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Core Topics in Critical Care Medicine
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Book description

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.

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  • Chapter 9 - Vasoactive drugs
    pp 58-65
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    The initial assessment of the critically ill patient should begin with a brief, targeted history and an appraisal of the patient's vital signs to identify life threatening abnormalities that merit immediate attention. The goals of resuscitation are usually achieved by the use of supplemental oxygen, fluid or red blood cell transfusion, inotropic support or antibiotics as needed. Physiological Scoring Systems (PSS) developed from the recognition that critically ill patients, and in particular patients who suffered cardiac arrests, often had long periods of deterioration before the crisis or medical emergency occurred. Medical emergency teams (METs) and critical care outreach (CCO) teams aim to provide critical care skills rapidly to critically ill patients. Referrals to the critical care services may happen from any level, but the final decision to admit a patient to a critical care bed should be made by an experienced critical care physician.
  • Chapter 11 - Pain control
    pp 72-76
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    Patients who present in emergency situations are assumed to have a full stomach and in the UK, it is recommended that a rapid sequence induction (RSI) is used in intubation. The majority of anaesthetic induction agents is vasodilators and has cardiodepressant effects. This chapter discusses extubation/weaning protocols. Tracheostomy is utilized in critical care units to facilitate weaning after prolonged ventilation. A cricothyroidotomy is usually performed as an emergency procedure when a secure airway is needed and attempts at orotracheal or nasotracheal intubation have failed. The anatomical landmark and insertion of a mini tracheostomy are similar to performing cricothyroidotomy. Generally they are not recommended for ventilation as the airway resistance is high but recent small studies have been carried out where the combination of a mini tracheostomy plus non-invasive ventilation (NIV) has been used in patients with respiratory failure due to neuromuscular disorder.
  • Chapter 12 - Sedation
    pp 77-84
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    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.
  • Chapter 13 - Ethics
    pp 85-90
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    It is estimated that in excess of 10,000 critically ill or injured patients are transferred between hospitals each year in the UK. The optimal mode of transport selected for a patient transfer depends upon a number of factors. These include: the indication for, and urgency of, transfer; time to organize/mobilize transport; weather and traffic conditions; space; and cost. Current guidelines recommend that a minimum of two people accompany the transfer of a critically ill patient in addition to the staff required to operate the transport vehicle. The decision to transfer a critically ill patient is usually shared between the critical care consultants at the referring and receiving hospitals in collaboration with their consultant colleagues in the relevant specialities. Continuous monitoring of the ECG, SpO2 blood pressure and ETCO2 should be maintained throughout the transfer and recorded on the patient transfer sheet.
  • Chapter 14 - Organ donation
    pp 91-98
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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.
  • Chapter 15 - Sepsis
    pp 99-107
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    The different functions of an information system in critical care are: bedside charting, clinical record keeping, electronic prescribing (physician order entry), integration with other hospital systems, decision support, remote access, and multi-site communication. The information system generates an enormous amount of data. Attempting to keep all of it inevitably creates storage issues even in the age of the multilayer DVD and the terabyte hard drive. A good archiving system performs a form of triage on the data that is generated based on the duration of usefulness for that data. In order for the huge amount of data generated by the information system to continue to be useful it has to be converted to a database format. A successful implementation of the critical care information system requires an examination of every aspect of the workflow of the critical care unit and how the system will impact (and improve) on it.
  • Chapter 16 - Multiple organ failure
    pp 108-115
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    This chapter focuses on invasive blood pressure monitoring, and components of the invasive blood pressure monitoring system. It explains the complications of invasive blood pressure monitoring, central venous pressure monitoring and cardiac output monitoring. Central venous pressure monitoring measures pressure in the great veins of the thorax usually the superior vena cava and the right atrium. It involves introducing a catheter into a vein so that the tip of the catheter lies at the junction of the superior vena cava and the right atrium. Haemodynamic monitoring is most informative when it is used to supplement clinical judgement. Clinical parameters may be used to determine cardiac output. Poor cerebral perfusion leads to agitation and confusion. A reduction in renal perfusion leads to decreased urine output and subsequently to anuria. Skin perfusion is a clinically useful sign and can be determined using the capillary refill time.
  • Chapter 17 - Immunosuppressed patients
    pp 116-123
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    The reason for the imaging request should be stated on the referral form to allow the most appropriate imaging technique to be used. It may be helpful to discuss the clinical problem with a radiologist. Most hospitals in the UK now use a picture archiving and communication system (PACS) to store X-ray, computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound examination images directly onto the hospital computer system. This chapter discusses X-ray imaging that includes chest X-ray and abdominal X-ray, and CT scanning that includes CT head, CT cervical spine, CT chest, and CT abdomen. Nuclear medicine techniques are useful in searching for occult foci of infection by the administration of radioactive labelled white blood cells. Doppler ultrasound uses alterations in reflection of the ultrasound beam by flowing blood cells and can be used to assess either arterial or venous flow.
  • Chapter 18 - Principles of antibiotics use
    pp 124-129
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    The failure of cardiovascular system to maintain adequate organ perfusion pressure causes inadequate oxygen delivery resulting in tissue hypoxia, lactic acidosis and end organ damage. Inotropes affect the force of myocardial contraction. A positive inotrope will increase myocardial contractility. Vasopressors cause vasoconstriction of blood vessels (most act by α1 receptor activation) and therefore increase mean arterial blood pressure (MAP) and systemic vascular resistance (SVR). Vasoactive drugs are used to support tissue perfusion and hence oxygenation. Vasoactive drugs act on various receptors in the body to produce their effects. Treatment with vasoactive drugs should be considered, if optimization of oxygenation, ventilation and adequate fluid resuscitation fail to restore cardiac output. Therapy may need to be started with minute-by-minute assessment of the patient's response. The response to vasoactive drugs is often unpredictable and dependent on the cause of shock and baseline circulation.
  • Chapter 19 - Fluid and electrolyte disorders
    pp 130-147
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    Critically ill patients are at high risk of malnutrition, due to the nature of their illness and hypermetabolic catabolic state. This chapter presents an assessment of the nutritional status and nutritional requirements by calculating resting energy expenditure for caloric requirements, calculating protein requirements, calculating non-protein (carbohydrates and lipids) components, and by calculating micronutrients including vitamins, electrolytes and trace elements. Nutritional support can be given through one of two routes: enteral feeding (EF) (via the gastrointestinal tract) or parenteral feeding (PN), intravenous (via either peripheral or central vein). Pharmaco/immunonutrition is a relatively new concept in critical care feeding. Some ICUs now have protocols for the use of immunonutrition feeds. The chapter discusses the different complications of nutritional support such as refeeding syndrome, overfeeding, hyperglycaemia, electrolyte imbalances and micronutrient deficiency, and different complications of enteral nutrition, and parenteral nutrition.

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