests per year in Europe • Survival to hospital discharge presently approximately 5-10% • Bystander CPR is vital intervention before arrival of emergency services • Early resuscitation and prompt defibrillation (within 1-2 minutes) can result in >60% survival Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths BLS • D = danger • R = response (AVPU scale) • S = shout / send / call for help • A = airway • B = breathing • C = circulation APPROACH SAFELY! Scene Rescuer Victim Bystanders Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths CHECK RESPONSE Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths Alert-Voice-Pain-Unresponsive CHECK RESPONSE SHOUT FOR HELP Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths OPEN AIRWAY Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths CHECK BREATHING Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths CHECK BREATHING • Look, listen and feel for NORMAL breathing • Do not confuse agonal breathing with NORMAL breathing AGONAL BREATHING • Occurs shortly after the heart stops in up to 40% of cardiac arrests • Described as barely, heavy, noisy or gasping breathing • Recognise as a sign of cardiac arrest http://www.youtube .com/watch?feature =player_detailpage &v=ICODRFoWZkw #t=73s Gasping . . . Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths 30 CHEST COMPRESSIONS Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths • Place the heel of one hand in the centre of the chest • Place other hand on top • Interlock fingers • Compress the chest – Rate 100 min-1 – Depth 4-5 cm – Equal compression : relaxation • When possible change CPR operator every 2 min CHEST COMPRESSIONS Berg et al, 2001 Bloodpressure Time Berg RA et al. Resuscitation. 2001;104:2465-2470. Interrupting chest compressions for rescue breathing can adversely affect hemodynamics during CPR for VF Chest compressions RESCUE BREATHS Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths RESCUE BREATHS • Pinch the nose • Take a normal breath • Place lips over mouth • Blow until the chest rises • Take about 1 second • Allow chest to fall • Repeat CONTINUE CPR 30 2 Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths THE NEED FOR DEFIBRILATION • ventricular fibrillation: 80% of victims • only treatment: electrical defibrillation • this means: delivering an electric shock with a device called an “Automated External Defibrillator” (AED) USING AN AED • a device that delivers electric shocks to victims with cardiac arrest • analyses the rhythm of the victim and decides when a shock is needed • AEDs have been placed in strategic locations such as casinos, on board of international flights and in major airport terminals, public places, shopping and sport centers http://www.fsps.muni.cz/aed/mapa/?lang=en DEFIBRILLATION Call 112 Approach safely Check response Shout for help Open airway Check breathing Attach AED Follow voice prompts SWITCH ON AED • Some AEDs will automatically switch themselves on when the lid is opened ATTACH PADS TO CASUALTY’S BARE CHEST ANALYSING RHYTHM DO NOT TOUCH VICTIM SHOCK INDICATED • Stand clear • Deliver shock SHOCK DELIVERED FOLLOW AED INSTRUCTIONS 30 2 NO SHOCK ADVISED FOLLOW AED INSTRUCTIONS 30 2 IF VICTIM STARTS TO BREATHE NORMALLY PLACE IN RECOVERY POSITION CPR IN CHILDREN • Adult CPR techniques can be used on children • Compressions 1/3 of the depth of the chest AED IN CHILDREN • Age > 8 years • use adult AED • Age 1-8 years • use paediatric pads / settings if available (otherwise use adult mode) • Age < 1 year • use only if manufacturer instructions indicate it is safe Approach safely Check response Shout for help Open airway Check breathing Call 112 30 chest compressions 2 rescue breaths Approach safely Check response Shout for help Open airway Check breathing Call 112 Attach AED Follow voice prompts CHAIN OF SURVIVAL Face mask + ambu Airway Advanced airway - intubation Waveform capnography must be used to confirm and continually monitor tracheal tube placement, and may be used to monitor the quality of CPR and to provide an early indication of return of spontaneous circulation (ROSC). Supraglottic airway Portex Minitrach LUCAS 2 Chest Compression System Heart rhythms associated with cardiac arrest • shockable rhythms - ventricular fibrillation / pulseless ventricular tachycardia (VF/pVT) • non-shockable rhythms - asystole and pulseless electrical activity (PEA) Defibrillation BIPHASIC : 150 – 200 – MAX MONOPHASIC : 200 – 260 – 360 J Shock energy Drugs, fluids … • i.v. lines ( v.jug. externa) • intraosseal (tuberositas tibiae) Drugs • Adrenalin = epinephrine - 1 mg IV every 3-5 min • Amiodaron – if VF persist after third shock give 300 mg bolus IV (in glucose) • Atropin – bradydcardia – 0,5-1 mg IV • Vasopressin / terlipressin - 40IU IV Ultrasound Peri-arrest ultrasound may be used to identify reversible causes of cardiac arrest • Pulmonary Embolism • Tamponade • Hypovolemia • Ao Dissection • Pneumothorax https://youtu.be/-P-rbof0xv8 • Drugs and advanced airways are still included among ALS interventions, but are of secondary importance to early defibrillation and high quality, uninterrupted chest compressions Cardiac Arrest Management Demo: Resuscitation Council (UK) https://youtu.be/jQYHQr3ebLo Post-resuscitation care at ICU hypothermia Ethics . . . . We don´t start CPR • Danger for rescuer • Devastating trauma • Certain signs of death • Terminal condition of disease • D.N.R. order • Living will THANK´S FOR YOUR ATTENTION . . . Questions ?