1	CCM PA / ARNP GUIDELINES for EVALUATION & TREATMENT of ICU and IMC PATIENTS Carl W. Peters, MD Critical Care Medicine
2	PA / ARNP GUIDELINES General: This information is for general guidance to assist you in the management of common ICU / IMC problems when you are by yourself
3	PA / ARNP GUIDELINES Be aggressive in using supplementary sources to help you figure out what is best to do: Try “Up-to-Date” accessed from: U/F Anesthesia Dept web site House Staff Manual section Scroll down to “UP-tO-DATE” Chose your subject It’s a quick reference Try any of several textbooks of Critical Care: Accessible via the UF Dept of Anesthesiology website à Critical Care Division pull-down menu à Education
4	PA / ARNP GUIDELINES Concerned about the best management strategy ? Contact one of the people on duty in the ICU Fellow (494-9189) Anesthesia resident The ICU front desk clerk (265-0025) can get you connected to the proper person.
5	PA / ARNP GUIDELINES
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7	PA / ARNP GUIDELINES Remember: Most of these patients are still seriously ill, precariously balanced on a number to treatment modalities Stability can “turn south” quickly If you need assistance: get it early !
8	PA / ARNP GUIDELINES Chest pain Dysrhythmias HypOtension HypERtension Respiratory Issues Basics of ventilator management Airway management, easy & difficult Urinary Symptoms Mental Status Changes Intracranial pressure management Hyperbaric Oxygen Therapy Acid-Base Basics
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10	Chest Pain
11	Chest Pain Evaluation Guidelines Causes of chest pain are NUMEROUS # 1, 8, & 9 can kill the quickest H & P SELDOM IF EVER excludes these big killers, though may provide DIRECTION Appropriate TESTING is the key—gather the correct DATA to support your evaluation
12	Chest Pain Evaluation Guidelines If you are called for Chest Pain (or equivalent: Heaviness ? Chest Ache ?) Review history: Is Patient at risk for cardiac or acute pulmonary decompensation ? Examine: Most often unrevealing…..but….. Check Vital signs yourself Murmur ? Irregular Heart Rate ? Fast or slow ? Breath sounds: asymmetric ? Wheezing ? Râles ? Gather data: EKG, CXR, ABG (order all STAT, tell the RN & time the order !) Note: avoid new arterial sticks if there is much likelihood of LYSIS Consider enzymes, but order three, three, three sets, NEVER ONLY 1 set Follow up the results, call primary service
13	Chest Pain Three quick killers: Acute myocardial infarction Pulmonary embolus Thoracic aortic dissection
14	Chest Pain Work-up Address airway and hemodynamic stability issues Oxygen and airway support Ensure a working IV is something bigger needed (16 ga ? 14 ga ?) Order (STAT) the three tests that can be done quickly EKG, Arterial blood gas analysis, Chest x-ray Other tests, too, but take longer CPK, CPK-MB, troponin If things look bad Hypotension, hypoxemia, patient looks “near death” (in extremis) GET HELP EARLY
15	Chest Pain Work-up Specific tests to order: Troponin, CPK + MB fraction Order THREE SETS of each, 8 hours apart No place for only one set; always order three If you get any, get three sets (Is any of this unclear ??!!) Echocardiogram Cardiology fellow can do, if needed, if she / he sees the patient for the chest pain
16	Chest Pain Work-up: the EKG
17	EKG Changes Coronary Insufficiency
18	M.I. EKG Changes by Location
19	Infarction-related EKG changes
20	EKG Classic Myocardial infarction (STEMI)
21	EKG Example Antero-Lateral MI
22	EKG Example Infero-Posterior MI
23	EKG Example Antero-Septal MI
24	Don’t be Fooled by Right Bundle Branch Block
25	Don’t be Fooled by Left Bundle Branch Block
26	Don’t be Fooled by Pericarditis
27	Acute Pulmonary Embolus
28	EKG Guidance For more info about EKG’s try these web sites: Http://medlib.med.Utah.edu/kw/ecg/image_index/index.html WWW.ecglibrary.com/ Chow’s textbook on EKG interpretation: “Electrocardiography in Clinical Practice”
29	Chest Pain: Thoracic Aortic Aneurysm Seldom seen anew in IMC Often discovered on chest x-ray done for another reason Symptoms May have NO symptoms Chest pain may be presenting symptom “Tearing” or “ripping” back pain with dissection Signs Findings on CXR (see next screen) Hypotension, tachycardia, looks critically ill Sweaty, pale, constantly moving to get comfortable
30	Chest Pain: Thoracic Aortic Aneurysm
31	Chest Pain: Thoracic Aortic Aneurysm Management: GET IMMEDIATE HELP Call the surgeons STAT Treatment of proximal T.A.A. is surgical; distal T.A.A.: medical Control airway if needed Control BP with quick-acting meds IV Nipride + β-Blocker such as esmolol IV α and β-Blocker infusion such as labetalol Must reduce shearing force on aorta (dp / dt) Target SBP ~ 100-110 mm Hg; HR ~ 70-75 bpm Type & Cross for LOTS of blood products Get good IV access (two big peripherals to start)
32	Chest Pain: Pulmonary Embolism Mortality of PE diagnosed promptly and treated correctly: ~ 6% Mortality of undiagnosed significant PE: ~ 30% (same as MI) The diagnosis can be subtle, and masquerade as many other serious and not-too-serious problems BE SUSPICIOUS
33	Pulmonary Embolism: Be Suspicious Pulmonary Embolism mimics many conditions that appear in ICU’s Every patient in the IMC / ICU is at major risk for a PE à BE SUSPICIOUS Unless the signs and symptoms are well explained by another condition, investigate PE
34	Pulmonary Embolism: Risk Factors
35	Pulmonary Embolism Signs & symptoms
36	Pulmonary Embolism: When to be Suspicious Feeling paranoid about missing a PE ??? Well, don’t feel alone; this diagnosis is difficult to get right Think of it when these kinds of things happen: New tachypnea in any of our patients, with hypoxemia (relative to Fi0₂) & hypocarbia Deterioration in respiratory status New infiltrate or volume loss on CXR Hemoptysis New hemodynamic instability You will seldom go wrong by thinking of PE when a patient’s condition “goes south”
37	Pulmonary Embolism: Diagnosis IN OUR PATIENT POPULATION, NO LAB TEST RULES OUT A P.E. ONCE YOU HAVE DECIDED THAT IT’S A POSSIBILITY (this includes having a normal blood gas) D-dimers are seldom negative in the SICU So don’t count on them They will be negative with NO PE, but there are many other causes of (+) D-dimers besides PE, so is very sensitive but not specific Repeat that statement to yourself!! You must investigate further with a radiologic study
38	Pulmonary Embolism: Diagnosis In 2008, the diagnostic test of choice is contrast spiral CT done with the PE protocol Be advised: this requires a large dye load injected through 20-gauge PIV or “Power PICC line” or large-bore central line Renal protection may be needed with bicarb & NAC Inferior back-up test is VQ scan; may used when kidneys are already at the edge If the risks of hemorrhage are low and the suspicion is high, consider anticoagulation even before the diagnostic test is done Use unfractionated heparin – can be gone quickly
39	Pulmonary Embolism: Diagnosis Always get lower extremity Doppler studies, too If they are “+”, that warrants heparin by itself, so PE protocol CT might not be necessary in a person with borderline renal function
40	Pulmonary Embolism: Diagnosis Remember!! There is a MASSIVE PE protocol on the Shands Hospital web site to use when needed Involves many services: Trauma CCM PRIMARY SERVICE (don’t forget) Interventional radiology Possibly pulmonary Possibly CT surgery LOOK IT UP ON LINE !
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42	PA / ARNP GUIDELINES Dysrhythmias Assessment issues Cardiovascular stability associated with the rhythm Unstable: Indications for immediate electricity Unstable: Indications for pacing Details of the dysrhythmia What does the 12-lead show ? What is the rhythm generator ? When to use medications, when not, & what to use ?
43	PA / ARNP GUIDELINES Dysrhythmias Instability—how does the patient look? VFib ?—USE ELECTRONS NOW VTach ?—Maybe electrons, maybe medications, depending on the stability Profound bradycardia—Impending arrest, START CPR Ashen, sweaty, thready pulse, altered mental status ? What’s the Blood pressure on the art line ? Punch the manual BP button—get art line and manual bp measurements Check the leads; run a strip Do all this at once, TAKE ACTION FAST
44	PA / ARNP GUIDELINES Dysrhythmias
45	PA / ARNP GUIDELINES Dysrhythmias Get a copy of this book Keep your ACLS certification up-to-date These cards come with the book; you can carry them with you
46	PA / ARNP GUIDELINES Chaotic rhythm STAT-PAGE HELP! Check leads, shake the patient while the code cart is coming Don’t defibrillate a sleeping patient with loose leads!!! DEFIBRILLATE: Biphasic—150J Monophasic—360J Quicker shock = better recovery (there’s a linear relationship with time)
47	Ventricular Fibrillation
48	Ventricular Fibrillation
49	Ventricular Fibrillation
50	Torsade (a kind of VFib) Give MAGNESIUM STAT !!!
51	PA / ARNP GUIDELINES Dysrhythmias Ventricular Tachycardia Stable or UNSTABLE Wide complex tachycardia (greater than 120 msec — three small boxes) Regular — may have a pulse STAT-PAGE HELP!!! UNSTABLE ? Synch’d Cardioversion Push the “synch” button on the machine
52	Ventricular Tachycardia
53	Ventricular Tachycardia
54	Ventricular Tachycardia
55	12-lead EKG of Ventricular Tachycardia
56	Ventricular Tachycardia (RV focus – Looks Weird!!)
57	3^rd Degree Blockàà Asystole
58	Asystole
59	VTach à Asystole
60	PA / ARNP GUIDELINES Dysrhythmias Dysrhythmias — when you have time to think… Always get a 12-lead EKG Run a strip from the monitor onto paper Look back to earlier strips Check the electrolytes—K⁺ & Mg⁺⁺ Ask these questions: Fast or slow? Either can be unstable — may need electricity or pacing Sinus or non-sinus Drugs or electricity may be needed
61	A-FIB with WPW: Needs Electricity
62	Atrial Fibrillation: Probably Stable
63	AVNRT: May Need Electricity
64	Bradycardia and Long QT: May need Meds or Pacing
65	1st-Degree Heart Block
66	2^nd-Degree Heart Block Type 1 2^nd degree = Look for GROUP BEATING, followed by a dropped beat Lengthening PR interval, then dropped QRS No bad prognosis
67	2^nd-Degree Heart Block Type 2 2^nd degree = Look for GROUP BEATING SAME PR intervals, then dropped QRS BAD NEWS – may forecast 3^rd-degree heart block Call for help – may need a pacemaker
68	3^rd Degree AV Block May Need Pacing
69	Dysrhythmia Workup If the patient has a dysrhythmia, do this: Do a cardiac exam: new murmur ? S₃? Check appropriate labs: lytes, O₂sat, Hct, Mg⁺⁺ Stat lab is quickest Correct abnormal values What drugs is the patient on ? Digoxin ? Check a level ? Get an EKG, maybe a rhythm strip Look at his / her history, and an OLD EKG
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71	Hypotension Think of the following 5 problems: Preload – not enough filling Afterload – not enough resistance Contractility – not enough strength of contraction Rate – too fast to fill adequately, too slow to eject enough Rhythm – chaotic, non-synchronized – can’t fill or eject Ask: how sudden is this ?? If acute — get help quickly as evaluation begins.
72	Hypotension Think of the four types of Shock Cardiogenic – heart can’t pump well enough (a “girlly-man” heart) – like acute MI Hypovolemic – not enough volume for the heart to pump – like trauma, dehydration, GI bleeding Distributive – the arterial tree is bigger than the blood it contains – like sepsis / SIRS, C-spine fracture Obstructive – Something mechanical is interfering with the blood flow to and from the heart
73	Hypotension: Cardiogenic
74	Hypotension: Hypovolemic
75	Hypotension: Distributive Vasodilation Sepsis C-spine impingement Adrenal insufficiency Anaphylaxis
76	Hypotension: Obstructive Cardiac tamponade Heart can’t fill Muffled heart sounds, narrow pulse pressure Drain QUICKLY – get help
77	Hypotension: Preload Common causes: Dehydration Poor intake (NPO) High losses (diarrhea) Look for skin tenting: forehead, dorsum of hand, chest GI bleeding Have good IV access Give a bolus of fluid Send investigational labs
78	Hypotension: Preload Mechanical obstructions to ventricular filling cause decreased preload —think about them Massive pulmonary embolism Tension Pneumothorax
79	Hypotension: Afterload Think vasodilation: Sepsis Fever ? Very high or very low WBC count with lots of bands ? Adrenal insufficiency Should the patient receive steroid supplement ? Allergic reaction Did the patient just get a new medication ? Spinal cord injury Delayed spinal shock from expanding spinal hematoma or abscess ?
80	Hypotension: Contractility The heart can’t pump well enough to maintain the BP/cardiac output The muscle is weak New MI or ischemia!!! Infections – sepsis cardiomyopathy / myocardial depression Valvular lesions
81	Hypotension Rhythm Rate
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83	Hypertension Can only be evaluated within the context of the patient’s history and clinical situation Few specific BP values demand any specific treatment in and of themselves Decide if the BP warrants immediate treatment Hypertensive emergency Hypertensive urgency
84	Hypertensive EMERGENCY Hypertensive emergencies Acute, Life-threatening, Usually associated with marked increases in blood pressure (BP) Generally ≥ 180 / 120 mm Hg
85	Hypertensive EMERGENCY Examples Ischemic stroke or subarachnoid or intracerebral hemorrhage Acute pulmonary edema Angina pectoris or acute myocardial infarction Aortic dissection Withdrawal of antihypertensive therapy Acute increase in sympathetic activity
86	Hypertensive EMERGENCY Medications Nitroprusside — an arteriolar and venous dilator, given as an intravenous infusion. Initial dose: 0.25 to 0.5 µg / kg / min Maximum dose: 8 to 10 µg / kg / min which should be continued for no more than 10 minutes. Nitroglycerin — a venous and, to a lesser degree, arteriolar dilator, given as an intravenous infusion. Initial dose: 5 µg / min; maximum dose: 100 µg / min. Labetalol — an α- and ß-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg / min (or MORE, as you know)
87	Hypertensive EMERGENCY Medications Nicardipine — a calcium channel blocker, given as an intravenous infusion. Initial dose: 5 mg / h; Maximum dose: 15 mg / h (if we could only get it) Fenoldopam — a peripheral dopamine-1 receptor agonist, given as an intravenous infusion. Initial dose: 0.1 µg / kg / min; The dose is titrated at 15 min intervals, depending upon the blood pressure response Hydralazine — an arteriolar dilator, given as an intravenous bolus. Initial dose: 10 mg given every 20 to 30 minutes; Maximum dose: 20 mg.
88	Hypertensive EMERGENCY Medications Propranolol — a ß-adrenergic blocker, given as an intravenous infusion and then followed by oral therapy. Dose: 1 to 10 mg load, followed by 3 mg / h Phentolamine — an α-adrenergic blocker, given as an intravenous bolus. Dose: 5 to 10 mg every 5 to 15 minutes Enalaprilat — an angiotensin converting enzyme inhibitor, given as an intravenous bolus. Dose: 1.25 mg every six hours.
89	Hypertensive EMERGENCY More examples
90	Papilledema
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92	Respiratory Issues Evaluation Guidelines
93	Respiratory Issues What will you see / hear / get asked about by the nurses ? Tachypnea Wheezing Stridor (i.e. after extubation) ABG abnormalities Asymmetric or decreased breath sounds Secretions !! Chest pain (more respiratory in nature)
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95	Respiratory Issues: Tachypnea Respiratory rate above ~ 14 – 18 breaths / minute List of causes is miles long Ask yourself a few memory refreshment questions, as you go see the patient: Is he: Intubated, trach’ed, spontaneous ? Is he: Acute or chronic ? Why is patient in ICU / IMC ? New vital signs (including SpO₂ and PetCO₂)
96	Respiratory Issues: Tachypnea (cont’d) Examination findings: Asymmetric sounds ? Wheezing or stridor ? Patient’s general appearance – does he look like the guy on the previous slide ? What immediate steps to take Suction, neb, chest tube, intubate ??? Tests to order: ABG, CXR, others as indicated (maybe ask for help from……..CCM Team)
97	Respiratory Issues: Wheezing Wheezing is caused by airway obstruction The air can’t get OUT; it’s trapped in the periphery Common Causes: Asthma / COPD Anaphylaxis / allergic reaction, causing airway edema and narrowing Anatomic obstruction Foreign body (more in kids) Tumor obstructing a bronchus Treatment Starts with the proper diagnosis
98	Respiratory Issues: Stridor Opposite of wheezing i.e. the air can’t get in High pitched sound on inspiration Watch the breathing pattern to time the sound Most commonly seen, in the ICU / IMC environment, as post-extubation stridor
99	Respiratory Issues: Stridor Treatment Meds: Racemic epinephrine 0.5 mg / 2.5 mL NS nebulized q 1 to 2 hrs Diurese BIPAP and helium / oxygen mix 70% / 30% ratio Helium decreases density, gas flow more easily through narrowed airways Respiratory therapy can get the tanks Do this only with CCM fellow or attending involvement
100	Respiratory Issues: ABG Abnormalities Look at the Acid-Base section of this series, at the end, for particulars of ABG analysis
101	Respiratory Issues: Chest pain/Pneumothorax
102	Chest Pain: Pneumothorax “Collapsed” lung Common ICU Causes: High pressure ventilation Line insertion Trauma Sometimes after having put chest tube to water seal
103	Chest Pain: Tension Pneumothorax Tension Pneumothorax Note: Shifted trachea, away from the affected side Shifted heart sounds, away from the affected side Hyper-resonant hemithorax from trapped high-pressure air (the affected side) Hypotension
104	Tension Pneumothorax: Emergent Treatment
105	Tension Pneumothorax: Definitive Treatment Placement of chest tube Be meticulously sterile in placement technique Don’t take all day to do it Unless you’re a whiz at placing these, decompress the chest cavity first, then place the tube….. Call for help…these tubes have complications And we have seen them, believe me !
106	Respiratory Issues: Secretions Secretions complicate all aspects of respiratory care Thin & watery, use Robinul 0.2 mg IV Q8h x ~ 48 hours Thick, use albuterol 2.5mg + Mucomyst 20% 2ml combo nebs Secretions must be addressed – otherwise the patients never leave
107	Pulmonary Edema Cardiogenic or non-cardiogenic Wheezing, rales S3, murmurs Diaphoretic, sitting up Tachypneic, dyspneic Marginal saturation
108	Pulmonary Edema Treatment for cardiogenic edema: think L, M, N, O, P: Lasix Morphine Nitrates Oxygen Phlebotomy – in the old days Intubate or NIPPV if needed
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110	Basics of Ventilator Management Parameters that are controlled: Tidal volume Respiratory rate Inspired fraction of oxygen PEEP Pressure support Other parameters à à ask the respiratory therapist, Fellow, resident, Staff
111	Basics of Ventilator Management Respiratory Rate Start with 10 – 12 bpm Get ABG in ~ 30 minutes Follow PetCO₂ Plan on weaning: This must be addressed from the beginning Tidal volume Generally 7 – 8 ml / kg with PEEP Use ideal BW or adjusted BW Generally, low-tidal volume ventilation is best
112	Basics of Ventilator Management FiO₂ Target is down to 0.3 to 0.4, with a PaO₂/ FiO₂ ratio of about 300 Target sat is >95% May need FiO₂> 0.4, but consider this a temporizing measure until other adjustments can be made.
113	Basics of Ventilator Management CPAP / PEEP “Minimal” is ~ 5 cm H₂O May need more to keep the alveoli in the dependent areas open, ~ 10 cm H₂O Can use CPAP to be able to come down on the FiO₂ Pressure support Patient with a tracheostomy, “minimal” is ~ 5 cm H₂O Patient with an ETT, “minimal” is ~ 10 cm H₂O Smaller tubes require more PS at “minimum” Higher resistance with smaller tube
114	How PEEP Works
115	How PRESSURE SUPPORT works
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117	Airway Management Guidelines What You Must Do in an Airway Emergency: Recognize the emergency Start assisting respirations with an ambu-bag and 100% oxygen With cricoid pressure, if the patient is unconscious Mobilize the troops — CALL FOR HELP!!! CCM fellow (494-9189) / attending / resident Respiratory therapy, nurses Organize yourself and the group CALL a CODE if you must, to get people there
118	Airway Management Guidelines Organization—Yourself You Take Charge!! IMMEDIATELY INSIST UPON QUIET IN ROOM !! Go to the head of the Bed, start bagging Give orders as you bag You can better see those who can help you from head of bed Position patient for best respiratory support Raise patient’s face to level of intubator’s xiphoid, remove HOB + raise head ~ 2 inches with folded towels (no pillows) Pull chin up into “sniff position”, not chin to chest Do the bagging YOURSELF Wear gloves & other needed protection Slow the breathing, yours and the patient’s ! Prepare your plan
119	Endotracheal Intubation: Head Positioning Elevate head ~ 10 cm’s Allows better alignment of airway axes Folded towels under the head: won’t collapse like a pillow will, & will give better support Pillows get in the way, don’t stabilize the head
120	Endotracheal Intubation: Head Positioning Look what positioning can do for you ! Try to imagine intubating this patient if positioned as on the left
121	Endotracheal Intubation: Head Positioning
122	Airway Management Guidelines Organize à the group Keep control of the scene MINIMIZE CHAOS ! KEEP THE ROOM QUIET ! Recognize who can help you: charge nurse, others Issue specific directions to specific individuals to do specific tasks Make eye contact – helpers become engaged Avoid mushy “Somebody get…” directions; since nobody or 20 people will try to do it Give simple instructions, speak clearly Outline plan to the group as you go Don’t raise your voice more than a little bit INSIST OTHERS BE QUIET AND LISTEN EMPTY OUT ROOM IF YOU HAVE TO
123	Airway Management Guidelines Organize à your equipment Look at anesthesia record for airway / intubation history, if you have time Easy intubation yesterday ? Mandatory fiberoptic awake intubation last 4 operations ? Grade 4 airway despite looking easy from the outside ? What type of laryngoscope blade was used successfully Special “tricks” Lots of cricoid pressure, “BURP” maneuver needed ?
124	Airway Management Guidelines Organize à your equipment Stiletted high-low evac-ETT 8.0 & 7.5 for men; 7.5 & 7.0 for women Leave in package, check the balloon with syringe Small dab of surgical lube in connector before stiletting makes stilette removal much easier Bend in “hockey-stick” shape
125	Airway Management Guidelines Organize à your equipment (continued) Laryngoscope Working handle with back-up (? short handle ?) Blades – Most start with MAC-4 for unknown airway Have a backup blade – other type (Miller 2) Suction Make sure it works & is tightly connected to hose Place under patient’s right shoulder Easily found be feel
126	Airway Management Guidelines Before you intubate, know this: Previous airway instrumentation Was it easy or hard? à look at the previous anesthesia record !! DO NOT ASSUME it will be easy !! What is the airway like now ?: Quick airway evaluation à may have immediate need for help / back-up
127	Airway Management Guidelines Small chin ? Short neck ? Small mouth ? Overbite ? What do you see when the patient opens his mouth ?
128	Airway Management Guidelines How does one correctly provide BAG-Valve mask ventilation ? Turn the page
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132	Airway Management: Cricoid Pressure Locate “lump” below Adam’s Apple Press gently with thumb and forefinger Too much pressure can obscure the view Patient starts to wretch ? Let off, roll the patient to side
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135	Definitive Airway Management
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143	Airway Management Laryngoscopic View
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145	Airway Backups
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156	Intubating through the LMA
157	Intubating through the LMA
158	Intubating through the LMA
159	Intubating through the LMA As long as the intubating LMA is in place, there is NO HURRY to intubate with the ETT Use the bronchoscope, thusly Place Fastrack re-inforced ETT on bronchoscope Insert B-scope into LMA, ID-ing the epiglotis-lifter, the cords, the carina Slide the well-lubed ETT over the b-scope into the trachea, inflate the cuff Remove B-scope slowly, correctly placing the ETT in correct tracheal position CAREFULLY (DUH!!!!) remove the LMA GET AN X-RAY
160	Combitube
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163	Airway Management: Cricothyrotomy Feel for the landmarks, find the depression Make vertical incision through the skin Pull the skin lateral Make horizontal incision through the cricoid membrane Insert the device
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172	Bronchoscopic Intubation
173	Bronchoscopic Intubation Preparation (for my technique): Inform the patient, ask permission (if not already done) Call respiratory for the bronchoscopy cart Give 0.2 mg of Robinul to dry secretions Give it EARLY Draw up 10 mL of 4% Lidocaine, attach a Mucosal Atomization Device (next slide) Have the patient sit up, if possible (even a little bit) Be pre-oxygenating the patient
174	Bronchoscopic Intubation Use of M.A.D. Use to anesthetize the airway Patient opens mouth, spray back as far as soft palate Wait 2 minutes, do so again but farther back Keep going all the way down the throat Save 2 – 3 mL Available in anesthesia workroom, by the O.R.
175	Bronchoscopic Intubation: Intubating Oral Airways
176	Bronchoscopic Intubation Load ETT (without connector) onto bronchoscope Insert intubating oral airway, covered with lidocaine ointment, SLOWLY into patients mouth, as far as will go. Spray remaining 3 mL of lido spray onto cords via oral airway (slide the MAD down the oral airway; it will be aimed at cords)
177	Bronchoscopic Intubation Insert scope through airway, with tube loaded and suction attached Slowly advance scope, look for vocal cords
178	Bronchoscopic Intubation Advance scope through cords, look for carina Slowly advance ETT off scope into lungs, inflate balloon, confirmation distance above carina Remove scope, secure tube, You’re done
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180	Mental Status Change Evaluation Guideline
181	Mental Status Change Evaluation Guideline Newly depressed mental status ? Do the quick things first ABC’s – always first, then Check the vital signs What’s the glucose Is the patient receiving lots of sedatives or narcotics 0.4 mg Narcan in 9ml NS (= 40 mcg / mL), give 0.25 – 0.5 mL (maybe repeat once or twice) Won’t put into acute withdrawal, but will start to wake up an accidental OD, like from an overaggressive PCA baseline dosage Consider Thiamine (300 mg); it’s cheap and effective Then think AEIOU TIPS
182	Mental Status Change Evaluation Guideline Trauma Infection Psychiatric Stroke Alcohol Epilepsy, Endocrine, Electrolytes Insulin Overdose, Oxygen Uremia
183	Mental Status Change A à Alcohol Mental Jog for TOXINS Ethanol: check a level Methanol: blindness Isopropanol: N & V, non-acidemic ketosis Ethylene glycol (antifreeze): Very acidemic Urine glows under a woods lamp Envelope-shaped crystals in the urine Other drugs of abuse Get a tox screen
184	Mental Status Change E à Epilepsy, Endocrine, Electrolytes Endocrine Thyroid storm or coma Send FT4, TSH DKA – see next slide Adrenal function Poor MS with hypotension Low sodium, high K⁺ Give steroids after sending level (Dex if ACTH Stim test planned) Epilepsy Is the patient in non-convulsive status epilepticus ? Get an EEG Have Neurology see the patient Is the anticonvulsant level too high ? Check the anticonvulsant level
185	Mental Status Change E à Epilepsy, Endocrine, Electrolytes Electrolytes – sodium!! High or low When correcting, do so slower than it took to get to where it is now Uncertain of duration? à no faster than 0.5 mEq correction per hour Usually need not correct all the way back to normal
186	Mental status changes Hypernatremia correction Hypernatremia Indicates free water deficit Correct with free water replacement -- but how much ? Must calculate deficit ! Sodium = 160 mEq, 100 kg male Water deficit = [(actual – desired) / desired] X 0.65 X wt. (in kg) 160 - 140 / 140 X (0.65 X 100) = 9.2 L free water deficit
187	Mental status changes Hypernatremia correction (cont’d) EXAMPLE: Correct Na = 160 mEq / L to Na = 140 MAX 0.25 – 0.5 mEq / hour 160 – 140 = 20 X 0.5 = 40 hours to correct a 9.2 liter deficit 9,200 mL / 40 hours = ~ 230 mL / hour Start SLOWER, ~ 100 mL / hour Measure sodium ~ every 2 hr LEAVE detailed orders to be called If: Correction faster than 0.5 mEq / hour Then: Have nurse STOP infusion in the meantime Faster correction can mean DEATH BY CEREBRAL EDEMA
188	Mental status changes Hyponatremia correction Determine cause SIADH is not corrected by salt replacement Cerebral Salt Wasting (CSW) is a continuous process that needs continuous correction If it’s appropriate to correct, figure sodium deficit: (target Na – actual Na) X 0.65 X wt. (in kg) Only correct back to the [Na⁺] that will stop the problem (i.e. seizures)….usually 125 to 130 mEq / L
189	Mental status changes Hyponatremia correction (cont’d) EXAMPLE: Sodium = 115 mEq / L (125 – 115) X 0.65 X 100 = 650 mEq Sodium to correct to 125 Go SLOW (max 0.5 mEq / hour); too fast risks death / neuro destruction from CPM 3% saline = 513 mEq / L of sodium 650 / 513 = 1.26 L 3% saline needed (Na⁺ deficit) 1260 mL needed / 20 hours = 63 mL / hour
190	Mental status changes Hyponatremia correction (cont’d) Go at half that rate, ~ 30 mL / hour Get frequent Na checks (minimum q2h) CALL YOU WITH EACH RESULT Max 0.5 mEq / hour change NOTE: 3% saline MUST be delivered VIA CENTRAL LINE PICC, 3-lumen, introducer, PA catheter
191	Mental status changes Sodium in the Neuro Patient Sodium may be abnormal in the Neuro patient from three additional causes: Diabetes insipidus à sodium will be HIGH SIADH (syndrome of inappropriate ADH) à sodium will be LOW CSW à sodium will be LOW How do you ID each problem??? One must understand the pathophysiology ! Check out THIS REF: J Neurosurg Anesthesiol. 2006 Jan;18(1):57-63 Following slides are from there
192	Mental status changes Sodium in the Neuro Patient Diabetes insipidus à sodium will be HIGH While one can have nephrogenic DI, in neuro patients, the problem is absence of ADH ADH (antidiuretic hormone) “opens the gates” to recover free water in