The Difference Between Life and Death: Early Interventions in Critical Illness

1
The Difference Between Life and Death Early
Interventions in Critical Illness

• Catherine Martin Frederick, RN, MSN, ACNP-BC,
  CCRN
• Erica DeBoer, RN, MA, CCRN

2
Healthcare in the Rural Setting

• Rural healthcare workers provide primary health
  care to the geographic majority of Canada,
  Australia and the United States
• Vast majority of injured patients receive total
  care in a rural hospital transfer to higher
  level of care not necessary

3
Rural Critical Care

• The level of care provided in a rural community
  hospital for seriously ill or injured patients
  during initial assessment and stabilization,
  during subsequent interhospital transfer, or
  during subsequent admission to the local rural
  hospital (Thompson, et. al., 1995)

4
Rural Critical Care Maintaining Competency

• Limits of Advanced Life Support courses
• Teach initial stabilization and
  identification/treatment of life-threatening
  problems
• Little education on care beyond initial
  stabilization
• Subsequent admission
• Interhospital transfer
• Lack of recognition of rural context for
  emergency medicine
• Literature focus on ATLS/trauma, however, trauma
  accounts for only 1/3 of rural hospital
  emergencies

5
Glasgow Coma Scale (GCS)
6
Abbreviated Injury Scale (AIS)
7
Injury Severity Score (ISS)
Online calculator www.trauma.org
8
Revised Trauma Score (Champion, et. al., 1989)
RTS 0.9368 GCS 0.7326 SBP 0.2908 RR
Online calculator www.trauma.org
9
APACHE II

• High/low values use worst over 24-hr period
• Temperature
• Heart Rate
• Respiratory Rate
• Systolic B/P
• Diastolic B/P
• Sodium
• Potassium
• Creatinine
• WBC

• Altitude above sea level
• FiO2 ()
• pH
• pO2
• pCO2
• HCO3
• Age
• Glasgow Coma Score
• Acute Renal Failure
• Chronic Organ Failure

Online Calculator www.icumedicus.com
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Sepsis and Early Goal Directed Therapy
11
Sepsis

• Healthcare-associated infections are one of the
  top 10 leading causes of death in the U.S.1 The
  US Centers for Disease Control and Prevention
  (CDC) estimates that 1.7M patients experience a
  hospital-acquired infection each year.
• Hospitals have invested considerable resources in
  methods to reduce hospital-acquired infections
  (HAIs) screening, hand washing, etc. However,
  prevention measures often fail.
• The clinical and economic impact of an infection
  can be far greater if the patient becomes septic.
  Effective measures to prevent sepsis and to
  diagnose and manage these patients are critical
  to decrease mortality and reduce hospital costs.

1Centers for Disease Control and Prevention
(CDC), http//www.cdc.gov/ncidod/dhqp/healthdis.ht
ml
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The Burden of Severe Sepsis
Post-Operative
Emergency Dept.
Medical Wards
Intensive Care Units
U.S. Sepsis Statistics

• Severe sepsis is reported in 2.26 cases per 100
  hospital discharges and one in five admissions to
  the ICU.1
• Of the 750,000 severe sepsis cases each year in
  the US, an estimated 215,000 patients die.1
• Mortality associated with severe sepsis is
  30-50.2

1Angus, DC et al. Critical Care Medicine. 2001
291303-1310 2Shapiro NI, et al. Critical Care
Medicine, 2006 34 1025-1032
12
13
Sepsis Leading cause of death in non-coronary
ICUs
Angus DC et al. Crit Care Med. 2001 American
Heart Association. Heart Disease and Stroke
Statistics 2008 Update National Center for Heath
Statistics
13
14
Impact of Avoidable Medical Events(Zhan, et.
al., 2003)
14
15
Pathophysiology Sepsis
Endothelium
16
Sepsis Review Disease Progression
Source Bone et al. Chest 1992
17
Finding the Solution - Surviving Sepsis Campaign
Guidelines endorsed by American Assn. of
Critical Care Nurses American College of Chest
Physicians American College of Emergency
Physicians Canadian Critical Care
Society European Society of Clinical Microbiology
and Infectious Diseases European Society of
Intensive Care Medicine European Respiratory
Society Indian Society of Critical Care
Medicine International Sepsis Forum Japanese
Association for Acute Medicine Japanese Society
of Intensive Care Medicine Society of Critical
Care Medicine Society of Hospital
Medicine Surgical Infection Society World
Federation of Critical Care Nurses World
Federation of Societies of intensive and Critical
Care Medicine German Sepsis Medicine Latin
American Sepsis Institute

• The goal of the SSC is to increase awareness and
  improve outcomes in severe sepsis, leading to a
  25 reduction in mortality in 5 years.
• The campaign includes evidence-based guidelines
  developed by a group of international experts and
  endorsed by 18 international organizations.

17
18
What is Early Goal Directed Therapy?

• Early Goal-Directed Therapy (EGDT) is a
  comprehensive strategy for identifying and
  treating septic patients that includes
• Identification of high-risk patients based on
  early pathogenesis
• Mobilization of resources for intervention
• Performance of a consensus-derived protocol to
  reverse early hemodynamic perturbations
• The core objectives of EGDT in sepsis management
  are to
• Detect and treat occult global tissue hypoxia
  early before organ damage becomes irreversible.
• Achieve a systemic oxygen delivery and demand
  balance

18
19
The Golden Hour Time is Tissue

• The transition to severe disease occurs during
  the critical period when definitive recognition
  and treatment provide maximum outcomes benefits

AMI Trauma Stroke Sepsis
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Early Interventions

• Resuscitation Bundle
• Fluid resuscitation!! 20ml/kg or 500-1000 ml over
  30 minutes
• Labs
• Lactic Acid
• Blood Cultures prior to antibiotic administration
• Antibiotics need to be administered within 3
  hours of sepsis identification

21
Early Interventions

• Resuscitation Bundle

• When hypotension persists start vasopressors
• Norepinephrine- 2-20 mcg/min
• Dopamine 2-20 mcg/kg/min
• Transfuse PRBCs for Hct lt30
• If Hct gt30 and ScvO2 continues to be lt70
  consider Dobutamine (2-20 mcg/kg/min)

22
Resuscitation Bundle

• Goals of Therapy
• (Within 6 hours of Identification)
• SBPgt100
• MAPgt65
• CVP 8-12
• CI gt 2.5
• Urine Output gt 0.5 ml/kg/hr
• ScvO2 gt 70

23
Management Bundle

• Low dose steroids
• Xigris if inclusion criteria is met
• Glucose control (lt150)
• Ventilation with low tidal volumes
• DVT prophylaxis
• PUD prophylaxis

24
EGDT Saves Lives
34 reduction in mortality 21 reduction in mean
length of stay
Rivers, et al., Early Goal-directed Therapy in
the Treatment of Severe Sepsis and Septic Shock.
New England Journal of Medicine, Vol 345, No.
19, November 8, 2001, 1368-1377.
24
Source Rivers et al NEJM 2001
25
EGDT is Cost-Effective
Shorr, 2007
Shapiro, 2006
Trzeciak, 2006
Median Hospital Facility Costs
cost per life saved of 32,336
39.2 reduction
Becker, 2007
cost decreased an average of 9,346 per
patient.
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26
Traumatic Brain Injury
27
Primary vs. Secondary Injury

• Primary injury occurs at the moment of impact,
  the actual insult to brain
• Secondary injury damage evolves over time as a
  result of inadequate delivery of nutrients and
  oxygen to the cells

28
Secondary Injury

• Hypotension
• Hypoxia, hypocapnia
• Hyperthermia
• Hyperglycemia
• Cerebral edema ?ICP
• Cerebral hypoperfusion

29
Brain Trauma Foundation 2007 Severe TBI
Guidelines

• BP Oxygenation
• Hyperosmolar Tx
• Prophylactic Hypothermia
• DVT Prophylaxis
• Indications for ICP Monitoring
• ICP Monitoring
• ICP Thresholds

• CPP Thresholds
• Brain Oxygen Monitoring
• Anesthetics, Analgesics Sedatives
• Nutrition
• Anti-Seizure
• Hyperventilation
• Steroids

30
Management Strategies...

• Prevent and treat secondary injury
• Avoid hypoxia and hypotension
• Improve patient outcome

CT scans reveal left subdural hematoma with mass
effect
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Oxygenation

• Hypoxia poor outcome
• Hypoxia Hypotension gt 75 mortality
• Early resuscitation, use 100 FiO2
• Remember the basics!
• Low pO2 vasodilatation
• PaO2 gt90 mm Hg
• Avoid hyperventilation
• PaCO2 35-45 mm Hg

32
Optimize MAP

• PREVENT HYPOTENSION!
• Target MAP is gt 90 and CPP gt 60
• Numerous studies identified one episode of low BP
  in pre-hospital or in-hospital results in
  increased mortality
• HOW?
• Fluids
• Vasopressors Improves CBF and metabolic delivery
• Decreases ischemia in TBI patients
• Avoid Nipride

33
Pre-Hospital Resuscitation

• GCS lt 8 ? Intubate
• Keep SaO² 100
• Keep pCO² 35-40 mm Hg
• NEVER BAG PATIENT!!
• MAP gt 90 mm Hg
• Do not actively re-warm

34
Initial Interventions

• Establish / Maintain Airway
• SaO2 100
• pCO2 35-40 mm Hg
• ETCO2 monitoring
• Central Line / CCO Swan Ganz / Arterial Line
• Place NG/OG tube, Foley catheter unless
  contraindicated

35
Early Interventions/Management

• Maintain MAP gt 90 mm Hg
• Administer fluids/albumin to keep CVP 6-10
• CT scan
• Neurosurgical procedures
• ICP / Ventriculostomy / Licox

36
Cerebral Tissue Oxygenation Monitor

• Licox Monitor
• Brain tissue oxygen and tissue temperature
• Intracranial pressure
• PbtO2 placed in the cerebral white matter
• O2 sensitivity area 13 mm²

37
Operating Room

• Early decompressive hemicraniectomy
• Before pupils are fixed dilated
• When refractory ICP management
• First 24 hours after injury

38
Keep the Brain in the Zone

• ICP lt 20
• PBtO2 gt 20
• CPP gt 90
• MAP gt 90
• Temp 36-37C
• Tight Glycemic Control

39
Sanford TBI Data
40
Acute Myocardial Infarction
41
Myocardial Infarction

• Non-STEMI
• Non ST-elevation myocardial infarction
• Partially blocked artery
• Decreased blood flow to a portion of the
• heart
• STEMI
• ST-elevation myocardial infarction
• Completely blocked artery
• No blood flow to a portion of the heart
• Substantial risk of death and disability
• Critical need for quick reperfusion

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ACC/AHA Guidelines - Management of Acute
UA/NSTEMI (2007)

• American Heart Association
• www.americanheart.org
• American College of Cardiology
• www.acc.org

44
Initial Management

• Oxygen
• Oral antiplatelet agents
• ASA 160-325 mg OR
• Clopidogrel 300 mg loading dose, then 75 mg daily
• Nitrates
• Morphine
• Beta Blockers
• Non-Dihydropyridine calcium antagonist (if beta
  blockers contraindicated)
• Diltiazem
• Verapamil
• ACE Inhibitor/ARB (if pulmonary congestion or
  LVEF lt 40)

45
TIMI (Thrombolysis in Myocardial Infarction) Risk
Score

• Determined by the sum of the presence of 7
  variables on admission (1 point for each)
• Age 65 y
• At least 3 risk factors for CAD
• Prior coronary stenosis 50
• ST-segment deviation on ECG presentation
• At least 2 anginal events in previous 24 hours
• Use of aspirin in previous 7 days
• Elevated serum cardiac enzymes

46
TIMI Risk Score
47
GRACE Scorecard
48
Risk Stratification

• High Risk
• Elevated cardiac enzymes
• ST depression
• Transient ST elevation
• gt20 minutes rest pain
• Hemodynamic instability
• Signs/symptoms of CHF

• Moderate Risk
• No high risk features
• Previous MI
• Previous CABG
• T-wave inversions
• Rest pain lt20 minutes, promptly relieved with NTG
• Age gt 70
• Low Risk
• No high or moderate risk features
• Progressive angina without prolonged rest pain
• Normal cardiac enzymes
• Normal ECG with pain

49
Initial Treatment Invasive vs. Conservative
Strategy

• Invasive
• IV anticoagulation
• Unfractionated heparin
• Low-molecular-weight heparin
• IV antiplatelet agent
• Abciximab
• Eptifibatide
• Tirofiban
• Early cardiac catheterization
• Oral antiplatelet (after cath)
• Lipid lowering agent

• Conservative
• IV anticoagulation
• Unfractionated heparin
• Low-molecular-weight heparin
• Oral antiplatelet agent
• IV antiplatelet agent
• Eptifibatide
• Tirofiban
• Study of LV function
• Echocardiogram
• Nuclear ventriculogram
• Stress test
• Lipid lowering agent

50
ACC/AHA Guidelines - Management of Acute STEMI
(2007)

• American Heart Association
• www.americanheart.org
• American College of Cardiology
• www.acc.org

51
Reperfusion Therapy

• STEMI patients presenting to a hospital with PCI
  capability should be treated with primary PCI
  within 90 min of first medical contact as a
  systems goal8
• STEMI patients presenting to a hospital without
  PCI capability, and who cannot be transferred to
  a PCI center and undergo PCI within 90 min of
  first medical contact, should be treated with
  fibrinolytic therapy within 30 min of hospital
  presentation as a systems goal, unless
  fibrinolytic therapy is contraindicated

52
Contraindications to Fibrinolytic Therapy

• SBP gt 180mmHg
• DBP gt 110mm Hg
• Right vs. left arm SBP difference gt 15mm Hg
• History of structural CNS disease
• History of closed head or facial trauma within
  last 3 months

• Recent ( 6 weeks) major trauma, surgery, or
  GI/GU bleed
• Bleeding or clotting disorder or on anticoagulant
  therapy
• CPR gt 10 minutes
• Pregnancy
• Advanced systemic disease (end-stage cancer,
  liver, or kidney disease)

53
High Risk Patients Primary PCI Preferable

• Heart Rate 100
• SBP lt 100 mmHg
• Systemic hypoperfusion
• Cool, clammy skin
• Pulmonary edema
• Rales auscultated over gt1/2 of lung fields

54
Primary vs. Facilitated PCI

• A planned reperfusion strategy using full-dose
  fibrinolytic therapy followed by immediate PCI is
  not recommended and may be harmful
• Facilitated PCI using regimens other than
  full-dose fibrinolytic therapy might be
  considered as a reperfusion strategy when ALL of
  the following are present
• Patients are at high risk
• PCI is not immediately available within 90
  minutes
• Bleeding risk is low (younger age, absence of
  poorly controlled hypertension, normal body
  weight)

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Anticoagulation Following Fibrinolytics

• Patients who have undergone reperfusion with
  fibrinolytics should receive anticoagulant
  therapy for a minimum of 48 hours, and preferably
  for the duration of the hospitalization, up to 8
  days
• Regimens other than unfractionated heparin UFH
  are recommended if anticoagulant therapy is given
  for more than 48 hours

56
STRIVE Clinical Pathways

• Strategies and Therapies for Reducing Ischemic
  and Vascular Events
• Interdisciplinary scientific committee of experts
  working to develop evidence-based educational
  initiatives with the goal of optimization of
  acute coronary syndrome (ACS) and ischemic stroke
  management
• www.strivecme.com

57
American Heart Association Mission Lifeline

• National, community-based initiative
• Goals
• Improve quality of care and outcomes for heart
  attack patients
• Improve health care system readiness and response

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American Heart Association Mission Lifeline

• Addresses continuum of care for STEMI patients
• Preserves a role for the local STEMI-referral
  hospital
• Understands the issues specific to rural
  communities
• Promotes different solutions/protocols for rural
  vs. urban/suburban areas
• Recognizes there is no one-size-fits-all
  solution
• Knows the issues of implementing national
  recommendations on a community level

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American Heart Association Mission Lifeline

• Services
• Define the ideal practice
• Recommend strategies to achieve the ideal
  practice
• Provide resources/tools to achieve the ideal
  practice
• Recommend metrics for structure, process and
  outcomes
• Recommend criteria for recognition and
  certification
• For more information
• www.americanheart.org/missionlifeline

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Overdose
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Management of Critically Ill Patients After Acute
Overdose

• Respiratory Support
• Ensure airway patency oral/nasal airway,
  Endotracheal intubation if needed
• Ensure adequate ventilation noninvasive
  positive pressure or mechanical ventilation if
  needed
• Prevent aspiration
• NG/OG tube
• HOB 30º

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Management of Critically Ill Patients After Acute
Overdose

• Cardiovascular Support
• Sympathomimetics
• Fluid resuscitation
• Vasopressors

63
Management of Critically Ill Patients After Acute
Overdose

• Neurologic Support
• Oxygenation/ventilation
• Normotension
• Normothermia
• Antiepileptics

64
Management of Critically Ill Patients After Acute
Overdose

• Renal Support
• Fluid resuscitation
• Normotension
• Minimize other
• nephrotoxic interventions

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Activated Charcoal

• Reduces absorption of substance by up to 60
• If within ½ hour of ingestion, gastric lavage
  done prior
• Given via oral route or via NG/OG tube
• May give with sorbitol to increase transit time
• Contraindications
• Antidote given
• Ingestion of caustic agent (strong acid or
  alkali)

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Acute Overdose Antidote Information

• Trujillo, M. H., Guerrero, J., Fragachan, C.,
  Fernandez, M. A. (1998). Pharmacologic
  antidotes in critical care medicine A practical
  guide for drug administration. Critical Care
  Medicine, 26(2).
• California Poison Control System Antidote Chart
  (includes suggested quantities to stock)
• http//www.rphworld.com/pharmacist/viewlink-25090.
  html

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Rural Critical Care Future Directions

• RESEARCH NEEDED!!!
• Telemedicine
• Clinical links with tertiary care centers
• Staff rotation
• Protocol sharing
• Joint quality, safety, educational, and research
  programs
• Nurse recruitment and retention
• Promote continued education/certification

68
Rural Critical Care Organizations

• New South Wales Rural Critical Care Clinical
  Nurse Consultants
• www.ruralcriticalcare.asn.au
• Rural and Remote Health
• www.rrh.org.au
• Society of Rural Physicians of Canada
• www.srpc.ca/rcc.htm

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References

• Peake, S. L. Judd, N. (2007). Supporting
  rural community-based critical care. Current
  Opinion in Critical Care, 13(6).
• Ross, E. L. Bell, S. E. (2009). Nurses
  comfort level with emergency interventions in the
  rural hospital setting. Journal of Rural Health,
  25(3).
• Thompson, J., MacLellan, K., ONeill, T.
  (1995). Rural critical care. Society of Rural
  Physicians of Canada website http//www.srpc.ca/r
  cc.htm. Accessed 9/27/09.

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Thank You!

• martinca_at_sanfordhealth.org
• deboere_at_sanfordhealth.org