Critical Care Medicine

Main objectives

• Early recognition and resuscitation of critically ill patients
• Stabilization of airway, breathing, and circulation
• Prevention, detection, and treatment of organ failure
• Continuous reassessment using clinical examination, monitoring, laboratory tests, and imaging
• Safe transfer, rehabilitation, and communication with patients and families

Common indications for ICU care

• Acute respiratory failure requiring oxygen therapy, non-invasive ventilation, or mechanical ventilation
• Shock, including septic, cardiogenic, hypovolemic, or anaphylactic shock
• Severe sepsis or septic shock
• Acute cardiac events, dangerous arrhythmias, or cardiac arrest
• Acute kidney injury requiring renal replacement therapy
• Severe trauma, burns, poisoning, or major post-operative complications
• Altered consciousness, coma, and acute neurological emergencies

Core components of management

1. Airway and ventilation: airway protection, oxygen therapy, blood-gas assessment, and mechanical ventilation when needed.
2. Hemodynamic support: intravenous fluids, vasoactive drugs, ECG and blood-pressure monitoring, and treatment of the underlying cause of shock.
3. Organ support: ventilators for lung failure, dialysis for kidney failure, and nutritional support for critically ill patients.
4. Infection control: prompt cultures when appropriate, source control, and rational antimicrobial therapy.
5. Monitoring: continuous observation of vital signs, urine output, neurological status, fluid balance, laboratory values, and bedside ultrasound where available.
6. Prevention of ICU complications: prevention of pressure injuries, venous thromboembolism, delirium, stress ulcers where indicated, device-related infection, and ICU-acquired weakness.

ABCDE approach in critical care

• A - Airway
• B - Breathing
• C - Circulation
• D - Disability
• E - Exposure/Examination

A - Airway

• Can the patient speak clearly? This usually indicates a patent airway.
• Look and listen for obstruction: snoring, gurgling, stridor, wheeze, vomitus, blood, facial swelling, or foreign body.
• In trauma, assume a possible cervical-spine injury until assessed.

• Open the airway using appropriate positioning or airway manoeuvres.
• Suction secretions or vomitus.
• Use airway adjuncts if trained and appropriate.
• Give high-concentration oxygen when indicated and prepare for definitive airway management if airway protection is failing.

B - Breathing

• Respiratory rate, work of breathing, chest movement, ability to speak, oxygen saturation, and skin colour.
• Listen to breath sounds and examine the chest.
• Obtain blood gas testing and chest imaging when needed.

• Give oxygen and target an appropriate saturation range.
• Assist ventilation with bag-mask ventilation or non-invasive ventilation where indicated.
• Identify and treat immediately reversible causes, such as severe asthma, pulmonary oedema, tension pneumothorax, or opioid-induced respiratory depression.
• Escalate early for intubation and mechanical ventilation if there is exhaustion, hypoxaemia, hypercapnia, or reduced consciousness.

C - Circulation

• Pulse rate, rhythm, blood pressure, capillary refill, peripheral temperature, urine output, and mental state.
• Look for bleeding, dehydration, sepsis, or signs of shock.
• Obtain ECG, intravenous access, and relevant blood tests, including lactate where shock is suspected.

• Control external haemorrhage immediately.
• Give intravenous fluids when appropriate, while avoiding indiscriminate fluids in conditions such as cardiogenic pulmonary oedema.
• Give blood products for major haemorrhage as guided by protocol.
• Start vasoactive drugs in an appropriately monitored setting when hypotension persists despite correction of reversible causes.
• Treat the cause: for example, antibiotics and source control for sepsis, reperfusion for acute coronary occlusion, or control of bleeding in trauma.

D - Disability

• Level of consciousness using AVPU: Alert, responds to Voice, responds to Pain, Unresponsive, or use the Glasgow Coma Scale.
• Pupillary size and reaction.
• Blood glucose.
• Seizures, new focal neurological deficits, agitation, pain, or delirium.

• Correct hypoglycaemia promptly.
• Treat active seizures according to emergency protocols.
• Ensure adequate oxygenation and perfusion, since hypoxia and shock can depress consciousness.
• Consider causes such as stroke, intracranial injury, poisoning, infection, metabolic disturbance, or medication effects.

E - Exposure and examination

• Fully inspect the patient for rashes, wounds, bleeding, swelling, signs of infection, pressure injuries, medical-alert jewellery, drains, and device complications.
• Measure temperature.
• Examine the back when safe, especially in trauma.

• Manage findings such as wounds, burns, bleeding, anaphylaxis signs, or infection sources.
• Prevent heat loss and preserve dignity by re-covering the patient promptly after examination.

Key principles

• Ensure personal and team safety first.
• Obtain help early.
• Apply monitoring early: pulse oximetry, ECG, blood pressure, and frequent temperature assessment.
• Do not move to the next stage without addressing a life-threatening abnormality.
• Repeat the ABCDE assessment after every intervention and whenever the patient changes.
• Once stabilized, take a focused history, perform a full examination, investigate the cause, and plan definitive treatment.

ICU Services

Main ICU services

1. Continuous monitoring
   • Continuous ECG, oxygen saturation, respiratory rate, blood pressure, and temperature monitoring
   • Frequent assessment of consciousness, urine output, fluid balance, and laboratory results
   • Invasive monitoring where needed, such as arterial blood pressure and central venous access
2. Airway and respiratory support
   • Oxygen therapy and high-flow nasal oxygen
   • Non-invasive ventilation
   • Endotracheal intubation and invasive mechanical ventilation
   • Airway suctioning, chest physiotherapy, and weaning from ventilatory support
3. Cardiovascular and shock management
   • Management of sepsis, haemorrhage, heart failure, arrhythmias, and cardiac arrest
   • Intravenous fluid therapy, blood transfusion, and vasoactive or inotropic drugs
   • ECG monitoring and, when necessary, advanced haemodynamic assessment
4. Renal and metabolic support
   • Management of acute kidney injury, electrolyte imbalance, acid-base disorders, and severe hyperglycaemia or hypoglycaemia
   • Renal replacement therapy, including dialysis or continuous renal replacement therapy
5. Neurological care
   • Care of patients with coma, stroke, seizures, head injury, encephalopathy, or raised intracranial pressure
   • Neurological observations, sedation management, and seizure control
6. Infection and sepsis management
   • Early identification of infection and sepsis
   • Collection of cultures, administration of antimicrobials, and source control
   • Strict infection-prevention measures, especially for ventilators, central lines, urinary catheters, and wounds
7. Nutrition and supportive care
   • Enteral or parenteral nutrition
   • Pain control, sedation, delirium assessment, pressure-area care, and prevention of venous thromboembolism
   • Early mobilization and physiotherapy to reduce ICU-acquired weakness
8. Post-operative and trauma care
   • Monitoring and support after major surgery, severe trauma, burns, or organ transplantation
   • Detection and management of post-operative bleeding, respiratory compromise, shock, and organ dysfunction
9. Emergency procedures
   • Central venous and arterial catheter placement
   • Airway procedures, chest drain insertion, emergency pacing or cardioversion, and bedside ultrasound-guided procedures
10. Communication, rehabilitation, and end-of-life care

• Regular communication with patients and families
• Planning transfer to a high-dependency unit or ward once stable
• Rehabilitation planning and compassionate, ethical end-of-life care when recovery is not possible

Field Medical Services

Main functions

• Scene safety and triage: assess hazards, identify casualties, and prioritize treatment according to urgency.
• Immediate life support: use the ABCDE approach to manage airway obstruction, respiratory failure, shock, severe bleeding, altered consciousness, and exposure-related problems.
• Trauma care: control catastrophic haemorrhage, apply dressings and tourniquets where indicated, splint fractures, manage burns, and prevent hypothermia.
• Basic emergency treatment: administer oxygen, provide analgesia, establish intravenous or intraosseous access when appropriate, and treat conditions such as anaphylaxis, seizures, asthma, hypoglycaemia, and cardiac arrest.
• Evacuation and referral: communicate with receiving facilities, monitor the patient during transport, document care, and transfer patients safely.
• Public-health support: during disasters, services may include outpatient care, infection prevention, maternal and child care, vaccination support, and disease surveillance.

Personnel and equipment

Principles

1. Ensure rescuer and scene safety.
2. Call for help and use available resources efficiently.
3. Treat life-threatening problems before definitive diagnosis.
4. Reassess repeatedly during treatment and transport.
5. Maintain infection prevention, documentation, communication, and patient dignity.

1. Hospital governance and management strategy
2. Infrastructure and facility planning
3. Health information technology and digital systems
4. Workforce planning and essential manpower
5. Essential equipment, supplies, and maintenance
6. Patient-care systems, safety, and quality improvement
7. Incident, disaster, and surge-capacity management
8. Coordination with referral hospitals, public-health agencies, ambulance services, and field medical institutions

Critical Care Medicine

Main objectives

• Early recognition and resuscitation of critically ill patients
• Stabilization of airway, breathing, and circulation
• Prevention, detection, and treatment of organ failure
• Continuous reassessment using clinical examination, monitoring, laboratory tests, and imaging
• Safe transfer, rehabilitation, and communication with patients and families

Common indications for ICU care

• Acute respiratory failure requiring oxygen therapy, non-invasive ventilation, or mechanical ventilation
• Shock, including septic, cardiogenic, hypovolemic, or anaphylactic shock
• Severe sepsis or septic shock
• Acute cardiac events, dangerous arrhythmias, or cardiac arrest
• Acute kidney injury requiring renal replacement therapy
• Severe trauma, burns, poisoning, or major post-operative complications
• Altered consciousness, coma, and acute neurological emergencies

Core components of management

1. Airway and ventilation: airway protection, oxygen therapy, blood-gas assessment, and mechanical ventilation when needed.
2. Hemodynamic support: intravenous fluids, vasoactive drugs, ECG and blood-pressure monitoring, and treatment of the underlying cause of shock.
3. Organ support: ventilators for lung failure, dialysis for kidney failure, and nutritional support for critically ill patients.
4. Infection control: prompt cultures when appropriate, source control, and rational antimicrobial therapy.
5. Monitoring: continuous observation of vital signs, urine output, neurological status, fluid balance, laboratory values, and bedside ultrasound where available.
6. Prevention of ICU complications: prevention of pressure injuries, venous thromboembolism, delirium, stress ulcers where indicated, device-related infection, and ICU-acquired weakness.

• A - Airway
• B - Breathing
• C - Circulation
• D - Disability
• E - Exposure/Examination

A - Airway

• Can the patient speak clearly? This usually indicates a patent airway.
• Look and listen for obstruction: snoring, gurgling, stridor, wheeze, vomitus, blood, facial swelling, or foreign body.
• In trauma, assume a possible cervical-spine injury until assessed.

• Open the airway using appropriate positioning or airway manoeuvres.
• Suction secretions or vomitus.
• Use airway adjuncts if trained and appropriate.
• Give high-concentration oxygen when indicated and prepare for definitive airway management if airway protection is failing.

B - Breathing

• Respiratory rate, work of breathing, chest movement, ability to speak, oxygen saturation, and skin colour.
• Listen to breath sounds and examine the chest.
• Obtain blood gas testing and chest imaging when needed.

• Give oxygen and target an appropriate saturation range.
• Assist ventilation with bag-mask ventilation or non-invasive ventilation where indicated.
• Identify and treat immediately reversible causes, such as severe asthma, pulmonary oedema, tension pneumothorax, or opioid-induced respiratory depression.
• Escalate early for intubation and mechanical ventilation if there is exhaustion, hypoxaemia, hypercapnia, or reduced consciousness.

C - Circulation

• Pulse rate, rhythm, blood pressure, capillary refill, peripheral temperature, urine output, and mental state.
• Look for bleeding, dehydration, sepsis, or signs of shock.
• Obtain ECG, intravenous access, and relevant blood tests, including lactate where shock is suspected.

• Control external haemorrhage immediately.
• Give intravenous fluids when appropriate, while avoiding indiscriminate fluids in conditions such as cardiogenic pulmonary oedema.
• Give blood products for major haemorrhage as guided by protocol.
• Start vasoactive drugs in an appropriately monitored setting when hypotension persists despite correction of reversible causes.
• Treat the cause: for example, antibiotics and source control for sepsis, reperfusion for acute coronary occlusion, or control of bleeding in trauma.

D - Disability

• Level of consciousness using AVPU: Alert, responds to Voice, responds to Pain, Unresponsive, or use the Glasgow Coma Scale.
• Pupillary size and reaction.
• Blood glucose.
• Seizures, new focal neurological deficits, agitation, pain, or delirium.

• Correct hypoglycaemia promptly.
• Treat active seizures according to emergency protocols.
• Ensure adequate oxygenation and perfusion, since hypoxia and shock can depress consciousness.
• Consider causes such as stroke, intracranial injury, poisoning, infection, metabolic disturbance, or medication effects.

E - Exposure and examination

• Fully inspect the patient for rashes, wounds, bleeding, swelling, signs of infection, pressure injuries, medical-alert jewellery, drains, and device complications.
• Measure temperature.
• Examine the back when safe, especially in trauma.

• Manage findings such as wounds, burns, bleeding, anaphylaxis signs, or infection sources.
• Prevent heat loss and preserve dignity by re-covering the patient promptly after examination.

Key principles

• Ensure personal and team safety first.
• Obtain help early.
• Apply monitoring early: pulse oximetry, ECG, blood pressure, and frequent temperature assessment.
• Do not move to the next stage without addressing a life-threatening abnormality.
• Repeat the ABCDE assessment after every intervention and whenever the patient changes.
• Once stabilized, take a focused history, perform a full examination, investigate the cause, and plan definitive treatment.

Main ICU services

1. Continuous monitoring
   • Continuous ECG, oxygen saturation, respiratory rate, blood pressure, and temperature monitoring
   • Frequent assessment of consciousness, urine output, fluid balance, and laboratory results
   • Invasive monitoring where needed, such as arterial blood pressure and central venous access
2. Airway and respiratory support
   • Oxygen therapy and high-flow nasal oxygen
   • Non-invasive ventilation
   • Endotracheal intubation and invasive mechanical ventilation
   • Airway suctioning, chest physiotherapy, and weaning from ventilatory support
3. Cardiovascular and shock management
   • Management of sepsis, haemorrhage, heart failure, arrhythmias, and cardiac arrest
   • Intravenous fluid therapy, blood transfusion, and vasoactive or inotropic drugs
   • ECG monitoring and, when necessary, advanced haemodynamic assessment
4. Renal and metabolic support
   • Management of acute kidney injury, electrolyte imbalance, acid-base disorders, and severe hyperglycaemia or hypoglycaemia
   • Renal replacement therapy, including dialysis or continuous renal replacement therapy
5. Neurological care
   • Care of patients with coma, stroke, seizures, head injury, encephalopathy, or raised intracranial pressure
   • Neurological observations, sedation management, and seizure control
6. Infection and sepsis management
   • Early identification of infection and sepsis
   • Collection of cultures, administration of antimicrobials, and source control
   • Strict infection-prevention measures, especially for ventilators, central lines, urinary catheters, and wounds
7. Nutrition and supportive care
   • Enteral or parenteral nutrition
   • Pain control, sedation, delirium assessment, pressure-area care, and prevention of venous thromboembolism
   • Early mobilization and physiotherapy to reduce ICU-acquired weakness
8. Post-operative and trauma care
   • Monitoring and support after major surgery, severe trauma, burns, or organ transplantation
   • Detection and management of post-operative bleeding, respiratory compromise, shock, and organ dysfunction
9. Emergency procedures
   • Central venous and arterial catheter placement
   • Airway procedures, chest drain insertion, emergency pacing or cardioversion, and bedside ultrasound-guided procedures
10. Communication, rehabilitation, and end-of-life care

• Regular communication with patients and families
• Planning transfer to a high-dependency unit or ward once stable
• Rehabilitation planning and compassionate, ethical end-of-life care when recovery is not possible

Main functions

• Scene safety and triage: assess hazards, identify casualties, and prioritize treatment according to urgency.
• Immediate life support: use the ABCDE approach to manage airway obstruction, respiratory failure, shock, severe bleeding, altered consciousness, and exposure-related problems.
• Trauma care: control catastrophic haemorrhage, apply dressings and tourniquets where indicated, splint fractures, manage burns, and prevent hypothermia.
• Basic emergency treatment: administer oxygen, provide analgesia, establish intravenous or intraosseous access when appropriate, and treat conditions such as anaphylaxis, seizures, asthma, hypoglycaemia, and cardiac arrest.
• Evacuation and referral: communicate with receiving facilities, monitor the patient during transport, document care, and transfer patients safely.
• Public-health support: during disasters, services may include outpatient care, infection prevention, maternal and child care, vaccination support, and disease surveillance.

Personnel and equipment

Principles

1. Ensure rescuer and scene safety.
2. Call for help and use available resources efficiently.
3. Treat life-threatening problems before definitive diagnosis.
4. Reassess repeatedly during treatment and transport.
5. Maintain infection prevention, documentation, communication, and patient dignity.

1. Hospital governance and management strategy
2. Infrastructure and facility planning
3. Health information technology and digital systems
4. Workforce planning and essential manpower
5. Essential equipment, supplies, and maintenance
6. Patient-care systems, safety, and quality improvement
7. Incident, disaster, and surge-capacity management
8. Coordination with referral hospitals, public-health agencies, ambulance services, and field medical institutions

1. Hospital management strategies
2. Infrastructure and health IT
3. Essential manpower and equipment
4. Patient care, safety, and quality management
5. Coordination with hospitals and field medical services
6. A combined short note on all sections

Hospital Management: Combined Short Note

1. Management strategies

• Setting service goals, policies, standard operating procedures, and clinical pathways
• Budgeting, procurement, inventory control, and preventive maintenance
• Monitoring indicators such as bed occupancy, waiting time, mortality, infection rates, readmissions, and patient satisfaction
• Conducting audits, incident reporting, risk management, and quality-improvement activities
• Maintaining disaster preparedness, surge capacity, and business-continuity plans

2. Infrastructure

• Outpatient department, emergency department, wards, operating theatres, ICU/HDU, laboratory, radiology, pharmacy, blood bank, and rehabilitation services
• Safe water supply, electricity with backup generators, medical-gas systems, ventilation, fire safety, waste disposal, sanitation, and security
• Isolation rooms and infection-control facilities
• Clearly marked patient routes, emergency exits, ambulance access, and disability-friendly design
• Adequate bed capacity, including contingency areas for mass-casualty events or outbreaks

3. Use of information technology

• Electronic health records and electronic prescribing
• Laboratory, radiology, pharmacy, and bed-management information systems
• Telemedicine for remote consultation and referral support
• Digital appointment, queue, and patient-tracking systems
• Clinical alerts for allergies, drug interactions, abnormal laboratory results, and deteriorating patients
• Dashboards for monitoring bed occupancy, staffing, infection rates, supplies, and outcomes

4. Essential manpower

• Doctors and specialists
• Nurses, midwives, and nursing assistants
• Pharmacists, laboratory scientists, radiographers, and physiotherapists
• Emergency medical technicians and ambulance staff
• Infection-control, quality, biomedical-engineering, information-technology, and administrative staff
• Housekeeping, security, kitchen, laundry, maintenance, and waste-management staff

5. Equipment and supplies

• Reliable procurement and stock control
• Emergency medicines and consumables
• Biomedical maintenance and calibration
• Backup power, oxygen, water, and communication systems
• Safe storage of medicines, blood products, and sterile supplies

6. Patient care and safety

• Triage and rapid assessment in emergencies
• Accurate identification of patients
• Safe prescribing and medication administration
• Infection prevention, hand hygiene, and antimicrobial stewardship
• Pain management, nutrition, rehabilitation, and psychosocial support
• Informed consent, privacy, respectful communication, and family involvement
• Safe discharge planning, follow-up, and referral

7. Coordination with other institutions and field services

• Primary health centres and community health workers
• Referral hospitals and specialist centres
• Ambulance, prehospital, and field medical services
• Public-health authorities, blood banks, laboratories, and rehabilitation centres
• Disaster-management agencies and emergency medical teams