Critical Illness

Aka: Critical Illness, Catastrophic Illness, Intensive Care, Critical Care, Unstable Patient, Unstable Status

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II. Indications

  1. Cardiovascular Emergencies
    1. Ventricular Fibrillation or Pulseless Ventricular Tachycardia
    2. Asystole or Pulseless Electrical Activity (PEA)
    3. Unstable Bradycardia
    4. Unstable Tachycardia
    5. Acute Coronary Syndrome
    6. Aortic Dissection
    7. Cardiac Tamponade
    8. Cardiogenic Shock (Acute Pulmonary Edema)
    9. Hypertensive Emergency
  2. Respiratory Emergencies
    1. Pulmonary Embolism
    2. Foreign Body Aspiration
    3. Tension Pneumothorax
    4. Status Asthmaticus
    5. Acute Respiratory Failure
    6. Acute Respiratory Distress Syndrome (ARDS)
    7. Corona Virus 19 (COVID-19, SARS-CoV2)
  3. Neurologic Emergencies
    1. Status Epilepticus
    2. Closed Head Injury
    3. Brainstem Herniation
    4. Cerebrovascular Accident
    5. Penetrating Neck Trauma
  4. Fluids, Electrolytes and Nutrition Emergencies (as well as renal emergencies)
    1. Hemorrhagic Shock
    2. Metabolic Acidosis
  5. Infectious Emergencies
    1. Septic Shock
    2. Meningitis
    3. Encephalitis
  6. Abdominal Emergencies
    1. See Acute Abdomen
    2. Abdominal Aortic Aneurysm
    3. Ruptured Ectopic Pregnancy
  7. Trauma and Environmental Injuries
    1. Heat Related Illness
    2. Burn Injury
    3. Hypothermia Management
    4. Unknown Ingestion
    5. Biological Weapon
    6. Chemical Weapon
    7. Mass Casualty Incident
    8. Blast Injury
    9. Gunshot Wound
    10. Knife Wound

III. Findings: Most significant markers of Critical Illness

  1. Tachypnea
  2. Metabolic Acidosis

IV. Imaging

  1. Bedside Ultrasound
    1. Cardiac Ultrasound
    2. Rapid Ultrasound in Shock (RUSH Exam)
    3. Lung Ultrasound for Pneumothorax (Sliding Lung Sign, Lung Point)
    4. Bedside Lung Ultrasound in Emergency (Blue Protocol)
    5. Inferior Vena Cava Ultrasound for Volume Status
    6. Abdominal Aorta Ultrasound
    7. DVT Ultrasound (including Focused Lower Extremity Venous Ultrasound)
  2. Radiology Department Transfer in Unstable Patients
    1. Balance diagnostic yield of imaging (e.g. AAA, Dissection, Sepsis or Hemorrhage source) with risk of decompensation in radiology
      1. Those too unstable for CT, may be too unstable to forego definitive imaging for reversible cause
      2. Consolidate all needed imaging to complete in one trip to radiology (e.g. CT chest, Abdomen and Pelvis)
    2. Nursing and medical provider should accompany critically ill, Unstable Patients to allow for continued Resuscitation
      1. Be prepared for worst case scenarios, and bring protentially needed Resuscitation equipment (including Ambu Bag)
      2. Make use of imaging protocol pauses to perform Resuscitation tasks (e.g. IV medication, transfusion initiation)
      3. Monitor Vital Signs and cardiac rhythm should be easily visualized from imaging control window
    3. Complete critical stabilization procedures prior to imaging (e.g. Endotracheal Intubation, Vascular Access, Chest Tube)
      1. If considering Endotracheal Intubation after imaging, consider instead performing before imaging
    4. References
      1. Weingart and Swaminathan in Swadron (2023) EM:Rap 23(1): 2-3

V. Management: Specific Cohorts

  1. See Obesity and Emergency Stabilization
  2. See CPR in Pregnancy
  3. See Trauma in Pregnancy
  4. See Hemodialysis Emergency
  5. See Oncologic Emergencies
  6. See Emergencies in Children

VI. Management: Respiratory

  1. Monitoring
    1. Capnography continuous
    2. Venous Blood Gas or Arterial Blood Gas as indicated to answer clinical questions
  2. Noninvasive Ventilation
    1. Positive End-Expiratory Pressure (PEEP)
    2. High Humidity High Flow Nasal Oxygen (High Flow Nasal Cannula, HHFNC)
      1. Children with acute respiratory distress (Croup, Respiratory Syncytial Virus)
      2. Post-Extubation (prevents re-intubation)
    3. Continuous Positive Airways Pressure (CPAP)
    4. Bilevel Positive Airway Pressure (BiPaP)
  3. Mechanical Ventilation
    1. See Rapid Sequence Intubation
    2. See Endotracheal Intubation
    3. See Mechanical Ventilation
    4. See Post-Intubation Sedation and Analgesia

VII. Management: FEN

  1. Blood Sugar Management
    1. See Glucose Control in the Intensive Care Unit
    2. See Diabetes Mellitus Glucose Management
    3. See Perioperative Diabetes Management
    4. See Diabetes Sick Day Management
  2. Nutrition
    1. See Nutrition in the Intensive Care Unit
    2. See Feeding Critically Ill Patients (includes Enteral Nutrition for Intubated Patients)
    3. See Enteral Nutrition
  3. Fluid Status
    1. See Fluids and Electrolytes in Critical Care
    2. See Inferior Vena Cava Ultrasound for Volume Status
    3. See Fluid Resuscitation in Trauma
  4. Electrolytes
    1. See Fluids and Electrolytes in Critical Care
    2. See Hypernatremia
    3. See Hyponatremia
    4. See Hyperkalemia Management
    5. See Hypokalemia
    6. See Hypomagnesemia
    7. See Hypocalcemia

VIII. Management: Sedation and Analgesia

  1. See Sedation and Analgesia in Intensive Care (includes Insomnia Management in Critical Care)
  2. See Richmond Agitation Sedation Scale (RASS, Modified RASS)
  3. Critical Care Pain Observation Tool (CPOT)
  4. See Acute Pain Management
  5. See Procedural Sedation and Analgesia

IX. Management: Complications

  1. See Anemia in the Intensive Care Unit
  2. See Critical Illness Myopathy
  3. See Critical Illness Related Metabolic Bone Disease
  4. Fever
    1. See Fever in the Intensive Care Unit
    2. See Postoperative Fever
    3. See Sepsis
  5. Serum Troponin Elevation
    1. See Troponin Increase in ICU Patients

X. Management: Prevention

  1. See Thromboprophylaxis in Critical Illness and Major Trauma
  2. See Gastric Ulcer Prevention in Patients with Critically Illness (Gastrointestinal Prophylaxis)
  3. See Drug-induced Nephrotoxicity
    1. Avoid NSAIDs
    2. Avoid ACE Inhibitors and Angiotensin Receptor Blockers
      1. May consider continuing if chronic use for Congestive Heart Failure
      2. Alternative: Hydralazine and Isosorbide Dinitrate
  4. Delirium Prevention
    1. See Insomnia Management in Critical Care

XI. Management: Disposition

  1. See Transfer of the Critically Ill Patient
  2. See Critical Care Follow-up

XII. Resources

  1. Internet Book of Critical Care (EMCRIT.org)
    1. https://emcrit.org/ibcc/guide/

XIII. References

  1. Marino (2014) The ICU Book, p. 901-22

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