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ICU Study Notes - Comprehensive Reference

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SECTION 1: Introduction to Intensive Care and General Patient Management

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Module 1.1 - Overview of the Intensive Care Unit and Allied Health Roles

• A specialised hospital ward providing continuous monitoring and life support for patients with life-threatening illness or injury
• Staffed at a higher nurse-to-patient ratio than general wards (typically 1:1 or 1:2)
• Patients are managed for single or multiple organ failure, post-major surgery, trauma, and critical medical illness

• Intensivist / Critical Care Physician - overall medical management
• ICU Nurse - continuous bedside monitoring, medication administration, personal care, safety checks
• Physiotherapist - respiratory care, early mobilisation, weaning from ventilation
• Speech Pathologist - swallowing assessment, communication aids for intubated patients
• Dietitian/Nutritionist - caloric requirement calculation, enteral/parenteral feeding plans
• Pharmacist - medication review, dose adjustment for organ impairment, drug interaction checking
• Social Worker/Psychologist - family support, psychological care of patient and family
• Occupational Therapist - cognitive and functional rehabilitation

• Respiratory failure requiring ventilatory support
• Haemodynamic instability (shock states)
• Acute neurological deterioration (Glasgow Coma Scale < 8)
• Post-operative monitoring after major surgery
• Multi-organ dysfunction syndrome (MODS)

• Haemodynamic stability without vasopressor support
• Adequate respiratory function (weaned from ventilator, SpO2 ≥ 94% on ≤ 4 L/min O2)
• Conscious, oriented, able to protect airway
• Manageable nursing needs for step-down unit

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Module 1.2 - Fundamental Hygiene and Skin Integrity Care in the ICU

• Daily full body wash (bed bath) - reduces bacterial colonisation and promotes comfort
• Oral hygiene at minimum 2-hourly using chlorhexidine 0.12-0.2% mouthwash - prevents ventilator-associated pneumonia (VAP)
• Eye care for sedated/unconscious patients - lubricating drops, taping eyelids closed to prevent corneal drying/ulceration
• Hair and nail care, catheter care (meatal hygiene daily)

• ICU patients are at high risk due to: immobility, poor perfusion, incontinence, malnutrition, sedation, oedema
• Use validated risk assessment tool (Braden Scale) on admission and regularly
• Pressure injury staging:
  • Stage 1 - non-blanchable erythema, intact skin
  • Stage 2 - partial thickness skin loss, blister or open wound
  • Stage 3 - full thickness skin loss, subcutaneous tissue visible
  • Stage 4 - full thickness tissue loss, bone/tendon/muscle exposed
  • Unstageable - depth unknown, covered by slough/eschar
  • Deep tissue pressure injury - purple discolouration, intact skin

• Turn and reposition every 1-2 hours (unless contraindicated)
• Use pressure-relieving mattresses and heel protectors
• Keep skin clean and dry; use barrier creams for incontinence
• Maintain nutrition and hydration
• Avoid shearing forces during repositioning

• Head-to-toe skin inspection each shift
• Document location, stage, size, and appearance of any wounds
• High-risk areas: sacrum, heels, occiput, ears, elbows, trochanters, scapulae, malleoli

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Module 1.3 - Patient Positioning, Mobilisation, and Early Rehabilitation in ICU

• Improves ventilation-perfusion (V/Q) matching
• Reduces aspiration risk
• Prevents pressure injuries and contractures
• Optimises cardiac output and cerebral perfusion

• Recommended for 16-18 hours/day in severe ARDS
• Requires minimum 5 trained staff
• Eyes, ears, and pressure points must be padded
• Careful management of all lines, tubes, and drains
• Contraindications: open abdomen, unstable spine, raised intracranial pressure, anterior chest wounds, severe haemodynamic instability

• Defined as rehabilitation started within 48-72 hours of ICU admission
• Benefits: reduces ICU-acquired weakness (ICUAW), prevents delirium, shortens ventilator duration and ICU/hospital length of stay
• ABCDEF Bundle approach to ICU liberation:
  • A - Assess, prevent, and manage pain
  • B - Both SAT (Spontaneous Awakening Trial) and SBT (Spontaneous Breathing Trial)
  • C - Choice of analgesia and sedation (minimise sedation)
  • D - Delirium - assess, prevent, and manage
  • E - Early mobility and Exercise
  • F - Family engagement and empowerment

1. Passive range of motion (PROM) in bed
2. Active-assisted exercises in bed
3. Sitting up in bed, dangling at bedside
4. Sitting out of bed (chair)
5. Standing with assistance / tilt table
6. Walking with assistance / zimmer frame
7. Independent walking

• Active vasopressor infusion at high doses (e.g. noradrenaline > 0.2 mcg/kg/min)
• Acute respiratory distress requiring high FiO2 (> 0.6) or high PEEP (> 10 cmH2O)
• Unstable arrhythmias
• Active bleeding or haemodynamic instability
• Agitation (RASS +2 or above)
• Uncontrolled intracranial pressure

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Module 1.4 - Airway Care and Management of Drains and Catheters

• ETT cuff pressure maintained at 20-30 cmH2O (high cuff pressure causes tracheal ischaemia; low pressure causes aspiration and VAP)
• Suction only when clinically indicated (not routinely) using aseptic non-touch technique
• Oral hygiene every 2-4 hours
• Secure tube and document lip-level position (average: 21 cm at the lip in women, 23 cm in men)
• Secure and reposition to alternate corners of mouth every 24 hours (if oral)
• Head of bed elevated ≥ 30° at all times

• Tracheostomy inserted when prolonged ventilation (> 7-14 days) is expected
• Care: clean stoma with saline/soap and water; change inner cannula every 8 hours or PRN
• Cuff pressure checked 2-3 times daily
• Suction via tracheostomy as needed
• Spare tracheostomy tube (same size and one size smaller) and dilators kept at bedside at all times
• Emergency: if tube dislodges, cover stoma and attempt oral intubation first

• Indications: pneumothorax, haemothorax, pleural effusion, post-cardiac surgery drainage
• Placed to underwater-seal drainage (UWSD) system
• Nursing care:
  • Keep drainage bottle below the level of the chest
  • Observe for swinging (respiratory movement confirms patent drain)
  • Note volume, colour of drainage each hour (post-op) or each shift
  • Do NOT clamp unless changing bottles or on specific instruction
  • Milking/stripping: avoid unless specifically ordered (increases negative pressure)
  • Document air leak (bubbling) - sustained bubbling at rest indicates ongoing air leak

• Indications: urinary output monitoring, urinary retention, major surgery, sacral pressure injury management
• Use aseptic technique for insertion; use smallest effective size
• Nursing care: maintain closed drainage system; keep tubing below bladder level; peri-urethral hygiene daily; observe colour, volume, and character of urine
• Catheter-associated UTI (CAUTI) prevention: remove catheter as soon as possible; avoid unnecessary manipulation

• Indications: enteral feeding, gastric decompression, medication administration
• Placement confirmed by: X-ray (gold standard), pH ≤ 5.5 of aspirate
• Care: tape securely, check position before each feed, flush with 30 mL water before and after feeds and medications, elevate head 30-45°
• Monitor for gastric residuals if concerns regarding aspiration

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SECTION 2: Monitoring and Haemodynamic Support in Critical Care

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Module 2.1 - Fundamentals of Bedside Monitoring in ICU

• ECG (cardiac rhythm and rate)
• SpO2 (peripheral oxygen saturation via pulse oximetry)
• Non-invasive blood pressure (NIBP) - minimum hourly
• Invasive arterial blood pressure (IBP) - continuous, via arterial line
• Respiratory rate
• Temperature (core: rectal/oesophageal/bladder > peripheral: axillary/tympanic)
• End-tidal CO2 (EtCO2) - in ventilated patients, indicates ventilation adequacy

• Measures haemoglobin oxygen saturation non-invasively using light absorption
• Limitations: inaccurate with poor perfusion, nail polish, hypothermia, arrhythmia, carboxyhaemoglobin (CO poisoning reads falsely high), methaemoglobinaemia, dark skin pigmentation
• Always correlate with arterial blood gas (ABG)

• Waveform monitoring of exhaled CO2
• Waveform suddenly drops to zero: ETT disconnection, cardiac arrest, oesophageal intubation
• Rising EtCO2: hypoventilation, increased metabolism, re-breathing
• Falling EtCO2: hyperventilation, decreased cardiac output, pulmonary embolism

• Hyperthermia (> 38.3°C): infection, systemic inflammatory response, drug reaction, blood transfusion
• Hypothermia (< 36°C): common in ICU (vasodilation from sepsis, operative exposure); associated with coagulopathy, cardiac arrhythmias, and poor immune function
• Targeted temperature management (TTM): 32-36°C after cardiac arrest

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Module 2.2 - ECG Monitoring and Recognition of Critical Arrhythmias

• P wave: atrial depolarisation
• PR interval: AV nodal conduction (normal 0.12-0.20 s)
• QRS complex: ventricular depolarisation (normal < 0.12 s)
• ST segment: ventricular plateau
• T wave: ventricular repolarisation
• QT interval: total ventricular electrical activity (correct with heart rate - QTc normal < 440 ms in men, < 460 ms in women)

1. Rate - fast/slow/normal
2. Rhythm - regular/irregular
3. P waves - present, morphology, relationship to QRS
4. PR interval
5. QRS width
6. ST segment changes
7. T wave changes
8. QT interval

• 4Hs: Hypoxia, Hypovolaemia, Hypo/Hyperkalaemia (and other metabolic), Hypothermia
• 4Ts: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (PE or coronary)

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Module 2.3 - Vascular Access Devices and Invasive Haemodynamic Monitoring

• Gauge: 14G (trauma/resuscitation) > 16G > 18G > 20G > 22G
• Sites: antecubital fossa, forearm, dorsum of hand
• Change every 72-96 hours (or per institutional policy)
• Inspect for infiltration, phlebitis, infection at each shift

• Indications: vasopressor administration, CVP monitoring, repeated blood sampling, large volume resuscitation, total parenteral nutrition (TPN), no peripheral access
• Sites: internal jugular vein (IJV), subclavian vein (SCV), femoral vein
• Confirmation: post-insertion chest X-ray (tip should be at junction of SVC and right atrium)
• Complications: pneumothorax, haemothorax, arterial puncture, air embolism, infection (CLABSI), thrombosis

• Indications: continuous blood pressure monitoring, frequent ABG sampling, haemodynamic instability, vasopressor infusion
• Site: radial artery (most common), femoral artery
• Allen's test before radial insertion (checks ulnar artery patency)
• Care: zero-referencing at level of right atrium (phlebostatic axis: 4th intercostal space, mid-axillary line); keep transducer at same level; flush system with heparinised saline; observe insertion site for haematoma

• Normal: 2-8 mmHg (or 3-10 cmH2O)
• Elevated CVP (> 12 mmHg): fluid overload, cardiac tamponade, right heart failure, tension pneumothorax
• Low CVP (< 2 mmHg): hypovolaemia
• CVP is a poor predictor of fluid responsiveness in isolation - must be interpreted alongside clinical status

• Provides: CVP, pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PAWP), cardiac output (CO), cardiac index (CI), mixed venous oxygen saturation (SvO2)
• Normal values: PAWP 6-12 mmHg, CO 4-8 L/min, CI 2.5-4 L/min/m²
• Largely replaced by less invasive monitoring (e.g. echocardiography, LiDCO, PiCCO)

• Rapidly assesses cardiac function, filling status, pericardial effusion, wall motion abnormalities
• Available to trained intensivists/anaesthetists at bedside
• Views used: subcostal 4-chamber, parasternal long/short axis, apical 4-chamber

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Module 2.4 - Fluid Balance Monitoring and Clinical Correlation

• Total Fluid Balance = Total Inputs - Total Outputs
• Strict input/output (I&O) monitoring is mandatory in ICU

• IV fluids (maintenance, resuscitation, drug infusions)
• Enteral feeds
• Oral intake
• Blood products

• Urine (minimum 0.5 mL/kg/hr expected; oliguria < 0.5 mL/kg/hr; anuria < 100 mL/24hr)
• Nasogastric/surgical drainage
• Stool
• Insensible losses: ~500-800 mL/day (higher with fever: +10% per 1°C above 37°C)
• Chest drain output

• Important objective measure of fluid status
• Weight gain of > 1 kg/day usually represents fluid retention
• Oedema only clinically detectable when interstitial fluid has increased by > 2.5-3 L

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SECTION 3: Infection Prevention, Occupational Safety, and Antibiotic Stewardship

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Module 3.1 - Principles of Infection Prevention and Control in ICU

• Impaired immunity (critical illness, steroids, malnutrition)
• Invasive devices (ETT, CVC, IDC, arterial lines) provide portals of entry
• Disrupted skin and mucosal barriers
• Prolonged hospitalisation and antibiotic exposure selects resistant organisms

• Hand hygiene (most important single measure): 5 moments of hand hygiene (WHO)
  1. Before touching a patient
  2. Before a clean/aseptic procedure
  3. After body fluid exposure risk
  4. After touching a patient
  5. After touching patient surroundings
• PPE: gloves, gown, mask (as required by risk)
• Safe handling and disposal of sharps
• Environmental cleaning and decontamination

• Spore-forming, toxin-producing anaerobe; antibiotic-associated
• Contact precautions; alcohol gel is NOT effective (use soap and water)
• Treat with oral vancomycin or fidaxomicin (metronidazole for mild cases)

• Examples: MRSA, VRE, ESBL-producing Enterobacteriaceae, carbapenem-resistant organisms (CRO/KPC)
• Management: screen on admission, isolate (single room where possible), contact precautions, decolonisation (e.g. MRSA - mupirocin nasal + chlorhexidine body wash)

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Module 3.2 - Occupational Exposures and Healthcare Worker Safety

• Sharps/needlestick injuries: highest risk for bloodborne pathogen transmission
• Blood/body fluid splash: eyes, mucous membranes, broken skin
• Respiratory exposure: airborne/droplet pathogens
• Chemical and radiation exposure

1. Immediate first aid: wash wound with soap and water for ≥ 2 minutes; do NOT squeeze or suck; flush eyes/mucous membranes with water
2. Report immediately to supervisor and occupational health
3. Source patient: obtain consent for HIV, HBV, HCV serology (with appropriate counselling)
4. Healthcare worker: baseline serology
5. Post-exposure prophylaxis (PEP):
   • HIV: commence within 72 hours (ideally < 1 hour); 28-day combination antiretroviral regimen
   • HBV: HBIg + hepatitis B vaccine if unvaccinated
   • HCV: no effective PEP; monitor and treat early if seroconversion
6. Follow-up: 6 weeks, 3 months, 6 months

• Don before entering patient zone; doff in correct sequence to avoid self-contamination
• Correct doffing order: gloves first → hand hygiene → gown → hand hygiene → mask/respirator → hand hygiene → eye protection

• ICU nurses are at high risk for musculoskeletal injury (manual repositioning of sedated patients)
• Use mechanical lifts, slide sheets, and team-lifting techniques
• Safe patient handling programs are mandatory in ICU settings

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Module 3.3 - Alimentary Prophylaxis and Antibiotic Stewardship in Critical Care

• Physiological stress in ICU causes hypoperfusion of gastric mucosa → breakdown of mucosal barrier → stress ulcers
• Risk factors for GI bleeding: mechanical ventilation > 48 hours, coagulopathy, head injury, burns > 35% BSA, renal replacement therapy, history of GI ulcer
• Agents:
  • Proton pump inhibitors (PPIs): pantoprazole 40 mg IV/oral daily (most widely used)
  • H2-receptor antagonists: ranitidine (largely phased out), famotidine
  • Sucralfate: coats mucosa (potential benefit: less VAP compared to PPIs in some studies)
• Enteral nutrition itself provides mucosal protection - reduces need for pharmacological SUP

• All ICU patients at risk of venous thromboembolism
• Pharmacological: low molecular weight heparin (LMWH) e.g. enoxaparin 40 mg SC daily (adjust for weight and renal function)
• Mechanical: graduated compression stockings (TED stockings), intermittent pneumatic compression (IPC) devices
• Contraindications to pharmacological prophylaxis: active bleeding, thrombocytopenia, high-risk surgery (e.g. neurosurgery) - use mechanical only

• Goal: use the right antibiotic, at the right dose, for the right duration, for the right patient
• Principles:
  • De-escalation: broaden empirically, then narrow based on culture and sensitivity results
  • Duration: shortest effective course (e.g. uncomplicated pneumonia 5-7 days; sepsis 7 days; endocarditis 4-6 weeks)
  • Source control: drain abscess, remove infected devices, debride infected tissue
  • Therapeutic drug monitoring (TDM): aminoglycosides (gentamicin, tobramycin), vancomycin - check trough/peak levels

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SECTION 4: Nutrition, Fluid Management, and Metabolic Care in ICU

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Module 4.1 - Methods of Nutritional Support in Critical Illness

• Critical illness causes a hypermetabolic, hypercatabolic state (proteolysis, gluconeogenesis, insulin resistance, lipolysis)
• Poor nutrition leads to: muscle wasting (sarcopenia), impaired wound healing, immune dysfunction, prolonged ventilator dependence, increased infections
• ICU-acquired malnutrition (loss of > 10% body weight) is independently associated with increased mortality

• Assess nutritional risk on admission using validated tool (e.g. NRS-2002, NUTRIC score)
• Estimate caloric requirements: 25-30 kcal/kg/day (acute phase); 20-25 kcal/kg/day (chronic phase)
• Protein requirements: 1.2-2.0 g/kg/day (higher in burns, trauma, obesity)

• Preferred route when gut is functioning
• Commenced within 24-48 hours of ICU admission (early EN)
• Benefits: preserves gut mucosal integrity (reduces bacterial translocation), cheaper, physiological, lower complication rates than parenteral
• Routes: nasogastric (NG), nasojejunal (NJ), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic jejunostomy (PEJ)
• Post-pyloric feeding (NJ/PEJ) for patients with: gastroparesis, high aspiration risk, recurrent high gastric residuals

• Standard polymeric formula: 1-1.5 kcal/mL
• High protein: for wound healing, burns, trauma
• Semi-elemental/elemental: short gut, severe malabsorption, pancreatitis
• Disease-specific: renal (fluid/electrolyte restricted), diabetic (lower glycaemic impact), hepatic (branched-chain amino acid enriched)

• Check gastric residual volume (GRV): generally acceptable < 250-500 mL (institutional variation); volume > this triggers hold and reassessment
• Observe for: diarrhoea, abdominal distension, vomiting, regurgitation
• Constipation is common in ICU: early enteral feeding, mobility, adequate fibre

• Administered via central venous access (CVC due to osmolarity; peripheral PN only if osmolarity < 900 mOsm/L)
• Used when: gut not functional (ileus, bowel obstruction, short bowel syndrome), enteral feeding contraindicated or insufficient
• Contains: glucose, amino acids, lipid emulsions, electrolytes, vitamins, trace elements
• Complications: hyperglycaemia, liver dysfunction (IFALD), infections (CLABSI), refeeding syndrome, electrolyte disturbances

• Occurs when nutrition is reintroduced rapidly after prolonged starvation
• Caused by rapid intracellular shift of phosphate, potassium, and magnesium on insulin release
• Key feature: severe hypophosphataemia (< 0.5 mmol/L)
• At-risk patients: anorexia nervosa, alcoholism, prolonged fasting/starvation, cancer with weight loss
• Prevention: start at ≤ 10 kcal/kg/day, increase slowly over 4-7 days; supplement phosphate, potassium, magnesium, and thiamine before and during refeeding; monitor electrolytes daily

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Module 4.2 - Practical Tube Care and Feeding Procedures in ICU

1. Explain procedure, position patient at 45-90° if possible
2. Measure tube length (nose → ear → xiphisternum)
3. Lubricate tip, insert through nostril, ask patient to swallow as tube advances
4. Confirm placement: aspirate and test pH (≤ 5.5 confirms gastric position); chest X-ray if doubt
5. Document external length and date of insertion
6. Secure with tape; reassess position before each use

• Flush with 30 mL sterile water before and after feeds, and before and after medications
• Crush medications and flush separately (not all medications safe to crush - check pharmacy)
• Monitor external tube length - any migration out indicates possible misplacement
• Change tube every 4-6 weeks (or per manufacturer recommendation)

• Check every 4-6 hours or per protocol
• If GRV 250-500 mL: continue feed, reassess in 4 hours, consider prokinetic (metoclopramide 10 mg QID or erythromycin 250 mg BD)
• If GRV > 500 mL: hold feed, inform medical team, reassess position

• Metoclopramide: dopamine antagonist; 10 mg TDS-QID (caution: extrapyramidal side effects)
• Erythromycin: motilin receptor agonist; 70-125 mg TDS IV (low-dose for gut motility effect); avoid if QT prolonged

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Module 4.3 - Principles of Fluid and Electrolyte Management in ICU

• 30 mL/kg crystalloid IV in first 3 hours for septic shock
• Reassess after each 500 mL bolus with dynamic fluid responsiveness measures:
  • Passive leg raise (PLR) - most practical; positive response = increase in SV/pulse pressure by > 10%
  • Pulse pressure variation (PPV) > 12-13% in ventilated patients = fluid responsive

• Most common electrolyte disorder in ICU
• Causes: SIADH, heart failure, cirrhosis, excessive hypotonic fluids
• Symptoms: nausea, headache, confusion, seizures, coma (if < 120 mmol/L acute)
• Treatment: fluid restriction (if normovolaemic/hypervolaemic); hypertonic saline 3% for severe symptomatic cases
• Caution: correct no faster than 8-10 mmol/L per 24 hours (risk of osmotic demyelination syndrome if corrected too rapidly)

• ICU causes: AKI, rhabdomyolysis, acidosis, cell lysis, potassium-sparing diuretics
• Cardiac risk: peaked T waves → widening QRS → sine wave pattern → VF/asystole
• Treatment sequence:
  1. Calcium gluconate or calcium chloride IV (membrane stabilisation) - if ECG changes
  2. Insulin 10 units + 50 mL 50% dextrose IV (shifts K+ intracellularly)
  3. Salbutamol nebulisation (beta-2 agonist - shifts K+ intracellularly)
  4. Sodium bicarbonate (if acidotic)
  5. Remove source; frusemide if not oliguric
  6. Resonium (kayexalate) - binds K+ in gut (slow; hours to days)
  7. Haemodialysis/haemofiltration - definitive treatment for refractory hyperkalaemia with AKI

• Causes: GI losses (vomiting, diarrhoea, NG drainage), diuretics, refeeding, alkalosis
• ECG: U waves, flattened T waves, prolonged QT, arrhythmias
• Treatment: IV KCl via central line (max 40 mmol/hr in monitored patient; max 10-20 mmol/hr via peripheral line)

• Common after refeeding, alcoholism, DKA treatment, poor nutrition
• Causes: respiratory muscle weakness, ventilator weaning failure, cardiac dysfunction, haemolysis
• Treatment: IV phosphate replacement (sodium or potassium phosphate)

• Causes: GI losses, diuretics, PPIs, alcoholism, refeeding
• Predisposes to refractory hypokalaemia, arrhythmias (especially Torsades de Pointes), seizures
• Treatment: IV magnesium sulfate 10-20 mmol over 1-4 hours

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SECTION 5: Cardiac Emergencies, ACLS Concepts, and Respiratory Support

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Module 5.1 - Recognition and Initial Support of Cardiac Emergencies in ICU

• Unstable angina (UA): ischaemic chest pain at rest; no troponin rise; no ST changes
• NSTEMI: troponin rise, +/- ST depression or T-wave inversion; no ST elevation
• STEMI: troponin rise, ST elevation in ≥ 2 contiguous leads (or new LBBB) = medical emergency

• Chest pain (may be absent in diabetics, elderly, post-op patients)
• ST elevation ≥ 1 mm in limb leads or ≥ 2 mm in precordial leads
• Reciprocal ST depression in opposite leads
• New LBBB pattern

• M - Morphine (pain relief, reduce sympathetic activation) - note: some evidence of harm; use judiciously
• O - Oxygen (only if SpO2 < 90%)
• N - Nitrates (GTN sublingual/IV - do NOT give if right ventricular infarct or hypotension)
• A - Aspirin 300 mg chewed loading dose + P2Y12 inhibitor (ticagrelor 180 mg or clopidogrel 300-600 mg)
• Reperfusion:
  • Primary PCI (percutaneous coronary intervention): preferred if available within 90-120 min
  • Thrombolysis: if PCI not available within 120 min of symptom onset

• Cause: > 40% myocardial infarction, massive MI, acute valve dysfunction, massive PE
• Features: hypotension (SBP < 90 mmHg for > 30 min), cool clammy skin, oliguria, altered consciousness, elevated lactate, low CO/CI
• Management: revascularisation (PCI), vasopressors (noradrenaline), inotropes (dobutamine), consider intra-aortic balloon pump (IABP) or VA-ECMO

• Fluid accumulation in pericardium compresses cardiac chambers → reduced cardiac output
• Beck's Triad: hypotension + muffled heart sounds + raised JVP
• ECG: sinus tachycardia, low-voltage QRS, electrical alternans
• Management: pericardiocentesis (needle aspiration) - emergency surgical drainage if traumatic

• SBP > 180/120 mmHg WITH end-organ damage (encephalopathy, MI, stroke, aortic dissection, acute pulmonary oedema, AKI)
• Management: IV antihypertensives (labetalol, nicardipine, GTN infusion, sodium nitroprusside)
• Reduce MAP by no more than 25% in first hour (risk of organ hypoperfusion if reduced too rapidly)

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Module 5.2 - Essential Respiratory Care and Airway Management in ICU

• CPAP (Continuous Positive Airway Pressure): single pressure level; keeps alveoli open; for cardiogenic pulmonary oedema, OSA
• BiPAP (Bi-level Positive Airway Pressure): two levels (IPAP + EPAP); supports inspiration and maintains PEEP; for COPD exacerbation, respiratory muscle weakness, Type 2 failure
• Contraindications to NIV: unable to protect airway, vomiting, facial trauma, haemodynamic instability, failure to improve after 1 hour

• Failure of NIV or high-flow oxygen
• GCS ≤ 8 (unable to protect airway)
• Apnoea or impending respiratory arrest
• Refractory hypoxaemia (PaO2/FiO2 < 150 despite maximal NIV)
• Haemodynamic instability requiring definitive airway

• Acute onset (within 1 week of clinical insult or new/worsening respiratory symptoms)
• Bilateral opacities on CXR/CT (not fully explained by effusions/lobar collapse/nodules)
• Not fully explained by cardiac failure/fluid overload
• PaO2/FiO2 classification:
  • Mild: 200-300 mmHg (PEEP ≥ 5 cmH2O)
  • Moderate: 100-200 mmHg
  • Severe: < 100 mmHg

• Lung-protective ventilation: Vt 6 mL/kg IBW, plateau pressure ≤ 30 cmH2O
• Higher PEEP strategy (titrated PEEP tables)
• Prone positioning ≥ 16 hours/day for severe ARDS (PaO2/FiO2 < 150)
• Conservative fluid management
• Neuromuscular blockade (NMBA) for severe ARDS (cisatracurium 48-hour infusion - reduces dysynchrony)
• Permissive hypercapnia: accept PaCO2 up to 60 mmHg to avoid high pressures/volumes

• Criteria to attempt SBT (Spontaneous Breathing Trial):
  • Underlying cause resolved
  • FiO2 ≤ 0.4 and PEEP ≤ 8 cmH2O
  • SpO2 ≥ 92%
  • Haemodynamically stable (low-dose or no vasopressors)
  • Adequate conscious state, cooperative
  • Cough/secretion management adequate
• SBT: 30-120 min trial on minimal support (T-piece, CPAP, or low pressure support 5/5 cmH2O)
• SBT pass criteria: SpO2 > 92%, RR < 35, HR and BP stable, not increasing WOB, comfortable
• Extubation criteria (after successful SBT):
  • Able to follow commands
  • Cough and gag reflex present
  • Secretions manageable
  • Cuff leak present (if concern for post-extubation stridor)

• Caused by laryngeal/subglottic oedema
• Treatment: nebulised adrenaline (1 mL 1:1000 in 3 mL saline), IV dexamethasone
• If severe: reintubation may be necessary

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Quick Reference: Critical Values in ICU

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Common ICU Scoring Systems

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Key Medication Infusions in ICU (Quick Reference)

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