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This chapter discusses the different types of scoring systems that include specific, generic, anatomical and functional scoring systems. The measurement of outcome is important as considerable resources are expended in providing intensive care. Outcome in intensive care can be measured with respect to mortality, morbidity, disability and quality of life. There are many influences on outcome which can be broadly grouped into patient factors, disease factors and intensive care factors. The process by which a scoring system becomes an outcome probability model is through multiple logistic regression. The scoring systems in common use in critical care include the Acute Physiology and Chronic Health Evaluation (APACHE), Simplified Acute Physiology Score (SAPS), Mortality Probability Model (MPM), Sequential Organ Failure Assessment (SOFA), Trauma and Injury Severity Score (TRISS), and the ASCOT. These scores can also be used on trauma patients in all settings.
Cardiac arrhythmias can be broadly classified based on the heart rate as bradyarrhythmia (<60 bpm) and tachyarrhythmia (>100 bpm). Physiological bradycardia can often be found in athletes whilst pathological bradycardia signifies sinus node or conduction pathway abnormalities, which may or may not be associated with drugs, autonomic or endocrine dysfunction. Acute management of arrhythmias depends on the haemodynamic status of the patient and the type of arrhythmia. Patients who exhibit adverse features will require urgent treatment to resolve the arrhythmia. Narrow complex and broad complex tachyarrhythmias without adverse signs are managed differently in the acute setting. Most sinus tachycardias are related to underlying causes and will resolve once the cause is rectified. Broad complex tachycardias are due to a number of underlying rhythms. In the long term, implantable cardiovertordefibrillator (ICD) insertion is beneficial for patients who have structurally abnormal hearts with ventricular arrhythmias.
Antibiotics should only be administered after microbiological specimens are taken, except in emergencies. Most antibiotics are removed from the body via the kidneys. Renal failure may cause the accumulation of a drug, or its metabolites. This is a particular problem with glycopeptides and aminoglycosides where toxic levels are associated with severe and permanent side effects such as ototoxicity and renal impairment. Organisms resistant to multiple antibiotics such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) have emerged in healthcare environments and have proved difficult to control in many countries. Prophylaxis is recommended where a bacteraemia is expected, and the resultant infection may result in significant morbidity or mortality. The commonly used antibiotics on intensive care unit are: beta-lactams, carbapenems, aminoglycosides, glycopeptides, quinolones, macrolides, rifampicin, oxazolidinone and nitroimidazoles. The three major classes of anti-fungal drug are: azoles, polyenes, and echinocandins.
The critical care unit manages patients with a vast range of disease and injuries affecting every organ system. The unit can initially be a daunting environment, with complex monitoring equipment producing large volumes of clinical data. Core Topics in Critical Care Medicine is a practical, comprehensive, introductory-level text for any clinician in their first few months in the critical care unit. It guides clinicians in both the initial assessment and the clinical management of all CCU patients, demystifying the critical care unit and providing key knowledge in a concise and accessible manner. The full spectrum of disorders likely to be encountered in critical care are discussed, with additional chapters on transfer and admission, imaging in the CCU, structure and organisation of the unit, and ethical and legal issues. Written by Critical Care experts, Core Topics in Critical Care Medicine provides comprehensive, concise and easily accessible information for all trainees.
This chapter outlines the indications for admissions to the critical care unit (CrCU), and role of scoring systems to aid admission. The admission criteria should be based on need of the patient rather than bed availability. A number of steps could be taken if a critically ill patient presents in the absence of an available bed in the unit. The choice is often determined by the severity of illness, haemodynamic stability, ease of oxygenation, necessity of advanced interventions, time of the day and availability of medical staff. Patients who are deemed to have irreversible or severe organ system damage which is likely to prevent reasonable recovery should have treatment limits in place. All admitted patients should be handed over to one of the critical care doctors. A timely discharge from the CrCU is just as important as timely admission.
Deliberate self-poisoning is usually an intentional oral ingestion of a variety of drugs by previously well adults and makes up 95% of cases. This chapter explains airway and breathing, and circulation in the initial assessment and resuscitation phase. In the clinical examination the patient's symptoms and signs elicited on physical examination provide clues to the most likely drugs involved and guide early therapy especially when the cause is unidentified. The chapter lists out various investigations that include electrocardiogram, arterial blood gases, radiology and drug screening. The importance of maintaining physiological stability whilst minimizing the toxic effects of drug ingestion is paramount. The toxicity can be diminished by preventing drug absorption, inhibition of toxic metabolite formation, and augmentation of drug elimination. The general care of the unconscious patient includes regular monitoring of vital signs and organ support. The chapter lists out management of specific drugs that include salicylates (aspirin).
The three parts of the respiratory control system are: sensors, central control and respiratory muscles. The different disorders of ventilation include hypoventilation syndromes and hyperventilation syndromes. The three main types of hypoventilation syndromes are: obesity hypoventilation syndrome, respiratory neuromuscular disorders and primary alveolar hypoventilation. Alveolar hyperventilation exists when PaCO2 decreases below 4.5 kPa. It is not the same as hyperpnoea which is increased minute ventilation with a normal PaCO2. Detailed history and clinical examination along with knowledge of coexistent disorders can provide clues to the cause of hyperventilation. An elevated pH is suggestive of a primary respiratory alkalosis; a low pH will show a metabolic acidosis. Widened A-a gradient suggests presence of a primary pulmonary disorder. Low bicarbonate suggests a chronic nature of the disorder and implies an organic cause. Transcutaneous PCO2 or arterial PCO2 during sleep studies can help to exclude psychogenic hyperventilation.
Fluid and electrolyte balance is an important everyday practice on the intensive care unit. The different types of fluids are crystalloids that include Hartmann's solution, normal (isotonic) saline, dextrose, and colloids that include albumin, starch and gelatins. The disorders of sodium concentration are nearly always caused by excess free water (hyponatraemia) or free water loss (hypernatraemia). The potassium balance is affected by hypokalaemia and hyperkalaemia. The abnormalities in magnesium are caused by hypomagnesaemia and hypermagnesaemia. The abnormalities in phosphorous are caused by hypophosphataemia and hyperphosphataemia. The abnormalities in calcium are caused by hypocalcaemia and hypercalcaemia. Hypercalcaemia is not a common problem in intensive care. In 90% of cases, the underlying cause is hyper-parathyroidism or malignancy. Treatment is indicated when the hypercalcaemia is associated with adverse effects, or when the serum calcium is greater than 14 mg/dl (ionized calcium above 3.5 mmol/l).