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

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Title: 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
10
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
12
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
20
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.
25
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
31
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

42
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43
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)

55
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

58
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

59
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

60
Overdose
61
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

62
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

65
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)

66
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

67
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

69
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.

70
Thank You!
  • martinca_at_sanfordhealth.org
  • deboere_at_sanfordhealth.org
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