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ICU Manual
Prem Kumar, TA Naufal Rizwan, Sushma Vijay Pingale, G Ninoo George, Marun Raj
SECTION 1: INTENSIVE CARE UNIT
CHAPTER 1:
SETTING UP AN ICU
INITIAL PLANNING
INFRASTRUCTURE
INDIAN SOCIETY OF CRITICAL CARE MEDICINE (ISCCM) PROVIDE GUIDELINES FOR EACH LEVEL ICU PLANNING IN INDIA
Level I (Table 1.1)
Level II (Table 1.2)
Level III
OTHER ISSUES
Heating, Ventilation and Air-conditioning (HVAC) System of ICU
BIBLIOGRAPHY
SECTION 2: PHYSIOLOGY OF CRITICALLY ILL PATIENT
CHAPTER 2:
CRITICALLY ILL PATIENT AND OXYGENATION
OXYGEN CASCADE
Definition
Inspired Oxygen
Alveolar Oxygen
Arterial Oxygen
Microcirculation and Interstitium
Mitochondrial Level
Indices of Pulmonary O2 Transfer
Indices of Oxygen Dynamics
Regional Oxygen Indices
TISSUE OXYGENATION
VO2
Mixed Venous O2 Tension (SvO2)
Measures of O2 Exchange
ScvO2 (Mixed Venous O2 Saturation)
Lactate
BIBLIOGRAPHY
SECTION 3: VASCULAR ACCESS AND HEMODYNAMIC MONITORING
CHAPTER 3:
PERIPHERAL ARTERIAL CATHETERIZATION
INDICATIONS
EQUIPMENT
MONITORING SITES
Safer Arteries for Cannulation in Chronological Order
TECHNIQUE
Pre-requisites
Seldinger's Technique
Complications
Arterial Waveform (Figs 3.1 and 3.2)
Recent Advances in Arterial Pressure Monitoring
Artifacts of the Monitoring System
Fast-flush Test (Square Wave Test)
When is Fast Flush Test Done?
BIBLIOGRAPHY
CHAPTER 4:
PERIPHERAL VENOUS CATHETERIZATION
INSERTION TECHNIQUES (FIGS 4.1A TO F)
PRECAUTIONS
EQUIPMENT
PRINCIPLE
Advantages
Disadvantages
MIDLINE CATHETERS
BIBLIOGRAPHY
CHAPTER 5:
CENTRAL VENOUS CATHETERIZATION
APPLIED ANATOMY
Internal Jugular Vein (Fig. 5.1)
Subclavian Vein (Fig. 5.2)
Femoral Vein (Fig. 5.3)
TECHNIQUES
Internal Jugular Vein
Central Approach (Fig. 5.4)
Anterior Approach (Fig. 5.5)
Posterior Approach (Fig. 5.6)
Infraclavicular Approach (Figs 5.7A and B)
Advantages
Supraclavicular Approach (Figs 5.8A and B)
Femoral Vein Cannulation
Technique (Figs 5.9A and B)
Peripherally Inserted Central Venous Catheters
ULTRASOUND-GUIDED TECHNIQUES
Management of Catheter
Catheter-related Infection
Protocol for Catheter Management
BIBLIOGRAPHY
CHAPTER 6:
PULMONARY ARTERY CATHETERIZATION
HISTORY
Pulmonary Artery Catheter
PA Catheter Lumens
Indications
PERIOPERATIVE INDICATIONS
CLASS I
CLASS IIa
CLASS IIb
Technique
Special Situations of Difficulty in PA Catheterization
PHYSIOLOGICAL VARIABLES WITH PA CATHETERIZATION (TABLES 6.1 TO 6.3)
Measuring Cardiac Output
Pulmonary Artery Occlusion Pressure (Table 6.4)
Factors Causing Variability of PAOP in Measuring Preload
Complications
BIBLIOGRAPHY
CHAPTER 7:
HEMODYNAMIC MONITORING
THORACIC BIOIMPEDANCE PLETHYSMOGRAPHY
ESOPHAGEAL AND TRANSCUTANEOUS DOPPLER MONITORING
Capnography
Uses of Capnography in ICU
Pulse Oximetry
MUCOSAL TONOMETRY
Mean Arterial Pressure
Invasive Arterial Blood Pressure Monitoring
Clinical Applications of IBP Monitoring
Central Venous Pressure Monitoring (Fig. 7.1)
ScvO2
Monitoring with PA Catheter
Measures of Left Ventricular Preload
Mixed Venous Oxygen Saturation (SvO2)
Echocardiography
Ultrasonography
Interpretations
Dynamic Parameters of Fluid Responsiveness
SYSTOLIC PRESSURE VARIATION
Interpretation of SPV
Pulse Pressure Variation
Stroke Volume Variation
LIMITATIONS OF DYNAMIC PARAMETERS
Preload Responsiveness by Passive Leg Raising Test
PiCCO/NiCOM System
BIBLIOGRAPHY
SECTION 4: SHOCK
CHAPTER 8:
AN OVERVIEW OF SHOCK
DEFINITION
CLASSIFICATION (TABLE 8.1)
CLINICAL FEATURES
Diagnosis (Table 8.2 and Flow chart 8.1)
Management
End Points of Resuscitation
Fluid Management
Crystalloid vs Colloid (Table 8.3)
Vasopressors/Inotropes (Table 8.4)
BIBLIOGRAPHY
CHAPTER 9:
HYPOVOLEMIC SHOCK
ETIOLOGY
PATHOPHYSIOLOGY (Flow chart 9.1)
Diagnosis
Management
KEY ELEMENTS OF MANAGING HEMORRHAGIC SHOCK
BIBLIOGRAPHY
CHAPTER 10:
OBSTRUCTIVE SHOCK
CAUSES
PATHOPHYSIOLOGY
CLINICAL FEATURES
Diagnosis
AIR EMBOLISM
Diagnosis
Management
BIBLIOGRAPHY
CHAPTER 11:
CARDIOGENIC SHOCK
DEFINITION
CHARACTERISTICS
PATHOGENESIS (Flow chart 11.1)
CLINICAL FEATURES
HIGH-RISK PATIENTS FOR CARDIOGENIC SHOCK
Investigations
Electrocardiogram
Chest X-ray
Echocardiography with Color Flow Doppler
Pulmonary Artery Catheterization
LEFT HEART CATHETERIZATION AND ANGIOGRAPHY
Treatment
General Measures
Pharmacotherapy
INVASIVE PROCEDURES IN CARDIOGENIC SHOCK
Aortic Counter Pulsation
Procedure
Ventricular Assist Devices
Reperfusion-revascularization
VASOPRESSORS
BIBLIOGRAPHY
CHAPTER 12:
MULTIPLE ORGAN DYSFUNCTION SYNDROME
DEFINITION
ETIOLOGY
PATHOPHYSIOLOGY
CLINICAL SYNDROMES
SCORING SYSTEMS
Prevention
Management
Prognosis
BIBLIOGRAPHY
SECTION 5: INFECTION AND IMMUNE DISORDERS IN ICU
CHAPTER 13:
APPROACH TO NOSOCOMIAL INFECTIONS
RISK FACTORS
Common Causes of Nosocomial Infection in ICU
Timeline of Evolution of Organisms Causing Nosocomial Infections in ICU
MECHANISMS OF DRUG RESISTANCE
NOSOCOMIAL PNEUMONIA
Definitions
Microbiology of HAP/VAP (Tables 13.1 and 13.2)
Risk Factors for MDR Pathogens
Pathogenesis
Clinical Features
Diagnosis
Management (Flow chart 13.1 and Table 13.4)
Prevention
SMART Approach
Guidelines for Prevention of Catheter-associated of Urinary Tract Infection (CAUTI)
Guidelines for Prevention of Catheter-related Bloodstream Infections
Guidelines for Preventing Surgical Site Infections
BIBLIOGRAPHY
CHAPTER 14:
URINARY TRACT INFECTIONS
DEFINITIONS
RISKS (TABLE 14.1)
COMMON ORGANISMS CAUSING URINARY TRACT INFECTION
Diagnosis (Flow chart 14.1 and Tables 14.2 and 14.3)
Urine Analysis
Management (Table 14.4)
Complicated UTI
Pyelonephritis
Treatment of CAUTI
Treatment of Urosepsis
PREVENTION OF CAUTI—RECOMMENDATIONS BY HICPAC (HEALTHCARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE) 2009 GUIDELINES
Key Recommendations for Prevention of CAUTI
BIBLIOGRAPHY
CHAPTER 15:
SEPSIS AND SEPTIC SHOCK
DEFINITIONS
PATHOGENESIS
Diagnosis
Diagnostic Criteria
SEPSIS
SEVERE SEPSIS
Management of Severe Sepsis and Septic Shock
Initial Resuscitation
Screening and Diagnosis of Sepsis
ANTIMICROBIAL THERAPY
Source Control
Prevention of Infection
HEMODYNAMIC SUPPORT
Fluid Therapy
Vasopressors/Inotropes
Adjunctive Therapy
Supportive Therapy
Blood Component Administration
Immunoglobulins and Selenium
Recombinant Activated Protein C (rhAPC)
Mechanical Ventilation of Sepsis-induced Acute Respiratory Distress Syndrome
Sedation, Analgesia, and Neuromuscular Blockade
Glycemic Control
Renal Replacement Therapy
Bicarbonate Therapy
DVT Prophylaxis
Stress Ulcer Prophylaxis
Nutrition
BIBLIOGRAPHY
CHAPTER 16:
PRINCIPLES OF ANTIBIOTIC USE IN ICU
PRINCIPLES OF ANTIBIOTIC PRESCRIPTION
COMMON CAUSES OF INFECTION IN ICU
PHARMACOKINETIC PRINCIPLES (TABLE 16.2)
Empirical Therapy for Sepsis without an Obvious Focus of Primary Infection
Empirical Antibiotic Therapy Based on Infection Site (Table 16.3)
STEPS TAKEN TO PREVENT ANTIBIOTIC RESISTANCE
Presurgery Antibiotic Prophylaxis
BIBLIOGRAPHY
CHAPTER 17:
TROPICAL INFECTIONS
SEVERE MALARIA
Diagnosis
Management
Supportive Care
Severe Malaria in Pregnancy
DENGUE
Clinical Features
Differential Diagnosis
Investigations
Management of Dengue and Dengue Hemorrhagic Fever
BIBLIOGRAPHY
CHAPTER 18:
ANAPHYLAXIS
INTRODUCTION
DEFINITIONS
ETIOLOGY AND PREDISPOSING FACTORS
Pathophysiology
CLINICAL MANIFESTATIONS
Diagnosis
Treatment (Flow chart 18.1)
ROLE OF EPINEPHRINE IN ANAPHYLAXIS
Prevention
BIBLIOGRAPHY
SECTION 6: POISONING AND ENVENOMATION
CHAPTER 19:
GENERAL PRINCIPLES OF POISONING
MANIFESTATIONS
NEUROLOGICAL EXAMINATION
Temperature
CARDIOVASCULAR
METABOLIC
MANAGEMENT
Assessment
Specific Treatment
Reduce Absorption
Increase Elimination
Specific Antidotes
BIBLIOGRAPHY
CHAPTER 20:
POISONING
ORGANOPHOSPHORUS AND CARBAMATE POISONING (TABLE 20.1)
Clinical Features
Cholinergic Symptoms
Nicotinic Symptoms
Intermediate Syndrome
Delayed Polyneuropathy
Investigations
Management
General Measures
Specific Measures
ORGANOCHLORINE AND PYRETHROID POISONING (TABLE 20.2)
Clinical Features
Management
Oleander Poisoning
Oduvanthalai Poisoning
Rodenticide Poisoning
Corrosive Poisoning
Kerosene Poisoning
Investigations
Chest X-ray
BIBLIOGRAPHY
CHAPTER 21:
DRUG OVERDOSE
SEDATIVES AND HYPNOTICS
Clinical Features
Treatment
ANTIDEPRESSANTS
Clinical Features
Treatment
ACETAMINOPHEN POISONING
Clinical Features
Treatment
OPIOIDS
BETA-BLOCKERS
BIBLIOGRAPHY
CHAPTER 22:
ENVENOMATION
SCORPIONS (SCORPIONIDAE)
Clinical Features
Treatment
CATERPILLARS AND MOTHS (LEPIDOPTERA)
Clinical Features
Treatment
REPTILE BITES
Introduction
Crotalinae (Pit Viper) Bites
Pathophysiology
Clinical Features
Diagnosis
Treatment
Emergency Management
Discharge Criteria
Coral Snake (Elapid) Bite
Treatment
Emergency Management
Cobra Bite
Clinical Features
Treatment
BIBLIOGRAPHY
SECTION 7: BURNS
CHAPTER 23:
CLASSIFICATION AND EVALUATION OF BURNS
CLASSIFICATION
Three Zones
Five Depths (Fig. 23.1)
Five Causative Types
PHYSIOLOGICAL DISTURBANCES (TABLE 23.1 AND Flow chart 23.1)
BURNS ASSESSMENT
Initial Evaluation
Indications of Endotracheal Intubation
Modes of Securing the Airway
SECONDARY SURVEY
BIBLIOGRAPHY
CHAPTER 24:
MANAGEMENT OF BURNS
EARLY RESUSCITATIVE PHASE
End Points of Fluid Resuscitation
WOUND MANAGEMENT PHASE
Perioperative Care of Burns Patient
REHABILITATIVE PHASE
Carbon Monoxide Poisoning
MANAGEMENT OF CARBON MONOXIDE POISONING
Chemical Burns
Electric Injury
COMPLICATIONS
BIBLIOGRAPHY
SECTION 8: RESPIRATORY DISEASES IN INTENSIVE CARE UNIT
CHAPTER 25:
APPROACH TO ACUTE RESPIRATORY FAILURE
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
TREATMENT (Flow chart 25.1)
Respiratory Care
Nonventilator Therapy
Noninvasive Ventilation
Intubation and Mechanical Ventilation (Table 25.4)
BIBLIOGRAPHY
CHAPTER 26:
ACUTE LUNG INJURY AND ACUTE RESPIRATORY DISTRESS SYNDROME
DEFINITION
PATHOPHYSIOLOGY
Diagnosis
Radiographic Findings
MANAGEMENT
Initial Ventilator Settings
Goals
WEANING PROTOCOL FOR ARDS
FLUID MANAGEMENT
NUTRITIONAL SUPPORT
BIBLIOGRAPHY
CHAPTER 27:
ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
INTRODUCTION
RISK FACTORS
PATHOPHYSIOLOGY (Flow chart 27.1)
DIAGNOSIS
Clinical Presentation
Pulmonary Function Test (Fig. 27.1)
Acute Exacerbation
CLINICAL ASSESSMENT
Treatment (Table 27.2)
Supplemental Oxygen Therapy
Inhaled Bronchodilators
Corticosteroids
Antibiotics
Indications for ICU Admission
Indications of Mechanical Ventilation
Ventilation Strategy
Detecting Intrinsic PEEP
Application of External PEEP
Weaning from Mechanical Ventilation
Parameters Indicating Weaning Success
Prognosis
BIBLIOGRAPHY
CHAPTER 28:
ACUTE SEVERE ASTHMA
CLINICAL FEATURES
DIAGNOSIS
Pulmonary Function Tests
Risk Factors Associated with Mortality due to Asthma
Arterial Blood Gas Analysis
Chest X-ray
MANAGEMENT (TABLE 28.3 AND Flow chart 28.2)
Adjunctive Therapies
Noninvasive Ventilation
Endotracheal Intubation and Mechanical Ventilation (Table 28.4)
Initial Ventilator Settings
Dynamic Hyperinflation
Extubation Criteria
BIBLIOGRAPHY
CHAPTER 29:
DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM
PATHOPHYSIOLOGY (Flow chart 29.1)
CLINICAL FEATURES AND DIAGNOSIS
Electrocardiogram
Lab Investigations
Venous Ultrasonography
Chest X-ray
CT–Chest
MRI
V/Q Scan
Echocardiography
PREVENTION (TABLES 29.3 TO 29.6)
TREATMENT (Flow chart 29.3)
Algorithm for PE Management
Anticoagulation (Table 29.7)
New Oral Anticoagulants
Duration of Anticoagulation
IVC Filters
Indications
Treatment of RV Dysfunction
Thrombolysis
BIBLIOGRAPHY
CHAPTER 30:
OBSTRUCTIVE SLEEP APNEA AND OBESITY HYPOVENTILATION SYNDROME
HISTORY
INTRODUCTION
OBSTRUCTIVE SLEEP APNEA
Diagnosis
Pathophysiology of OSA
Central Sleep Apnea
OBESITY HYPOVENTILATION SYNDROME
Goals for NIV in OHS
Indications of Tracheostomy in OHS
Respiratory Stimulants
Perioperative Management
BIBLIOGRAPHY
SECTION 9: APPROACH TO MECHANICAL VENTILATION
CHAPTER 31:
BASICS OF MECHANICAL VENTILATION
NEGATIVE PRESSURE VENTILATION
POSITIVE PRESSURE VENTILATION
VENTILATOR DESIGN
NOMENCLATURES AND THEIR SIGNIFICANCE
BREATH TYPE (Figs 31.1 to 31.4)
Control
Trigger
Limit
Cycling
Expiration
Effects of Positive Pressure Ventilation and PEEP
BIBLIOGRAPHY
CHAPTER 32:
INITIATION OF VENTILATION
INITIAL VENTILATOR SETTINGS
Mode
Tidal Volume
FiO2
Respiratory Rate
I:E Ratio
PEEP
Trigger Sensitivity
Inspiratory Flow Pattern
Pressure Support
Ventilator Alarms
High and Low Airway Pressure Alarm
High and Low Minute Ventilation Alarm
Low-expired Tidal Volume Alarm
Apnea Alarm
High and Low FiO2 Alarm
High Respiratory Rate Alarm
BIBLIOGRAPHY
CHAPTER 33:
MODES OF VENTILATION
BASIC MODES OF VENTILATION
Volume-controlled Ventilation/Assist Control
Initial Settings
Advantages
Disadvantages
Indications
Pressure Control Ventilation
Initial Settings
Advantages
Disadvantages
Indications
Synchronized Intermittent Mandatory Ventilation
Initial Settings
Merits
Demerits
Indications
PRESSURE SUPPORT VENTILATION (FIG. 33.5)
Pressure-regulated Volume Control
Initial Settings
Indications
Airway Pressure Release Ventilation
Initial Settings
Advantages
Disadvantage
Indications
Inverse Ratio Ventilation
Initial Settings
Advantage
Disadvantages
Indication
Biphasic Positive Airway Pressure
Initial Settings
Indications
Advantages
Liquid Ventilation
Total Liquid Ventilation
Partial Type
Indications
Advantages
Disadvantages
High Frequency Ventilation
Types (Tables 33.1 and 33.2)
High Frequency Oscillatory Ventilation
Principle
Indications
Advantages
Disadvantages
Closed Loop Ventilation
Adaptive Support Ventilation
Initial Settings
Advantages
ASV Characteristics
Proportional Assist Ventilation
Initial Settings
Indications
Advantages
Disadvantages
Characteristics
Neutrally Adjusted Ventilatory Assist
Prerequisites
BIBLIOGRAPHY
CHAPTER 34:
WEANING FROM MECHANICAL VENTILATION
DEFINITION OF WEANING
WEANING CRITERIA
Measuring Parameters for Weaning (Figs 34.1 to 34.3)
Weaning Indices
Weaning Techniques
Weaning Trial
Weaning Protocol of Synchronized Intermittent Mandatory Ventilation (SIMV) (Flow chart 34.2)
Weaning Protocol of PSV (Flow chart 34.3)
Weaning Protocol of T Tube
Weaning with CPAP/BiPAP
Weaning Success
Weaning Failure
Extubation
Prerequisites for Extubation
Our Institutional Protocol for Extubation
Indications for Paralyzing a Patient in Mechanical Ventilation
BIBLIOGRAPHY
CHAPTER 35:
PATIENT VENTILATOR ASYNCHRONY
VARIABLES CONTRIBUTING TO ASYNCHRONY (Flow chart 35.1)
Physiologic Effects of Patient Ventilator Asynchrony
Diagnosis of Patient Ventilator Asynchrony (Figs 35.2 to 35.4)
Management of Patient Ventilator Asynchrony (Table 35.2)
BIBLIOGRAPHY
CHAPTER 36:
NONINVASIVE VENTILATION
DEFINITION
EQUIPMENT (INTERFACE)
PROTOCOL FOR MANAGING PATIENTS PLANNED FOR NIPPV
Prerequisites for Using NIPPV
Factors Associated with NIPPV Failure
Noninvasive Ventilatory Modes
Continuous Positive Airway Pressure
Initial Settings
Bilevel Positive Airway Pressure
Initial Settings
Pressure Support Ventilation
Initial Settings
Indications
ASTHMA
Acute Exacerbation of COPD
Cardiogenic Pulmonary Edema
Negative Pressure Pulmonary Edema (Postobstructive)
PNEUMONIA
Type 1 Respiratory Failure
Obstructive Sleep Apnea
Goals for NIV in Obstructive Hypoventilation Syndrome
Postoperative Patients
BIBLIOGRAPHY
SECTION 10: CARDIOVASCULAR DISEASES IN ICU
CHAPTER 37:
CARDIAC ARRHYTHMIAS
SUPRAVENTRICULAR ARRHYTHMIAS
Atrial Fibrillation
Classification
Mechanism
Etiology
Cardiac Causes
Noncardiac Causes
Clinical Features
Investigations
Management
Atrial Flutter
ECG Findings (Fig. 37.2)
Treatment
Focal Atrial Tachycardias
Chaotic Atrial Tachycardia (Multifocal Atrial Tachycardia)
Supraventricular Reentrant Tachycardias
Atrioventricular Nodal Reentrant Tachycardia
Atrioventricular Reentrant Tachycardia
VENTRICULAR ARRHYTHMIAS
Ventricular Premature Complex
Ventricular Tachycardia
ECG Findings (Figs 37.8 to 37.10)
Supports SVT with Aberrancy
Supports VT
Management
Long-term Prevention
Specific Types/Scenarios
Arrhythmogenic Right Ventricular Cardiomyopathy
ECG
Catecholaminergic Polymorphic Ventricular Tachycardia
Brugada Syndrome
Torsades de Pointes
Causes
Treatment
Ventricular Flutter and Fibrillation
Sinus Bradycardia
Sinus Pause or Sinus Arrest
Sinoatrial Exit Block
AV Block
Management
BIBLIOGRAPHY
CHAPTER 38:
ACUTE HEART FAILURE
DEFINITION
CLASSIFICATION
Simplified Classification Based on ESC Guidelines
PATHOPHYSIOLOGY
CLINICAL FEATURES
Symptoms
Signs
BIOMARKERS
Renal Function Tests
Chest Radiography
Electrocardiography
Echocardiography
Management
Emergency Care
Management of Acute Heart Failure
Based on Initial Clinical Status
Based on Systolic Blood Pressure
Based on Re-evaluation of Patient's Clinical Status
SPECIFIC THERAPIES FOR ACUTE HEART FAILURE
Diuretics
VASODILATORS
Classification
Nitrates
Sodium Nitroprusside
Nesiritide
Inotropes and Inodilators
Dobutamine
Mechanism
Adverse Effects
Dopamine
Epinephrine
Phosphodiesterase (PDE IIIa) Inhibitors (Milrinone, Enoximone)
Levosimendan
OTHER DRUGS USED IN THE TREATMENT OF ACUTE HEART FAILURE
Digoxin
Arginine Vasopressin Antagonists
Calcium-channel Blockers
Istaroxime
Nonpharmacologic Therapies
Ultrafiltration
Hypertonic Saline
Novel Agents/Drugs Under Study
Cardiorenal Syndrome in Hospitalized Patients
Criteria for Discharge
BIBLIOGRAPHY
CHAPTER 39:
APPROACH TO ACUTE MYOCARDIAL INFARCTION
DEFINITION
UNIVERSAL DEFINITION OF MYOCARDIAL INFARCTION
UNIVERSAL MYOCARDIAL INFARCTION CLASSIFICATION OF TYPE
Pathophysiology (Flow chart 39.1)
CLINICAL FEATURES
Symptomatology (Table 39.3)
Signs
Investigations
Posterior MI
ECG MANIFESTATIONS OF ISCHEMIA IN THE SETTING OF LBBB
Serum Markers of Cardiac Damage
Cardiac Troponins (Troponin T and I)
CK-MB
Echocardiography
Management
ANTIPLATELET THERAPY
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
PAIN CONTROL
Nitrates
Beta-blockers
Dosage
ACE Inhibitors/ARB
Aldosterone Antagonists
Calcium-channel Blockers
Magnesium
Glucose Control
Oxygen
LIMITATIONS OF INFARCT SIZE
Fibrinolysis
Fibrinolytics and Their Dosages
Alteplase
Tenecteplase
Streptokinase
Reteplase
PERCUTANEOUS CORONARY INTERVENTION
Primary PCI
Rescue PCI
Advantages of PCI Over Fibrinolysis
Indications for Delayed Coronary Angiography with PCI
Anticoagulants
Benefits of Anticoagulation
Unfractionated Heparin Dose (Table 39.10)
Low-Molecular-Weight Heparin
Parenteral Factor Xa Antagonists
Direct Thrombin Inhibitors
Complications of Acute Myocardial Infarction
Mechanical Complications
Ventricular Septal Rupture
Acute Mitral Regurgitation
Ventricular Free Wall Rupture
Ventricular Pseudoaneurysm
Ventricular Aneurysm
Intra-aortic Balloon Counterpulsation
RV Failure
Dynamic LVOT Obstruction
Arrhythmic Complications
Embolic Complications
Inflammatory Complications
Early Pericarditis
Late Pericarditis (Dressler's Syndrome)
BIBLIOGRAPHY
CHAPTER 40:
HYPERTENSIVE CRISIS
DEFINITION
HYPERTENSIVE EMERGENCY (PREVIOUSLY MALIGNANT HYPERTENSION)
HYPERTENSIVE URGENCY
Pseudo Emergencies
Pathophysiology
Precipitating Factors of Hypertensive Crisis
Diagnosis
INVESTIGATIONS
Blood Tests
Electrocardiography (ECG)
Chest X-ray
CT/MRI Brain
Management
Sodium Nitroprusside
Labetolol
Nitroglycerin
Management of Specific Hypertensive Crises
Other Special Scenarios
Hypertensive Urgencies
BIBLIOGRAPHY
CHAPTER 41:
CARDIAC TAMPONADE
DEFINITION
PATHOPHYSIOLOGY
PRECIPITATING FACTORS
CLINICAL FEATURES
BECKS TRIAD (USEFUL CLUE FOR DIAGNOSIS OF TAMPONADE)
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
Electrocardiography
Chest X-ray
M Mode/2D Echocardiogram
Doppler Echocardiography
Cardiac Catheterization
MANAGEMENT
Pericardiocentesis
Surgical Drainage
Recurrent Effusions
BIBLIOGRAPHY
SECTION 11: RENAL AND ELECTROLYTE DISTURBANCES IN ICU
CHAPTER 42:
ACUTE KIDNEY INJURY
INTRODUCTION
CHARACTERISTICS
CATEGORIES
Prerenal Azotemia
Intrinsic Acute Kidney Injury
Postrenal AKI
DIAGNOSIS
Current Definition of AKI
MARKERS FOR RENAL DYSFUNCTION IN AKI
Urine Output
Serum Creatinine
Serum Urea
Urine Abnormalities
New Biomarkers
Cystatin C
NGAL
IL-18
KIM-1
Prevention
Pharmacological
Treatment for Established Renal Failure
Indications of Dialysis in AKI
Complications of AKI
BIBLIOGRAPHY
CHAPTER 43:
RENAL REPLACEMENT THERAPY
INTRODUCTION
Indications of Renal Replacement Therapy
ACCESS
HEMODIALYSIS VERSUS PERITONEAL DIALYSIS
INTERMITTENT HEMODIALYSIS VERSUS SLOW LOW EFFICIENCY DIALYSIS
SLOW LOW EFFICIENCY DIALYSIS VERSUS CONTINUOUS RENAL REPLACEMENT THERAPY
ADVERSE EFFECTS OF RENAL REPLACEMENT THERAPY
CONCLUSION
BIBLIOGRAPHY
CHAPTER 44:
HYPONATREMIA
CAUSES
PSEUDOHYPONATREMIA
TRUE HYPONATREMIA (< 275 MOSM/KG)
Clinical Features
Investigations
Treatment
Cardinal Rules of Correction of Hyponatremia
ASYMPTOMATIC HYPONATREMIA
SYMPTOMATIC HYPONATREMIA
Steps in Correcting Hyponatremia
Step 1: Expected Change in Sodium
Step 2 : Liters Infusate and Hours to Correct (Table 44.2)
Step 3: Rate of Infusion
OSMOTIC DEMYELINATION SYNDROME
HYPERNATREMIA
Causes
Hypovolemic
Euvolemic
Hypervolemic
Clinical Features
Investigations
Treatment
Step 1: Calculate the Water Deficit
Step 2: Correction of Water Deficit
MANAGEMENT OF DIABETES INSIPIDUS
Central Diabetes Insipidus (DI)
Partial Central DI
Nephrogenic DI
BIBLIOGRAPHY
CHAPTER 45:
POTASSIUM
POTASSIUM BALANCE IN HEALTH AND DISEASE
HYPOKALEMIA
Causes
Renal Loss
Gastrointestinal Loss
Transcellular Shifts
Clinical Features
Management
HYPERKALEMIA
Pseudohyperkalemia
Metabolic Acidosis
Renal Disease
Critical Illness
Clinical Features
Diagnosis
Management (Table 45.3)
BIBLIOGRAPHY
CHAPTER 46:
CALCIUM
CALCIUM METABOLISM
Functions of Calcium
HYPOCALCEMIA
Causes (Table 46.1)
Clinical Features
Cardiopulmonary Manifestations
Neuromuscular Manifestations
CHVOSTEK'S SIGN
TROUSSEAU SIGN
Investigations
Treatment
Severe Symptomatic Hypocalcemia
Chronic Hypocalcemia (Mostly Seen with Hypoparathyroidism)
HYPERCALCEMIA
Clinical Features
Neuropsychiatric
Gastrointestinal
Renal
DIAGNOSTIC WORKUP
Blood Investigations
Serum Albumin
Serum PTH, Serum Phosphorus
PTHrP
Urine Calcium
Chest X-ray
ECG
Treatment
Hydration
Diuretics
Bisphosphonates
Steroids
Other Drugs
Dialysis
BIBLIOGRAPHY
CHAPTER 47:
PHOSPHORUS
INTRODUCTION
METABOLISM
HYPOPHOSPHATEMIA
Increased Renal Phosphate Excretion
PTH/PTHrP Dependent
PTH/PTHrP Independent
Impaired Intestinal Phosphate Absorption
Redistribution of ECF Phosphate into Cells
Accelerated Net Bone Formation
Clinical Features
Mild Hypophosphatemia (2–2.5 mg/dL)
Severe Hypophosphatemia (<2 mg/dL)
Investigations
Biochemistry
Radiology
Treatment
Mild-to-Moderate Hypophosphatemia
Severe Hypophosphatemia
Other Measures
Calcimimetic Drugs (Cinacalcet)
Vitamin D Preparations
Surgery
HYPERPHOSPHATEMIA
Clinical Features
Neuromuscular
Cardiovascular
Metastatic Calcification
Investigations
Treatment
Sevelamer Hydrochloride
Lanthanum Carbonate
Binders-containing Aluminum
Hemodialysis
BIBLIOGRAPHY
CHAPTER 48:
MAGNESIUM
HYPOMAGNESEMIA
Clinical Features
Neuromuscular
Cardiovascular
Electrolyte Homeostasis
Skeletal System
Treatment
Mild Cases
Severe Cases
HYPERMAGNESEMIA
Clinical Features
Investigations
Treatment
Hydration and Diuretics
Calcium
Hemodialysis
BIBLIOGRAPHY
SECTION 12: GASTROINTESTINAL DISEASES IN ICU
CHAPTER 49:
UPPER GASTROINTESTINAL BLEEDING
PEPTIC ULCER
VARICEAL BLEED
MALLORY-WEISS TEAR
BOERHAAVE'S SYNDROME
VASCULAR ANOMALIES
MANAGEMENT
History
Hemodynamic Assessment
Fluid, Electrolyte, and Blood Replacement
Blood Replacement
Nasogastric Intubation and Gastric Lavage
Benefits of NG Intubation
Disadvantages of NG Intubation
PHARMACOLOGIC THERAPY
ENDOSCOPY
SPECIFIC CONDITIONS
Endoscopic Therapy for Peptic Ulcer
Indication
Endoscopic Therapy for Varices
Nonendoscopic Treatment Options for Varices
Balloon Tube Tamponade (Sengstaken-Blakemore or Minnesota Tube)
Transvenous Intrahepatic Portosystemic Shunts (TIPSS)
Surgical Portosystemic Shunts
BIBLIOGRAPHY
CHAPTER 50:
LOWER GASTROINTESTINAL BLEEDING
ETIOLOGY
Diverticulosis
Anorectal Disease
Angioectasias
Neoplasms
Inflammatory Bowel Disease
INVESTIGATIONS
Anoscopy and Sigmoidoscopy
Colonoscopy
Nuclear Scintigraphy (Technetium-labeled Red Blood Cell)
Arteriography
Push Enteroscopy and Capsule Endoscopy
TREATMENT
Hemodynamic Assessment
Volume Resuscitation
SPECIFIC MEASURES
Colonoscopy
Intra-arterial Embolization
Surgical Treatment
BIBLIOGRAPHY
CHAPTER 51:
ACUTE PANCREATITIS
GENERAL CONSIDERATIONS
ETIOLOGY
PATHOGENESIS
CLINICAL FEATURES
INVESTIGATIONS
Elevated Serum Amylase and Lipase
Nonpancreatic Causes for Increased Serum Amylase
Other Blood Investigations
RADIOLOGY
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
General Measures
Specific Measures
Necrosectomy
ERCP
BIBLIOGRAPHY
CHAPTER 52:
ACUTE LIVER FAILURE
INTRODUCTION
CLASSIFICATION
CAUSES OF ACUTE LIVER FAILURE (TABLE 52.3)
Viral Hepatitis
Acetaminophen Poisoning
PATHOPHYSIOLOGY
CLINICAL FEATURES
ASSOCIATIONS OF ACUTE HEPATIC FAILURE
Hepatic Encephalopathy
Clinical Features (Table 52.4)
Cerebral Edema
Mechanism
Clinical Features
Coagulopathy
Infections
Metabolic and Electrolyte Disturbances
Renal Abnormalities
Pulmonary Complications
PROGNOSIS
Causes of Death in Fulminant Hepatic Failure
TREATMENT
General Measures
Specific Measures
Hepatic Encephalopathy
Cerebral Edema
Hypoglycemia and Electrolyte Abormalities
Renal Failure
Respiratory Failure
Hypotension
Infection
Bleeding
LIVER TRANSPLANTATION
Contraindications
Auxiliary Liver Transplantation
BIBLIOGRAPHY
CHAPTER 53:
ABDOMINAL INFECTIONS IN ICU
INTRODUCTION
CLASSIFICATION
Uncomplicated IAI (Intra-abdominal Infection)
Complicated IAI (Table 53.1)
Localized Peritonitis
Primary Peritonitis
Secondary Peritonitis
Tertiary Peritonitis
PATHOPHYSIOLOGY
CLINICAL FEATURES
INVESTIGATIONS
MANAGEMENT
Resuscitation
Source Control
Drainage
Debridement
Establishing Bowel Continuity
Antimicrobial Treatment (Table 53.2)
DURATION OF TREATMENT
GI Colonization
Acalculous Cholecystitis
Risk Factors
Pathophysiology
Clinical Features and Diagnosis
Management
BIBLIOGRAPHY
SECTION 13: HEMATOLOGICAL DISORDERS IN INTENSIVE CARE UNIT
CHAPTER 54:
HEMOLYTIC ANEMIA AND SICKLE CELL CRISIS
HEMOLYTIC ANEMIA
Intrinsic RBC Defect
Extrinsic Factors
Diagnosis
Complications
Treatment
SICKLE CELL CRISIS
Pathophysiology
Clinical Manifestation
Lab Findings
Management of Crisis
BIBLIOGRAPHY
CHAPTER 55:
DISSEMINATED INTRAVASCULAR COAGULATION AND HEPARIN-INDUCED THROMBOCYTOPENIA
DISSEMINATED INTRAVASCULAR COAGULATION
Pathophysiology
Clinical Features
Lab Findings
Treatment
HEPARIN-INDUCED THROMBOCYTOPENIA
Clinical Features
Investigations
Management
Platelet Dysfunction
BIBLIOGRAPHY
CHAPTER 56:
IMMUNE THROMBOCYTOPENIC PURPURA
PATHOGENESIS
CLASSIFICATION OF IMMUNE THROMBOCYTOPENIC PURPURA
CLINICAL FEATURES
Acute ITP
Chronic ITP
Bleeding Manifestations
LABORATORY FINDING
Blood
The Marrow
Tests for Platelet Antibodies
TREATMENT
1st Line Therapy
Corticosteroids
Immunoglobulins
2nd Line Therapy
Immunosuppressants
Corticosteroid-sparing Agents
Monoclonal Antibodies
Splenectomy
Thrombopoietin Receptor Agonists
Vinca Alkaloids
EMERGENCY TREATMENT OF ACUTE BLEEDING
BIBLIOGRAPHY
SECTION 14: ENDOCRINE DISORDERS IN INTENSIVE CARE UNIT
CHAPTER 57:
DIABETIC KETOACIDOSIS
PRECIPITATING FACTORS
BASIC PATHOPHYSIOLOGY OF DIABETIC KETOACIDOSIS (Flow chart 57.1)
CLINICAL FEATURES
Symptoms
Signs
MANAGEMENT GOALS
ASSESSMENT AND MONITORING
FLUID REPLACEMENT
INSULIN THERAPY
ELECTROLYTE CORRECTION
BIBLIOGRAPHY
CHAPTER 58:
HYPEROSMOLAR HYPERGLYCEMIC STATE
PATHOPHYSIOLOGY
CLINICAL FEATURES
Laboratory Findings
Management
BIBLIOGRAPHY
CHAPTER 59:
DIABETES INSIPIDUS
VASOPRESSIN: NEURAL HORMONE
ETIOLOGY
Nephrogenic Diabetic Insipidus
Congenital Nephrogenic DI
Acquired Nephrogenic DI
Central Diabetic Insipidus
Acquired
Inherited
Gestational Diabetes Insipidus
Primary Polydipsia (Dipsogenic Diabetes Insipidus)
Clinical Manifestations of Diabetes Insipidus
Lab Investigations
Treatment of Central Diabetes Insipidus
Available Formulations
Administration—Principles
Long-term Management
Treatment of Nephrogenic Diabetes Insipidus
COMPLICATIONS
BIBLIOGRAPHY
CHAPTER 60:
SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE
INTRODUCTION
PATHOPHYSIOLOGY
Causes of SIADH
Clinical Features of SIADH
Diagnosis of SIADH (Table 60.3)
Treatment of SIADH
Free Water Restriction
Increasing Osmolar Load in Diet
Overcoming ADH Action
Use of Hypertonic Saline
Risk of Osmotic Demyelination Syndrome
BIBLIOGRAPHY
CHAPTER 61:
THYROID EMERGENCIES
INTRODUCTION
THYROID STORM
Clinical Features
Precipitating Factors
Scoring (Table 61.1)
Management
Pharmacologic Therapy
Thyroid Ophthalmopathy
MYXEDEMA COMA
PATHOGENESIS
Clinical Features (Fig. 61.1)
Diagnosis
Treatment Goals (Fig. 61.2)
General Measures in Management
Hormone Replacement
Predictors of Mortality
BIBLIOGRAPHY
CHAPTER 62:
ADRENAL EMERGENCIES
ADRENAL CRISIS
Pathophysiology
Etiology of Adrenal Insufficiency
PRIMARY (↑ ACTH)
Precipitating Factors
Clinical Features
Investigations
Treatment Goals
Volume Correction
Glucocorticoids Replacement for Primary Insufficiency
Correction of Metabolic Abnormalities
Treatment of Underlying Cause
BIBLIOGRAPHY
SECTION 15: OBSTETRIC EMERGENCIES
CHAPTER 63:
OBSTETRIC HEMORRHAGE
CAUSES OF OBSTETRIC HEMORRHAGE
CLASSIFICATION
ANTEPARTUM HEMORRHAGE
Placenta Previa
Criteria for Terminating Expectant Management
Abruption of Placenta
Common Complications Associated with Placental Abruption
Criteria for Conservative Management
Vasa Previa
POSTPARTUM HEMORRHAGE
Management of Severe Blood Loss (Flow chart 63.1)
BIBLIOGRAPHY
CHAPTER 64:
HYPERTENSIVE DISORDERS OF PREGNANCY
CLASSIFICATION OF HYPERTENSIVE DISORDERS IN PREGNANCY
DEFINITIONS
PRE-ECLAMPSIA
Risk Factors
Pathogenesis (Flow chart 64.1)
Clinical Features
Diagnostic Criteria
Management
Lab Investigations
Treatment
Antihypertensive Therapy (Table 64.2)
Other Agents
Seizure Prophylaxis
Magnesium Sulfate
Actions
Dosage Regimens
Pharmacokinetics
Cardiac Effects of Hypermagnesemia
Complications of Severe Pre-eclampsia
HELLP SYNDROME
Diagnostic Criteria
Clinical Features
Diagnosis
Management
ECLAMPSIA
Management
BIBLIOGRAPHY
CHAPTER 65:
ACUTE FATTY LIVER OF PREGNANCY
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
LAB INVESTIGATIONS
DIFFERENTIAL DIAGNOSIS (TABLE 65.1)
COMPLICATIONS
MANAGEMENT
BIBLIOGRAPHY
CHAPTER 66:
AMNIOTIC FLUID EMBOLISM
PATHOPHYSIOLOGY
CLINICAL FEATURES
LAB INVESTIGATIONS
MANAGEMENT
BIBLIOGRAPHY
SECTION 16: NEUROLOGICAL DISORDERS IN INTENSIVE CARE UNIT
CHAPTER 67:
CEREBROVASCULAR DISEASES
TRANSIENT ISCHEMIC ATTACK
Definition
Features of Transient Ischemic Attacks
Management of Transient Ischemic Attacks
STROKE
Definition
Types
ISCHEMIC STROKE (80%)
Pathophysiology
Large Artery Atherosclerotic Disease
Small Vessel or Penetrating Artery Disease (Lacunes)
Embolic Stroke (Box 67.1)
CLINICAL FEATURES
Focal Neurological and Ocular Symptoms
Motor Symptoms
Speech/Language Disturbances
Sensory Symptoms
Visual Symptoms
Vestibular Symptoms
Behavioral/Cognitive Symptoms
Nonfocal Neurological Symptoms
HEMORRHAGIC STROKE
Pathophysiology
Intracerebral and Cerebellar Hemorrhage
Subarachnoid Hemorrhage
Subdural and Extradural Hemorrhage/Hematoma
CLINICAL FEATURES OF HEMORRHAGIC STROKE
Assessment of Acute Stroke
Early Interventions
Thrombolytics in Ischemic Stroke
MANAGEMENT OF CEREBRAL EDEMA
Rehabilitation
General Management
Secondary Prevention
Blood Pressure Control
For Ischemic Stroke/TIA
Antiplatelets
Anticoagulants
Statins
BIBLIOGRAPHY
CHAPTER 68:
STATUS EPILEPTICUS
DEFINITION
ETIOLOGY
TYPES
CONVULSIVE
Nonconvulsive (Including Complex Partial and Absence Status)
SIMPLE PARTIAL STATUS EPILEPTICUS
COMPLICATIONS
INVESTIGATIONS
Importance of EEG
TREATMENT
General Measures
Specific Measures
Advantages of Fosphenytoin Over Phenytoin
BIBLIOGRAPHY
CHAPTER 69:
MENINGITIS AND ENCEPHALITIS
DEFINITION
CLASSIFICATION
ACUTE BACTERIAL MENINGITIS
Routes of Spread
PATHOGENESIS (Flow chart 69.1)
CLINICAL FEATURES
Classic Triad
Features of Raised ICP
INVESTIGATIONS
CSF Analysis
IMAGING
DIFFERENTIAL DIAGNOSIS
TREATMENT
Antibiotics
ANTIBIOTICS BASED ON ORGANISMS
Corticosteroids
Other Measures
Prognosis
Sequelae
VIRAL MENINGITIS
Etiology
Routes of Entry
Clinical Features
INVESTIGATIONS
CSF Analysis
Exceptions
Other Investigations
Differential Diagnosis
Treatment
For Severe HSV, EBV, VZV
For HIV Meningitis
Prognosis
TUBERCULAR MENINGITIS
Etiology
Pathogenesis
Clinical Features
Prodromal Stage (2 weeks–2 months)
Later Stage
Sequelae
Investigations
Treatment
Antituberculous Therapy
Steroids
FUNGAL MENINGITIS
Investigations
Treatment
VIRAL ENCEPHALITIS
Definition
Etiology
Clinical Features
Investigations
CSF Analysis
MRI, CT, EEG
Brain Biopsy
TREATMENT
General Measures
Specific Measures (Table 69.8)
Sequelae
BIBLIOGRAPHY
CHAPTER 70:
ALCOHOL WITHDRAWAL SYNDROME
SYMPTOMS
Tremulousness
Hallucinosis
“Alcoholic Mania” (Also Called as Hallucinatory Insanity of Drunkards)
Seizures (Rum Fits or Whiskey Fits)
DELIRIUM TREMENS
Clinical Features
Pathogenesis
Investigations
Management
Management of Withdrawal Symptoms
MANAGEMENT OF DELIRIUM TREMENS
BIBLIOGRAPHY
CHAPTER 71:
DELIRIUM IN INTENSIVE CARE UNIT
DEFINITION
CLINICAL FEATURES
TERMINAL DELIRIUM
Sundowning
Etiology
Non-neurologic Causes
Neurologic Causes
Toxic/Withdrawal States
Pathology and Pathophysiology
Differential Diagnosis
Investigations
Treatment
General Measures
Specific Measures (Medications)
Electroconvulsive Therapy
BIBLIOGRAPHY
SECTION 17: NEUROMUSCULAR DISORDERS
CHAPTER 72:
GUILLAIN-BARRÉ SYNDROME
GENERAL CONSIDERATIONS
ETIOLOGY
PATHOGENESIS
CLINICAL FEATURES
Motor
Sensory
Cranial Nerves
Autonomic Involvement
Findings which Help in Diagnosis
Clinical
Laboratory
Electrodiagnostic
Findings Reducing the Possibility of GBS
Differential Diagnosis
Infections
Noninfectious
Treatment
General Measures
Specific Measures
Prognosis
BIBLIOGRAPHY
CHAPTER 73:
MYASTHENIA GRAVIS
ETIOLOGY
PATHOGENESIS
Normal
Myasthenia Gravis
Relationship between Thymus Gland and Myasthenia Gravis
CLINICAL FEATURES
INVESTIGATIONS
Antibodies Assay
Electrodiagnostic Testing
Prerequisites
Impression
Anticholinesterase Test
Imaging
TREATMENT
Anticholinesterase Medications
Glucocorticoids
Prednisolone
Other Immunosuppressive Drugs
Plasmapheresis
IV Immunoglobulin
Thymectomy
EVALUATING THE EFFECTIVENESS OF TREATMENT
MYASTHENIC CRISIS
Definition
Causes
Treatment
BIBLIOGRAPHY
CHAPTER 74:
PERIODIC PARALYSIS
HYPOKALEMIC PERIODIC PARALYSIS
Types
HypoKPP Type 1 (90%)
HypoKPP Type 2 (10%)
HYPERKALEMIC PERIODIC PARALYSIS
Description
Investigations
Treatment
Potassium-aggravated Myotonia
ANDERSON'S SYNDROME
BIBLIOGRAPHY
CHAPTER 75:
CRITICAL ILLNESS POLYNEUROPATHY
PREDISPOSING FACTORS
PATHOLOGY
PATHOGENESIS
CLINICAL FEATURES
Screening
Diagnosis
Differential Diagnosis
TREATMENT
BIBLIOGRAPHY
SECTION 18: APPROACH TO A TRAUMA PATIENT
CHAPTER 76:
ADVANCED TRAUMA LIFE SUPPORT
INTRODUCTION
AIRWAY
BREATHING
CIRCULATION
Early Resuscitation
Late Resuscitation
Resuscitation Fluids
Isotonic Crystalloids
Hypertonic Saline
Colloids
Packed RBCs
Plasma
Platelets
MASSIVE TRANSFUSION
Definition
Criteria for Activation of Massive Transfusion Protocol (Flow chart 76.1)
Goals of Massive Transfusion Protocol (Table 76.5)
COMPLICATIONS
Disability
Exposure
Secondary Survey
BIBLIOGRAPHY
CHAPTER 77:
OPEN FRACTURES
INTRODUCTION
CLASSIFICATION
ANTIBIOTIC COVER
SURGICAL DEBRIDEMENT AND IRRIGATION
WOUND CLOSURE
SKELETAL FIXATION (Figs 77.1 to 77.5)
BIBLIOGRAPHY
CHAPTER 78:
PELVIC FRACTURES
INTRODUCTION
ADVANCED TRAUMA LIFE SUPPORT
HEMODYNAMIC STATUS
FRACTURE STABILITY
PNEUMATIC ANTISHOCK GARMENT
PELVIC BINDERS
ANTERIOR EXTERNAL FIXATOR (Figs 78.2 and 78.3)
ACUTE FRACTURE FIXATION
ANGIOGRAPHY
PELVIC PACKING
OPEN PELVIC FRACTURES (FIG. 78.4)
BIBLIOGRAPHY
CHAPTER 79:
FAT EMBOLISM SYNDROME
ETIOLOGY
PATHOGENESIS
CLINICAL FEATURES
DIAGNOSIS
MANAGEMENT
BIBLIOGRAPHY
CHAPTER 80:
ABDOMINAL TRAUMA
INTRODUCTION
MECHANISM OF INJURY
DIAGNOSTIC PRINCIPLES IN GENERAL
Grey-Turner Sign
Cullen Sign
Kehr Sign
Balance Sign
LAB INVESTIGATIONS
X-rays
Ultrasonogram
Computerized Tomography Scan
DIAGNOSTIC PERITONEAL LAVAGE
Indications
Procedure for Diagnostic Peritoneal Lavage
Interpretation of Diagnostic Peritoneal Lavage
Limitations of Diagnostic Peritoneal Lavage
ANGIOGRAPHY
PREOPERATIVE MANAGEMENT
DAMAGE CONTROL SURGERY
ABDOMINAL COMPARTMENT SYNDROME
Clinical Features
Measurement of Intra-abdominal Pressure (Fig. 80.1)
Procedure
Treatment
BIBLIOGRAPHY
CHAPTER 81:
VASCULAR TRAUMA OF EXTREMITIES
INTRODUCTION
HISTORICAL PERSPECTIVE
EPIDEMIOLOGY
CLINICAL PRESENTATION (TABLE 81.1)
NONINVASIVE IMAGING
Duplex Ultrasonography
Angiography
INVASIVE STUDIES
MANAGEMENT OF EXTREMITY TRAUMA
Prehospital Care
Emergency Room Care
Operative Room Management
Subclavian and Axillary Vessels (Figs 81.1 and 81.2)
Brachial and Upper Radial and Ulnar Vessel Injuries (Figs 81.3 and 81.4)
Lower Radial and Ulnar Vessel Injuries
Femoral Vessel Injury (Figs 81.5A and B)
Popliteal Vessel Injury (Fig. 81.6)
Tibial Vessel Injury
COMPARTMENT SYNDROME
BIBLIOGRAPHY
CHAPTER 82:
TRAUMATIC HEAD INJURY
INTRODUCTION
PRIMARY INJURY
SECONDARY INJURY
Management of Traumatic Brain Injury
Airway
Breathing
Circulation
Intracranial Hypertension
General Care of TBI Patients
Physiotherapy and Rehabilitation
BIBLIOGRAPHY
CHAPTER 83:
THORACIC TRAUMA
INJURY TO CHEST WALL
Flail Chest
INJURY TO PLEURA
Pneumothorax
Clinical Features
Treatment of Pneumothorax and Hemothorax
INJURY TO LUNG
INJURY TO HEART
INJURY TO AORTA
Evaluation of the Chest Injuries
Traumatic Rupture of Aorta
Dissection of Aorta
INJURY TO ESOPHAGUS
BIBLIOGRAPHY
SECTION 19: ULTRASONOGRAPHY
CHAPTER 84:
ROLE OF ULTRASOUND IN CRITICAL CARE
INTRODUCTION
PHYSICS OF ULTRASOUND
Imaging Modes
A-mode
B-mode
M-mode
Doppler
Selection of Ultrasound Transducer
ULTRASOUND IMAGE CHARACTERISTICS
Transducer Movements (Figs 84.3 to 84.7)
Imaging (Figs 84.8A and B)
NEEDLE ORIENTATION
Clinical Uses of Ultrasound in ICU (Table 84.3)
PULMONARY EMBOLISM
Bedside Lung Ultrasound in Emergency Protocol for Acute Respiratory Failure
Cardiac Arrest Ultrasound Exam Protocol for Cardiac Arrest
Fluid Administration Limited by Lung Sonography Protocol
Secure European System for Applications in a Multi-vendor Environment (SESAME) Protocol
PROCEDURAL USES OF ULTRASOUND
BIBLIOGRAPHY
SECTION 20: ACID-BASE DISORDERS
CHAPTER 85:
BASICS OF ACID-BASE BALANCE
BASIC CONCEPTS AND TERMINOLOGIES
Actual Bicarbonate
Standard Bicarbonate
Base Excess
Indications for Arterial Blood Gas Analysis
Regulation of the Acid-Base Balance
Chemical Buffering
Hemoglobin
Respiratory Compensation
Renal Compensation
BIBLIOGRAPHY
CHAPTER 86:
METABOLIC AND RESPIRATORY ACID-BASE DISORDERS
METABOLIC ACIDOSIS (TABLE 86.1)
Normal Anion Gap Acidosis
High Anion Gap Acidosis
Compensation for Metabolic Acidosis
Clinical Features of Metabolic Acidosis
Management of Metabolic Acidosis
Metabolic Alkalosis
Chloride Sensitive Metabolic Alkalosis
Chloride-resistant Metabolic Alkalosis
Compensation for Metabolic Alkalosis
Clinical Features of Metabolic Alkalosis
Treatment of Metabolic Alkalosis
Use of Hydrochloric Acid in Metabolic Alkalosis
Respiratory Acidosis
Management
Respiratory Alkalosis
BIBLIOGRAPHY
CHAPTER 87:
INTERPRETATION OF ACID-BASE DISORDER
STEPWISE APPROACH FOR INTERPRETATION OF ABG
ARTERIAL BLOOD GAS EXERCISES
Interpretation
ABG Diagnosis = Normal Anion Gap Metabolic Acidosis
Interpretation
ABG Diagnosis = Chloride Sensitive Metabolic Alkalosis
Interpretation
ABG Diagnosis = Acute Respiratory Acidosis with Fully Compensated Metabolic Alkalosis
Interpretation
ABG Diagnosis = Acute Respiratory Alkalosis with Fully Compensated Metabolic Acidosis
Interpretation
ABG Diagnosis = Mixed Respiratory Acidosis and Metabolic Alkalosis
BIBLIOGRAPHY
SECTION 21: NUTRITIONAL SUPPORT
CHAPTER 88:
NUTRITION AND METABOLISM IN CRITICALLY ILL PATIENTS
PATHOPHYSIOLOGY OF NUTRITION IN ILLNESS
NUTRITIONAL ASSESSMENT
History
Clinical Examination
Anthropometric Measurements
Laboratory Examination
Nutritional Requirements
Harris–Benedict Equation
Indirect Calorimetry
Carbohydrate Requirements
Lipids
Proteins
Micronutrients
Vitamins
Trace Elements
BIBLIOGRAPHY
CHAPTER 89:
ENTERAL AND PARENTERAL NUTRITION
TIMING OF NUTRITIONAL SUPPORT
ROUTES FOR GIVING NUTRITIONAL SUPPORT
Enteral Nutrition
Starting the Enteral Feeds
Nursing a Patient on Enteral Feeds
Complications of Enteral Feeding
Parenteral Nutrition
Indications
Access for the Parenteral Nutrition
Parenteral Nutrition Solutions
Formulations and Administration
Monitoring
Complications of Total Parenteral Nutrition
REFEEDING SYNDROME
BIBLIOGRAPHY
SECTION 22: SEDATION AND ANALGESIA IN ICU
CHAPTER 90:
SEDATION AND ANALGESIA FOR CRITICAL CARE PATIENTS
ISSUES TO BE ADDRESSED FOR MANAGEMENT OF PAIN AND SEDATION IN ICU
PAIN AND SEDATION CONSIDERATIONS
ASSESSMENT OF PAIN (Tables 90.1 and 90.2)
PAIN SCALES
Visual Analog Scale
Numeric Rating Scale
Wong-Baker FACES Pain Scale
Verbal Descriptor Scale
Short-form McGill Pain Questionnaire (Tables 90.3 and 90.4)
Scales Used for Sedation Assessment in ICU
Scale Used for Assessing Delirium in ICU
Management of Pain and Sedation (Flow charts 90.1 and 90.2)
Options of Regional Analgesia
Regional Analgesia Techniques
Epidural Analgesia (Table 90.9)
Continuous Peripheral Nerve Catheter Analgesia
BIBLIOGRAPHY
CHAPTER 91:
PATIENT-CONTROLLED ANALGESIA
PRE-REQUISITES
MECHANICS ABOUT THE DEVICE
HOW TO WRITE AN ORDER FOR PCA?
Information to be Gathered While Using PCA Pump
Advantages of PCA
Disadvantages
Key Points About PCA
Advantages of Peripheral Nerve Block Infusions (Table 91.3)
BIBLIOGRAPHY
SECTION 23: AIRWAY MANAGEMENT IN ICU
CHAPTER 92:
RAPID SEQUENCE INDUCTION
ESSENTIAL COMPONENTS OF RAPID SEQUENCE INDUCTION (TABLE 92.1)
INDICATIONS OF RAPID SEQUENCE INDUCTION
CRICOID PRESSURE
ALTERNATIVE TO SUCCINYLCHOLINE–ROCURONIUM?
BIBLIOGRAPHY
CHAPTER 93:
ENDOTRACHEAL INTUBATION IN CRITICAL CARE
BASIC ANATOMY
FAST-TRACK EVALUATION AND AIRWAY ASSESSMENT BEFORE INTUBATION
ADJUNCTS FOR AIRWAY MANAGEMENT
Equipment Required for Endotracheal Intubation (Fig. 93.6)
INTUBATION TECHNIQUES
MANAGEMENT OF DIFFICULT AIRWAY
Suspected Cervical Spine Injury
CARE OF ENDOTRACHEAL TUBE IN ICU
BIBLIOGRAPHY
CHAPTER 94:
TRACHEOSTOMY
EMERGENCY TRACHEOSTOMY
Indications
Prerequisites for Emergency Tracheostomy
Technique for Emergency Tracheostomy
Steps of Tracheostomy
ELECTIVE TRACHEOSTOMY
Types of Elective Tracheostomy
TYPES OF TRACHEOSTOMY (FIG. 94.1)
High Tracheostomy
Mid-tracheostomy
Lower Tracheostomy
Tracheostomy Tubes
Parts of a Tracheostomy tube
CRICOTHYROIDOTOMY/MINITRACHEOSTOMY
Types
Cricothyroidotomy in Children
Anatomy
Surgical Steps
Potential Advantages of Tracheostomy Over Tracheal Intubation
Percutaneous Dilational Tracheostomy
Instruments Required
Technique
Rule of Thumb for Selecting the Cannula
Tracheostomy Care
Suctioning Technique
BIBLIOGRAPHY
SECTION 24: TRANSFUSION PRACTICE IN ICU
CHAPTER 95:
BLOOD TRANSFUSION: COMPONENTS AND INDICATIONS
COMPONENT SEPARATION (Flow chart 95.1)
Packed Red Cells
Compatibility
Storage
Dosage and Administration
Processing of RBC's
Platelets
Different Types of Platelet Processing
Fresh Frozen Plasma
Dosage
Cryoprecipitate
Indications
Dosage and Administration
BIBLIOGRAPHY
CHAPTER 96:
COMPLICATIONS OF BLOOD TRANSFUSION
ADVERSE REACTIONS TO TRANSFUSION
Transfusion Reactions (Table 96.2)
Febrile Nonhemolytic Transfusion Reaction
Acute Hemolytic Transfusion Reactions
Delayed Hemolytic Reaction
Anaphylactic and Allergic Reactions
Nonimmunologic Reactions
ODC Curve
Citrate Intoxication and Hyperkalemia
Hypothermia
Acid-base Disturbances
Coagulation Abnormalities
MASSIVE BLOOD TRANSFUSION
Definition
Complications
BIBLIOGRAPHY
SECTION 25: FLUID MANAGEMENT
CHAPTER 97:
PERIOPERATIVE FLUID BALANCE
BASIC PHYSIOLOGY OF FLUID BALANCE
Fluid Compartments (Fig. 97.1 and Table 97.1)
Normal Exchange of Fluid and Electrolytes
Regulation of Fluid Balance
Disturbances in Fluid Balance
Assessment of Fluid Balance
History
BIBLIOGRAPHY
CHAPTER 98:
FLUID RESUSCITATION
FLUID MANAGEMENT IN PERIOPERATIVE PATIENTS
Maintenance Fluid Therapy
Replacement Fluid Therapy (Table 98.3)
Intravenous Fluids
Crystalloids
Colloids
Human Albumin
Dextran
Gelatin
Hydroxyethyl Starch (HES)
BIBLIOGRAPHY
SECTION 26: CARDIOPULMONARY RESUSCITATION
CHAPTER 99:
BASIC LIFE SUPPORT
INTRODUCTION
PHYSIOLOGY OF CARDIOPULMONARY RESUSCITATION
Cardiac Pump Mechanism
Thoracic Pump Mechanism
ADULT BASIC LIFE SUPPORT SEQUENCE (Flow chart 99.1)
Immediate Recognition and Activation of the Emergency Response System
SEQUENCE OF ADULT BASIC LIFE SUPPORT SKILLS
AIRWAY MANAGEMENT (TABLE 99.3)
Special Situations
Acute Coronary Syndromes
Drowning
Stroke
Foreign-body Airway Obstruction
Hypothermia
Monitoring Cardiopulmonary Resuscitation
BIBLIOGRAPHY
CHAPTER 100:
ADVANCED CARDIAC LIFE SUPPORT
INTRODUCTION
ADJUNCTS FOR AIRWAY MANAGEMENT
MANAGEMENT OF ADULT CARDIAC ARREST
Cardiopulmonary Resuscitation Quality
Return of Spontaneous Circulation (ROSC)
Shock Energy
Drug Therapy
Advanced Airway
Reversible Causes
Defibrillation
Drug Therapy (Tables 100.3 and 100.4)
Return of Spontaneous Circulation after Cardiac Arrest
Monitoring Cardiopulmonary Resuscitation
Access for Delivering Parenteral Medications
Other Therapies and its use in Cardiac Arrest
Precordial Thump
BIBLIOGRAPHY
CHAPTER 101:
CARDIAC ARREST IN SPECIAL SITUATIONS
INTRODUCTION
ANAPHYLAXIS
Basic Life Support Modifications
Advanced Cardiac Life Support Modifications
PREGNANCY
Key Interventions to Prevent Arrest
Basic Life Support Modifications
Advanced Cardiac Life Support Modifications
Pulmonary Embolism
Morbid Obesity
TRAUMA
Basic Life Support Modifications
Advanced Cardiac Life Support Modifications
HYPOTHERMIA
Basic Life Support Modifications
Advanced Cardiac Life Support Modifications
ASTHMA
Electrolyte Disturbances
Potassium
Advanced Cardiac Life Support Modifications
Magnesium
DROWNING
Electric Shock/Lightening Strike
Basic Life Support Modifications
Advanced Cardiac Life Support Modifications
PERCUTANEOUS CORONARY INTERVENTION
CARDIAC TAMPONADE
CARDIAC SURGERY
BIBLIOGRAPHY
SECTION 27: BRAIN DEATH
CHAPTER 102:
CARE OF A BRAIN DEAD PATIENT
DEFINITION
PHYSIOLOGY OF BRAIN DEATH
Central Nervous System
Respiratory System
Cardiovascular System
Temperature Regulation
Hypothalamopituitary Function
Immune System
Privileging
Notification
Reasonable Accommodation
Responsibilities of the Physician Determining Brain Death
STEPS FOR DETERMINING BRAIN DEATH
DIAGNOSTIC CRITERIA FOR THE CLINICAL DIAGNOSIS OF BRAIN DEATH
Coma or Unresponsiveness
Absence of Brainstem Reflexes
Apnea Test
Confirmatory Tests for Brain Death
MANAGEMENT OF HEARTBEATING BRAIN DEATH ORGAN DONOR
General Medical Criteria
Exclusion Criteria for Organ Donation
Obtaining Consent for Organ Donation
Investigations
Clinical Management of the Organ Donor
MANAGEMENT OF 2ND PHASE
Management of Cardiovascular System
Monitoring
Management of Hypotension
MANAGEMENT OF RESPIRATORY SYSTEM
Interventions for Pulmonary Stability
MANAGEMENT OF ENDOCRINE SYSTEM
HPA Axis Dysfunction
Anterior Hypothalamic: Pituitary Endocrine Function
Posterior Hypothalamic Pituitary Deficiency
QUADRUPLE HORMONAL REPLACEMENT THERAPY (TABLE 102.4)
Renal System
Hepatic System
Hypothermia
Hematology
BIBLIOGRAPHY
SECTION 28: MEDICAL ETHICS
CHAPTER 103:
ETHICS IN CRITICAL CARE
END-OF-LIFE CARE
BIBLIOGRAPHY
APPENDICES
APPENDIX 1:
NORMAL BIOCHEMICAL VALUES
REFERENCE VALUES FOR LABORATORY TESTS
APPENDIX 2:
CLINICAL SCORES, INDICES AND EQUATIONS
APACHE II SCORING SYSTEM
MODS SCORING SYSTEM
SOFA SCORING SYSTEM
GOLD CRITERIA FOR GRADING SEVERITY OF COPD
LEVELS OF RISK ASSOCIATED WITH INCREASING BODY MASS INDEX
WAIST CIRCUMFERENCE AND RISK
SF-MPQ (SHORT FORM–MCGILL PAIN QUESTIONNAIRE)
RAMSAY SEDATION SCALE (RSS)
RICHMOND AGITATION SEDATION SCALE (RASS)
Oxygen Saturation at Various Chambers and Vessels
Parameters Measured by Pulmonary Artery (PA) Catheter
Derived Parameters Obtained with Data from PA Catheter
Grading of Diffuse Axonal Injury (DAI)
Glasgow Coma Scale
Marshall Scale: CT Scan Categories for Head Injury
Differences Between Pre-renal Azotemia and Acute Kidney Injury
APPENDIX 3:
DRUGS, DOSAGES AND SIDE EFFECTS
CARDIOVASCULAR SYSTEM
RESPIRATORY SYSTEM
ELECTROLYTE IMBALANCE
ENDOCRINE DISORDERS
GASTROINTESTINAL DISORDERS
HEPATIC DYSFUNCTION
HEMATOPOIETIC DISORDERS
CENTRAL NERVOUS SYSTEM
INFECTIOUS DISEASES
APPENDIX 4:
ICU ROUNDS
ESSENTIAL DATA AND ASSESSMENT FOR MANAGEMENT OF CRITICALLY ILL PATIENTS
History
Physical Examination
External Device Data
Laboratory Data
Imaging Data
INDEX
TOC
Index
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