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Physician intensive care unit
Critical Care Services
Critical Care
What resources are available at http://www.qureshiuniversity.com/criticalcareworld.html?
Guidelines for the mentioned occupations:
  1. Physician, critical care unit, existing

  2. Physician, critical care unit, in training

  3. Physician, critical care unit, aspiring

  4. Nurse, critical care unit, existing

  5. Nurse, critical care unit, in training

  6. Nurse, critical care unit, aspiring

  7. Nurse, critical care unit, manager at the critical care unit location

  8. Physician, critical care unit, manager at the critical care unit location

  9. Others connected to critical care

What should critical care unit staff be aware of at the critical care unit’s specific location?
An existing critical care unit physician can have various seniority levels.
An existing critical care unit nurse can have various seniority levels.
Several positions must conduct research: physician, critical care unit, existing/in training/aspiring and nurse, critical care unit, existing/in training/aspiring.

What is the role of Doctor Asif Qureshi in critical care?
Guide for existing critical care unit physicians via the Internet.
Guide for more than 900 occupations.

Doctor Asif Qureshi is guiding you from a distance through the Internet.
You have to remain at the critical care unit location for 8 hours of duty if you are assigned the duty of an existing critical care unit physician, critical care unit physician manager, existing critical care unit nurse, or critical care unit nurse manager at that location.

If anyone needs face-to-face tutorials, a meeting can be arranged in Chicago, Illinois.

An existing critical care unit physician must have answers to these questions ahead of time.
  1. Annotation or definition.

  2. Assessment of a patient by a physician.

  3. Assessment of a Patient Needing Critical Care

  4. Advanced Cardiovascular Life Support (ACLS)

  5. Airway Management

  6. Activities of Everyday Living

  7. Admission and Discharge Criteria: Critical Care Services/ Criteria for discharge from medical emergency room

  8. Basic life support

  9. Cardiopulmonary resuscitation guidelines.

  10. Communications relevant to the intensive care unit.

  11. Critical Care Drug Manual

  12. Critical Care Beds

  13. Critical care units in the state.

  14. Critical care unit record

  15. Critical care unit beds in a room.

  16. Critical care unit equipment.

  17. Coma

  18. Dehydration, Rehydration, and Hyperhydration

  19. Diagnosing Medical Acid Base Disorders

  20. Depression

  21. Equipment Used in an Intensive Care Unit

  22. Existing Patients in Critical Care

  23. Evaluation, diagnosis, and treatment of an unconscious patient.

  24. Feeding problems

  25. Fluid Requirements in Adults

  26. Follow up of patient.

  27. Guidelines for intensive care unit design, dimensions, resources, staff.

  28. Glasgow Coma scale analysis.

  29. Global guide for various professions

  30. Health Calculations

  31. Home Care Services for Seniors

  32. ICU Medical Conditions

  33. Intensive care unit management.

  34. Intensivist

  35. Locations of hospitals’ critical care units in various states around the world.

  36. Mechanical Ventilation

  37. Monitoring the critically ill patient

  38. Nasogastric (Ryles) Tubes

  39. Negligent death in the intensive care unit

  40. New Critical Care Patient

  41. Nutrition in intensive care

  42. Protocols & Guidelines

  43. Pulse oximeter

  44. Questions state director of health needs to answer.

  45. Questions must be answered before sending patients home from the critical care unit of a hospital in the state.

  46. Refusing to eat/drink

  47. Remote collaboration systems in critical care: http://www.qureshiuniversity.com/criticalcareworld.html

  48. Resources - Intensive Care Unit

  49. Respiratory System Questions

  50. Respiratory monitoring

  51. Reversible Causes of Cardiac Arrest: H's and T's

  52. Self-Care

  53. Specific Medical Cases

  54. Staff in the ICU

  55. Treatment of a Patient in a Coma

  56. What should every type of physician know?

Annotation or definition.
What are other names for a critical care unit (CCU)?
Intensive care unit
Intensive therapy unit
Intensive treatment unit

What does a critical care unit (CCU) look like?


What is critical care?
Critical care provides support for patients whose conditions are potentially life-threatening. These patients need: constant and close monitoring; support for their organ systems from specific equipment; and medication to keep the body functioning normally while they recover.

Heart attack; stroke; pneumonia; poisoning; surgical complications; major trauma resulting from accidents, burns, violence etc. are all examples of critical illness. Critical care deals with a wide range of conditions but typically all patients will have problems with one or more of their organ systems, particularly the respiratory (lungs) and cardiovascular (heart) organ systems. Patients usually require intensive monitoring and most need some form of support such as mechanical ventilation (breathing) and/or drugs to help the heart and circulation function.

The length of stay in the critical care unit can vary.

Monitors, intravenous (IV) tubes, feeding tubes, catheters, breathing machines, and other equipment are common in critical care units. They can keep a person alive, but can also increase the risk of infection.

Many patients in critical care recover, but some die. Having advance directives in place is important. They help health care providers and family members make end-of-life decisions if you are not able to make them.

Critical care medicine is the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury (SCCM definition).

Critical care is a maturing specialty whose practitioners are “intensivists” and who practice is moving from consult based “open” units, to multidisciplinary “closed” units.

Critical illness is a very specific series of disease syndromes which arise from an enormous spectrum of causes.

A wide variety of disease processes are treated with a limited number of interventions, in an intensive nursing environment.

It is important to differentiate patients who are in critical care units from those with “critical illness”, which is characterized by acute loss of physiologic reserve.

Critical illness should not be compartmentalized into medical and surgical, the problems experienced by critically ill patients and the treatments given are essentially the same, although the causes may differ.

Critical Care is about medicine, care, compassion and organization.

The best intensive care units are the ones with the most effective management structures.

Your first step to become a critical care practitioner is to understand critical illness.

Critical illness occurs when an injury overwhelms physiologic reserve to the extent that life cannot be sustained without outside intervention.

Physiologic reserve decreases with age and chronic disease

Law of Diminishing Reserve: prolonged critical illness depletes physiologic reserve.

There is no single indicator of reserve, although there are many different clinical and laboratory markers of individual organs’ reserve.

Multi-Organ Dysfunction Syndrome” is the internationally recognized term to describe loss of physiologic reserve and progressive organ injury through failure associated with critical illness.

Outcome prediction models and severity of illness scoring systems use chronic health information and age as indicators of physiologic reserve.

They also use markers of organ dysfunction to quantify how sick the patient is.

Why might intensive care be required?
Patients usually require admission to an ICU because their medical condition(s) demands interventions, equipment, medications, monitoring and/or clinical expertise that can only be delivered in an ICU. For some patients, care in an intensive care unit is the best option immediately following their operation (surgery). Other patients may require support from a breathing machine (ventilator) for pneumonia or other lung conditions. Certain medications can only be administered in an ICU.

Intensive care units offer a higher level of monitoring and treatment than an ordinary hospital ward. There are more nurses, doctors, physiotherapists and assistants per patient and there is specialist equipment that is only available in the ICU. In general, senior staff are closely involved in the hour-by-hour management of patients. Staff are specially trained to care for the most unwell patients.

“Planned” admissions (organised in advance)

There are some operations (surgical procedures) where patients are best managed in intensive care immediately after their surgery. There are other operations after which patients would normally return directly to the hospital room/ward from the theatre recovery area. A particular patient might have other problems or illnesses that mean their doctors believe a period of observation or treatment in intensive care will assist in their recovery.

The staff will use special transfer equipment to carefully observe the patient throughout the journey to an ICU.There will be a comprehensive handover of all the important medical history of the patient, the reasons for the operation, events that have taken place during the operation and details of the operation itself. The surgeons will usually visit the patient in intensive care a short time later.

There might be occasions when surgery is cancelled due to a lack of intensive care beds. In many countries, intensive care units operate at or very near their full capacity. Trying to assess demand for intensive care beds is a real challenge for staff. If surgery is cancelled it is very likely that an emergency patient required admission.

Emergency admissions

Patients with an acute illness will generally be seen first by the emergency department team or by one of the general medical, surgical or specialist teams. If the patient’s condition is assessed as requiring a higher level of monitoring or treatment, then they contact the intensive care team. Patients frequently require a period of stabilisation before it is safe to move them to the intensive care unit. For example, it may be necessary to perform emergency investigations in the X-ray department before the patient is moved.

The intensive care team and the admitting team will often reassess the patient together and discuss the further management with the patient, their family or next of kin and sometimes their Primary Care provider. Not all patients will benefit from being taken to intensive care, and sometimes the intensive care team will advise that care in an ICU will not improve the course of their medical condition or that the conditions can be managed on the general ward. In these situations they will assist by ensuring that the patient is comfortable and their dignity is respected. If the team feel the patient will benefit from intensive care, then they will admit the patient to the ICU. Doctors and nurses make these decisions with as much involvement from the patient as is possible.

On the ICU

Following admission to the ICU, it can take several hours to stabilise the patient in their new environment.

Assessment of a patient by a physician.
  1. First time assessment of a patient in a critical situation by an intensive care physician.

  2. Follow-up of a patient in a critical care unit by a specific physician.

  3. Follow-up of a patient by a specific physician or team of physicians at home.

  4. Home care of a patient after a diagnosis and treatment at a critical care unit.

  5. Critical care unit record

New Critical Care Patient

First time assessment of a patient in a critical situation by an intensive care physician.

Where is the patient now?

____________________________________

What seems to be the issue or issues?

____________________________________

What assessment type does the patient need at this point?
____________________________________

Emergency health assessment on the spot.
Emergency health assessment in a medical emergency room.
Emergency health assessment in an intensive care unit.
Emergency health assessment for pregnancy, childbirth, and puerperium for women of childbearing age.
Emergency medicolegal case of human.
Non-emergency medicolegal case of human.
Detailed health assessment for patient.
Follow-up health assessment.
New issue that does not need an emergency assessment.
Personality disorders screening

Emergency health assessment in an intensive care unit.

First, analyze Glasgow Coma scale, then analyze vital signs including consciousness.

When was the patient normal?

____________________________________

Can the patient open both eyes spontaneously?

____________________________________

Can the patient talk or make noise relevant to age?

____________________________________

Can the patient walk or move extremities relevant to age?

____________________________________
If yes, Glasgow Coma scale is 15.
Glasgow Coma scale of 15 means the patient is not in a coma.
The patient can have less serious medical issues.
Go ahead with vital signs, including consciousness.

Level of consciousness
Pulse rate:
Respiratory rate:
Blood pressure:
Temperature:

What is the oxygen saturation by pulse oximetry?

Arterial blood gas

1. Is the pH normal?
2. Is the CO2 normal?
3. Is the HCO3 normal?
4. Match the CO2 or the HCO3 with the pH
5. Does the CO2 or the HCO3 go the opposite direction of the pH?
6. Are the pO2 and the O2 saturation normal?

1. Metabolic Acidosis
2. Metabolic Acidosis, Fully Compensated
3. Metabolic Acidosis, Partially Compensated
4. Metabolic Acidosis, Uncompensated
5. Metabolic Alkalosis
6. Metabolic Alkalosis, Partially Compensated
7. Metabolic Alkalosis, Uncompensated
8. Respiratory Acidosis
9. Respiratory Acidosis, Fully Compensated
10. Respiratory Acidosis, Partially Compensated
11. Respiratory Acidosis, Uncompensated
12. Respiratory Alkalosis
13. Respiratory Alkalosis, Fully Compensated
14. Respiratory Alkalosis, Partially Compensated
15. Respiratory Alkalosis, Uncompensated

What best describes the diagnosis among the listed critical care diagnoses?
1. Acute respiratory failure type 1 (hypoxemic), type 2 (hypercapnic/ventilatory), type 3 (peri-operative), type 4 (shock)
2. Acute renal failure
3. Acute vision loss
4. Cardiac dysrhythmia
5. Coma
6. Chronic respiratory (lung) failure with or without acute sequelae.
7. Chronic renal failure with or without acute onset
8. Dementia and Alzheimer’s: What are the differences?
9. Diabetic coma in type 2 diabetes
10. Diabetic ketoacidosis (DKA)
11. Heart failure
12. Medical conditions that need further evaluation and treatment in a critical care unit
13. Multiple organ failure
14. Not taking care of oneself
15. Polytrauma
16. Poisoning and drug overdose
17. Post-operative intensive care
18. Renal conditions that need critical care services or dialysis
19. Septicemia
20. Shock
21. Stroke
22. Trauma
23. Traumatic brain injury
24. Unconsciousness or coma
25. Starvation; survival needs from state.
26. Critical Care of the Burn Patient: The First 48 Hours.
27. Other issues that need critical care.

If a person does not have a critical care diagnosis, that person can still have a medical emergency diagnosis.

Who is the treating doctor?

__________________________________________

What's your answer?

__________________________________________

Forward this to him or her.
http://www.qureshiuniversity.com/criticalcareworld.html

Diagnosis

What is the diagnosis?

__________________________________________

What is the treatment plan?

__________________________________________

What is the day, date, time, and location you are answering these questions?

____________________________________

Here are further guidelines.

Questions state director of health needs to answer.
All facts must be available through the Internet
How many total critical care units with total critical care unit beds are available in the state at this point?
What are the locations and mailing addresses of the critical care units?
What is the profile of staff at these critical care units 24 hours a day, 7 days a week?
Who is who among physicians at these critical care units?
Who among physicians at these critical care units is in training?
Who among physicians at these critical care units is aspiring to tenured status?
What equipment is available at these critical care units?
What is the profile with diagnosis and treatment of each patient in each critical care unit at this point?


We have to reach a correct diagnosis and mobilize the best treatment possible for each patient.

Fluid Requirements in Adults
Estimating energy, protein & fluid requirements for adult clinical conditions
Calculating fluids for an elderly person refusing to eat or drink.

How do you calculate the total quantity of fluids to be administered through a nasogastric tube for an elderly person refusing to eat or drink?

Fluid calculations per 24 hours for a patient who needs critical care.

How do you calculate fluid requirements for every 24 hours for a patient who needs critical care?

Get answers to these questions.

What is the weight (in kilograms) of the person?

What is the age of the person?

What method will you utilize for to calculate fluids for 24 hours for a patient who needs critical care?
Fluid Requirements in Adults
For example Adult >75 years: 27 mL/kg body weight

Fluid Requirements in Adults

Method 1

Weight (kilogram [kg]) x 25-35 milliliter (mL)=mL fluid required daily:

  • 25 mL/kg for congestive heart failure or renal disease
  • 30 mL/kg for average adults
  • 35 mL/kg for patients with infection or draining wounds

Method 2

  • 1000 mL for the first 10 kg actual body weight
  • +50 mL fluid/kg for the next 10 kg actual body weight (or 1500 mL for the first 20 kg of body weight)
  • +15 mL fluid/kg for each additional kg over 20 kg (add this to the base of 1500 mL)

Method 3*

1 mL/kilocalorie of intake = mL fluid required daily

*If a patient’s calorie intake is poor, this method will underestimate fluid needs in many cases.

Method 4

(kg body weight – 20) x 15 +1500 = mL fluid required daily

Method 5

  • Average healthy adult: 30-35 mL/kg body weight
  • Adult 55-75 years: 30 mL/kg body weight
  • Adult >75 years: 25 mL/kg body weight

Dietary Reference Intakes: adequate intakes (AIs) for water

  • Adult males (>19 years): 3.7 liters (L)/day
  • Adult females (>19 years): 2.7 L/day

An increase or decrease in a patient’s fluid needs is based on a number of factors. Use clinical judgment to adjust fluid estimates as needed. The following factors can increase fluid requirements:

  • Fever
  • Nasogastric tube for suctioning
  • Fistula wound drains
  • Diarrhea
  • Vomiting
  • Hyperventilation
  • Respirator
  • Excessive perspiration
  • Pressure ulcer (stages II, III, IV)
  • Circulating air bed for wound-healing treatment

The following factors can decrease fluid requirements:

  • Congestive heart failure
  • Cardiac disease
  • Renal disease
  • Dilutional hyponatremia
  • Edema or ascites

Global guide for various professions
My Name: Asif Qureshi
Attached photograph: What do I look like?
Abilities, skills details: Executive level abilities, executive guide.
I can guide 45 essential departments in the state and outside the state.
I can guide 892 professions in the state and outside the state. This includes teachers, lawyers, engineers, physicians.
I can guide 14 specific types of physicians serving in various healthcare settings.

I am a good investigator.
I can guide various professionals including teachers, lawyers, engineers, and physicians.

Nowadays, doctors, for example Doctor Asif Qureshi, impart training to intensivists that is a physician intensive care unit from his home office through computer and Internet.

My biographical data or curriculum vitae can be found at http://www.qureshiuniversity.com/aboutthefounder.html. Doctor Asif Qureshi has been a licensed physician since 1993. His original physician’s license was issued in Karnataka, Asia.
At this point, he has doctorate-level executive experience.
Executive-level knowledge and executive guide.

I can guide 45 essential departments in the state and outside the state.
I can guide 892 professions in the state and outside the state. This includes teachers, lawyers, engineers, physicians. I can guide 14 specific types of physicians serving in various healthcare settings.

I am a good investigator.
I can guide various professionals including teachers, lawyers, engineers, and physicians.
Here are further facts.

Specific Medical Cases
Aisha (mummy), age 77, at Srinagar, Kashmir, on November 25, 2016.
What was the day, date, month, and year of death?
Friday, November 25, 2016 5PM
Srinagar, Kashmir, Asia.

Staff in the ICU
  1. Physician intensive care unit existing.

  2. Physician intensive care unit aspiring

  3. Nurse, Intensive Care Unit

  4. Physiotherapists

  5. Dieticians

  6. Speech therapists

  7. Pharmacists

  8. Occupational therapists

  9. Social Workers

  10. Hospital Sanitation Worker

  11. In addition to doctors and nurses, there are a variety of people who work in the Intensive Care Unit (ICU) – including physiotherapists, dieticians, speech therapists and other support staff.

    Doctors in the ICU are also referred to as Intensivists. They are specialists who have completed advanced training in intensive care medicine or a related speciality such as anaesthetics, cardiology or emergency medicine. They are responsible for coordination of patient care in the ICU and will consult with other specialists.

    There is usually an ICU Consultant leading a team of doctors who normally examine patients on a daily basis to assess their progress and decide all aspects of treatment and care.

    Nurses in the ICU usually look after just one or two patients only. Many have special experience, education and training in caring for critically ill and injured patients. They work with the doctors and other healthcare professionals to ensure all the patient’s needs are met in terms of treatment, care and comfort. Their role is to give the drugs and fluids prescribed by the doctors, monitor a patient’s blood pressure, heart rate and oxygen levels, allowing for early identification of changes in a patient’s condition. In addition, nurses are responsible for keeping the patient as comfortable as possible in practical ways such as changing sheets, cleaning teeth, regularly washing and turning the patient, and generally attending to their needs.
    Here are further guidelines.

    Physiotherapists attend to patients in ICU (often when they are asleep) to exercise muscles in their arms and legs to prevent joints from becoming stiff and, sometimes to help strengthen the chest muscles and lungs of patients who need help with breathing while in ICU. And they are there to help recovering patients with exercises to aid their physical strength after a long period in bed, preparing them to become mobile again.

    Dieticians work out patients’ nutritional needs and how best they will be fed. Sometimes this can be through a nasogastric tube (a tube that goes up the nose and down into the stomach) or through a drip straight into the vein.

    Speech therapists may also be involved, especially if a patient has a tracheostomy. (A tracheostomy is a procedure to make a hole in the throat and insert a tube, which is connected to a ventilator or ?breathing machine'.) Later, the speech therapist may recommend a speaking valve on the tracheostomy.

    Pharmacists attend ward rounds and assist doctors and nurses with advice regarding medications as well as ensuring a supply of medication for patients.

    Occupational therapists evaluate the ability of the patient to carry out everyday activities of daily living and develop treatment plans to improve the patient’s abilities

    Social Workers are available at most large hospitals.
    Here are further guidelines.

Hospital Sanitation Worker
Differences between critical care unit cleanliness and residential or residential home office unit cleanliness.

What are you inspecting for housekeeping?
Critical care unit
Residential or residential home office unit

How is a critical care unit’s cleanliness different from that of a residential or residential home office unit?
Critical care unit: visual inspection, fluorescent markers/gels, microbiology testing, ATP monitoring, methods to gauge cleanliness in a critical care unit.
A critical care unit has the domestic staff vital for ensuring that the unit is kept clean at all times.
A residential or residential home office unit does not have similar protocols as a critical care unit.

Communications relevant to the intensive care unit.
What are the best methods of communications relevant to the intensive care unit?
Email communications
Internet displays

Communications specialists must monitor any blocks to communications, including emails to and from admin@qureshiuniversity.com.

Physicians in an intensive care unit should also communicate via the telephone to get oriented to each other’s English language skills. Email communications and Internet displays are proffered and required for communications.
Here is an example.
Email: admin@qureshiuniversity.com
Internet displays for intensive care units: http://www.qureshiuniversity.com/criticalcareworld.html
Circulate this to everyone.
Maintain records of all guidelines displayed at http://www.qureshiuniversity.com/criticalcareworld.html in a secure location.
You will need these guidelines at some point in the future.

In which locations are you preserving or recording facts and guidelines from the resources listed at http://www.qureshiuniversity.com/criticalcareworld.html ?

Critical care unit record
Intensivist
What should be included in the critical care unit record for the patient?

What is the profile of the patient?
Name:
Date of birth:
Address:
Family:
Emergency contact person:

What is the location of the critical care unit?

____________________________________

For example: Critical care unit, SKIMS, Soura, Srinagar, Kashmir, Asia.

What brings the patient to the critical care unit?

____________________________________

What is the day, date, time of arrival to a critical care unit?

____________________________________

For example: Tuesday, November 25, 2014, 12:10 pm

What is the profile of the physician supervisor of the critical care unit?

____________________________________

Who brought the patient to the critical care unit?

____________________________________

What is the health status of the patient on the day, date, and time of arrival to the critical care unit?

____________________________________

Who are the physician, nurse, social worker, and technologists to look after the patient?

____________________________________

Who are among supervising physician, nurse, social worker, and technologist to look after the patient?

____________________________________

What is the diagnosis for this patient?

____________________________________

What is the treatment plan for this patient?

____________________________________

How often will there be a follow-up from a physician?

____________________________________

Does the critical care unit have a computer with www.qureshiuniversity.com connected to the Internet?

____________________________________

If you have any issue, email admin@qureshiuniversity.com or call 7735616102 Chicago, Illinois, North America, and you will get answers within 24 hours.

Locations of hospitals’ critical care units in various states around the world.
What are the locations of hospitals’ critical care units in various states around the world?
North American States
  1. Alabama (AL)

  2. Alaska (AK)

  3. Arizona (AZ)

  4. Arkansas (AR)

  5. Alberta (AB)

  6. British Columbia (BC)

  7. California (CA)

  8. Colorado (CO)

  9. Connecticut (CT)

  10. Delaware (DE)

  11. Florida (FL)

  12. Georgia (GA)

  13. Hawaii (HI)

  14. Idaho (ID)

  15. Illinois (IL)

  16. Indiana (IN)

  17. Iowa (IA)

  18. Kansas (KS)

  19. Kentucky (KY)

  20. Louisiana (LA)

  21. Maine (ME)

  22. Maryland (MD)

  23. Massachusetts (MA)

  24. Michigan (MI)

  25. Minnesota (MN)

  26. Mississippi (MS)

  27. Missouri (MO)

  28. Montana (MT)

  29. Manitoba (MB)

  30. Mexico (MX)

  31. Nebraska (NE)

  32. Nevada (NV)

  33. New Hampshire (NH)

  34. New Jersey (NJ)

  35. New Mexico (NM)

  36. New York (NY)

  37. North Carolina (NC)

  38. North Dakota (ND)

  39. New Brunswick (NB)

  40. Newfoundland and Labrador (NL)

  41. Northwest Territories (NT)

  42. Nova Scotia (NS)

  43. Nunavut (NU)

  44. Ohio (OH)

  45. Oklahoma (OK)

  46. Oregon (OR)

  47. Ontario (ON)

  48. Pennsylvania (PA)

  49. Prince Edward Island (PE)

  50. Quebec (QC)

  51. Rhode Island (RI)

  52. South Carolina (SC)

  53. South Dakota (SD)

  54. Saskatchewan (SK)

  55. Tennessee (TN)

  56. Texas (TX)

  57. Utah (UT)

  58. Vermont (VT)

  59. Virginia (VA)

  60. Washington (WA)

  61. West Virginia (WV)

  62. Wisconsin (WI)

  63. Wyoming (WY)

  64. Yukon (YT)

  65. Central America

  66. Cuba/Puerto Rico/Dominican Republic/Haiti

  67. Island


  68. Asian States

  69. Albania

  70. Andorra

  71. Armenia

  72. Austria

  73. Azerbaijan

  74. Arkhangelsk Oblast

  75. Anhui Province

  76. Afghanistan

  77. Assam

  78. Arunachal Pradesh

  79. Andhra Pradesh

  80. Andaman and Nicober Islands

  81. Balochistan

  82. Bahrain

  83. Bangladesh

  84. Belarus

  85. Belgium

  86. Bhutan

  87. Bihar

  88. Brunei

  89. Bosnia and Herzegovina

  90. Bulgaria

  91. Chechnya

  92. Croatia

  93. Cyprus

  94. Czech Republic

  95. Cambodia

  96. Chukotka Autonomous Okrug

  97. Chhattisgarh

  98. Daman and Diu

  99. Dadra and Nagar Haveli

  100. Dagestan

  101. Denmark

  102. Delhi

  103. England

  104. Estonia

  105. East Timor

  106. Finland

  107. Fujian Province

  108. France

  109. Gujarat

  110. Goa

  111. Georgia

  112. Germany

  113. Gibraltar

  114. Greece

  115. Gansu Province

  116. Guangdong Province

  117. Guangxi Province

  118. Guizhou

  119. Heilongjiang

  120. Hong Kong

  121. Hubei

  122. Hainan Province

  123. Henan Province

  124. Hunan Province

  125. Himachal Pradesh

  126. Hungary

  127. Inner Mongolia

  128. Indonesia

  129. Iran

  130. Iraq

  131. Iceland

  132. Ireland

  133. Italy

  134. Japan

  135. Jeddah

  136. Jiangxi Province

  137. Jordan

  138. Jiangsu

  139. Jiangxi

  140. Jilin

  141. Jharkhand

  142. Kashmir

  143. Karnataka

  144. Kazakhstan

  145. Kerala

  146. Korea - North

  147. Korea - South

  148. Kyrgyzstan

  149. Kuwait

  150. Kaliningrad Oblast

  151. Lakshadweep

  152. Latvia

  153. Liechtenstein

  154. Lithuania

  155. Luxembourg

  156. Laos

  157. Lebanon

  158. Liaoning Province

  159. Liaoning

  160. Manipur

  161. Mizoram

  162. Maharashtra

  163. Madhya Pradesh

  164. Meghalaya

  165. Malaysia

  166. Maldives

  167. Magadan Oblast

  168. Mongolia

  169. Myanmar

  170. Macedonia

  171. Malta

  172. Medina

  173. Mecca

  174. Moldova

  175. Monaco

  176. Montenegro

  177. Nagaland

  178. Netherlands

  179. Northern Ireland

  180. Norway

  181. Ningxia

  182. Nepal

  183. Oman

  184. Orissa

  185. Puducherry

  186. Punjab

  187. Peshawar

  188. Philippines

  189. Poland

  190. Portugal

  191. Palestine

  192. Qinghai

  193. Qatar

  194. Rajasthan

  195. Romania

  196. Sikkim

  197. Syria

  198. Sindh

  199. Singapore

  200. Sri Lanka

  201. Scotland

  202. Serbia

  203. Slovakia

  204. Slovenia

  205. Spain

  206. Sweden

  207. Switzerland

  208. Shaanxi Province

  209. Shandong

  210. Shanxi

  211. Sichuan

  212. Taiwan

  213. Tajikistan

  214. Thailand

  215. Tibet

  216. Tripura

  217. Tamil Nadu

  218. Turkey

  219. Turkmenistan

  220. Ukraine

  221. Uzbekistan

  222. Uttarakhand

  223. United Arab Emirates

  224. Uttar Pradesh

  225. Vietnam

  226. Vatican City

  227. Wales

  228. West Bengal

  229. Xinjiang

  230. Yunnan

  231. Yamalia

  232. Yemen

  233. Yamalo-Nenets Autonomous Okrug

  234. Zhejiang
    Africa

  235. Algeria

  236. Angola

  237. Burundi

  238. Benin

  239. Burkina Faso

  240. Botswana

  241. Cape Verde

  242. Côte d'Ivoire

  243. Comoros

  244. Cameroon

  245. Central African Republic

  246. Chad

  247. Canary Islands

  248. Ceuta

  249. Democratic Republic of the Congo

  250. Djibouti

  251. Egypt

  252. Eritrea

  253. Ethiopia

  254. Equatorial Guinea

  255. Gabon

  256. Gambia

  257. Ghana

  258. Guinea

  259. Guinea-Bissau

  260. Kenya

  261. Liberia

  262. Libya

  263. Lesotho

  264. Madagascar

  265. Malawi

  266. Mauritius

  267. Mayotte

  268. Mozambique

  269. Mali

  270. Mauritania

  271. Madeira

  272. Melilla

  273. Morocco

  274. Niger

  275. Nigeria

  276. Namibia

  277. Réunion

  278. Rwanda

  279. Republic of the Congo

  280. São Tomé and Príncipe

  281. Saint Helena

  282. Senegal

  283. Sierra Leone

  284. Seychelles

  285. Somalia

  286. South Africa

  287. Swaziland

  288. South Sudan

  289. Sudan

  290. Tanzania

  291. Togo

  292. Tunisia

  293. Uganda

  294. Western Sahara

  295. Zambia

  296. Zimbabwe
    Australia

  297. Northern Territory

  298. South Australia

  299. Queensland

  300. New South Wales

  301. Victoria (Australia)

  302. Western Australian

  303. Tasmania

  304. New Zealand
    Latin

  305. Acre (Asif Province)

  306. Alagoas

  307. Amapá

  308. Amazonas

  309. Bahia

  310. Buenos Aires Province

  311. Ceará

  312. Chubut Province

  313. Córdoba Province

  314. Goiás

  315. Bolivia

  316. Chile

  317. Colombia

  318. Ecuador

  319. Falkland Islands

  320. French Guiana

  321. Guyana

  322. Paraguay

  323. Peru

  324. Río Negro

  325. Santa Cruz

  326. Santa Fe Province

  327. Salta Province

  328. South Georgia

  329. Suriname

  330. Uruguay

  331. Venezuela
http://www.qureshiuniversity.com/states.html

Kashmir
Critical Care Units in Kashmir
How many total critical care units are there in Kashmir at this point?
There are 2 critical units at two different locations.
They include 12 beds and 20 beds.

What is the name and location of critical care units in Kashmir at this point?
  1. Soura Institute of Medical Sciences Critical Care Unit, Srinagar, Kashmir.

  2. King Hospital Intensive Care Unit (formerly the SMHS Hospital, Srinagar, Kashmir).

What should be the ratio of patients to intensive care unit physicians and intensive care unit nurses?
For every patient there should be one intensive care unit physician and one intensive care unit nurse at the location of the patient. You need to email admin@qureshiuniversity.com every day.

What needs to be accomplished immediately relevant to critical care in Kashmir?
This was circulated on November 12, 2016.
Staff, including critical care physicians, need to be increased.
Location space for critical care needs to be enhanced.
Resources for critical care need to be enhanced.
Enhance communications relevant to critical care in Kashmir.
Medical education for critical care physicians needs to be monitored.
Remote collaboration systems http://www.qureshiuniversity.com/criticalcareworld.html and critical care from Doctor Asif Qureshi must be circulated to all.

Medical superintendent, Soura Institute of Medical Sciences, Srinagar, Kashmir.

Questions you need to answer:

What is the profile of the medical superintendent of the Soura Institute of Medical Sciences in Srinagar, Kashmir?
What are your duties at this specific location?
How are you enhancing critical care at the mentioned location?
How about establishing a critical care unit on the ground floor of the Soura Institute of Medical Sciences where the canteen used to be located?
How would you describe critical care services at this hospital at this point?
What do you know about remote collaboration systems in critical care as defined at www.qureshiuniversity.com/criticalcareworld.html?


Medical superintendent, King Hospital Intensive Care Unit (formerly the SMHS Hospital), Srinagar, Kashmir.

Questions you need to answer:

What is the profile of the medical superintendent of King Hospital Critical Care Unit (formerly SMHS Hospital) in Srinagar, Kashmir?
Where is profile of the critical care unit staff on the Internet at this location, including physicians in the critical care unit?
What do you know about remote collaboration systems in critical care as defined at www.qureshiuniversity.com/criticalcareworld.html?
How do staff, including existing critical care physicians, follow up on patients in the hospital and at home?

Assessment of a patient by a physician.
  1. First time assessment of a patient in a critical situation by an intensive care physician.

  2. Follow-up of a patient in a critical care unit by a specific physician.

  3. Follow-up of a patient by a specific physician or team of physicians at home.

  4. Home care of a patient after a diagnosis and treatment at a critical care unit.

  5. Critical care unit record
Here are further facts.
Who is responsible for educating new staff and continuing the education of existing staff in the state relevant to medical emergencies?
State department of public health.
State department of health.
You need to connect existing staff and new staff to these resources http://www.qureshiuniversity.com/criticalcareworld.html

Monitoring the critically ill patient
What should you monitor in a critically ill patient relevant to age?
1. Level of consciousness
2. Pulse
3. Blood pressure
4. Respiratory rate (ventilated and/or non-ventilated)
5. Oxygenation SpO2
6. Temperature (core)
7. Urine output in 1 hour and in 24 hours
8. Pain
9. Nutrition in intensive care
10. Complaint/complaints if any:


Do you have any complaints or problems now?
What complaints or problems do you have now?
How should this complaint be resolved?

Nine vital signs must be monitored in a critically ill patient.
If normal, do not proceed with any invasive or complicated analysis.
If all nine vital signs are normal, it means the individual is normal now.
He/She may have been critically ill previously.

What should be monitored if any of the eight vital signs are low or high relevant to age and medical condition?
Arterial pH
Serum sodium
Serum potassium
Serum Urea
Serum creatinine
Glucose
Hematocrit
White blood cell count
Glasgow coma score

What standard of human blood serum chemistry normal values do you follow?
What standard of human blood serum chemistry normal values do I follow?
http://www.qureshiuniversity.com/BloodSerumChemistryNormalValues.pdf

What resources are essential for a critical care unit (CCU)?
Internet with www.qureshiuniversity.com.
Critical care unit staff.
Critical care unit beds in a room.

Remote collaboration systems in critical care: http://www.qureshiuniversity.com/criticalcareworld.html
What are remote collaboration systems in critical care http://www.qureshiuniversity.com/criticalcareworld.html?
Critical care units are in different locations in and outside the state, and guidelines for staff, including for existing critical care physicians and others, are available through the Internet and uploaded at another location (for example, remote collaboration systems for critical care) http://www.qureshiuniversity.com/criticalcareworld.html.

Some hospitals have installed teleconferencing systems that allow doctors and nurses at a central facility (in the same building, at a central location serving several local hospitals, or in rural locations or another more urban facility) to collaborate with on-site staff and speak with patients (a form of telemedicine).

Doctor Asif Qureshi’s guidelines on remote collaboration systems for critical care http://www.qureshiuniversity.com/criticalcareworld.html must be circulated to all staff, including existing, in training, and aspiring critical care unit physicians, at the critical care location.

What are other names for remote collaboration systems for critical care http://www.qureshiuniversity.com/criticalcareworld.html?
EICU
Virtual ICU
Tele-ICU

The resources at http://www.qureshiuniversity.com/criticalcareworld.html are examples of EICU, virtual ICU, and tele-ICU.

How have the remote collaboration systems for critical care or tele-ICU changed critical care forever http://www.qureshiuniversity.com/criticalcareworld.html?
Take a look at this http://www.qureshiuniversity.com/criticalcareworld.html Critical care unit physicians and others staff in North American states, Asian states, African states, Latin American states, and Australian states can get guidelines on locations of critical care in and outside the state.

Respiratory monitoring
Respiratory Monitoring in the ED
Respiratory Monitoring and Management of the Patient in the Intensive Care Unit

How do you measure your breathing rate?
The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises.

Questions on Ventilation

Q1. How do we monitor ventilation?
The main way to monitor ventilation in the ED is via end-tidal CO2 (ETCO2)

Q2. How do we measure the ETCO2?
ETCO2 is measured via capnometers (carbon dioxide meters), which can be either qualitative (“Is there ETCO2?”) or quantitative (“What is the ETCO2?”).

Q3. Does the ETCO2 relate to the PaCO2? That is, can we use ETCO2 as a marker of arterial CO2 concentration?
The answer is no, except in specific circumstances.

Q4. What influences the ETCO2—PaCO2 gradient?
The gradient may be increased by:

1.Reduced pulmonary blood flow — e.g following cardiac arrest, hypovolaemia, and shock.
2.Anatomical dead space
3.COPD

Q5. Ok, but once we know the ETCO2–PaCO2 gradient in the particular patient, surely we can use it as a marker? That is, does the gradient remain stable?
Sadly, no, the gradient is unstable. In studies with anaesthetised patients, the gradient remains stable in only 60-80% of patients.

Q6. Why is the gradient useful then?
A high ETCO2 invariably means there is a high PaCO2, which generally means impending respiratory failure! As a side note, the PvCO2 is also unreliable as a marker of PaCO2.

Q7. When and why should we use ETCO2 monitoring?
1. To help verify correct placement of the endotracheal tube (ETT).

Particularly during the peri-intubation period, as the mortality of unrecognised oesophageal intubation approaches 100%… It can also provide rapid recognition of extubation, for example during ongoing CPR or with transport of the ventilated patient.

2. As an adjunct to procedural sedation.

It provides an early warning of bradypneoa and apnoea predicting the development of hypoxia due to respiratory depression up to a minute prior to pulse oximetry. In real time, therefore, it is superior to pulse oximetry in identifying oversedation and apnoea.

3. In Traumatic Brain Injury to monitor for hypocapneoa

Hyperventilation drives hypocapnoea, which MAY worsen the outcome in traumatic brain injury, by decreasing coronary blood flow resulting in areas of brain ischaemia. Although the arterial CO2 (PaCO2 ) is the gold standard measurement, the ETCO2 may guide ventilation, with the caveat regarding unstable ETCO2–PaCO2 gradients.

4. To help predict the prognosis of ongoing CPR.

An ETCO2 of less than 10mmHg following 20 minutes of CPR is a very poor prognostic sign, suggesting resuscitation attempts should be ceased.

5. To detect Return of Spontaneous Circulation (ROSC).

A sudden rise in ETCO2 may indicate ROSC. Rhythm and pulse checks should be considered.

Questions on Oxygenation

Pulse oximetry provides non-invasive (almost) real-time measurement of oxygen saturations. It differentiates oxyhaemoglobin from reduced (deoxy) haemoglobin, by using the different absorption wavelengths of the different haemoglobins. Newer models can even differentiate between oxy-, deoxy-, meth- and carboxy- haemoglobin variants! The value it gives is called the SpO2 and is expressed as a percentage.

Q1. What are the limitations of pulse oximetry?
Answer and interpretation

Pulse oximetry needs a good waveform which is a measure of the arterio-venous (AV) difference. Without a good AV difference, and hence waveform, it is inaccurate. Things that affect the AV difference include hypotension, hypothermia, and peripheral vasoconstriction.

Accuracy:
•Between 70-100% the accuracy is good (+/- 2% for each standard deviation)
•Between 50-70% the accuracy decreases somewhat (+/- 3%)
•Below 50% pulse oximetry is inaccurate
… although we would hope that once saturations reached 50% there would be other clinical markers of hypoxia…

Q2. What are the myths associated with pulse oximetry?
Answer and interpretation
Pulse oximetry (using modern devices) is NOT affected by…
•Anaemia (it is still accurate down to 2.3 g/dL Hb)
•Acidemia
•Ambient Light
•Dark Skin
•Nail Polish (red is ok, although darker colours may affect the reading to a mild degree)

Q3. What is “pulse oximetry lag”?
Answer and interpretation

Pulse oximetry does not show current oxygenation – it shows PAST oxygenation.

This lag may be up to 2-3 minutes in critically ill patients, due to reduced blood flow from vasoconstriction or hypothermia. In this respect, it is not a real time monitor, although forehead pulse oximetry probes have less lag.

Q4. What about dyshaemoglobinaemias?
Answer and interpretation

Although newer pulse oximetry monitors can differentiate between different haemoglobin states, most hospitals do not have these monitors. Met-haemoglobinaemia and carboxy-haemoglobinaemia both result in PaO2 overestimation, as these haemoglobins absorb a similar light wavelength to oxy-haemoglobin.

Q5. When should we use pulse oximetry?
Answer and interpretation
To reduce hypoxemic episodes, especially whenever definitive airway management is being obtained. It may also be used to titrate FiO2 – to prevent hyperoxaemia.

Pulse oximetry DOES NOT confirm ETT placement.

In the words of the authors, (which is true of all monitors, tests and investigations), never rely on monitoring over clinical judgement!

Q6. What should we not use pulse oximetry for?
Answer and interpretation
Pulse oximetry DOES NOT confirm ETT placement.

Level of consciousness
Normal Level of Consciousness

A normal level of consciousness implies that a patient is either in a state of awareness, alertness and wakefulness, or in one of the stages of normal sleep and from which they can be readily awakened.

Altered Level of Consciousness (ALOC)

Altered or abnormal levels of consciousness describe states that vary between full consciousness and unconsciousness.

Altered levels of consciousness can include:
  1. Confusion: A disorientation regarding a person, place or time that makes it difficult to reason or follow commands. Causes include sleep deprivation, fever or drug abuse.

  2. Delirium: A fluctuating state between hyperawareness, and a state of disorientation and sluggishness. Causes can include intoxication or medications.

  3. Lethargy: A state of severe drowsiness, listlessness, apathy accompanied with reduced alertness. It may also be referred to as somnolence. Causes can include anemia, sickness, underactive thyroid and others.

  4. Obtundation: A more severe reduction in alertness than with lethargy, along with slow responses to stimuli, longer periods of sleep and drowsiness between these periods. Causes can include seizures and poisoning, among many others.

  5. Stupor: A severe level of impaired consciousness in which a person is unresponsive except to vigorous and regular stimulation that must be repeated. Causes can include stroke, drug overdose, lack of oxygen, brain swelling and others.

  6. Coma: A state of unresponsiveness, even to stimuli, and may lack a gag reflex or pupillary response.

How many medical conditions are treated within a critical care unit?
24 medical conditions
ICU Medical Conditions
What medical conditions are treated within a critical care unit?
  1. Acute Respiratory Failure.

  2. Acute renal failure.

  3. Acute Vision Loss
      Case of Insha Mushtaq Lone, age 14 years on November 30, 2016
      Location of patient: Shopian, Kashmir as of November 30, 2016

  4. Cardiac dysrhythmia.

  5. CO2 retention

  6. Dementia and Alzheimer's: What Are the Differences?

  7. Diabetic Coma in Type 2 Diabetes

  8. Diabetic Ketoacidosis (DKA)

  9. Heart Failure

  10. Medical conditions that need further evaluation and treatment in a critical care unit.

  11. Multiple organ failure.

  12. Not taking care of self.

  13. Polytrauma

  14. Poisoning & Drug Overdose

  15. Post-operative Intensive Care

  16. Respiratory (Lung) Failure

  17. Renal conditions that need critical care services or dialysis

  18. Septicemia.

  19. Shock

  20. Stroke

  21. Trauma

  22. Traumatic Brain Injury.

  23. Unconsciousness or Coma

  24. Others.
Guidelines for ICU Admission, Discharge, and Triage
Diagnosis Model
This model uses specific conditions or diseases to determine appropriateness of ICU admission.
A. Cardiac System

1. Acute myocardial infarction with complications
2. Cardiogenic shock
3. Complex arrhythmias requiring close monitoring and intervention
4. Acute congestive heart failure with respiratory failure and/or requiring hemodynamic support
5. Hypertensive emergencies
6. Unstable angina, particularly with dysrhythmias, hemodynamic instability, or persistent chest pain
7. S/P cardiac arrest
8. Cardiac tamponade or constriction with hemodynamic instability
9. Dissecting aortic aneurysms
10. Complete heart block

B. Pulmonary System

1. Acute respiratory failure requiring ventilatory support
2. Pulmonary emboli with hemodynamic instability
3. Patients in an intermediate care unit who are demonstrating respiratory deterioration
4. Need for nursing/respiratory care not available in lesser care areas such as floor or intermediate care unit
5. Massive hemoptysis
6. Respiratory failure with imminent intubation

C. Neurologic Disorders

1. Acute stroke with altered mental status
2. Coma: metabolic, toxic, or anoxic
3. Intracranial hemorrhage with potential for herniation
4. Acute subarachnoid hemorrhage
5. Meningitis with altered mental status or respiratory compromise
6. Central nervous system or neuromuscular disorders with deteriorating neurologic or pulmonary function
7. Status epilepticus
8. Brain dead or potentially brain dead patients who are being aggressively managed while determining organ donation status
9. Vasospasm
10. Severe head injured patients

D. Drug Ingestion and Drug Overdose

1. Hemodynamically unstable drug ingestion
2. Drug ingestion with significantly altered mental status with inadequate airway protection
3. Seizures following drug ingestion

E. Gastrointestinal Disorders

1. Life threatening gastrointestinal bleeding including hypotension, angina, continued bleeding, or with comorbid conditions
2. Fulminant hepatic failure
3. Severe pancreatitis
4. Esophageal perforation with or without mediastinitis

F. Endocrine

1. Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis
2. Thyroid storm or myxedema coma with hemodynamic instability
3. Hyperosmolar state with coma and/or hemodynamic instability
4. Other endocrine problems such as adrenal crises with hemodynamic instability
5. Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring
6. Hypo or hypernatremia with seizures, altered mental status
7. Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias
8. Hypo or hyperkalemia with dysrhythmias or muscular weakness
9. Hypophosphatemia with muscular weakness

G. Surgical

1. Post-operative patients requiring hemodynamic monitoring/ventilatory support or extensive nursing care

H. Critical Care Nephrology

I. Acute Renal Failure
2. Chronic Renal Failure

I. Miscellaneous

1. Septic shock with hemodynamic instability
2. Hemodynamic monitoring
3. Clinical conditions requiring ICU level nursing care
4. Environmental injuries (lightning, near drowning, hypo/hyperthermia) 5. New/experimental therapies with potential for complications

Objective Parameters Model

The criteria listed, while arrived at by consensus, are by necessity arbitrary. They may be modified based on local circumstances. Data demonstrating improved outcome using specific criteria levels are not available.

Vital Signs

* Pulse < 40 or > 150 beats/minute
* Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's usual pressure
* Mean arterial pressure < 60 mm Hg
* Diastolic arterial pressure > 120 mm Hg
* Respiratory rate > 35 breaths/minute

Laboratory Values (newly discovered)

* Serum sodium < 110 mEq/L or > 170 mEq/L
* Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
* PaO2 < 50 mm Hg
* pH < 7.1 or > 7.7
* Serum glucose > 800 mg/dl
* Serum calcium > 15 mg/dl
* Toxic level of drug or other chemical substance in a hemodynamically or neurologically compromised patient

Radiography/Ultrasonography/Tomography (newly discovered)

* Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs
* Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic instability
* Dissecting aortic aneurysm

Electrocardiogram

* Myocardial infarction with complex arrhythmias, hemodynamic instability or congestive heart failure
* Sustained ventricular tachycardia or ventricular fibrillation
* Complete heart block with hemodynamic instability

Physical Findings (acute onset)

* Unequal pupils in an unconscious patient
* Burns covering > 10% BSA
* Anuria
* Airway obstruction
* Coma
* Continuous seizures
* Cyanosis
* Cardiac tamponade

What are various types of care units within a critical care unit?
Neonatal intensive care unit (NICU)
Pediatric intensive care unit (PICU)
Psychiatric intensive care unit (PICU)
Coronary care unit (CCU): Also known as cardiac intensive care unit (CICU)
Post-anesthesia care unit (PACU)
High dependency unit (HDU)
Critical care unit staff. Here are further guidelines.

How many critical care units are there in the world?
In 2013, every state in North America, Asia, Africa, Australia, and Latin America had 5-10 critical care units with 10-15 beds in each critical care unit.
Follow up of patient.
ICU follow-up care
What is the profile of the patient?
Name:
Date of birth:
Address:
Family:
Emergency contact person:

What is the diagnosis for this patient?

____________________________________

What is the treatment plan for this patient?

____________________________________

How often will there be a follow-up from a physician?

____________________________________

Doctor Nadia
Where are you now?

Every day, you must communicate 3PM updates for Aisha via email at admin@qureshiuniversity.com

Name of the person: Aisha (mummy)
Age: 77
Date and time of evaluation: November 6, 2016, at 3PM local time in Srinagar.
Evaluation by: Doctor Nadia

Can she spontaneously open her eyes?

Can she talk or make some noises?

Can she move both her upper and lower limbs?

Level of consciousness:
Pulse rate:
Respiratory rate:
Blood pressure:
Temperature:
Nasogastric (Ryles) Tubes

Personalized Meal Schedule

Name of liquid food: ________________________________________________________

Total amount of liquid food daily:

_____________________________________________

Total amount of water daily:

__________________________________________________

Meal schedule: _____________________________________________________________

Hospital Discharge Planning: A Guide for Families and Caregivers
Home care of a patient after a diagnosis and treatment at a critical care unit.

Who will take care of the patient at home?
What is the schedule for every 24 hours at home?
What specific physician or team of physicians is responsible for taking care of this patient?
Who among nurses can provide home care for this person in addition to other family members?
What will you remind a specific physician or team of physicians responsible for taking care of this patient?
Who among specific physicians from the local hospital in Srinagar, Kashmir, are responsible for following up with this person?
What is the profile of the specific local physician or team of local physicians responsible for following up with this person?
How often will there be follow-up?
Will there be follow-up at home, in the hospital, or both?
What is the exact day, date, time, and location of follow-up?
Who will take care of the patient at home?
What is the schedule for every 24 hours at home?
What seems to be the issue?


Some Basic Questions for Caregivers to Ask

Questions about the illness:

What is it and what can I expect?
What should I watch out for?
Will we get home care and will a nurse or therapist come to our home to work with my relative?
How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-up medical appointments?
Have I been given information either verbally or in writing that I understand and can refer to?


What kind of care is needed?
Bathing
Dressing
Eating (are there diet restrictions, e.g., soft foods only? Certain foods not allowed?)
Personal Hygiene
Grooming
Toileting
Transfer (moving from bed to chair)
Mobility (includes walking)
Medications
Managing symptoms (e.g., pain or nausea)
Special equipment
Coordinating the patient?s medical care
Transportation
Household chores/errand/housework
Taking care of resources

Questions when my relative is being discharged to the home:*

Is the home clean, comfortable and safe, adequately heated/cooled, with space for any extra equipment?
Are there stairs?
Will we need a ramp, handrails, grab bars?
Are hazards such as area rugs and electric cords out of the way?
Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Where do I get this equipment?
Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get these items?
Do I need to hire additional help?


Questions about training:

Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment?
Have I been trained in transfer skills and preventing falls?
Do I know how to turn someone in bed so he or she doesn?t get bedsores?
Who will train me?
When will they train me?
Can I begin the training in the hospital?


Questions when discharge is to a rehab facility or nursing home:

How long is my relative expected to remain in the facility?
Who will select the facility?
Is the facility clean, well kept, quiet, a comfortable temperature?
Does the facility have experience working with families of my culture/language?
Does the staff speak our language?
Is the food culturally appropriate?
Is the building safe (smoke detectors, sprinkler system, marked exits)?
Is the location convenient? Do I have transportation to get there?


For longer stays:

How many staff are on duty at any given time?
What is the staff turnover rate?
Is there a social worker?
Do residents have safe access to the outdoors?
Are there special facilities/programs for dementia patients?
Are there means for families to interact with staff?
Is the staff welcoming to families?


Questions about medications:

Why is this medicine prescribed? How does it work? How long the will the medicine have to be taken?
How will we know that the medicine is effective?
Will this medicine interact with other medications?prescription and nonprescription? or herbal preparations that my relative is taking now?
Should this medicine be taken with food? Are there any foods or beverages to avoid?
Can this medicine be chewed, crushed, dissolved, or mixed with other medicines?
What possible problems might I experience with the medicine? At what point should I report these problems?
Does the pharmacy provide special services such as home delivery, online refills or medication review and counseling?


Questions about follow-up care:*

What health professionals will my family member need to see?
Have these appointments been made? If not, whom should I call to make these appointments?
Where will the appointment be? In an office, at home, somewhere else?
What transportation arrangements need to be made?
How will our regular doctor learn what happened in the hospital or rehab facility?
Whom can I call with treatment questions? Is someone available 24 hours a day and on weekends?


Questions about finding help in the community:

What agencies are available to help me with transportation or meals?
What is adult day care and how do I find out about it?
Where do I start to look for such care?


Questions about my needs as a caregiver:*

Will someone come to my home to do an assessment to see if we need home modifications?
What services will help me care for myself?
Does my family member require help at night and if so, how will I get enough sleep?
Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper?
What medical conditions and limitations do I have that make providing this care difficult?
Where can I find counseling and support groups?
How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs?


ICU follow-up care
Post-ICU Follow Up Clinic

What should a critical care unit do in case there is an issue relevant to a patient?
Call 7735616102 Chicago, Illinois, and leave a message.

Who is calling?
For example: I am Doctor Nasreen Jan Chashoo.
How old is the patient?
What is the diagnosis?
What treatment have you given so far?
What problem(s) are you having?
What is your contact information, including e-mail, telephone, and location?
Your call will be returned within hours or minutes.

Dementia and Alzheimer's: What Are the Differences?
Dementia and Alzheimer's: What Are the Differences?
Dementia and Alzheimer’s disease aren’t the same. You can have a form of dementia that’s completely unrelated to Alzheimer’s disease.

Q. Is there a cure for dementia?
A. These issues need further research.

If dementia is caused by some other treatable medical condition, then there may be a cure. Causes of treatable dementia include: thyroid deficiency, hydrocephalus, vitamin deficiency, and side effects of medications. A thorough evaluation is of central importance when dementia presents, and there is not a documented cause. An example of a documented cause would be a cognitive deficit that occurs following a stroke and is consistent with what would be expected, given the area of the brain shown on a brain scan as impacted.

Q. What is dementia?
A. Essentially, dementia is mental deterioration that results in cognitive deficits, including impairment in memory.

Q. What causes dementia in some older persons?

A. One or more conditions may cause dementia in older persons. Two common dementing conditions are Alzheimer’s Disease and stroke (sometimes called Vascular or Multi-Infarct Dementia).

Alzheimer's Disease is a progressive brain disease that eventually causes severe impairment in most areas of mental functioning.

EXAMPLE A person with Alzheimer's disease may have mild symptoms initially but later may not remember to use a cup for drinking or a toothbrush for brushing teeth. Eventually, the person may not recognize loved ones.

Strokes cause damage (called infarcts) to one or more parts of the brain. Strokes may severely affect one or more areas of mental and/or physical functioning and leave other areas quite unaffected.

EXAMPLE A person who has had one or more strokes may exhibit poor short term memory but excellent long term memory, difficulty expressing thoughts but an ability to think clearly, or confusion about time and place but good command of information about his or her own Managing Resources and medical conditions.

The fact that the person has a cognitive deficit does not mean that the person has no cognitive strengths. It is important to offer the person opportunities to do activities that are possible. One woman who had very limited ability to express herself in words was still able to play a musical instrument and to coordinate her clothing and accessories very well.

Q. Are people with dementia mentally ill?
A. Dementia itself is not a mental illness. However, some people with Alzheimer’s Disease develop psychiatric and behavioral symptoms as part of the disease process. Also, people with dementia may have coexisting conditions, such as depression or anxiety. Psychiatric and behavioral symptoms, such as agitation, intense anxiety, and paranoid thoughts, may be treated with medications. Before concluding that a symptom requires treatment with medications, it is important to rule out other causes. A behavior, such as agitation, may have a variety of causes other than a psychiatric condition, such as, pain, hunger, constipation, or side effects of medication. If agitation is caused by pain, the solution would be to seek to identify and treat the cause of the pain.

EXAMPLE A woman who had limited communication skills due to prior strokes appeared agitated and repeatedly called out for help. Her behavior could appear, without further inquiry, to be irrational. In fact, she had a serious and painful infection. Her behavior was a rational response to her condition, given her limited communication skills.

Q. Are people with dementia competent to make decisions for themselves?
A. Some are. Some are not. A neurologist or psychiatrist can evaluate and advise regarding competency.

EXAMPLE A person with short term memory loss alone may be quite capable of making Managing Resources and personal decisions. On the other hand, a person with severe impairments in broad areas of mental functioning may not be competent to understand relevant facts and make rational decisions. Q. Does dementia present in the same way all the time in the affected person?

A. No. Symptoms of dementia may vary from day to day for various reasons.

EXAMPLE If a person is hospitalized, the change in routine may cause greater mental difficulties during and just after the hospital stay. When out of the normal place and routine, the person is less able to rely on the usual ways of compensating for the impairments. Also, the person may feel more anxious or depressed, thus reducing the level of mental functioning. If new medication is introduced, it may have side effects that compound problems in mental functioning.

2. DEMENTIA AND LEGAL COMPETENCE

Q. Can a person with dementia execute a valid Medical or General Power of Attorney, Living Will, or Will ?
A. The answer depends upon the type and severity of the mental impairment. If the person is not able to know what he or she is doing by signing the document, then there is a lack of the necessary capacity. If the person does know, then there may be requisite capacity even though the person may be confused about time and place. Some courts have found certain individuals with dementia, caused by stroke or Alzheimer’s Disease, to have the necessary capacity and to be competent to execute such documents. Witness testimony as to what the person understood, at the time of signing, is often important. The opinion of the treating physician may also be helpful.

EXAMPLE In one case, a woman with Alzheimer’s Disease was found to have sufficient capacity to execute a valid Will because she knew the value and contents of her estate and to whom she desired to leave that estate, even though she was confused about her current living arrangements.

3. COMMUNICATING WITH PERSONS WHO HAVE DEMENTIA

Q. In general, how should we best communicate with the person with dementia?
A. Keep in mind that, if we live long enough, we may one day have dementia and consider how we would wish to be treated. Here are a few general principles.

Have surroundings simple and well organized. Placing identifying signs on closet doors, drawers, and the bathroom door may help reduce confusion. Having favorite possessions, pictures, or paintings on display may help the person feel safe and at home. Putting a large bright sticker next to your speed dial number on the person’s telephone will make it easier for the person to call you.

Establish routines. Speak calmly, slowly, and simply. Do not criticize. Instead, praise the person. Do not display impatience. Instead, adjust your pace to the pace of the person.

If the person is perceiving something incorrectly, do not argue. We are used to trusting what our brains tell us and are likely to continue that trust even when the brain is damaged and no longer sending correct information. Instead of arguing, change the topic.

Try to understand and take account of the particular problems that the person has in mental or physical functioning. Do not talk about the person to a third party as if the person is not there. The person will feel isolated and demeaned. Include the person in the discussion.

Finally, remember that communication does not always involve words. Touch is extremely important to older persons. For a family member to hug the person and hold the person’s hand can convey love and affection. By conveying love, showing the person that he or she is still useful and needed, and building the person’s self esteem, we can create a more accepting and loving environment that may help the person achieve the best possible functional level.

Q. How should we communicate if the person has short term memory loss?
A. If the person has short term memory loss, give frequent cues and reminders, especially as to time and place. Try talking about events from long ago. Some people are most comfortable talking about when they were raising a family or the work they once did.

EXAMPLE Say “You had a nice lunch earlier, and soon it will be time for dinner.” Ask about a place where the person once lived or a job the person held some time ago.

Q. How should we communicate if the person has difficulty expressing thoughts of any length or retrieving words from memory?
A. Ask targeted questions that can be answered with a few words instead of open ended questions. A question calling for a short answer gives the person a chance to feel successful. A question calling for a long answer may cause the person to feel embarrassed and frustrated over the inability to formulate and keep in mind a lengthy answer. Also, even if the person does not speak at length, it is fine to tell the person information. Some people who have difficulty expressing themselves understand everything you say.

EXAMPLE Instead of asking “What did you have for lunch?” ask “Did you enjoy lunch?” or “Did you have ice cream today?”

Q. What should we do if if the person is slow to understand, speak, or proceed with an activity?
A. Understand that the person may take longer to process what you are saying and to respond to your requests. If the person becomes distracted, reorient the person and repeat the request. Assure the person that there is no rush. Do not raise your voice or demand that the person go faster. If the person becomes anxious and tries to hurry, progress will be even more slow. 4. DEALING WITH COEXISTING PHYSICAL DISABILITIES

Q. How do we deal with physical disabilities that are present along with dementia?
A. Physical disabilities are sometimes present because of strokes, injuries from falls, and other causes. The greater the number and severity of the problems, the more difficult it is for the person to compensate for any one problem.

Keep surroundings and routines simple and consistent. Make the living area safe. Consider grab bars in the bathroom, a shower bench, carpeting rather than hard flooring, and eliminating anything with sharp edges. Providing a life line, so that the person can push a button for help, may increase safety and reduce anxiety.

Never tell the person that he or she could do better, is not trying hard enough, or must go faster. Instead, accommodate each particular problem as best you can. Success is not measured by speed. You can adjust your pace to proceed more slowly, but the person with impairments cannot adjust his or her pace to go faster. Also, give praise for what the person can do.

EXAMPLE If the person has some degree of paralysis that makes dressing difficult, consider pull over shirts with zippers rather than buttons, shoes with Velcro rather than laces, loose pants with elastic waist, and other items that are easy to handle and promote a feeling of independence and success.

Q. What if the person seems bored or engages in scratching or other repetitive actions?
A. Understand that the person may not be able to do the activities that once were fulfilling and has very little to do. Life may seem empty and boring.

If there is vision loss, reading may not be possible. Consider books on tape, radio programs, and music tapes.

If there is memory loss, the person may not be able to follow a movie plot. Consider a news program such as Headline News or reruns of a TV show the person used to enjoy.

Provide visual and auditory stimulation in the person’s surroundings, such as bright colors, paintings, a calendar, pictures, and, at times, appropriate holiday decorations. Try activities that are realistic, given the problems. If possible, take the person out to lunch or to the stores. Plan together future activities, so that the person can look forward to something positive and enjoyable. Involve the person as much as possible in the management of his or her affairs. If you handle the person’s Managing Resources, discuss and have the person make as many decisions as possible. Also, ask for advice about something you are doing. People love to feel useful and valued. Even in the final days of life, the person should be as ”in charge” as possible. Feeling in control reduces anxiety and promotes a content state of mind.

Q. What should we do if the person seems anxious, upset or difficult for no obvious reason?
A. Keep in mind that confusion and anxiety in older persons may intensify at night, a phenomenon called “sundowning.” It may help to have a light on at night so the person can see enough to be better oriented. Also, soft music may be a calming influence. Generally, people are helped by the presence of familiar items. If the person exhibits confusion or anxiety, start by orienting and reminding. If the person persists in saying something that is incorrect, ordinarily do not argue. Instead, change the topic. The person may shift attention to what you say and become more relaxed and cooperative.

EXAMPLE Say “It is evening, and you are in your room after having your dinner.” If the person says it is morning and time for breakfast, do not argue. This may only cause greater distress. Try to change the topic. You might compliment the person about some good quality the person displays, such as “Your hair looks nice today’” or “You have such a great sense of humor so much of the time.” Q. What if the person has trouble learning new things?

Sometimes people with dementia have difficulty learning anything that is new to them. Try explaining a new process simply several times. If possible, compare to something the person knew in the past.

EXAMPLE One woman told her family that she needed to pay the beautician for each visit to the nursing home beauty shop, even though the required procedure was that the beauty shop charge would be entered on the nursing home monthly bill. Her family explained the billing method and compared it to the way meals used to be entered on a monthly bill at a club the woman belonged to years ago. The woman was able to learn the nursing home billing process because of the comparison to a past similar process.

Q. What if the person says “Help me” and is not specific?
A. First orient the person as to time and place. Do not ask the person what is wrong or what do you want, as this may only increase distress if the person cannot elaborate. Instead, ask a few questions that call for short answers. This may assure the person that you care about them.

EXAMPLE “Are you warm enough ?” or “Do you need help to get to the bathroom?” or “Do you have any pain?” As you leave, assure that you will see the person soon.

Q. What if the person says “I want to go home”?
A. Often this does not mean the person wants to go to a house in which he or she once lived. What it may mean is that the person wants to feel comfortable and safe, as was the case in the past.

EXAMPLE Do not say “You are never going home.” This might cause the person to feel that he or she will never feel comfortable or safe again. Instead, try “You have a nice place here for right now , and we enjoy having you here.”

Q. What should you do if you have expressed your frustration or anger to the person with dementia?
A. Caregivers are often horrified at the anger and frustration they feel at times. Such feelings are a common experience for caregivers. Express your feelings, not to the person with dementia, but to a trusted confidant. Realize that it can be difficult to care for a person with dementia and that even a good person may become impatient at times. No one is perfect. If you have said something in frustration or anger to the person, catch yourself as quickly as possible and say that you are sorry. Try not to feel guilty or to reproach yourself. Turn the conversation in a positive direction. Let the person know that you enjoy visiting, so that the person does not come to feel that he or she is a burden. You might also praise the person and express your pride in the person’s accomplishments and efforts.

Q. What should you do to manage your feelings of frustration, anger, or fatigue?
If you are a family member involved in the care of the person with dementia, be sure that you take regularly scheduled breaks. If the person is living in an assisted living or nursing facility, and you become frustrated during visits, try taking a break for a few days or having shorter visits. If you are providing care in the person’s home or your home, arrange for alternate care givers and services, as needed. Check into services available in your local community that are designed to help caregivers, such as, informational seminars and support groups. It is important to take care of yourself and do things you enjoy, e.g.,take walks, go for a swim, see a movie, or engage in social activities.

There are risks in pushing yourself, rather than pacing yourself, in your care giving role. Caregiver syndrome is a debilitated condition brought on by unrelieved, constant caring for a person with a chronic illness or dementia. Depression and/or physical illness can result from trying to push yourself past your emotional limits. Keeping yourself well will enable you to be effective in your care giving role.

Nasogastric (Ryles) Tubes
Nasogastric Tube: Indications, Contraindications, Mini Case, Procedures, and Complication
Feeding by nasogastric tubes
Contra-indications
Inserting a nasogastric tube
Checking tube position
Securing and monitoring the tube
Medications
References
Nasogastric Tube: Indications, Contraindications, Mini Case, Procedures, and Complication

Diagnostic
Therapeutic purposes.

A nasogastric (NG) tube is used for the procedure. The placement of an NG tube can be uncomfortable for the patient if the patient is not adequately prepared with anesthesia to the nasal passages and specific instructions on how to cooperate with the operator during the procedure.

Indications
 
Diagnostic 
  • Evaluation of upper gastrointestinal (GI) bleed (ie, presence, volume)
  • Aspiration of gastric fluid content
  • Identification of the esophagus and stomach on a chest radiograph
  • Administration of radiographic contrast to the GI tract
Therapeutic 
  • Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often via the oropharynx
  • Relief of symptoms and bowel rest in the setting of small-bowel obstruction
  • Aspiration of gastric content from recent ingestion of toxic material
  • Administration of medication
  • Feeding
  • Bowel irrigation
Contraindications

Absolute contraindications
  • Severe midface trauma
  • Recent nasal surgery
Relative contraindications
  • Coagulation abnormality
  • Esophageal varices or stricture
  • Recent banding or cautery of esophageal varices
  • Alkaline ingestion

Nasogastric Tube Assembling Technique (NGT) 

Equipment

The following equipment is needed (also see image below):

  • Nasogastric tube
    • Adult - 16-18F
    • Pediatric - In pediatric patients, the correct tube size varies with the patient's age. To find the correct size, add 16 to the patient's age in years and then divide by 2 (eg, [8 y + 16]/2 = 12F)
  • Viscous lidocaine 2%
  • Oral analgesic spray (Benzocaine spray or other)
  • Syringe, 10 mL
  • Glass of water with a straw
  • Water-based lubricant
  • Toomey syringe, 60 mL
  • Tape
  • Emesis basin or plastic bag
  • Wall suction, set to low intermittent suction
  • Suction tubing and container
Positioning
  • Position the patient seated upright.
Technique

  1. Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's representative.
  2. Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask the patient to occlude each nostril and breathe through the other.
  3. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head tilted backwards (as shown in the images below), and ask the patient to sniff and swallow to anesthetize the nasal and oropharyngeal mucosa. In pediatric patients, do not exceed 4 mg/kg of lidocaine. Wait 5-10 minutes to ensure adequate anesthetic effect.
  4. Estimate the length of insertion by measuring the distance from the tip of the nose, around the ear, and down to just below the left costal margin. This point can be marked with a piece of tape on the tube. When using the Salem sump nasogastric tube (Kendall, Mansfield, Mass) in adults, the estimated length usually falls between the second and third preprinted black lines on the tube.
  5. Position the patient sitting upright with the neck partially flexed. Ask the patient to hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip of the nasogastric tube.
  6. Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it reaches the back of the nasopharynx, where resistance will be met (10-20 cm). At this time, ask the patient to sip on the water through the straw and start to swallow. Continue to advance the nasogastric tube until the distance of the previously estimated length is reached.
  7. Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient experiences respiratory distress, is unable to speak, has significant nasal hemorrhage, or if the tube meets significant resistance.
  8. Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach using the 60 mL Toomey syringe or by aspirating gastric content. Always obtaining a chest radiograph is recommended, in order to verify correct placement, especially if the nasogastric tube is to be used for medication or food administration.
  9. Apply Benzoin or another skin preparation solution to the nose bridge. Tape the nasogastric tube to the nose to secure it in place as shown. If clinically indicated, attach the nasogastric tube to wall suction after verification of correct placement.

Complications
  • Patient discomfort
    • Generous lubrication, the use of topical anesthetic, and a gentle technique may reduce the patient’s level of discomfort.
    • Throat irritation may be reduced with administration of anesthetic lozenges (eg, benzocaine lozenges [Cepacol]) prior to the procedure.
  • Epistaxis may be prevented by generously lubricating the tube tip and using a gentle technique.
  • Respiratory tree intubation


  • Nasogastric (NG) Tube
    Feeding Your Family Member in the ICU


    What does a nasogastric tube do?
    A nasogastric tube, or NG tube, is a special tube that carries food and medicine to the stomach through the nose.

    How long can a nasogastric tube be in place?
    Replace every six weeks.
    The use of a nasogastric tube is suitable for enteral feeding for up to six weeks. Polyurethane or silicone feeding tubes are unaffected by gastric acid and can therefore remain in the stomach for a longer period than PVC tubes, which can only be used for up to two weeks.

    What can you do to help with feeding your family member?
    1. Be prepared to answer questions about your family members nutritional status prior to their illness, for example: a) What is their height and usual weight?
    b) Have they lost weight recently?
    c) Had they been eating normally over the past week or had they lost their appetite?

    2. Ask about your family members’ nutrition in the ICU. If they are not eating or being fed ask:
    a) Why they are not being fed?
    b) When will they receive food?
    c) How will nutrition be provided?
    d) Are there any special nutrients that can be used to treat their illness (such as glutamine, high dose vitamins, fish oils, etc.)?

    3. Once feeding has been established (after 2-3 days), ask the nurse if your family member is getting enough nutrition by asking:
    a) Are they tolerating their feeds?
    b) Have they reached their goal rate?
    c) Is the head of the bed elevated?

    4. If you are concerned about your family members’ nutrition while in the ICU, you may ask to see a dietitian for advice. 5. If your family member is able to eat, check with the nurse or dietitian what foods are appropriate to bring in for them, and encourage them to take small amounts frequently.

    What is a nasogastric (NG) tube?
    A nasogastric (NG) tube is a flexible plastic tube that goes through the patient's mouth or nose into the stomach. It is designed to remove stomach contents or provide a route to give medication or food to a patient who cannot swallow. The portion of the NG tube outside of the patient may be plugged closed, connected to a delivery device or connected to a suction device. NG tubes may be inserted while the patient is in the emergency department, operating room, ICU, or regular hospital ward.

    Does a NG tube hurt?

    The insertion of the NG tube is somewhat uncomfortable for an awake patient but once in place the NG tube usually causes very little irritation. Some patients, however, remain uncomfortable as long as an NG tube is in place.

    How is the NG tube kept in place?
    Typically, tape is used to secure the NG tube to the patient's nose and hold the NG tube in place.

    How long is a NG tube used?

    That depends upon why the patient required the NG tube. Frequently a critically ill or injured patient's stomach does not function well because of the underlying illness or injury. That is, the stomach does not empty normally and the solids or liquids remain in the stomach unless they are drained. These patients are usually sick to their stomach and vomit. When this stomach condition occurs, an NG tube is necessary until the stomach function returns. Some patients require a NG tube after surgery until the effects of the surgery and anesthesia on the stomach wear off. If the NG tube was needed due to abnormal swallowing, then it remains in place until the swallowing improves or another option is considered.

    Are there any potential complications associated with use of a NG tube?

    Rarely, sores develop in the nose or mouth due to pressure caused by a NG tube.

    Home Nasogastric Tube Feeding

    This handout is designed to help you and your family understand how to give yourself feedings through your nasogastric tube after you go home.

    Tube feedings are given when you cannot eat enough or drink enough to have adequate nutrition for the body. Good nutrition is needed for your body to heal. Fluid is needed to prevent your body from getting dried out(dehydrated).

    A nasogastric (NG) tube is a long, narrow feeding tube that goes through your nose and down into your stomach.

    The NG tube is soft and bendable. (See the diagram)

    When you leave the hospital, you should be able to:

    ?Give yourself liquid food and water through the feeding tube

    ?Give yourself medication through the tube

    ?Take care of the tube

    ?“Trouble-shoot” problems if they arise

    This handout gives added information for you and your family. It should not replace discussions with your doctors, nurses, or dietitians.

    Understanding the Equipment

    Before giving your feeding, you will need:

    ?60cc syringe

    ?Liquid food prescribed by your doctor

    ?Measuring cup

    ?Clean food container

    ?IV pole or wall hook to hang the food container while receiving the feeding (optional in the home)

    The setup for feedings is shown below:

    To get your liquid food, attach the tube from the end of the food container to the end of your NG feeding tube. This is for intermittent or continuous feedings.

    Giving the Tube Feeding

    1. Always wash your hands thoroughly before touching the NG feeding tube, food, or medication.

    2. Check the placement of your feeding tube:

    ?Attach a 60cc syringe to the end of your feeding tube.

    ?Pull back on the plunger. You should see some gastric juices (yellow-green fluid). This is stomach content and tells you the tube is in your stomach.

    ?If you pull back more than 150cc of fluid, do not give yourself food. Inject the stomach content, which contains important minerals, back into the tube.

    Then flush with water. Wait for a few hours and check again.

    Tell your visiting nurse or your doctor if this occurs frequently.

    3. If stomach content does not show when you pull back on the plunger, you can use another method to check placement:

    ?Draw up 20cc of air into your syringe.

    ?Insert the air into your feeding tube while holding one hand over your stomach.

    ?Call your doctor if you see no stomach content and feel no air bubbles under your hand. This may indicate your tube has been displaced.

    4. To give yourself the feeding, follow these steps:

    ?Insert the tip of the tube from your food container into your feeding tube.

    ?Open the clamp slowly to adjust the speed of the feeding.

    ?Your meal should last 45 minutes to an hour. It is important to sit up or prop your head up while receiving your feeding. If you have choking or difficulty breathing during a feeding, stop the feeding and call your doctor immediately.

    ?When the feeding is done, fill the food container with the amount of water your doctor prescribes. This provides fluids for you and flushes out the tube.

    ?After the water is given, roll the clamp down to turn off and disconnect the food container.

    5. Wash out the food container after each use:

    ?Use dishwashing liquid and water to wash the container.

    ?Rinse the container thoroughly.

    ?Use a clean food container for each feeding.

    Giving Your Medication

    Medications can be given through your NG tube. Use the liquid form of your medication if it is available at your pharmacy. If the liquid form is not available, you must crush your pills.

    If the letters “SR” appear after the drug name on the label, this indicates the medication is “sustained-release.” Do not crush these pills. Check with your pharmacist or nurse to be sure that your pills may be crushed and given at the same time.

    To give your medication, follow these steps:

    ?Check for feeding tube placement (see “Giving the Tube Feeding,” Steps 2 and 3).

    ?Flush your feeding tube with 30cc of water before giving your medication.

    ?Crush the pills. To crush your pills, place them in a plastic bag, and then use a rolling pin or soup can as a crushing instrument. After you have crushed your pills finely, let the pieces dissolve in warm water (not hot water) so that no pieces will clog your tube.

    ?Draw medication up into your syringe by pulling back on the plunger.

    ?Attach the syringe to the end of the feeding tube. Then push on the plunger to give your medication.

    ?Flush the tube with 30cc of water after giving your medication.

    ?Some medications should be given with food; others on an empty stomach. Ask your pharmacist for directions.

    Mouth and Tube Care

    ?Brush your teeth at least twice daily, if your doctor says you may.

    ?Clean the area where the NG tube goes into your nostrils daily. Use a cotton-tip applicator moistened with warm water. If your nose becomes sore, you may apply water-soluble lubricant (such as Surgilube or K-Y jelly).

    ?Change your nasal tape every other day or when it is loose.

    Make sure the nasal tape is secure at all times. If your feeding tube falls out, call your doctor as soon as possible.

    ?To prevent a clogged feeding tube, flush your tube with water each time after giving a feeding or medication.

    ?If your tube becomes clogged, you can use these methods:

    ?Place the syringe into your feeding tube, and pull back on the plunger.

    ?Flush your tube with warm tap water.

    ?If you cannot unclog your tube, call your doctor immediately. It is important not to miss your prescribed liquid food and water.

    When to Call the Doctor

    ?If you choke or have difficulty breathing during a feeding, stop the feeding and call your doctor immediately.

    ?If you cannot unclog your tube, call your doctor immediately.

    ?If your feeding tube falls out or you cannot confirm that the end of the tube is in your stomach, call your doctor as soon as possible.

    ?Call your doctor if any of the following last for more than a day: diarrhea, constipation, nausea, dark urine, bad-smelling urine, dry mouth

    ?Call your doctor if the tube seems to be moving farther out.

    Nasogastric (Ryles) Tubes

    Personalized Meal Schedule

    Name of liquid food: ________________________________________________________

    Total amount of liquid food daily: _____________________________________________

    Total amount of water daily: __________________________________________________

    Meal schedule: _____________________________________________________________

Acid-Base Disorders
Diagnosing Medical Acid Base Disorders
Annotation or definition.
ABG interpreter
Multiple Choice Questions- Acid Base Balance
Normal Arterial Blood Gas Values
Questions you need to answer.
The Four Primary Disturbances of Acid-Base Balance
Types of Acid-Base Disorders

Questions you need to answer.
What is the acid base balance?
What may lead to acid base disorders?
Arterial Blood Gases - Indications and Interpretation
When is it ordered?
How is it used?
What does the test result mean?
Is there anything else I should know?
What can cause metabolic alkalosis?
What is compensation in acid base balance?
What is the paco2?
How does the body compensates for metabolic alkalosis?
What is compensated and uncompensated metabolic acidosis?
How do you compensate for metabolic acidosis?
What is respiratory acidosis?
What is the paco2?
How does excess co2 lead to respiratory acidosis?
What does hypercapnia cause?
Why does hypoventilation cause acidosis?
What is compensation in acid base balance?
What is Type 2 respiratory failure?
What is the treatment?
How do you treat respiratory failure?
What is respiratory alkalosis?
How does the body compensate for chronic respiratory alkalosis?
What is normal pH?
What is the definition for acid base disorder?
What does acidosis or alkalosis refer to?
What does acidemia or alkalemia refer to?
Which organs are key players in maintaining acid base balance?
What are the primary acid base disorders?
When would you consider metabolic acidosis?
When would you consider metabolic alkalosis?
When would you consider respiratory acidosis?
When would you consider respiratory alkalosis?
What are the required lab values and historical information you need to assess acid base disorders?
What are anions? List the anions?
What are cations? List the cations?
What is anion gap?
How do you calculate anion gap?
What are the compensatory measures for acid base disorders?
What is difference between bicarbonate value reported in arterial blood gases and bicarbonate reported in electrolytes?
What is the metabolic compensation for acute respiratory acidosis? How do you assess whether it is appropriate?
What is the metabolic compensation for chronic respiratory acidosis? How do you assess whether it is appropriate?
What is the metabolic compensation for acute respiratory alkalosis? How do you assess whether it is appropriate?
What is the respiratory compensation for chronic respiratory alkalosis? How do you assess whether it is appropriate?
What is the respiratory compensation for acute metabolic acidosis? What are the sensors and effectors for this response?
What is the respiratory compensation for chronic metabolic acidosis? How do you assess whether it is appropriate?
What is the respiratory compensation for acute metabolic alkalosis? How do you assess whether it is appropriate?
What is the respiratory compensation for chronic metabolic alkalosis? How do you assess whether it is appropriate?
What is bicarbonate gap?
Explain renal mechanism for regulation of acid base disorders?
What are the common causes for high anion gap metabolic acidosis?
What are the common causes for normal anion gap metabolic acidosis?
What are the common causes for metabolic alkalosis?
What are the common causes for respiratory acidosis?
What are the common causes for respiratory alkalosis?
What are the factors that stimulate kidney to excrete acid?
What are the factors that inhibit kidney to excrete acid?
How do you determine whether an acid base disorder is simple or mixed?
Explain CSF barrier for acid base disorders. How does it come into play clinically?
Give me your step by step approach to interpreting acid base disorders.
Describe the buffer system.
Describe how kidney excretes acid.
What is the relationship between Ventilation and pCO2
How do you calculate the hydrogen ion concentration?

Annotation or definition.
What is the acid base balance?
Your blood needs the right balance of acid and basic (alkaline) compounds to function properly. This is called the acid-base balance. Your kidneys and lungs work to keep the acid-base balance. Even slight variations from the normal range can have significant effects on your vital organs.

Acid and alkaline levels are measured on a pH scale. An increase in acidity causes pH levels to fall. An increase in alkaline causes pH levels to rise.

When the levels of acid in your blood are too high, it is called acidosis. When your blood is too alkaline, it is called alkalosis.

Respiratory acidosis and alkalosis are due to a problem with the lungs. Metabolic acidosis and alkalosis are due to a problem with the kidneys.

Each of these conditions is caused by an underlying disease or disorder. Treatment depends on the cause.

What may lead to acid base disorders?
Acidosis and alkalosis refer to physiologic processes that cause accumulation or loss of acid and/or alkali; blood pH may or may not be abnormal. Acidemia and alkalemia refer to an abnormally acidic (pH < 7.35) or alkalotic (pH > 7.45) serum pH.

Respiratory Acidosis

When you breathe, your lungs remove excess carbon dioxide from your body. When they cannot do so, your blood and other fluids become too acidic.

Causes

Chest deformities or injuries can cause respiratory acidosis to develop. So can chronic diseases of the lungs or airways. Other causes include overuse of sedatives and obesity (if your lungs cannot fully inflate).

Types

In chronic respiratory acidosis, symptoms develop over time. Because it happens slowly, your kidneys may adjust and return your body to a normal acid-base balance. Acute respiratory acidosis comes on suddenly, leaving the kidneys no time to adjust.

Symptoms

Symptoms may include fatigue, shortness of breath, and confusion.

Diagnosis

A complete physical examination is necessary. Diagnostic testing may include arterial blood gas test, metabolic panel, pulmonary function test, and chest X-ray.

Treatment

Treatment is targeted to the cause. Bronchodilator medications can correct some forms of airway obstruction. If your blood oxygen level is too low, you may require oxygen. Noninvasive positive pressure ventilation (NPPV) or a breathing machine may be necessary.

If you smoke, you will be advised to stop.

Risks

Respiratory acidosis is serious and requires immediate medical attention. Potential complications include respiratory failure, organ failure, and shock.

Prevention

You can take steps to help prevent some of the conditions that lead to respiratory acidosis. Maintain a healthy weight. Take sedatives only under strict doctor supervision and never combine them with alcohol. Do not smoke.

Metabolic Acidosis

Metabolic acidosis occurs either when your body produces too much acid, or when your kidneys are unable to remove it properly.

Causes

There are three main types of metabolic acidosis. Diabetic acidosis, or diabetic ketoacidosis, is a buildup of ketone bodies. This is usually due to uncontrolled type 1 diabetes. Hyperchloremic acidosis is when your body loses too much sodium bicarbonate, often after severe diarrhea.

Lactic acidosis is when too much lactic acid builds up. This can be due to:

•prolonged exercise
•lack of oxygen
•certain medications, including salicylates
•low blood sugar (hypoglycemia)
•alcohol
•seizures
•liver failure
•cancer

Other things that can trigger metabolic acidosis

Other things that can trigger metabolic acidosis include kidney disease and severe dehydration. Poisoning from ingestion of excess aspirin, ethylene glycol, and methanol are other causes.

Symptoms

Symptoms can include rapid breathing, fatigue, and confusion.

Risks

Severe cases can lead to shock and can be life threatening.

Diagnosis

Diagnostic testing may include serum electrolytes, urine pH, and arterial blood gases. Once acidosis is confirmed, other tests may be necessary to pinpoint the cause.

Treatment

The underlying condition behind the acidosis must be treated. In some cases, sodium bicarbonate is prescribed to return the blood to a normal pH.

Alkalosis

Alkalosis is when alkaline levels are too high due to decreased carbon dioxide or increased bicarbonate. There are five kinds of alkalosis.

Respiratory alkalosis is when your blood has low levels of carbon dioxide. This can be caused by a number of factors, including:
•lack of oxygen
•high altitude
•fever
•lung disease
•liver disease
•salicylate poisoning

When you have alkalosis, your body works to get your acid levels back to normal. That can leave carbon dioxide and bicarbonate levels at abnormal levels. This is called compensated alkalosis.

When your blood has too much bicarbonate, it is called metabolic alkalosis. This can happen from prolonged vomiting. Prolonged vomiting can also make you lose too much chloride. This is called hypochloremic alkalosis. Some diuretic medicines can cause you to lose too much potassium. This is called hypokalemic alkalosis.

Symptoms

Symptoms of alkalosis may include:
•muscle twitching, hand tremor, muscle spasms
•numbness and tingling
•nausea, vomiting

•lightheadedness, confusion

Risks

In severe cases, alkalosis can lead to arrhythmias or coma.

Diagnosis

Along with a physical exam, diagnostic testing for alkalosis may include a metabolic panel, blood gas analysis, urinalysis, and urine pH.

Treatment

Some medications can help correct chemical losses. Further treatment will depend on the cause

1.What are common causes of increased anion gap metabolic acidoses?
2.How is the urinary anion gap used in the diagnosis of normal anion gap metabolic acidoses?
3.What are the major types of renal tubular acidosis, and how are they diagnosed?
4.How is urinary chloride used in the diagnosis of metabolic alkalosis? 5.How is the ?Gap used to diagnose complex acid-base disorders?

Arterial Blood Gases - Indications and Interpretation

When is it ordered?
How is it used?
What does the test result mean?
Is there anything else I should know?


Indications

When is it ordered?
•Respiratory failure - in acute and chronic.
•Any severe illness which may lead to a metabolic acidosis - for example:
•Cardiac failure.
•Liver failure.
•Renal failure.
•Hyperglycaemic states associated with diabetes mellitus.
•Multiorgan failure.
•Sepsis.
•Burns.
•Poisons/toxins.

•Ventilated patients.
•Sleep studies.
•Severely unwell patients from any cause - affects prognosis.

Acid-Base Regulation and Disorders
Acid-Base Regulation

Mixed Acid Base Disorders

Acid-base disorders are changes in arterial P co 2 , serum HCO 3 - , and serum pH.
Acidemia is serum pH < 7.35.
Alkalemia is serum pH > 7.45.
Acidosis refers to physiologic processes that cause acid accumulation or alkali loss. Alkalosis refers to physiologic processes that cause alkali accumulation or acid loss.

Classification

Primary acid-base disturbances are defined as metabolic or respiratory based on clinical context and whether the primary change in pH is due to an alteration in serum HCO 3 - or in P co 2 .

Metabolic acidosis is serum HCO 3 - < 24 mEq/L. Causes are

•Increased acid production
•Acid ingestion
•Decreased renal acid excretion
•GI or renal HCO 3 - loss
Metabolic alkalosis is serum HCO 3 - > 24 mEq/L. Causes are
•Acid loss
•HCO 3 - retention
Respiratory acidosis is P co 2 > 40 mm Hg (hypercapnia). Cause is
•Decrease in minute ventilation (hypoventilation)
Respiratory alkalosis is P co 2 < 40 mm Hg (hypocapnia). Cause is
•Increase in minute ventilation (hyperventilation)

Whenever an acid-base disorder is present, compensatory mechanisms begin to correct the pH (see Primary Changes and Compensations in Simple Acid-Base Disorders). Compensation cannot return pH completely to normal and never overshoots.

Actual changes in pH depend on the degree of physiologic compensation and whether multiple processes are present.

Mixed Acid Base Disorders
v Mixed acid base disorders occur when there is more than one primary acid base disturbance present simultaneously. They are frequently seen in hospitalized patients, particularly in the critically ill.

When to suspect a mixed acid base disorder:
1.The expected compensatory response does not occur
2.Compensatory response occurs, but level of compensation is inadequate or too extreme 3.Whenever the PCO2 and [HCO3-] becomes abnormal in the opposite direction. (i.e. one is elevated while the other is reduced). In simple acid base disorders, the direction of the compensatory response is always the same as the direction of the initial abnormal change. 4.pH is normal but PCO2 or HCO3- is abnormal
5.In anion gap metabolic acidosis, if the change in bicarbonate level is not proportional to the change of the anion gap. More specifically, if the delta ratio is greater than 2 or less than 1.
6.In simple acid base disorders, the compensatory response should never return the pH to normal. If that happens, suspect a mixed disorder.

Mixed metabolic disorders
1.Anion Gap and Normal Anion Gap Acidosis.
This mixed acid base disorder is identified in patients with a delta ratio less than 1 which signifies that the reduction in bicarbonate is greater than it should be, relative to the change in the anion gap. Thus, implicating that there must be another process present requiring buffering by HCO3-, i.e a concurrent normal anion gap acidosis.
Example:
•Lactic acidosis superimposed on severe diarrhea. (note: the delta ratio is not particularly helpful here since the diarrhea will be clinically obvious) •Progressive Renal Failure
•DKA during treatment
•Type IV RTA and DKA

2. Anion Gap Acidosis and Metabolic Alkalosis

This mixed acid base disorder is identified in patients with a delta ratio greater than 1, which signifies a reduction in bicarbonate less than it should be, relative to the change in the anion gap. This suggests the presence of another process functioning to increase the bicarbonate level without affecting the anion gap, i.e. metabolic alkalosis.

Examples:

•Lactic acidosis, uremia, or DKA in a patient who is actively vomiting or who requires nasogastric suction.
•Patient with lactic acidosis or DKA given sodium bicarbonate therapy.
3. Normal Anion Gap Acidosis and Metabolic Alkalosis
This diagnosis can be quite difficult, because the low HCO3- and low PCO2 both move back toward normal when metabolic alkalosis develops. Also, unlike elevated anion gap acidosis, the anion gap will not indicate the presence of the acidosis.
Example:
•In patients who are vomiting and with diarrhea (note: all acid base parameters may fall within the normal range)

Mixed respiratory and respiratory–metabolic disorders

Having a good knowledge of compensatory mechanisms and extent of compensation will aid in identifying these disorders. Remember; compensation for simple acid-base disturbances always drives the compensating parameter (ie, the PCO2, or [HCO3-]) in the same direction as the primary abnormal parameter (ie, the [HCO3-] or PCO2). Whenever the PCO2 and [HCO3] are abnormal in opposite directions, ie, one above normal while the other is reduced, a mixed respiratory and metabolic acid-base disorder exists.

Rule of thumb:
•When the PCO2 is elevated and the [HCO3-] reduced, respiratory acidosis and metabolic acidosis coexist.
•When the PCO2 is reduced and the [HCO3-] elevated, respiratory alkalosis and metabolic alkalosis coexist

The above examples both produce very extreme acidemia or alkalemia and are relatively easy to diagnose. However more often, the disorder is quite subtle. For example, in cases of metabolic acidosis, the HCO3- is low and PCO2 low. If the PCO2 is normal or not aqequately reduced, this may indicate a subtle coexisting respiratory acidosis.

Mixed acid base disorders usually produce arterial blood gas results that could potentially be explained by other mixed disorders. Oftentimes, the clinical picture will help to distinguish. It is important to distinguish mixed acid base disorders because work up and management will depend on accurate diagnosis.

1. Chronic Respiratory Acidosis with superimposed Acute Respiratory Acidosis Example:
•Acute exacerbation of COPD secondary to acute pneumonia
•COPD patient with worsening hypoventilation secondary to oxygen therapy or sedative administration
2. Chronic Respiratory Acidosis and Anion Gap Metabolic Acidosis
Example:
•COPD patient who develops shock and lactic acidosis
3. Chronic Respiratory Acidosis and Metabolic Alkalosis
Example:
•Pulmonary insufficiency and diuretic therapy
•or COPD patient treated with steroids or ventilation (important to recognize as alkalemia will reduce acidemic stimulus to breathe)
4. Respiratory Alkalosis and Metabolic Acidosis
Example:
•Salicylate intoxication
•Gram negative sepsis
•Acute cardiopulmonary arrest
•Severe pulmonary edema

Metabolic alkalosis
What are the causes of metabolic alkalosis?
What is compensation in acid base balance?
What is the paco2?
How does the body compensates for metabolic alkalosis?


What are the causes of metabolic alkalosis?
Metabolic alkalosis is primary increase in bicarbonate (HCO3 -) with or without compensatory increase in carbon dioxide partial pressure (Pco2); pH may be high or nearly normal. Common causes include prolonged vomiting, hypovolemia, diuretic use, and hypokalemia.

Summary of causes of metabolic alkalosis
Causes of chloride-responsive alkalosis (urine chloride < 20 mEq/L) include the following:
  1. Loss of gastric secretions - Vomiting, NG suction

  2. Loss of colonic secretions - Congenital chloridorrhea, villous adenoma

  3. Thiazides and loop diuretics (after discontinuation)

  4. Posthypercapnia

  5. Cystic fibrosis

  6. Causes of chloride-resistant alkalosis (urine chloride >20 mEq/L) with hypertension include the following:
  7. Primary hyperaldosteronism - Adrenal adenoma, bilateral adrenal hyperplasia, adrenal carcinoma, glucocorticoid-remediable hyperaldosteronism ?

  8. 11B-HSD2 - Genetic, licorice, chewing tobacco, carbenoxolone

  9. CAH - 11-Hydroxylase or 17-hydroxylase deficiency

  10. Current use of diuretics in hypertension

  11. Cushing syndrome

  12. Exogenous mineralocorticoids or glucocorticoids

  13. Liddle syndrome

  14. Renovascular hypertension

  15. Causes of chloride-resistant alkalosis (urine chloride >20 mEq/L) without hypertension include the following:
  16. Bartter syndrome

  17. Gitelman syndrome

  18. Severe potassium depletion

  19. Current use of thiazides and loop diuretics

  20. Hypomagnesemia

  21. Other causes include the following:
  22. Exogenous alkali administration - Sodium bicarbonate therapy in the presence of renal failure, metabolism of lactic acid or ketoacids ?

  23. Milk-alkali syndrome

  24. Hypercalcemia

  25. Intravenous penicillin

  26. Refeeding alkalosis

  27. Massive blood transfusion

What is compensation in acid base balance?
To regain acid-base balance, the lungs may respond to a metabolic disorder, and the kidneys may respond to a respiratory disorder. If pH remains abnormal, the respiratory or metabolic response is called partial compensation. If the pH returns to normal, the response is called complete compensation.

What is the paco2?
PaCO2 is measured by arterial blood gases. Partial pressure refers to the pressure exerted by a specific gas in a mixture of other gases. The partial pressure of carbon dioxide at sea level is ordinarily 38 to 42 mm Hg.

How does the body compensates for metabolic alkalosis?
Compensation for metabolic alkalosis occurs mainly in the lungs, which retain carbon dioxide (CO2) through slower breathing, or hypoventilation (respiratory compensation). CO2 is then consumed toward the formation of the carbonic acid intermediate, thus decreasing pH. Metabolic Acidosis

What is compensated and uncompensated metabolic acidosis?
It can also occur as a compensatory response to chronic metabolic alkalosis. One key to distinguish between respiratory and metabolic acidosis is that in respiratory acidosis, the CO2 is increased while the bicarbonate is either normal (uncompensated) or increased (compensated).

How do you compensate for metabolic acidosis?
Compensation for a metabolic acidosis is hyperventilation to decrease the arterial pCO2. This hyperventilation was first described by Kussmaul in patients with diabetic ketoacidosis in 1874. The metabolic acidosis is detected by both the peripheral and central chemoreceptors and the respiratory center is stimulated.

Respiratory Acidosis
What is respiratory acidosis?
Respiratory acidosis, also called respiratory failure or ventilatory failure, is a condition that occurs when the lungs can't remove enough of the carbon dioxide (CO2) produced by the body. Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic.

What is the paco2?
PaCO2 is measured by arterial blood gases. Partial pressure refers to the pressure exerted by a specific gas in a mixture of other gases. The partial pressure of carbon dioxide at sea level is ordinarily 38 to 42 mm Hg.

How does excess co2 lead to respiratory acidosis?
Respiratory acidosis, also called respiratory failure or ventilatory failure, is a condition that occurs when the lungs can't remove enough of the carbon dioxide (CO2) produced by the body. Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic.

Causes: Acute Respiratory Acidosis
  1. Central Nervous System Depression
    1. Sedative Medications (e.g. Benzodiazepines)
    2. Cerebrovascular Accident
    3. Head Trauma
  2. Neuromuscular Disease
    1. Myasthenia Gravis
    2. Guillain-Barre
    3. Polio
    4. Muscular Dystrophy
    5. Hypokalemia
  3. Impaired lung motion
    1. Pleural Effusion
    2. Pneumothorax
    3. Crush injury
  4. Acute airway obstruction
    1. Foreign Body Aspiration
    2. Tumor
    3. Laryngospasm (e.g. Croup, Epiglottitis)
    4. Bronchospasm (e.g. Asthma)
  5. Acute Respiratory Disease
    1. Severe Pneumonia
    2. Pulmonary edema

Causes: Chronic Respiratory Acidosis

  1. Chronic Obstructive Pulmonary Disease
  2. Pickwickian Syndrome
  3. Chronic Neuromuscular Disease
    1. See Above
  4. Thoracic Cage limitation
    1. Kyphoscoliosis
    2. Scleroderma

Labs

  1. Arterial Blood Gas
    1. Arterial pH decreased
    2. Serum bicarbonate increased
    3. PaCO2 increased
  2. Acute Respiratory Acidosis
    1. PaCO2 increase by 10 mmHg decreases pH 0.08
    2. Bicarbonate increases 1 meq/L per 10 mmHg PaCO2 rise
  3. Chronic Respiratory Acidosis
    1. PaCO2 increase by 10 mmHg decreases pH 0.03
    2. Bicarbonate increases 4 meq/L per 10 mmHg PaCO2 rise
Why does hypoventilation cause acidosis?
Hypercapnia and respiratory acidosis ensue when impairment in ventilation occurs and the removal of carbon dioxide by the respiratory system is less than the production of carbon dioxide in the tissues. Lung diseases that cause abnormalities in alveolar gas exchange do not typically result in alveolar hypoventilation.

What is compensation in acid base balance?
To regain acid-base balance, the lungs may respond to a metabolic disorder, and the kidneys may respond to a respiratory disorder. If pH remains abnormal, the respiratory or metabolic response is called partial compensation. If the pH returns to normal, the response is called complete compensation.

Symptoms

Symptoms may include:
Confusion
Easy fatigue
Lethargy
Shortness of breath
Sleepiness

Forms of Respiratory Acidosis

There are two forms of respiratory acidosis: acute and chronic.

Acute respiratory acidosis occurs quickly. It is a medical emergency. Left untreated, symptoms will get progressively worse. It can become life-threatening.

Chronic respiratory acidosis develops over time. It does not cause symptoms. Instead, the body adapts to the increased acidity. For example, the kidneys produce more bicarbonate to help maintain balance.

Chronic respiratory acidosis may not cause symptoms. However, people with chronic respiratory acidosis may also get acute respiratory acidosis when another illness causes the condition to worsen. If you have any of the underlying causes of respiratory acidosis (defined below) and experience any of the symptoms of acute respiratory acidosis, it’s important to see a doctor right away. If you have any of the underlying causes of respiratory acidosis, be sure to see your doctor for treatment. The underlying cause could be serious. Your doctor may also want to perform tests to monitor your condition.

What is Type 2 respiratory failure?
Type 2 respiratory failure is caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected. Defined as the buildup of carbon dioxide levels (PaCO2) that has been generated by the body but cannot be eliminated. Causes of respiratory acidosis

A) CNS depression
    1. Opioids
    2. Oxygen in patient with chronic hypercapnia
    3. Central sleep apnea
    4. CNS lesion
    5. Extreme obesity (Pickwickian syndrome)
B) Neuromuscular disorders
    1. Myasthenia gravis
    2. Guillain-Barre
    3. ALS
    4. Poliomyelitis
    5. Muscular dystrophy
    6. Multiple Sclerosis
C) Chest wall or Thoracic Cage Abnormality
    1. Kyphoscoliosis
    2. Flail Chest
    3. Myxedema
    4. Rib Fracture
    5. Scleroderma
4) Disorders affecting gas exchange
    1. COPD
    2. Severe asthma or pneumonia
    3. Pneumothorax or Hemothorax
    4. Acute pulmonary edema
5) Airway obstruction
    1. Aspiration of foreign body
    2. Obstructive sleep apnea
    3. Laryngospasm
Prevention

Do not smoke. Smoking leads to the development of many severe lung diseases that can cause respiratory acidosis.
Losing weight may help prevent respiratory acidosis due to obesity (obesity-hypoventilation syndrome).
Be careful about taking sedating medicines, and never combine these medicines with alcohol.
Further medical research needs to go ahead based on findings.

What is the treatment?
How do you treat respiratory failure?

If chronic respiratory failure is severe, your doctor may recommend treatment in a long-term care center. One of the main goals of treating respiratory failure is to get oxygen to your lungs and other organs and remove carbon dioxide from your body. Another goal is to treat the underlying cause of the condition.

Respiratory Failure Treatment & Management

Treatment

•Treat underlying disorder
•Oxygen if the blood oxygen level is low
•Bronchodilator drugs to reverse some types of airway obstruction
•Noninvasive positive-pressure ventilation (sometimes called CPAP or BiPAP) or a breathing machine, if needed
•Corticosteroids and bronchodilators to reduce airway inflammation and resistance.
•Mechanical ventilator if ventilation fails.


Respiratory alkalosis
What is respiratory alkalosis?
Respiratory alkalosis is a medical condition in which increased respiration elevates the blood pH beyond the normal range (7.35-7.45) with a concurrent reduction in arterial levels of carbon dioxide. This condition is one of the four basic categories of disruption of acid-base homeostasis.

How does the body compensate for chronic respiratory alkalosis?
The kidneys help to compensate for respiratory alkalosis by decreasing the rate of hydrogen ions secretion into the urine and the rate of bicarbonate ion reabsorption. If an increase in pH occurs, a time period of 1 or 2 days is required for the kidneys to be maximally effective.

ABG interpreter
Four-Step Guide to ABG Analysis
1.Is the pH normal, acidotic or alkalotic?
2.Are the pCO2 or HCO3 abnormal? Which one appears to influence the pH?
3.If both the pCO2 and HCO3 are abnormal, the one which deviates most from the norm is most likely causing an abnormal pH. 4.Check the pO2. Is the patient hypoxic?
Take a look at this.
Take a look at this.

Normal Arterial Blood Gas Values
pH 7.35-7.45
PaCO2 35-45 mm Hg
PaO2 80-95 mm Hg
HCO3 22-26 mEq/L
O2 Saturation 95-99%
BE +/- 1
What is normal pH?
Normal Values
pH = 7.38 - 7.42
[H+] = 40 nM/L for a pH of 7.4
PaCO2 = 40 mm Hg
[HCO3] = 24 meq/L

What is the definition for acid base disorder?
Acid base disorder is considered present when there is abnormality in HCO3 or PaCO2 or pH.

What does acidosis or alkalosis refer to?
Acidosis and alkalosis refer to in-vivo derangement's and not to any change in pH.

What does acidemia or alkalemia refer to?
Acidemia (pH < 7.38) and Alkalemia (pH >7.42) refer to derangement's of blood pH.

Which organs are key players in maintaining acid base balance?
Kidney, Respiratory system and Central nervous system play a key roles in maintaining the acid base status.

What are the primary acid base disorders?
Primary acid base disorders
•Metabolic acidosis
•Metabolic alkalosis
•Respiratory acidosis
•Respiratory alkalosis

When would you consider metabolic acidosis?
Metabolic acidosis: loss of [HCO3] 0r addition of [H+]

When would you consider metabolic alkalosis?
Metabolic alkalosis: loss of [H+] or addition of [HCO3]

When would you consider respiratory acidosis?
Respiratory acidosis: increase in pCO2

When would you consider respiratory alkalosis?
Respiratory alkalosis : decrease in pCO2

What are the required lab values and historical information you need to assess acid base disorders?
Recquired lab values/information
•Arterial blood gases: pH, PaCO2,calculated bicarb
•Electrolytes: Na, K, Cl, HCO3
•BUN, Glucose, Creatinine
•Clinical history

What are anions? List the anions?
Anions
•Chloride
•Bicarbonate(Total CO2)
•Proteins
•Organic acids
•Phosphates
•Sulfates

What are cations? List the cations?
Cations
•Sodium
•Potassium
•Calcium
•Magnesium

What is anion gap?
Anion gap (AG)

Electrochemical balance: the total anions are the same as total Cations. An imbalance between Sodium, Chlorides and Total CO2.is measured as anion gap.

•Sum of Cations minus anions
•(Na+K)-(CL+HCO3)
•Use the measured total CO2 from venous blood as HCO3
•anion gap is an artifact because some anions are not measured
•gap is mainly due to unmeasured proteins, phosphates and sulfates
•Normal anion gap is 8-12 meq/L (Varies from Lab to Lab)

How do you calculate anion gap?
For practical purposes anion gap is calculated using only Sodium, Chlorides and Total CO2.((140-(104+24)) = 12.

What are the compensatory measures for acid base disorders?
Compensatory measures

•Buffering---occurs immediately

•Respiratory regulation of pCO2 is intermediate (12-24 hours)

•Renal regulation of [H] and [HCO3] occurs more slowly (several days)

What is difference between bicarbonate value reported in arterial blood gases and bicarbonate reported in electrolytes?
Calculated bicarbonate:
•calculated using the H-H equation
•From arterial blood
Total CO2:
•measured from venous blood
•includes bicarbonate and dissolved carbon dioxide
•runs slightly higher than calculated value from nomogram

What is the metabolic compensation for acute respiratory acidosis? How do you assess whether it is appropriate?
Hypoventilation: Respiratory acidosis
•Expected bicarbonate decrease No time for renal compensation. ? for acute CO2 retention (Buffering)
•Expected decrease in pH = 0.08 x (measured PaCO2 - 40)

What is the metabolic compensation for chronic respiratory acidosis? How do you assess whether it is appropriate?
•Expected bicarbonate elevation for chronic CO2 retention (Renal compensation) is ?0.35 x (current PaCO2-normal PaCO2) ?For example: 0.35 x ( 60-40)=0.35x20=7 meq/l

•Chronic: Expected drop in pH = 0.03 x (measured PaCO2 - 40)

What is the metabolic compensation for acute respiratory alkalosis? How do you assess whether it is appropriate?
Hyperventilation:
•The expected fall in bicarb for acute decrease in PaCO2 (Buffering) is 0.2 x (normal PaCO2-observed PaCO2)

What is the respiratory compensation for chronic respiratory alkalosis? How do you assess whether it is appropriate?
•The expected fall in bicarb for chronic hyperventilation: decrease in PaCO2 (Renal compensation) is : 0.5 x (normal PaCO2-observed (PaCO2)
•Expected pH: Compensation is almost complete

What is the respiratory compensation for acute metabolic acidosis? What are the sensors and effectors for this response?
When it comes to metabolic acid base disorders we usually do not think in terms of acute and chronic. Most of them are chronic.

Acidosis increases respiratory drive, alveolar ventilation and gets rid of Carbonic acid.
Respiratory system can never completely compensate for a metabolic defect.

Respiratory compensation attempts to maintain pH in a reasonable range.

What is the respiratory compensation for chronic metabolic acidosis? How do you assess whether it is appropriate?
Metabolic acidosis •Expected PaCO2 decrease: (Normal bicarb-Observed bicarb) x 1.2
•You can use the following crude formula 0.1 change in pH 10 mm change of PaCO2. If all else is well the PaCO2 should be the same as decimal values of pH i.e. for a pH of 7.28, the CO2 levels would be 28 mmHg.

Estimation of expected PaCO2 for a given acidic pH also enables us to determine whether respiratory compensation is appropriate.

Compensation is never complete. If the pH is normal there is probably a superimposed second acid base disturbance.

What is the respiratory compensation for acute metabolic alkalosis? How do you assess whether it is appropriate?
When it comes to metabolic acid base disorders we usually think in terms of acute and chronic. Most of them are chronic.

What is the respiratory compensation for chronic metabolic alkalosis? How do you assess whether it is appropriate?
Metabolic alkalosis •Only when it is severe and protracted
•It is unusual to see CO2 retention (I don't agree with Books and others)
•Less predictable

What is bicarbonate gap?
The bicarbonate gap
•useful in identifying mixed acidbase disorders
•in single acidbase disorder the difference between anion gap and the change in total CO2 should be negligible
•in other words change in total CO2 (Normal total CO2-observed total CO2) should be equal to anion gap.
•Excess bicarbonate gap suggests metabolic alkalosis
•Decrease in the gap suggests metabolic acidosis

Explain renal mechanism for regulation of acid base disorders?
Major functions
1.Reclamation of filtered bicarbonate
2.Generation of new bicarbonate in the distal tubule to replenish body buffer stores
3.Excretion of Acid ?titratable acidity
?ammonium formation
?free H+ excretion

•a dumb kidney is usually better than a smart Doctor
•Reclamation of filtered bicarbonate ?4000 meq / day in normal persons

What are the common causes for high anion gap metabolic acidosis?
Increased anion gap
Either due to addition or reduced excretion of acid
•reduced excretion of inorganic acids
?renal failure
?retention of sulphates and phosphates
?impaired net acid excretion (ATN)
?impaired ammonia excretion (Chronic renal failure)
•accumulation of organic acids
?ketoacidosis
?diabetic
?starvation
?alcoholic
?lactic acidosis (impaired cellular respiration with anaerobic glycolysis)
?shock
?septicemia
?profound hypoxemia
?ingestion
?salicilates
?methanol

What are the common causes for normal anion gap metabolic acidosis?
Normal anion gap
Either due to loss or failure to generate bicarbonate
•abnormally high bicarbonate loss
?Kidney fails to reabsorb
?renal tubular acidosis
?Kidney fails to regenerate
?Diuretics
?extra renal loss of bicarbonate
?Diarrhea
?ileal drainage
?acidifying salts have been added
?hyperalimentation
?ammonium chloride

What are the common causes for metabolic alkalosis?
Metabolic alkalosis
•loss of hydrogen ions from the body
?vomiting
?gastric suction
•net rate of renal bicarbonate generation is greater than normal
?volume contraction
?potassium depletion
?increased delivery of sodium to distal tubule (Loop diuretics)
?minerelocorticoid excess
•Rapid correction of ventilation in a patient with chronic CO2 retention (posthypercapnic alkalosis)
In severe alkalosis
•Cardiac arrhythmia
•Hypoventilation

What are the common causes for respiratory acidosis?
Respiratory Acidosis
Decreased alveolar ventilation
•acute respiratory acidosis (normal bicarbonate)
?narcotic overdose
?respiratory muscle paralysis
?acute airway obstruction
•Chronic respiratory acidosis (increased bicarbonate)
?COPD
?kyphoscoliosis
?Obesity hypoventilation syndromes
•End stage restrictive pulmonary disease

What are the common causes for respiratory alkalosis?
Respiratory alkalosis
•Acute hyperventilation (Light headedness, paresthesias, circumvoral numbness, tingling of extremities and tetany.)
?pain
?acute salicylism
?fever
?sepsis
?CHF
?PE
?Mechanical ventilation
?anxiety (breath with a paper bag)
•Chronic hyperventilation
?high altitude
?hepatic insufficiency
?pregnancy
?Diffuse interstitial fibrosis

What are the factors that stimulate kidney to excrete acid?
Excretion of acid stimulated by
•Acidemia
•Hypercapnea
•Volume depletion
•Chloride depletion
•? Hypokalemia
•Aldosterone

What are the factors that inhibit kidney to excrete acid?
Excretion of acid inhibited by
•Alkalemia
•Elevated [HCO3]
•Hypocapnea
•? Hyperkalemia

How do you determine whether an acid base disorder is simple or mixed?
Single acid base disturbance: the change in concentration of one anion is balanced by a reciprocal change in one other anion.
Mixed acid base disturbance: the anion patterns are more complex
•Bicarbonate gap is not equal to anion gap ?Excess bicarbonate gap suggests metabolic alkalosis
?Decrease in the gap suggests metabolic acidosis

•CO2 levels not in keeping with estimates
•Bicarbonate levels as estimated by nomogram from arterial blood gas significantly varies from venous total CO2 (bicarbonate)

Explain CSF barrier for acid base disorders. How does it come into play clinically?
Blood brain barrier
•Freely permeable to CO2
?responses occur instantaneously

•lag in equilibrating with bicarbonate

?early stages of metabolic acidosis 2-3 hour lag in respiratory response

?hyperventilation may persist even after correction of metabolic acidosis

Give me your step by step approach to interpreting acid base disorders.
Approach to interpreting Acid-base disturbance
1.Is the patient Acidemic or Alkalemic
2.Identify the primary Acidbase disorder by evaluating HCO3 and PaCO2
What is the [HCO3]
?Elevated------Metabolic alkalosis if alkalotic
?Decreased ---- Metabolic acidosis if acidotic

What is the PaCO2
?Elevated ---Respiratory acidosis if acidotic
?Decreased --- Respiratory alkalosis if alkalotic
3.What is the anion gap (to determine etiology of Metabolic acidosis)
4.What is the bicarbonate gap (to evaluate mixed disorders)
5.Is the degree of compensation what you expect (appropriate)?
6.Identify and understand the pathophysiology for the disorder

Describe the buffer system.
Buffering-Bicarbonate is in both ICF and ECF and participates in buffering capacity
Extracellular
•almost entirely through bicarbonate whose concentration highest of all buffers
•small contribution from phosphate

Intracellular

Buffer systems

•Hemoglobin can directly buffer protons ?H+ entry into RBC matched by exit of Na and K+

Describe how kidney excretes acid.
Excretion of Acid
•Titratable acidity ?mainly with phosphate
?10-30 meq / day

•Ammonia formation ?H+ combines with N3HO from NH4+ which is trapped in tubule
?baseline 30-60 meq / day, but may rise to as much as 250-400 meq / day

Excretion of free [H]
•maximally acidified urine -- pH = 4.5 -- will account for only 0.04 meq +H / L
•urinary acidification is important in order to titrate protons into phosphate and ammonium

What is the relationship between Ventilation and pCO2
•PaCO2 is inversely proportional to ventilation
•Ventilation increases in response to a drop in pH ?respiratory center in medulla
?responds to pH "intermediate" between that of CSF and plasma
?response is rapid
?response is more predictable for falls in pH
?for increase in pH ventilation decreases only when it is severe and protracted

Interrelationship between acute changes in CO2 and pH
pCO2 pH
70 7.10
60 7.20
50 7.30
40 7.40
30 7.50
20 7.60
This formula is usable because in the range of pH values we usually deal with, there is nearly linear relationship between pH and pCO2.

How do you calculate the hydrogen ion concentration?
Types of Acid-Base Disorders
  1. Metabolic Acidosis

  2. Metabolic Acidosis, Fully Compensated

  3. Metabolic Acidosis, Partially Compensated

  4. Metabolic Acidosis, Uncompensated

  5. Metabolic Alkalosis

  6. Metabolic Alkalosis, Partially Compensated

  7. Metabolic Alkalosis, Uncompensated

  8. Respiratory Acidosis

  9. Respiratory Acidosis, Fully Compensated

  10. Respiratory Acidosis, Partially Compensated

  11. Respiratory Acidosis, Uncompensated

  12. Respiratory Alkalosis

  13. Respiratory Alkalosis, Fully Compensated

  14. Respiratory Alkalosis, Partially Compensated

  15. Respiratory Alkalosis, Uncompensated

The Four Primary Disturbances of Acid-Base Balance
  1. Primary Respiratory Acidosis
    • initiating event:  V?A (hypoventilation)
      • chronic obstructive pulmonary disease (COPD)
      • weak respiratory muscles (neuromuscular diseases)
      • barbiturate poisoning (central nervous system depression)
    • resultant effects:  CO2 retention
      •  PaCO2,  [H+] and  pH
    • compensations: 2? metabolic alkalosis
      •  HCO3- retention via PaCO2 effect on renal proximal tubules

  2. Primary Respiratory Alkalosis
    • initiating event:  V?A (hyperventilation)
      • salicylate intoxication (over-aggressive aspirin therapy)
      • CNS disorders
      • hyperexcitability
      • psychogenic paroxysmal hyperventilation ("brown paper bag" therapy)
      • artificial ventilation
    • resultant effects:  CO2 elimination
      •  PaCO2,  [H+] and  pH
    • compensations: 2? metabolic acidosis
      •  HCO3- retention via reverse PaCO2 effect on renal proximal tubules

  3. Primary Metabolic Acidosis
    • initiating events: renal and extrarenal
      • diabetes mellitus and ketoacidosis (larger than normal anion gap)
      • severe shock or heart failure and lactic acidosis (larger than normal anion gap)
      • diarrhea and loss of bicarbonate ions (normal anion gap)
      • renal tubular acidosis and retention of hydrogen ions (normal anion gap)
    • resultant effects:  [H+] and/or  [HCO3-],  pH
    • compensations: 2? respiratory alkalosis
      (with renal participation if possible)
      •  CO2 elimination via  acid drive on ventilation
      • Kussmaul respiration (characteristic deep labored breathing)

  4. Primary Metabolic Alkalosis
    • initiating events: renal and extrarenal
      • chronic potassium ion depletion (aggressive diuretic therapy, hyperaldosteronism)
      • protracted vomiting (pyloric obstruction, gastric ulcers) and loss of gastric acids
      • dehydration and depletion of extracellular fluid volume (contraction alkalosis)
    • resultant effects:  [H+] and/or  [HCO3-],  pH
      • urine pH will be paradoxically low (acidic) if there is chronic depletion of potassium ions
    • compensations: 2? respiratory acidosis
      (with renal participation if possible)
      •  CO2 retention via  acid drive on ventilation
      • hypoventilation also  PaO2 which may limit compensation (hypoxic drive on breathing)
Multiple Choice Questions- Acid Base Balance
Q.1- A person was admitted in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/l and pH 7.1. What is the underlying acid-base disorder?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.2- In a man undergoing surgery, it was necessary to aspirate the contents of the upper gastrointestinal tract. After surgery, the following values were obtained from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.3- A young woman is found comatose, having taken an unknown number of sleeping pills an unknown time before. An arterial blood sample yields the following values: pH – 6.90, HCO3- 13 meq/liter, PaCO2 68 mmHg. This patient’s acid-base status is most accurately described as
a) Uncompensated metabolic acidosis
b) uncompensated respiratory acidosis
c) simultaneous respiratory and metabolic acidosis
d) respiratory acidosis with partial renal compensation

Q.4- A student is nervous for a big exam and is breathing rapidly, what do you expect out of the followings
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.5- A 45- year-old female with renal failure, missed her dialysis and was feeling sick, what could be the reason?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.6- An 80-year-old man had a bad cold. After two weeks he said, “It went in to my chest, I am feeling tightness in my chest, I am coughing, suffocated and unable to breathe!” What could be the possible reason?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.7- A post operative surgical patient had a naso gastric tube in for three days. The nurse caring for the patient stated that there was much drainage from the tube that is why she felt so sick. What could be the reason?
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.8- The p H of the body fluids is stabilized by buffer systems. Which of the following compounds is the most effective buffer system at physiological pH?
a) Bicarbonate buffer
b) Phosphate buffer
c) Protein buffer
d) All of the above

Q.9- Which of the following laboratory results below indicates compensated metabolic alkalosis?
a) Low p CO2, normal bicarbonate and, high pH
b) Low p CO2, low bicarbonate, low pH
c) High p CO2, normal bicarbonate and, low p H
d) High pCO2, high bicarbonate and High pH

Q.10- The greatest buffering capacity at physiological p H would be provided by a protein rich in which of the following amino acids?
a) Lysine
b) Histidine
c) Aspartic acid
d) Leucine

Q.11- Which of the following is most appropriate for a female suffering from Insulin dependent diabetes mellitus with a pH of 7.2, HCO3-17 mmol/L and pCO2-20 mm HG
a) Metabolic Acidosis
b) Metabolic Alkalosis
c) Respiratory Acidosis
d) Respiratory Alkalosis

Q.12- Causes of metabolic alkalosis include all the following except.
a) Mineralocorticoid deficiency.
b) Hypokalemia
c) Thiazide diuretic therapy.
d) Recurrent vomiting.

Q.13- Renal Glutaminase activity is increased in-
a) Metabolic acidosis
b) Respiratory Acidosis
c) Both of the above
d) None of the above

Q.14- Causes of lactic acidosis include all except-
a) Acute Myocardial infarction
b) Hypoxia
c) Circulatory failure
d) Infections

Q.15- Which out of the following conditions will not cause respiratory alkalosis?
a) Fever
b) Anxiety
c) Laryngeal obstruction
d) Salicylate toxicity

Q.16- All are true about metabolic alkalosis except one-
a) Associated with hyperkalemia
b) Associated with decreased ionic calcium concentration
c) Can be caused due to Primary hyperaldosteronism
d) Can be caused due to Renin secreting tumor

Q.17- Choose the incorrect statement out of the followings
a) Deoxy hemoglobin is a weak base
b) Oxyhemoglobin is a relatively strong acid
c) The buffering capacity of hemoglobin is lesser than plasma protein
d) The buffering capacity of Hemoglobin is due to histidine residues.

Q.18- Carbonic anhydrase is present at all places except-
a) Gastric parietal cells
b) Red blood cells
c) Renal tubular cells
d) Plasma

Q.19- All are true for renal handling of acids in metabolic acidosis except
a) Hydrogen ion secretion is increased
b) Bicarbonate reabsorption is decreased
c) Urinary acidity is increased
d) Urinary ammonia is increased.

Q.20- Choose the incorrect statement about anion gap out of the followings
a) In lactic acidosis anion gap is increased
b) Anion gap is decreased in Hypercalcemia
c) Anion gap is decreased in Lithium toxicity
d) Anion gap is decreased in ketoacidosis.

Q.21- Excessive citrate in transfused blood can cause which of the following abnormalities?
a) Metabolic alkalosis
b) Metabolic acidosis
c) Respiratory alkalosis
d) Respiratory acidosis

Answers- 1-a, 2-b, 3-c, 4-d, 5-a, 6-c, 7-b, 8-a, 9-d, 10-b, 11-a, 12-a, 13-c, 14-d, 15-c, 16-a, 17-c, 18-d, 19-b, 20-d, 21-a

Intensivist
Who is an intensivist?
Intensivist: A physician who specializes in the care of critically ill patients, usually in an intensive care unit (ICU).

An intensivist, also known as a critical care physician, is a medical doctor with special training and experience in treating critically ill patients.

Intensivists are physicians who direct and provide medical care in a hospital's intensive care unit (ICU), working with the attending physician of record and other staff such as critical care nurses, pharmacists, respiratory therapists, nutritionists, rehabilitation services, social workers, case managers and especially spiritual care - as well as physician specialists

How are intensivists different than other specialists, such as cardiologists, who treat critically ill patients?
Intensivists provide a comprehensive approach to caring for ICU patients rather than focusing on specific body systems, such as cardiologists or pulmonologists. In many instances, they have the primary responsibility for the patient rather than acting as a consultant, as many specialists do. Depending on the intensivist program, critical care physicians provide round-the-clock ICU care rather than being on call off-site or spending most of their time seeing office patients, in surgery or treating patients in other parts of the hospital.

How is an intensivist-led ICU different than a traditional ICU?
In a traditional approach, primary care physicians have the chief responsibility for treating their critically ill patients. They often bring in specialists as needed, such as a nephrologist if the patient has a kidney problem or pulmonologist if the patient is placed on a ventilator.

There are some clear drawbacks to this approach. For one, primary care doctors have little experience with critically ill patients, who are often suffering from multi-system problems or diseases. These doctors might average a handful of such patients a year. They also cannot devote large amounts of their time to monitoring and managing ICU patients since they may have other hospital patients as well as many patients to see throughout the day at their offices. As a result, care is generally fragmented and poorly coordinated.

Intensivists, on the other hand, spend their time each day in the ICU treating the critically ill. They are trained and experienced in dealing with the complex issues of the sickest patients as well as treating, or when possible, averting complications that often arise quickly.

Hospitalist

What is a Hospitalist?
A Hospitalist is a physician that is trained to specifically treat and be responsible for patients in the hospital. These doctors practice in the hospital 24 hours a day, seven days a week to provide immediate and ongoing care without delay.

What about my Primary Care Physician?
The Hospitalist will coordinate your care with your primary care physician. By working together, the hospitalist will have a full understanding of your current health and medical history. The Hospitalist will examine you and coordinate all other exams, tests, and treatments while you are in the hospital. Upon discharge from the hospital your medical care will transition back to your primary care physician.

What is a Pediatric Hospitalist?
Pediatric hospitalists are pediatricians who work in hospitals providing care for children ages 0-18.

Critical care unit staff.
What resources are essential for a critical care unit (CCU)?
Internet with www.qureshiuniversity.com.
Critical care unit staff.
Critical care unit beds in a room.
Critical care unit equipment.

What are various types of care units within a critical care unit?
Neonatal intensive care unit (NICU)
Pediatric intensive care unit (PICU)
Psychiatric intensive care unit (PICU)
Coronary care unit (CCU): Also known as cardiac intensive care unit (CICU)
Post-anesthesia care unit (PACU)
High dependency unit (HDU)

How many critical care units are there in the world?
In 2013, every state in North America, Asia, Africa, Australia, and Latin America had 5-10 critical care units with 10-15 beds in each critical care unit.

What should a critical care unit do in case there is an issue relevant to a patient?
Call 7735616102 Chicago, Illinois, and leave a message.

Who is calling?
For example: I am Doctor Nasreen Jan Chashoo.
How old is the patient?
What is the diagnosis?
What treatment have you given so far?
What problem(s) are you having?
What is your contact information, including e-mail, telephone, and location?
Your call will be returned within hours or minutes.

What is critical care?

Critical care provides support for patients whose conditions are potentially life-threatening. These patients need: constant and close monitoring; support for their organ systems from specific equipment; and medication to keep the body functioning normally while they recover.

Heart attack; stroke; pneumonia; poisoning; surgical complications; major trauma resulting from accidents, burns, violence etc. are all examples of critical illness. Critical care deals with a wide range of conditions but typically all patients will have problems with one or more of their organ systems, particularly the respiratory (lungs) and cardiovascular (heart) organ systems. Patients usually require intensive monitoring and most need some form of support such as mechanical ventilation (breathing) and/or drugs to help the heart and circulation function.

The length of stay in the critical care unit can vary.

Monitors, intravenous (IV) tubes, feeding tubes, catheters, breathing machines, and other equipment are common in critical care units. They can keep a person alive, but can also increase the risk of infection.

Many patients in critical care recover, but some die. Having advance directives in place is important. They help health care providers and family members make end-of-life decisions if you are not able to make them.

Critical care medicine is the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury (SCCM definition).

Critical care is a maturing specialty whose practitioners are “intensivists” and who practice is moving from consult based “open” units, to multidisciplinary “closed” units.

Critical illness is a very specific series of disease syndromes which arise from an enormous spectrum of causes.

A wide variety of disease processes are treated with a limited number of interventions, in an intensive nursing environment.

It is important to differentiate patients who are in critical care units from those with “critical illness”, which is characterized by acute loss of physiologic reserve.

Critical illness should not be compartmentalized into medical and surgical, the problems experienced by critically ill patients and the treatments given are essentially the same, although the causes may differ.

Critical Care is about medicine, care, compassion and organization.

The best intensive care units are the ones with the most effective management structures.

Your first step to become a critical care practitioner is to understand critical illness.

Critical illness occurs when an injury overwhelms physiologic reserve to the extent that life cannot be sustained without outside intervention.

Physiologic reserve decreases with age and chronic disease

Law of Diminishing Reserve: prolonged critical illness depletes physiologic reserve.

There is no single indicator of reserve, although there are many different clinical and laboratory markers of individual organs’ reserve.

Multi-Organ Dysfunction Syndrome” is the internationally recognized term to describe loss of physiologic reserve and progressive organ injury through failure associated with critical illness.

Outcome prediction models and severity of illness scoring systems use chronic health information and age as indicators of physiologic reserve.

They also use markers of organ dysfunction to quantify how sick the patient is.

Polytrauma
What is Polytrauma?
Polytrauma is defined as two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability.

What is polytrauma with vision impairment and blindness?
What is a closed chest wound?
What is an abdominal injury?
What is a crush injury?
What is a chest injury?
What is an open chest wound?

Here are further guidelines.
http://www.qureshiuniversity.com/trauma.html

What is Critical Illness?

Critical illness is a condition where life cannot be sustained without invasive therapeutic interventions.

A wide variety of diseases may lead to critical illness; however the number of interventions required is limited.

A high ratio of nurses to patients is characteristic of intensive care units.

Many doctors and nurses have a very poor understanding of what constitutes an intensive care patient: they are not merely standard medical or surgical patients, sicker than normal, perhaps plugged into ventilators. All intensive care patients fit into one of the following categories:

Patients admitted to intensive care for intensive monitoring, in anticipation of possible aggressive interventions: this is the coronary care model. Patients admitted to units which act as extensions of the post-operative recovery room, allowing abnormal perioperative physiology to reverse, with or without modulation of the normal stress response. Post operative cardiac care is an example of this model. Patients who require very intense nursing care, which would not be available elsewhere: an example of this is a burns unit.

Patients who do not necessarily require life sustaining treatments, but whose physiology is taken under control in order to prevent organ injury: neurosurgical critical care.

Patients who have minimal physiologic reserve, and who undergo acute potentially reversible injury, requiring life support until the abnormalities have been reversed and reserve restored: this is the archetypical medical intensive care patient (COPD with pneumonia requiring mechanical ventilation).

Patients who undergo an massive disruption to their physiology, due to an overwhelming stress response to injury, or inadequate compensation to the response: this is the patient frequently seen in surgical intensive care units – major trauma or sepsis such as pancreatitis.

It is important that you are able to differentiate between the types of patients that you look after in ICU: for routine post operative surgical patients - fluid balance, analgesia and heart rate control (control over the stress response) may be the over-riding priorities; rather than feeding, for example. It is also important to realize that patients admitted under one category may enter another: a patient following coronary bypass surgery may develop severe sepsis or acute lung injury.

It is important to differentiate patients who are in critical care units from those with “critical illness”, which is characterized by acute loss of physiologic reserve.

The patients in groups 5 and 6 have “critical illness”: their admission to ICU has followed an injury which has depleted endogenous reserves, and death is inevitable without life supporting interventions. These patients do not follow predictable courses of illness, such as “the ebb and flow paradigm”, originally described by Cuthbertson.

In many cases the course of illness is prolonged, and the underlying causes difficult to discern. Indeed there appears to be great interpatient variability – two patients with the exact same injury may follow different paths: one may follow the standard stress response - acute compensation, followed by hypermetabolism and catabolism and, after 4 to 7 days, resolution with fluid mobilization and anabolism. The second patient may rapidly develop multi organ failure and remain in intensive care for a prolonged period of time.

Examples of organ system failure include:

1) Central nervous system failure
2) Circulatory failure
3) Shock
4) Acute renal failure
5) Acute hepatic failure
6) Acute metabolic failure
7) Respiratory failure

The following services are INCLUDED in critical care and should not be reported separately:

1) Cardiac output measurements
2) Chest X-ray interpretation
3) Pulse oximetry
4) ABGs
5) EKG interpretation
6) Gastric intubation
7) Transcutaneous pacing
8) Ventilator management
9) Peripheral venous access
10) Arterial puncture
Endotracheal Intubation
Health Calculators
Peripheral Intravenous Access
Intensive care unit management.
ICU Equipment
MICU SEDATION GUIDELINES
DIAGNOSTIC APPROACH TO ACID-BASE DISORDERS-1
METABOLIC ACIDOSIS IN ICU PATIENT
Muscle Relaxant
Medical ventilator
Operating room management
Pain Management
    Defining Pain
    Classifying Pain
    Types of Pain
    The Assessment of the Patient with Pain
    Core questions to be answered as part of a pain assessment:
    Acute vs. Chronic Pain
    Psychogenic Pain
    Pain Control after Surgery
    Pelvic Pain
    Abdominal Pain
    Vascular Pain
    Pain Resources
    Treatment & Care
Pre-Anesthesia Consultation
Postanesthesia care unit (PACU)
Postoperative Care
Rapid Sequence Intubation
Mechanical Ventilation - Critical Care Medicine Tutorials
Weaning from Mechanical Ventilation
Agitation in Intubated Patients
Q: Is there anything else that anesthesiologists do?

Would you like to add anything?
Do you have better answer?
Does anyone else have a better answer?
Would you like to print Dr. Qureshi's research and development in Anaesthesia and Critical Care?

admin@qureshiuniversity.com
Are you an anesthetist?
Are you ready to answer relevant questions?
Would you like your profile to be displayed here?
Forward your profile with a photograph.
Here are further guidelines.
http://www.qureshiuniversity.com/criticalcare.html

Health Calculations
What are various health calculations?
How are various health calculations done?
When does a newborn need intensive care?
What is the Apgar score?
How do you calculate the Apgar score?
How do you calculate child growth and development?
When does a head injury need intensive care?
When does a postoperative case need intensive care?
What is the Glasgow Coma Scale?
How do you calculate the Glasgow Coma Scale?
When does respiratory failure need intensive care?
How do you calculate respiratory failure?
When does chronic renal failure need intensive care?
How do you calculate chronic renal failure?
When does acute renal failure need intensive care?
How do you calculate acute renal failure?
When does chronic heart failure need intensive care?
How do you calculate chronic heart failure?
When does live failure need intensive care?
How is liver failure calculated?
How is the due date of human pregnancy calculated?
How is the ideal body weight calculated?
How is starvation calculated?
How is malnutrition calculated?
How is the extent of disability calculated?
How is the drug dose for various age groups calculated?
How is heart rate on ECG calculated?
How is daily nutritional calorie intake calculated?
How is the body mass index calculated?
How is waist to hip ratio calculated?
How is cardiac risk calculated?
How are life stresses calculated?
How are water, sodium, and glucose requirement in acute dehydration calculated?
How are water, sodium, and glucose requirement in acute dehydration in adults calculated?
How is the number of times of specific exercise in physiotherapy calculated?
How is creatinine clearance calculated?
How is the number of hours a chronic renal failure needs dialysis calculated?
How is the resting metabolic rate calculated?
How is the medical ventilator configuration in critical care calculated?
How is the everyday exercise requirement for an adult calculated?
How is the everyday exercise requirement for schoolchildren calculated?
How is the quantity of water one needs every day calculated?
How is the quantity of nutrients one needs every day calculated?

How is the quantity of protein one needs every day calculated?

You need these values.
Age in years: 44.
Height in feet: 5 feet 10 inches
Gender: Male
Frame size (small, medium, large): Medium
Physical activity level: ???
Your daily protein intake should be more than 92 grams.

How is total calorie intake per person calculated?
The information supplied by you is as follows:
Age: 44 Years
Gender: Male
Weight: 75 Kgs (165.37 pounds)
Height: 178 Cms

For the above age, gender, weight, and height, you Require 2905.4175 calories daily.

Unconsciousness or Coma
Glasgow Coma scale analysis.
First, analyze Glasgow Coma scale, then analyze vital signs including consciousness.

When was the patient normal?
Can the patient open both eyes spontaneously?
Can the patient talk or make noise relevant to age?
Can the patient walk or move extremities relevant to age?


If yes, Glasgow Coma scale is 15.
Glasgow Coma scale of 15 means the patient is not in a coma.
The patient can have less serious medical issues.
Go ahead with vital signs, including consciousness.

When should you do on-the-spot endotracheal intubation?
If Glasgow coma scale is 9 or less with airway obstruction, even with gag reflex, you should intubate the patient.

Do you know how to calculate Glasgow coma scale?
How do you intubate a patient in coma with Glasgow coma scale less than 9 with gag reflex in respiratory distress?

When should you start an on-the-spot intravenous line?

If there is blood loss with hypotension.
In case of cardiopulmonary arrest.

Cardiopulmonary resuscitation if required.

The nearest hospital with critical care is 20 minutes by vehicle.
In case of head injury with coma, prolonging diagnosis and treatment for 20 minutes may cause patient to die.

That is what happened in this case.
Patient died even though seen by a neurosurgeon and an anesthetist.

Medical emergency diagnosis and treatment of trauma with coma with respiratory distress, or imbalance in circulation, should happen within 4-6 minutes of occurrence or report of a medical emergency.

Is that clear?
Do you have any questions for me?

Ability to perform calculations: Can the patient perform simple addition, multiplication, subtraction, and division? Are the responses appropriate for the patient’s level of education?
Are there any problems in calculations?


Consciousness

Level of alertness: Is the patient conscious?
If not, can the patient be awakened?
Can the patient remain focused on your questions and conversation?
What is attention span of the patient?

In case of altered sensorium, get answers to these questions.

How would you rate Glasgow Coma Scale of this patient in the range of 3—15, with a score of 3 indicating brain death (the lowest defined level of consciousness), and 15 indicating full consciousness?


Language

How are English language understanding, reading, writing, and speaking abilities of the individual?
The individual can understand, read, write, and speak the English language.
The individual is unable to understand, read, write, and speak the English language.

Assessment by medical emergency specialist in emergency medical situation.

What should be your focus of assessment in an emergency medical situation?
Glasgow coma scale.
Vital signs, including consciousness.
No pain, wounds, or abnormal findings that needs emergency treatment.
Mobility assessment (Is individual able to walk or make limb movements relevant to age?)
What is the profile of activities of daily living of the person, relevant to his/her age?
Is there any abnormality in activities of daily living of the person, relevant to his/her age?
Survival needs assessment.
Emotion: Anger, sadness, fear or emotions not relevant to situation need further evaluation

Admission and Discharge Criteria: Critical Care Services
Criteria for discharge from medical emergency room

1. Glasgow coma scale: 15.
2. Vital signs including consciousness: Normal
3. Mobility assessment: Normal.
4. Survival needs assessment: Yes.
5. Emotions: Normal relevant to situation.
6. Psychiatric evaluation if required: Normal

Emergency diagnosis and treatment and disability assessment are two different assessments.
For example, a person can be 100% mentally fit and 95% physically fit.

This is relevant to the individual’s age.
1. Vital signs including consciousness: Normal

Are vital signs including consciousness normal?
Yes.

No pain, wounds, or abnormal findings that needs emergency treatment.

2. Glasgow coma scale: 15.

Is Glasgow coma scale 15?
Yes.

3. Mobility assessment

Is individual able to walk or make limb movements relevant to age?
Normal

4. Survival needs assessment.

Does the individual have survival needs form the state?
Yes.

Is it safe for the individual at the residence?

5. Emotions: Anger, sadness, fear, or emotions not relevant to situation needs further evaluation. Normal.

Are emotions expression normal relevant to situation?

6. Psychiatric evaluation if required.

Is this individual mentally fit relevant to age?

Advice on discharge from medical emergency room.
This depends on original complaint and diagnosis with relevant treatment.
Treatment depends on the underlying cause.

What best describes the individual’s emotions at this point?

Basic life support
What should you know about basic life support?
Basic life support is meant for an unconscious patient.
All unconscious patients need basic life support.
Not all unconscious patients need cardiopulmonary resuscitation (breathing support, chest compressions). Only unconscious patients with cardiac arrest or respiratory arrest need cardiopulmonary resuscitation including breathing support and chest compressions).

Does the unconscious patient need basic life support with CPR or without CPR?

If the unconscious patient needs basic life support with cardiopulmonary resuscitation with chest compressions here are further guidelines.
http://www.qureshiuniversity.com/bls.html

Cardiopulmonary resuscitation guidelines.

Unconscious patient.

What type of patient needs basic life support?
An unconscious patient.

Do all unconscious patients need cardiopulmonary resuscitation?
No.

How should you evaluate and treat an unconscious patient?
Assessment is very important.
Not all unconscious patients need cardiopulmonary resuscitation.
For adults, assess the victim, activate EMS and get AED, check pulse, start CPR.

Cardiopulmonary resuscitation guidelines.

When do you start cardiopulmonary resuscitation in adults?
CPR is required someone's breathing or heartbeat has stopped, as in cases of electric shock, drowning, or heart attack. CPR is a lifesaving procedure in this situation.

What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation is a combination of rescue breathing and chest compressions.
Rescue breathing provides oxygen to a person's lungs.
Chest compressions keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue these procedures until the person's heartbeat and breathing return, or trained medical help arrives.

In what situations is a directive like "Do not Resuscitate" justified?
Old age more than 95 years with known complications.

What is unconsciousness?
Unconsciousness means being unable to see, hear, and talk.
Often, this is called a coma or being in a comatose condition.
An unconsciousness person will be unresponsive to activity, touch, sound, or other stimulation.
He or she will not be able to communicate and won’t respond to stimulation.

Conscious means able to see, hear, and talk.
In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking.

A person may be unconscious for a few seconds (as is the case with fainting) or for longer periods of time.

What are the causes of unconsciousness?
Alcohol use.
Drowning.
Electric shock
Substance abuse
Severe blood loss
8 H's and 6 T's: mnemonic for mechanisms
Hypoxia
Hypovolemia
Hyperkalemia
Hypokalemia
Hypoglycemia
Hypothermia
Hyperthermia (heat stroke)
Hydrogen ions (acidosis)
Thrombosis (MI/heart attack)
Tension pneumothorax
Tamponade
Toxins/therapeutics
Thromboembolism
Trauma

Advanced Cardiovascular Life Support (ACLS)
What is an advanced life support?
Advanced Life Support is the last step in the Chain of Survival and the beginning of patient recovery. ALS stabilizes the patient while therapy continues to be provided. Providers assess and treat the underlying causes of the patient's condition so as to prevent regression.

H’s and T’s of ACLS

Reversible Causes of Cardiac Arrest: H's and T's

Reversible Causes of Cardiac Arrest: H's and T's

Many different traumatic and medical conditions can lead to cardiac arrest in both adults and children. For example, electrical abnormalities, inherited disorders and structural changes in the heart can lead to cardiac arrest. Determining and treating the cause of cardiac arrest is critical to improving patient outcomes. Fortunately, many causes of cardiac arrest are reversible, including the conditions listed below. These conditions are often referred to by the mnemonic “H’s and T’s”:

Hypoxia: Hypoxia is a deficiency in the level of oxygen that reaches the tissues. This problem can occur due to a variety of conditions, such as lung disorders i.e. COPD and asthma. The condition can be reversed by administering oxygen either through BiPAP, a mechanical ventilator, or oxygen mask if the patient has spontaneous respirations.

Hypovolemia: One common cause of cardiac arrest is hypovolemia, which can develop due to excessive fluid or blood loss. It can occur as a result of extreme sweating, severe diarrhea and/or vomiting, or traumatic blood loss. Severe burns can also lead to hypovolemia. After initiating CPR, an intravenous line should be established if possible. The condition is reversed by administering fluids and blood products.

Hypothermia: Although not as common as other causes, hypothermia can also lead to cardiac arrest. When the body’s core temperature drops below 30 degrees Celsius, cardiac output is decreased, which can lead to cardiac arrest. The body may not respond to CPR and defibrillation during the hypothermic state, thus rewarming should be implemented as soon as possible. Depending on how low the body temperature is, passive external rewarming or active internal rewarming may be indicated.

Hypokalemia/Hyperkalemia: Potassium is an electrolyte which plays a role in maintaining normal contraction of the myocardium. If levels become too high or too low, cardiac arrest may ensue. Causes of hypokalemia include excessive vomiting/diarrhea or use of diuretics. Chronic kidney disease can also lead to potassium loss. Treatment may include a controlled but rapid infusion of potassium. Hyperkalemia may be caused by kidney disease, diabetes and as a side effect of certain drugs. Hyperkalemia can be treated by administering sodium bicarbonate or calcium chloride or by performing dialysis.

Hydrogen Ion (Acidosis) Acidosis can be either metabolic or respiratory. Either cause can lead to cardiac arrest. An arterial blood gas is a quick and accurate method to determine if a patient is acidotic. If a patient has respiratory acidosis, she or he can be treated by providing adequate ventilation. Metabolic acidosis may be treated by administering sodium bicarbonate.

Tension Pneumothorax: A tension pneumothorax develops when there is a buildup of air in the pleural space. The buildup causes a shift in the mediastinum and venous return to the heart is obstructed, which can lead to cardiac arrest. Signs of a tension pneumothorax may include unequal breath sounds, tracheal deviation, difficult ventilation and JVD. The condition can be treated with a needle decompression and/or insertion of a chest tube.

Tamponade (Cardiac): Another reversible cause of cardiac arrest is cardiac tamponade. The condition occurs when fluid or blood fills the pericardium. The fluid puts pressure on the heart and prevents the ventricles from filling properly. It may be caused by trauma to the chest such as a gunshot wound or by inflammation of the pericardium. A pericardiocentesis or a thoracotomy is needed to remove the fluid.

Toxins: One of the most common causes of cardiac arrest is ingestion of a toxins, or an overdose of some type of medication or street drug. One sign of cardiac arrest due to a drug overdose is a prolonged QT interval. In addition to supportive care, a reversing agent may be administered. For example, Narcan may be administered to reverse the effects of narcotic overdose.

Thrombosis Pulmonary: A pulmonary embolism can lead to cardiac arrest in some instances. A pulmonary embolism usually develops after a blood clot in another area of the body, such as the leg, travels to the pulmonary artery in the lung, leading to cardiac arrest. Prior to the arrest, the patient may exhibit symptoms such as shortness of breath, chest pain, decreased oxygen levels and a cough. Treatment usually includes embolectomy, fibrinolytic therapy or anticoagulant therapy.

Thrombosis Coronary: A coronary thrombosis is a blockage within the coronary artery. It occurs due to blood which has clotted in the vessel. The occlusion in the vessel prevents blood flow to the heart. Cardiac arrest can occur depending on the location and extent of the blockage. Treatment includes angioplasty and stent placement or coronary bypass surgery.


Cardiopulmonary resuscitation guidelines.

When do you start cardiopulmonary resuscitation in adults?
CPR is required someone's breathing or heartbeat has stopped, as in cases of electric shock, drowning, or heart attack. CPR is a lifesaving procedure in this situation.

What is cardiopulmonary resuscitation?
Cardiopulmonary resuscitation is a combination of rescue breathing and chest compressions.
Rescue breathing provides oxygen to a person's lungs.
Chest compressions keep the person's blood circulating.
Permanent brain damage or death can occur within minutes if a person's blood flow stops. Therefore, you must continue these procedures until the person's heartbeat and breathing return, or trained medical help arrives.

Here are further guidelines.

In what situations is a directive like "Do not Resuscitate" justified?
Old age more than 95 years with known complications.

What is the difference between being asleep and being unconscious?
Being asleep is not the same thing as being unconscious.
A sleeping person will respond to loud noises or gentle shaking; an unconscious person will not.

An unconscious person cannot cough or clear his or her throat. This can lead to death if the airway becomes blocked.

Is there a difference between unconsciousness and cardiopulmonary arrest?
Yes.

What is the difference between unconsciousness and cardio pulmonary arrest?
Unconsciousness is usually without cardiac arrest.
If unconsciousness is associated with cardiac arrest or respiratory arrest, cardiopulmonary resuscitation is required.

http://www.qureshiuniversity.com/comadiagnosis.html

Dehydration, Rehydration, and Hyperhydration
Dehydration and Oral Rehydration
Dehydration in Adults
Dehydration in Children

Dehydration means that the body has lost too much fluid. Dehydration can be caused by not drinking enough fluids, vomiting, or diarrhea.

Unconsciousness or Coma
How does one diagnose and treat an unconscious patient?

Eye Opening

Can the patient do spontaneous eye opening?
Is the patient capable of opening eyes to speech, to stimulus, to pain not applied to face, breast, genitals or not opening his/her eyes?

Spontaneous eye opening ? 4 points
Opens to verbal command, speech, or shout ? 3 points
Opens to pain, not applied to face ? 2 points
None ? 1 point

Verbal Response

Oriented ? 5 points

Is patient confused?
Confused conversation, but able to answer questions ? 4 points

Is patient making inappropriate responses?
Inappropriate responses, words discernible ? 3 points

Can patient make any incomprehensible spoken sounds or no spoken sounds?
Incomprehensible speech ? 2 points
None ? 1 point

Motor Response

Can patient move all extremities when instructed?
Obeys commands for movement ? 6 points

Can patient do purposeful movement to painful stimulus?
Purposeful movement to painful stimulus ? 5 points

Can patient withdraw from painful stimulus?
Withdraws from pain ? 4 points

Is there any spasticity or rigidity?
Abnormal (spastic) flexion, decorticate posture ? 3 points
Extensor (rigid) response, decerebrate posture ? 2 points
Is there any movement of extremities?
None ? 1 point

Did the coma start abruptly or gradually?
Were there problems with vision, dizziness, or numbness beforehand?
What is the Glasgow Coma Scale?
How is the Glasgow Coma Scale helpful?
Can a patient's diagnosis and treatment be done without the Glasgow Coma Scale?
How do you define coma?
What is the mathematical value of coma?
Is evaluation of coma in adults different than in children?
Here are further guidelines.
Here are further guidelines.

Respiratory (Lung) Failure
Answers to questions a physician on duty or physician’s supervisor on duty must know.

What is respiratory failure?
What are other names for respiratory failure?
What causes respiratory failure?
What are the types of respiratory failure?
What is the difference between acute and chronic respiratory failure?
What recommendations are there from a physician for chronic respiratory insufficiency?
What location does acute respiratory failure and chronic respiratory failure need treatment?
Who is at risk for respiratory failure?
What are the signs and symptoms of respiratory failure?
How is respiratory failure diagnosed?
Is there a difference between pediatric respiratory failure and adult respiratory failure?
What are the differences between pediatric respiratory failure and adult respiratory failure?
When does a person get combination of acute and chronic respiratory failure?
How have computers and Internet enhanced human heath care around the planet earth?
How do you differentiate between an acute and chronic medical condition?
What is the best location for critical care in the state or outside the state?
What are examples of chronic respiratory insufficiency?
How is respiratory failure treated?
What do you have to do living with respiratory failure?
What were clinical trials findings in recent months or a year?
What useful links are there relevant to this issue?
What is the difference between types 1 and type 2 respiratory failure?


Acute Respiratory Failure

What is acute respiratory failure?
What are the causes of acute hypoxemic respiratory failure?
What are the symptoms of acute respiratory failure?
What is the treatment for acute respiratory failure?
What are the individuations of mechanical ventilation in acute hypoxemic respiratory failure?
What should an internist know about mechanical ventilation?
What are the types of mechanical ventilation?


Chronic Respiratory Failure

What is chronic respiratory failure?
What are the causes of chronic respiratory failure?
What are the symptoms of chronic respiratory failure?
How is chronic respiratory failure diagnosed?
What is the treatment for chronic respiratory failure?


Pediatric respiratory failure

Is there a difference between pediatric respiratory failure and adult respiratory failure?
Yes.

What are the differences between pediatric respiratory failure and adult respiratory failure?

Many causes of pediatric respiratory failure, especially in neonates, are entirely different than causes of adult respiratory failure that may be acute or chronic.

Acid Base Balance in the Human Body

How should you answer these questions?
This depends on the type of question.
Answer should be a number, one word, or a list of words or terms.
Answers like this have accuracy.
After a number, one word or a list of words or terms, you can elaborate further.
Here are various examples.

What is the average pH in human blood?
7.4

What is the pH ranges of human blood?
7.35 to 7.45.

What are examples of various human acid-based disorders?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Mixed acid-based disorders
What is respiratory failure?
Respiratory failure is a condition in which not enough oxygen passes from your lungs into your blood. Your body's organs, such as your heart and brain, need oxygen-rich blood to work well.

Respiratory failure also can occur if your lungs can't properly remove carbon dioxide (a waste gas) from your blood. Too much carbon dioxide in your blood can harm your body's organs.

Both of these problems—a low oxygen level and a high carbon dioxide level in the blood—can occur at the same time.

Diseases and conditions that affect your breathing can cause respiratory failure. Examples include COPD (chronic obstructive pulmonary disease) and spinal cord injuries. COPD prevents enough air from flowing in and out of the airways. Spinal cord injuries can damage the nerves that control breathing.

Respiratory failure is not a disease per se but a consequence of the problems that interfere with the ability to breathe. The term refers to the inability to perform adequately the fundamental functions of respiration: to deliver oxygen to the blood and to eliminate carbon dioxide from it. Respiratory failure has many causes and can come on abruptly (acute respiratory failure)—when the underlying cause progresses rapidly—or slowly (chronic respiratory failure)—when it is associated over months or even years with a progressive underlying process. Typically, respiratory failure initially affects the ability either to take up oxygen (referred to as oxygenation failure) or to eliminate carbon dioxide (referred to as ventilatory failure). Eventually, both functions cease when the respiratory failure becomes severe enough.

Overview

To understand respiratory failure, it helps to understand how the lungs work. When you breathe, air passes through your nose and mouth into your windpipe. The air then travels to your lungs' air sacs. These sacs are called alveoli (al-VEE-uhl-eye).

Small blood vessels called capillaries run through the walls of the air sacs. When air reaches the air sacs, the oxygen in the air passes through the air sac walls into the blood in the capillaries. At the same time, carbon dioxide moves from the capillaries into the air sacs. This process is called gas exchange.

In respiratory failure, gas exchange is impaired.

Respiratory failure can be acute (short term) or chronic (ongoing). Acute respiratory failure can develop quickly and may require emergency treatment. Chronic respiratory failure develops more slowly and lasts longer.

Signs and symptoms of respiratory failure may include shortness of breath, rapid breathing, and air hunger (feeling like you can't breathe in enough air). In severe cases, signs and symptoms may include a bluish color on your skin, lips, and fingernails; confusion; and sleepiness.

One of the main goals of treating respiratory failure is to get oxygen to your lungs and other organs and remove carbon dioxide from your body. Another goal is to treat the underlying cause of the condition.

Acute respiratory failure usually is treated in an intensive care unit. Chronic respiratory failure can be treated at home or at a long-term care center.

Outlook

The outlook for respiratory failure depends on the severity of its underlying cause, how quickly treatment begins, and your overall health.

People who have severe lung diseases may need long-term or ongoing breathing support, such as oxygen therapy or the help of a ventilator (VEN-til-a-tor). A ventilator is a machine that supports breathing. It blows air—or air with increased amounts of oxygen—into your airways and then your lungs.

Other Names for Respiratory Failure

What are other names for respiratory failure?
•When respiratory failure causes a low level of oxygen in the blood, it's called hypoxemic (HI-pok-SE-mik) respiratory failure.
•When respiratory failure causes a high level of carbon dioxide in the blood, it's called hypercapnic (HI-per-KAP-nik) respiratory failure.

What causes respiratory failure?
Diseases and conditions that impair breathing can cause respiratory failure. These disorders may affect the muscles, nerves, bones, or tissues that support breathing, or they may affect the lungs directly.

When breathing is impaired, your lungs can't easily move oxygen into your blood and remove carbon dioxide from your blood (gas exchange). This can cause a low oxygen level or high carbon dioxide level, or both, in your blood.

Respiratory failure can occur as a result of:
•Conditions that affect the nerves and muscles that control breathing. Examples include muscular dystrophy, amyotrophic lateral sclerosis (ALS), spinal cord injuries, and stroke.

•Damage to the tissues and ribs around the lungs. An injury to the chest can cause this damage.
•Problems with the spine, such as scoliosis (a curve in the spine). This condition can affect the bones and muscles used for breathing.
•Drug or alcohol overdose. An overdose affects the area of the brain that controls breathing. During an overdose, breathing becomes slow and shallow.
•Lung diseases and conditions, such as COPD (chronic obstructive pulmonary disease), pneumonia, ARDS (acute respiratory distress syndrome), pulmonary embolism, and cystic fibrosis. These diseases and conditions can affect the flow of air and blood into and out of your lungs. ARDS and pneumonia affect gas exchange in the air sacs. •Acute lung injuries. For example, inhaling harmful fumes or smoke can injure your lungs.

Who is at risk for respiratory failure?
People who have diseases or conditions that affect the muscles, nerves, bones, or tissues that support breathing are at risk for respiratory failure. People who have lung diseases or conditions also are at risk for respiratory failure.

What are the signs and symptoms of respiratory failure?
The signs and symptoms of respiratory failure depend on its underlying cause and the levels of oxygen and carbon dioxide in the blood.

A low oxygen level in the blood can cause shortness of breath and air hunger (feeling like you can't breathe in enough air). If the level of oxygen is very low, it also can cause a bluish color on the skin, lips, and fingernails. A high carbon dioxide level can cause rapid breathing and confusion.

Some people who have respiratory failure may become very sleepy or lose consciousness. They also may develop arrhythmias (ah-RITH-me-ahs), or irregular heartbeats. These symptoms can occur if the brain and heart are not getting enough oxygen.

How is respiratory failure diagnosed?
Your doctor will diagnose respiratory failure based on your medical history, a physical exam, and test results. Once respiratory failure is diagnosed, your doctor will look for its underlying cause.

Medical History

Your doctor will ask whether you might have or have recently had diseases or conditions that could lead to respiratory failure.

Examples include disorders that affect the muscles, nerves, bones, or tissues that support breathing. Lung diseases and conditions also can cause respiratory failure.

Physical Exam

During the physical exam, your doctor will look for signs of respiratory failure and its underlying cause.

Respiratory failure can cause shortness of breath, rapid breathing, and air hunger (feeling like you can't breathe in enough air). Using a stethoscope, your doctor can listen to your lungs for abnormal sounds, such as crackling.

Your doctor also may listen to your heart for signs of an arrhythmia (irregular heartbeat). An arrhythmia can occur if your heart doesn't get enough oxygen.

Your doctor might look for a bluish color on your skin, lips, and fingernails. A bluish color means your blood has a low oxygen level.

Respiratory failure also can cause extreme sleepiness and confusion, so your doctor might check how alert you are.

Diagnostic Tests

To check the oxygen and carbon dioxide levels in your blood, you may have:
•Pulse oximetry. For this test, a small sensor is attached to your finger or ear. The sensor uses light to estimate how much oxygen is in your blood.

•Arterial blood gas test. This test measures the oxygen and carbon dioxide levels in your blood. A blood sample is taken from an artery, usually in your wrist. The sample is then sent to a laboratory, where its oxygen and carbon dioxide levels are measured.

A low level of oxygen or a high level of carbon dioxide in the blood (or both) is a possible sign of respiratory failure.

Your doctor may recommend other tests, such as a chest x ray, to help find the underlying cause of respiratory failure. A chest x ray is a painless test that takes pictures of the structures inside your chest, such as your heart, lungs, and blood vessels.

If your doctor thinks that you have an arrhythmia as a result of respiratory failure, he or she may recommend an EKG (electrocardiogram). An EKG is a simple, painless test that detects and records the heart's electrical activity.

How is respiratory failure treated?
Treatment for respiratory failure depends on whether the condition is acute (short-term) or chronic (ongoing) and its severity. Treatment also depends on the condition's underlying cause.

Acute respiratory failure can be a medical emergency. It often is treated in an intensive care unit at a hospital. Chronic respiratory failure often can be treated at home. If chronic respiratory failure is severe, your doctor may recommend treatment in a long-term care center.

One of the main goals of treating respiratory failure is to get oxygen to your lungs and other organs and remove carbon dioxide from your body. Another goal is to treat the underlying cause of the condition.

Oxygen Therapy and Ventilator Support

If you have respiratory failure, you may receive oxygen therapy. Extra oxygen is given through a nasal cannula (two small plastic tubes, or prongs, that are placed in both nostrils) or through a mask that fits over your nose and mouth.

Oxygen Therapy

Treatments for the Underlying Cause of Respiratory Failure

Once your doctor figures out what's causing your respiratory failure, he or she will plan how to treat that disease or condition. Treatments may include medicines, procedures, and other therapies.

Living With Respiratory Failure

One of the main goals of treating respiratory failure is to treat the underlying cause of the condition. However, sometimes it's hard to cure or control the underlying cause. Thus, respiratory failure may last for weeks or even years. This is called chronic respiratory failure.

Oxygen therapy and other treatments can help you breathe easier. However, your oxygen and carbon dioxide levels still may not be normal. Thus, you may have one or more of the following symptoms:
Shortness of breath
Rapid breathing
Tiredness and confusion

These symptoms may go away within a few weeks or last longer. Talk with your doctor about how to deal with these symptoms, and read the tips below.

Ongoing Care

If you have respiratory failure, see your doctor for ongoing medical care. Your doctor may refer you to pulmonary rehabilitation (rehab).

Rehab can involve exercise training, education, and counseling. Your rehab team might include doctors, nurses, and other specialists. They'll work with you to create a program that meets your needs.

If you smoke, quit. Talk to your doctor about programs and products that can help you quit smoking. Also, try to avoid secondhand smoke.

If you have trouble quitting smoking on your own, consider joining a support group. Many hospitals, workplaces, and community groups offer classes to help people quit smoking.

If you're on oxygen therapy, don't smoke. Oxygen isn't explosive, but it can worsen a fire. In the presence of oxygen, a small fire can quickly get out of control. Also, the cylinder that compressed oxygen gas comes in can explode when exposed to heat.

For more information about how to quit smoking, go to the Health Topics Smoking and Your Heart article. Although this resource focuses on heart health, it includes basic information about how to quit smoking.

Emotional Issues and Support

Living with respiratory failure may cause fear, anxiety, depression, and stress. Talk about how you feel with your health care team. Talking to a professional counselor also can help. If you're very depressed, your doctor may recommend medicines or other treatments that can improve your quality of life.

Joining a patient support group may help you adjust to living with respiratory failure. You can see how other people who have the same symptoms have coped with them. Talk to your doctor about local support groups or check with an area medical center.

Support from family and friends also can help relieve stress and anxiety. Let your loved ones know how you feel and what they can do to help you.

Prepare for Emergencies

If you have chronic respiratory failure, knowing when and where to seek help for your symptoms is important. You should seek emergency care if you have severe symptoms, such as trouble catching your breath or talking.

Call your doctor if you notice that your symptoms are worsening or if you have new signs and symptoms. Your doctor may change or adjust your treatments to relieve and treat symptoms.

Keep phone numbers handy for your doctor, hospital, and someone who can take you for medical care. You also should have on hand directions to the doctor's office and hospital and a list of all the medicines you're taking.

Chronic Respiratory Failure

What is chronic respiratory failure?
What are the causes of chronic respiratory failure?
What are the symptoms of chronic respiratory failure?
How is chronic respiratory failure diagnosed?
What is the treatment for chronic respiratory failure?


What is chronic respiratory failure?
Respiratory failure may be acute or chronic.

Acute respiratory failure is short term and chronic respiratory failure is long term. Acute respiratory failure happens suddenly and is treated as a medical emergency. Chronic respiratory failure develops over a longer amount of time and requires long-term treatment.

Chronic respiratory failure can also be classified as hypoxemic or hypercapnic respiratory failure. Low blood oxygen levels cause hypoxemic respiratory failure. High carbon dioxide levels cause hypercapnic respiratory failure.

What are the causes of chronic respiratory failure?
COPD (chronic obstructive pulmonary disease)
Spinal cord injuries
Nerve damage (involving the nerves that controls breathing)
Chronic alcohol abuse suppresses the respiratory center

What are the symptoms of chronic respiratory failure?
Difficulty breathing
Bluish tint to the skin or lips (due to oxygen deprivation)
Bluish fingernails
Rapid breathing
Fatigue
Agitation, anxiety, confusion or sleepiness

How is chronic respiratory failure diagnosed?
Medical History
Physical Examination

Pulse Oximetry Test

The doctor will measure your oxygen level using a small sensor that’s placed on the tip of your finger to see if you are getting enough oxygen. This is called the pulse oximetry test. In healthy patients, normal oxygen saturation will be 96 to100 percent. A low percentage, under 90 percent, indicates a abnormal or low oxygen level.

Arterial Blood Gas Test

The arterial blood gas test is a test used to check the level of oxygen and carbon dioxide in your blood. A doctor or nurse will take blood from the artery in your wrist. Then, they will send the blood to a lab for testing. The results of this test indicate the amount of oxygen and carbon dioxide in your blood.

What is the treatment for chronic respiratory failure?
Treating Chronic Respiratory Failure

Although acute respiratory failure is a medical emergency that must be treated in a hospital, chronic respiratory failure can be treated at home. In severe cases, medical professionals can help you manage it in a long-term health care center.

Treatment options typically include:
•treating the cause of the respiratory failure
•removing excess carbon dioxide from your body
•increasing your blood oxygen levels

Oxygen Therapy

If you don’t have enough oxygen in your blood, you may receive oxygen therapy. Oxygen therapy increases oxygen in your blood by increasing the amount you inhale. Oxygen travels through a tube, from an oxygen machine. The other end of the tube is connected to a mask that you wear over your mouth and nose. There are oxygen machines small enough to be portable and can be carried a shoulder bag.
Normal Blood Gases

Critical care units in the state.
What should the state department of health display via the Internet about critical care units in the state?
Number of critical care units in the state.
Number of beds in each critical care unit in the state.
Number of staff including intensivist having duties with each critical care unit in the state.
Resources required for each critical care unit in the state.

Pulse Oximetry
Fingertip Pulse Oximeter
What is Pulse Oximetry?
Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood. It is an easy, painless measure of how well oxygen is being sent to parts of your body furthest from your heart, such as the arms and legs.

A clip-like device called a probe is placed on a body part, such as a finger or ear lobe. The probe uses light to measure how much oxygen is in the blood. This information helps the health care provider decide if a person needs extra oxygen.

For people with COPD, asthma, Congestive Heart Failure (CHF) and other conditions, pulse oximetry is a technology used to measure the oxygen level in your blood and your heart rate. A finger pulse oximeter is equipped with technology to rapidly detect changes in your blood oxygen level. It can help give you the knowledge you need to take control of your condition. A finger pulse oximeter is easy to use – just clip it on your fingertip to get a blood oxygen reading.

How Does a Pulse Oximeter Work?
A finger pulse oximeter functions by shining light through your finger. The sensors detect how much oxygen is in your blood based on the way the light passes through your finger. Pulse oximetry is the technology calculating the results to display a number on the oximeter’s screen that tells you the percent of oxygen in your blood. A finger pulse oximeter also measures your pulse rate.


PureSAT® Technology

Only Nonin pulse oximeters have PureSAT® pulse oximetry technology, which is precise enough to measure the oxygen level from each pulse. The many other finger pulse oximeters for sale are less precise and need to calculate an average oxygen level across numerous pulses, which often results in delayed or inaccurate readings.

What are the risks of pulse oximetry?
All procedures have some risks. The risks of this procedure may include:
•Incorrect reading if the probe falls off the earlobe, toe, or finger
•Skin irritation from adhesive on the probe

Your risks may vary depending on your general health and other factors. Ask your healthcare provider which risks apply most to you. Talk with him or her about any concerns you have.

What does SpO2 mean?
SpO2 stands for Peripheral capillary oxygen saturation. It is an estimation of the oxygen saturation level.

Oxygen saturation is a term referring to the concentration of oxygen in the blood. It measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen.

What is the normal blood oxygen level?
Normal blood oxygen levels are considered 95-100 percent. Between 90 and 95 percent, your blood oxygen level is considered low but it is not necessarily indicative of a health issue.

If the level is below 90 percent, it is considered low resulting in hypoxemia. The causes of hypoxemia can be sleep apnea, asthma crisis, pulmonary infection, etc. In order to confirm that the value is reliable, we recommend you to take another measure while making sure you respect the good conditions described here. If the low value is confirmed, we recommend you contact and see your doctor to perform further analysis.

Blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart, and should be promptly addressed. Continued low oxygen levels may lead to respiratory or cardiac arrest.

Oxygen therapy may be used to assist in raising blood oxygen levels. Oxygenation occurs when oxygen molecules (O2) enter the tissues of the body. For example, blood is oxygenated in the lungs, where oxygen molecules travel from the air and into the blood. Oxygenation is commonly used to refer to medical oxygen saturation.

Everyone’s oxygen saturation fluctuates, especially when changing activities throughout the day. To determine your normal oxygen range, simply check your oxygen saturation 4 times a day for 5 days using your personal Nonin GO2 brand fingertip oximeter. Record each measurement in the activity log and be sure to also record what you were doing prior to checking.

Oxygen saturation measures how much oxygen the blood is carrying compared with its full capacity.

An SpO2 of greater than 95% is generally considered to be normal.
An SpO2 of 92% or less (at sea level) suggests hypoxemia.
In a patient with acute respiratory illness (e.g., influenza) or breathing difficulty (e.g, an asthma attack), an SpO2 of 92% or less may indicate a need for oxygen supplementation.

In a patient with stable chronic disease (e.g., COPD), an SpO2 of 92% or less should prompt referral for further investigation of the need for long-term oxygen therapy.

Pulse oximetry can be a useful aid in decision-making, but is not a substitute for a clinical assessment nor sufficient for diagnosis by itself. Arterial blood gas measurements, obtained by arterial puncture, remain the gold standard for measurement of oxygen saturation.

When Do I Take Action?
If the saturation drops below 90%, a variety of symptoms may begin to occur such as increased shortness of breath with activity, increased heart work (reflected by an increase in pulse rate), the presence of bluish lips or nail beds, headaches, clumsiness, and confusion.

Warning Signs

A sudden drop in your oxygen level—for example during a severe cold or the flu—can be a sign of trouble.

If you are on Long Term Oxygen Therapy, call your doctor if your normal oxygen setting is no longer maintaining your saturation and you feel sick. Also, call your supplier if you feel your oxygen system is not working.

A high resting pulse rate of greater than 100 or a low pulse of less than 40 (check with your doctor to determine your individual pulse ranges) are also reasons to call your doctor.*

During a severe breathing attack, it is possible to have a normal oxygen level. Seek medical help if you have severe shortness of breath, wheezing, or increased pulse rate, even if your oxygen saturation is normal.

*Please be sure to check with your doctor to determine your own pulse rate ranges.

Practice Pursed Lip Breathing

The act of pursed lip breathing, i.e., exhaling slowly against pursed lips as in the act of whistling, is useful to your breathing efficiency in many ways. Pursed lip breathing teaches you to breathe in a deeper, slower fashion. In addition, it helps you to empty your lungs more completely. This is particularly important in emphysema/COPD, where over-inflation of the lungs is a problem.

Some patients like to find out how long their oxygen saturation remains above 90% when their oxygen is turned off. It gives them a feeling of confidence when their oxygen flow is stopped for a short period.*

*Check with your physician before trying this on your own.

After you master pursed lip breathing, try doing this with exercise. Use your oximeter as you walk around the house and later outside and around the block. Try to walk at least 100 yards using pursed lip breathing. Use of a pedometer is helpful here. You will probably find out that pursed lip breathing will relieve your shortness of breath as well as improve your oxygen saturation, both at rest and during exercise.

[TIP: When practicing pursed lip breathing, take a full breath, shape your mouth as though you are whistling, and breathe out slowly to resist the speed of the air leaving your lungs.]

Reduce Shortness of Breath

Overinflation of the lungs puts the breathing muscles at a mechanical disadvantage, adding increased load to the breathing. This is often interpreted as an increased effort to breathe or "dyspnea," which is an unpleasant sensation of breathing. Often patients can reduce their shortness of breath by slow, deep breathing and exhaling. Practice using your oximeter with pursed lip breathing, using two or three seconds to breathe in, and four, five or six seconds to exhale. Find a comfortable breathing rate and pattern and watch your oxygen saturation increase at a given oxygen setting. With your doctor's approval, you might also be interested in trying this while breathing room air. Your oxygen saturation while breathing room air will be achieved by stopping your oxygen for 10 to 20 minutes. It takes this long to use up the residual oxygen in your lungs (the amount of air left after you exhale).*

Peripheral capillary oxygen saturation.

What should you always watch and measure in a patient with lung disease?
Peripheral capillary oxygen saturation.

What equipment is available to measure peripheral capillary oxygen saturation?
Pulse oximeter.

What are other names for Peripheral capillary oxygen saturation?
SpO2.
SpO2 stands for Peripheral capillary oxygen saturation.
SpO2 must be 95% or more.

What is oxygen saturation?
Oxygen is carried in the blood attached to haemoglobin molecules. Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry.

One haemoglobin molecule can carry a maximum of four molecules of oxygen, if a haemoglobin molecule is carrying three molecules of oxygen then it is carrying 3/4 or 75% of the maximum amount of oxygen it could carry.

One hundred haemoglobin molecules could together carry a maximum of 400 (100 x 4) oxygen molecules, if these 100 haemoglobin molecules were carrying 380 oxygen molecules they would be carrying (380 / 400) x 100 = 95% of the maximum number of oxygen molecules that could carry and so together would be 95% saturated.

Oxygen saturation is also refered to as SpO2.

What does it mean?
People always want to know what their oxygen saturation "should be". I hate giving figures (what should your blood pressure be?) but a fit, healthy young person will probably have an oxygen saturation of 95 - 99%. This will vary with age, degree of fitness, current altitude, oxygen therapy etc etc.

Pulse oximeters can either be used to take a 'one-off' reading from someone or can be left on for period of time. A single one-off reading often isn't much use, trends over a period of time give more information.

It is important to remember that pulse oximetry is only one way of monitoring breathing. It is also necessary, as a minimum, to record respiratory rate and if pulse oximetry is used the amount of oxygen they are receiving must be recorded. As with all clinical assessments the 'whole picture' must be looked at.

How does it work?
The colour of blood varies depending on how much oxygen it contains. A pulse oximeter shines two beams of light through a finger (or earlobe etc.), one beam is red light (which you can see when a pulse oximeter is used), one is infrared light (which you don't see).

These two beams of light can let the pulse oximeter detect what colour the arterial blood is and it can then work out the oxygen saturation. However there are lots of other bits of a finger which will absorb light (such as venous blood, bone, skin, muscle etc.), so to work out the colour of the arterial blood a pulse oximeter looks for the slight change in the overall colour caused by a beat of the heart pushing arterial blood into the finger.

This change in colour is very small so pulse oximeters work best when there is a good strong pulse in the finger (etc.) the probe is on. If the signal is too low the measured oxygen saturation may not be reliable and lower than this the pulse oximeter will not be able to work.

Limitations

Pulse oximeters rarely cause any harm directly, though apparently some older models could cause burns and there are reports of the probes causing pressure ulcers. However if their limitations are not borne in mind harm could be caused by someone having the wrong (or no) treatment. So it's important to know what the limitations are.

One limitation is that pulse oximeters cannot operate reliably with a poor signal. This has been refered to as a 'safe' limitation, in that the pulse oximeter is not able to give an accurate reading but in some way indicates this fact. Obviously pulse oximeters need to be technically capable of indicating this and the person using it must be aware of this point.

The other sort of limitation is more dangerous in that the pulse oximeter may appear to have a good signal and be displaying a saturation figure, but either the figure is inaccurate or gives a false sense of security.

Poor signal

Pulse oximeters need a strong regular pulse in the finger (or ear etc) that the probe is on.

A common problem is that people can have cold hands and feet, and have only a very weak pulse. In this case a pulse oximeter may display a reading but it might not be accurate. Some pulse oximeters have a means of indicating how strong the signal is they are receiving and it is important to check this. A still weaker signal may mean the pulse oximeter is not able to work at all.

An irregular signal can also cause problems for a pulse oximeter trying to determine oxygen saturation. This can be caused by an irregular heart beat or by the patient moving, shivering or fitting.

Poor positioning of the probe can cause inaccurate readings due to various problems. This can be a particular problem with very small fingers and very large ones. Make sure the probe is well on the finger.

Carbon dioxide

A pulse oximeter can cause a false sense of security by giving a good saturation figure when someone's breathing is completely inadequate. This is especially true when a patient is getting supplementary oxygen.

There are two main functions of breathing, one is getting oxygen out of the air and into the body, the other is getting carbon dioxide out of the body and into the air. It possible for someone to be getting enough oxygen into their body but not be getting rid of enough carbon dioxide.

Oxygen saturation by itself does not tell the whole story about breathing - this is especially true if someone is being given oxygen. As a minimum it is also necessary to record the respiratory rate, and if they are having oxygen, how much they are having.

Delays

There will be a delay between an event such as a patient taking off an oxygen mask and the subsequently less oxygenated blood passing through the finger the probe is on. It has been reported that there will be a longer delay if the pulse oximeter probe is attached to a toe compared with a finger or ear.

Another point is that pulse oximeters average signals over a period of time, this will cause a delay in giving a new (real) oxygen saturation.

Carbon monoxide

Carbon monoxide is a colourless, odourless gas that is produced in most fires. Breathing in carbon monoxide will lead to it becoming attached to haemoglobin in preference to oxygen, so it is only necessary to breath in a small amount of carbon monoxide to have a large amount of haemoglobin taken up by it and therefore not available to carry oxygen. For instance if 25% of someone's haemoglobin is taken up by carbon monoxide then only 75% is available to carry oxygen, and so their oxygen saturation could, at best, be only 75%.

Pulse oximeters will display an oxygen saturation which is approximately equal to the percentage of haemoglobin combined with oxygen plus the percentage of haemoglobin combined with carbon monoxide 1. So if someone has 25% of their haemoglobin saturated with carbon monoxide and a true oxygen saturation of 70% a pulse oximeter will display an oxygen saturation of about 95%. This is obviously extremely dangerous and for this reason pulse oximeters should not be used with people who may have inhaled smoke, ie anyone who has been involved with any sort of fire, unless you are certain that they do not have any significant level of carbon monoxide in their blood.

Methaemoglobin

Methaemoglobin is an abnormal type of haemoglobin that does not bind oxygen well. Normally 1-2% of people's haemoglobin is methaemoglobin, a higher percentage than this can be genetic or caused by exposure to various chemicals and depending on the level can cause health problems. A higher level of methaemoglobin will tend to cause a pulse oximeter to read closer to 85% regardless of the true level of oxygen saturation. For more information see:

Moyle JTB (2002) Pulse Oximetry 2nd ed. BMJ books, London

Skin pigmentation

Previous research on pulse oximetry has found that skin pigmentation has no clinically significant effect 1,2. Recently however it has been found that pulse oximeters from three manufacturers overestimated oxygen saturation in individuals with darkly pigmented skin at saturations below 80% 3. The authors suggested that pulse oximeters should carry a warning about this. Above 80% the researchers concluded that the effect was probably of no clinical significance.

Other issues

Nail varnish - Some research has shown that dark nail varnish bias pulse oximeter readings, but not by a clinically significant amount 1,2. However there are limitations to this research such as a lack of trials at lower saturations, so in practice nail carnish should still be removed.

Intravenous dyes (such as methylene blue, indigo carmine and indocyanine green) can cause inaccurate readings 3.

External interference. There have been reports of interference with pulse oximeter readings, for example from a nerver stimulator 4 and from a fluorescent light 5.

Bilirubin

There is evidence that bilirubin does not affect the accuracy of pulse oximetry and pulse oximeters are still accurate in the presence of severe hyperbilirubinaemia 1.

Anaemia

In theory there is no reason anaemia should cause pulse oximeters to be inaccurate and experiments in dogs have shown accuracy reliable enough for "clinical purposes" (Moyle 2002:49)2 as long as the packed cell volume was larger than 15%. Clinical experience has shown good performance with haemoglobin as low as 2.3 g/dl 2. Sickle cell disease

It has been shown that pulse oximetry can detect low oxygen saturation accurately in sickle cell disease 3, however other researchers have suggested caution in interpreting pulse oximetry values in sickle cell disease.

What do manufacturers of pulse oximeters have to do?
Up to January 1, 2016, pulse oximeter technology used to measure the oxygen level in your blood and your heart rate.

Manufacturers of pulse oximeters must enhance this technology so that arterial blood carbon dioxide and other arterial blood gas analysis are done through the pulse oximeter.

Human blood chemistry analysis, blood urea, creatinine, glucose, and other ingredients also should be possible through a pulse oximeter as soon as possible.

What should you not do in chronic respiratory failure?
Do not go ahead with any ventilation machine/mechanical ventilation.
Mechanical ventilation in chronic respiratory failure will make issues complicated.
Do not go ahead with excessive chest X-ray or CT (computerized tomography) scan to obtain a better view of your lungs.

What should be the focus of treatment for chronic respiratory failure?
Focus on restoring oxygen saturation above 95% through oxygen therapy.
Co2 normal concentration through respiratory exercises.
Bronchodilators when required.
Arterial Blood Gases
Interpretation of Arterial Blood Gases in Asthma

Guidelines for intensive care unit design, dimensions, resources, staff.
Why build a new intensive care unit or renovate an old one in the state or outside the state?
Nowadays, doctors, for example Doctor Asif Qureshi, impart training to intensivists that is a physician intensive care unit from his home office through computer and Internet.

All states must have intensive care units with computers and Internet so that physician intensive care units and the rest of the staff are updated regularly relevant to intensive care unit issues in the state or outside the state.


Home Care Services for Seniors
How should you care for elders at home?
Create a pleasant environment without any stress.
Make sure a person is around to take care of basic needs.
Progress of elders at home can be monitored, enhanced from other location including, ICU.

Medical conditions that need further evaluation and treatment in a critical care unit.
What are the situations in which a patient can be admitted to a critical care unit for further evaluation and treatment?
A patient older than 75 with breathlessness and chest pain can be admitted to a critical care unit for further evaluation and treatment.

In these situations, evaluations must be done in a medical emergency room.
If there are abnormal changes during the physical examination, such as ECG, the patient can be admitted to a critical care unit.
If a physical examination notes the ECG changes are reversed, the patient can be discharged from a critical care unit.

When can such a patient be discharged from a critical care unit?

Does the patient have any breathlessness or chest pains?
No.

Are there any abnormal changes on the ECG?
No.

Are there any changes on the new ECG compared to the previous ECG?
No.

Are there any biochemical abnormalities indicating cardiac damage?
No.

If “no” is the answer for all of these questions, a patient older than 75 with breathlessness and chest pains being evaluated in a critical care unit can be discharged after getting answers to all of the aforementioned questions.

Renal conditions that need critical care services or dialysis
What situations do not need critical care services?
If due to dehydration, lab error, or variations in normal lab values from lab to lab, urea or creatinine is reported to be higher, then such situations do not need intensive care services.

What issues are relevant to renal conditions that may or may not need critical care services and, in certain situations, no more evaluations or treatments?
Accuracy of human biochemical blood tests is not possible.
If you forward two samples drawn at the same time to two different labs for human blood tests, two different results will be reported.
Normal values of biochemistry tests also vary from lab to lab, and this needs to be standardized.

Ideally, where should patients with renal conditions that need critical care services or dialysis be admitted in the hospital?
Critical care unit of the hospital.
In some regions, patients with renal conditions that need critical care services or dialysis are placed a separate unit and this creates confusion.
All patients who need critical care services should be at one location.

I/we cannot ask physicians in the intensive care unit to move from location to location in search of patients because the structure of establishment is flawed.

Dialysis Here are further facts: www.qureshiuniversity.com/hemodialysis.html

Here are further facts: www.qureshiuniversity.com/nephrologyworld.html


Nutrition in intensive care
What is the best nutritional support for critically ill patients?
What nutritional support is best for critically ill patients?
How to provide nutrition for critically ill patients (Review)

Nutrition support refers to enteral or parenteral provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids. The fundamentals of nutrition support for critically ill patients will be reviewed here, including the goals, outcomes, indications, contraindications, and daily nutritional requirements. Access, formulations, prescribing, monitoring, and complications of enteral and parenteral nutrition are discussed separately. (See "Nutrition support in critically ill patients: Enteral nutrition" and "Nutrition support in critically ill patients: Parenteral nutrition".)

Goals of nutrition in the ICU

1. To preserve the lean body mass.
2. To maintain the immune function.
3. To avoid metabolic complications

Types of nutritional support
1. Enteral – Enteral nutrition is feeding via a tube placed in the gut to deliver liquid formulas containing all essential nutrients.
2. Parenteral – It is infusion of complete nutrient solutions into the blood stream via peripheral/central venous access to meet nutritional needs of the patient.

Self-Care
What are the Activities of Daily Living (ADLs)?
The Activities of Daily Living are a series of basic activities performed by individuals on a daily basis necessary for independent living at home or in the community. There are many variations on the definition of the activities of daily living but most organizations agree there are 5 basic categories.

1. Personal hygiene - bathing, grooming and oral care
2. Dressing - the ability to make appropriate clothing decisions and physically dress oneself
3. Eating - the ability to feed oneself though not necessarily to prepare food
4. Maintaining continence - both the mental and physical ability to use a restroom
5. Transferring - moving oneself from seated to standing and get in and out of bed

Whether or not an individual is capable of performing these activities on their own or if they rely on a family caregiver to perform the ADLs serves a comparative measure of their independence.

What are the Instrumental Activities of Daily Living (IADLs)?
IADLs are actions that are important to being able to live independently but are not necessarily required activities on a daily basis. The instrumental activities are more subtle than the Activities of Daily Living. They can help determine with greater detail the level of assistance required by an elderly or disabled person. The IADLs include:

1. Basic communication skills - such as using a regular phone, mobile phone, email or the Internet
2. Transportation - either by driving oneself, arranging rides or the ability to use public transportation
3. Meal preparation - meal planning, preparation, storage and the ability to safely use kitchen equipment
4. Shopping - the ability to make appropriate food and clothing purchase decisions
5. Housework - doing laundry, cleaning dishes and maintaining a hygienic place of residence
6. Managing medications - taking accurate dosages at the appropriate times, managing re-fills and avoiding conflicts
7. Managing personal resources - operating within resources and avoiding scams

Survival needs are required from the state system. There should be monitoring for intentional harms.

Survival needs monitoring

Who has the duty to provide and monitor survival needs of residents in the state?
The state department of human services.
The state department of food and supplies.
The state department of law.
Other similar departments in the state.
Here are further facts.

Why are the ADLs and IADLs Important?
Measuring an individual’s ability to perform the ADLs and IADLs is important not just in determining the level of assistance required but as a metric for a variety of services and programs related to caring for the elderly and for those with disabilities.
Activities of Daily Living (ADL)
ADL Function Independent Needs Help Dependent Cannot Do
Eating
Toileting
Bathing
Dressing
Grooming
Mouth care
Transferring bed/chair
Walking
Climbing stairs
Instrumental Activities of Daily Living (IADL)
IADL Function Independent Needs Help Dependent Cannot Do
Cooking
Shopping
Managing medications
Using the phone and looking up numbers
Doing housework
Doing laundry
Driving or using public transportation
Managing Resources
ADLs / IADLs Requires No Assistance Some Assistance Needed Complete Assistance Needed Not Applicable
Bathing
Dressing
Grooming
Oral Care
Toileting
Transferring
Walking
Climbing Stairs
Eating
Shopping
Cooking
Managing Medications
Uses the Phone
Housework
Laundry
Driving
Managing Resources
Passive Supervision (to prevent wandering or self-injury)
Totals
Recognizing a person’s limitations is the first step in developing a care plan (or making a referral for care) to provide the appropriate type and level of assistance. Determining the type of ADL and IADL care that is needed also enables a clear idea of whether or not staying at home with care is an option
Activities of Everyday Living
Self-Care

The term self-care describes the actions that an individual might take in order to reach optimal physical and mental health. Mental health professionals often use the term self-care to refer to one's ability to take care of the activities of daily living, or ADLs, such as feeding oneself, showering, brushing one's teeth, wearing clean clothes, and attending to medical concerns. Physical self-care, such as sleep and exercise, is also an ADL.

Self-care can also refer to activities that an individual engages in to relax or attain emotional well-being, such as meditating, or visiting a counselor. Because an extended failure to care for one’s self can result in illness or hospitalization, individuals who find themselves unable to take care of their own needs may find it helpful to speak to a therapist.

•Understanding Self-Care
•Why Self-Care Is Important
•How Therapy Can Help with Self-Care
•Self-Care Activities to Boost Well-Being
•Case Examples

Understanding Self-Care

An individual may experience difficulty with self-care for several reasons:
•Depression can sometimes inspire a lack of care for one’s condition: a loss of appetite or motivation, a lack of energy, or a sense of self-loathing. All of these can impair the ability to care for one’s self.
•Survivors of abuse or violence may find it challenging to maintain good self-care habits.
•Cognitive declines associated with dementia can impair self-care skills.
•Psychosis, a split from reality that may include hallucinations or delusions, can often have an affect on one's ability to care for oneself.

Self-care, beyond that which refers to ADLs, is not a selfish act. Individuals who do not take care of their own emotional and physical needs before attempting to resolve those of others may begin to experience a decline in their own emotional or physical state. Those individuals who care for others, either professionally or in personal life, may find themselves especially drained if they do not devote enough time to self-care. Once they have met their own needs, they may often find themselves better able to assist others in meeting their needs.

Taking care of the emotional self by managing anxiety, anger, sadness, and other feelings is also an important aspect of self-care. This type of self-care can often be accomplished by setting boundaries with people, especially those people who are not positive or supportive and may have a negative effect on one's mental state. Good, healthy relationships can help an individual maintain a positive frame of mind, but friends who only want to fulfill their own needs or family members who leave an individual feeling exhausted or depressed will likely not help an individual's mental or emotional state to improve. An individual who has trouble meeting emotional self-care needs may find it helpful to limit time with people who are neither supportive nor helpful.

Why Self-Care Is Important

Sometimes people attempt to meet the needs of family members, employers, children, friends, or society in general before meeting their own needs, and working to please and care for others often interferes with one's self-care routine and can take a toll on a person's well-being. People who have dependent personalities or experience depression, codependency, or anxiety may also fail to meet their self-care needs. However, self-care is often considered to be an important aspect of resiliency: those who are able to adequately meet their needs are often able to better cope with everyday stressors.

Because people who are able to meet their own physical and emotional needs are typically better equipped to care for others, it may be especially important for parents of children with behavioral challenges or other special needs to maintain a self-care routine. Fatigue, stress, anxiety, and worry may have a significant effect on well-being, but attending to physical and emotional needs may help prevent or reduce the effects of these issues, foster self-compassion, and leave parents more able to meet the needs of their child.

Self-care behaviors may also help mental health professionals and other health care providers avoid compassion fatigue, which can often result from work in a high-stress or traumatic environment and may lead to self-doubt, self-blame, and ethical or legal complications.

Individuals in a transition phase or those who are facing changing circumstances may neglect self-care. College students, for example, may experience excitement when first leaving home, but as they adjust to life in a different environment with new behaviors and responsibilities, they may experience significant stress, anxiety, and other emotional turmoil. However, those students who engage in behaviors that promote health—exercising, sleeping and eating well, and keeping in touch with loved ones—have been shown to face less stress during their transition, and research shows they are less likely to develop anxiety or depression or drop out. These self-care skills may also lead to resiliency that continues to have a positive effect throughout life.

How Therapy Can Help with Self-Care

Therapy can often uncover the root of a failure to care for one’s self. If depression is the cause, therapy can typically help relieve symptoms of depression and improve one’s mood, which will generally lead to one becoming able to meet self-care needs once again.

In the case of dementia, therapy can often help in the early stages by teaching new coping and communication skills. Therapy might also be useful in helping families learn how to cope with a loved one's dementia: In therapy, the family can learn ways to help their loved one maintain some level of self-care skills. Medication and a high level of care, such as daily activities at a hospital or community mental health center, might also help one's self-care skills improve.

The failure to care for oneself due to wanting to please or care for others, which might be seen of an individual in a codependent relationship or in the case of overly demanding family members, can indicate some difficulty with self-image and/or with setting boundaries. Therapy can help an individual develop a stronger self-image and become better able to say no to those who ask for too much.

Self-Care Activities to Boost Well-Being

Meeting one's own needs tends to make a person more able to help and support others and, generally speaking, to obtain more happiness and fulfillment from life. In order to facilitate your own healthy routine to make sure your needs are met, it can be helpful to develop a self-care plan centered on three key components: physical, mental, and spiritual self-care.

Eating well and exercising regularly are both aspects of physical self-care that have been shown to improve an individual's state of mind. Many reputable sources recommend about 75 to 150 minutes of physical activity each week. You do not have to run a marathon or pump iron; a simple 30-minute walk at least a few times a week will suffice. Prioritizing sleep is another physical self-care tactic. Try committing to 7-9 hours of sleep each night for a week and see how you feel when properly rested.

Regularly engaging your brain with puzzles and creative activities is a great way to make sure you are practicing mental self-care, as is simply taking a little time to be alone. Even people who thrive in the company of others generally need some time on their own to rest and process experiences.

Many assume the spiritual component of self-care means spending time in a church, mosque, temple, or other religious building. Religion, however, is only one expression of spirituality. You can practice spiritual self-care in many different ways such as volunteering to help others in need, spending time in the great outdoors connecting with nature, or reading about religious practices and values that intrigue you.
Here are further guidelines.

Critical care bed management: Can we do better?

InTouch Critical Care Bed

Basic needs. Simplified care. Exceptional outcomes.

Features & Benefits

Touch Screen

Control all bed functions with an easy, intuitive touch screen interface using a powerful on-bed Windows computer.

Zoom Motorized Drive System

This fully integrated system features front wheel drive and a compact base, allowing tighter turns and greater maneuverability.

iBed Awareness

Impact care efficiencies through monitoring local bed status information. It visually, audibly or remotely signals a change in preset positions.

Benefits of Early Mobility

Studies have shown that early mobility can, in some cases, decrease the overall length of stay in the ICU, reduce the incidence of ICU delirium, enhance muscle strength and increase ventilator-free days. Stryker's InTouch bed has features that may assist in early mobility exercises such as a 16" low bed height, an independent knee gatch and foot drop, a one-touch cardiac chair position, and siderails that support transferable skills and the necessary nose-over-toes position.

Connect to Help Prevent Adverse Events

By providing better bedside data and greater flexibility to connect, you can improve care efficiencies to help prevent adverse events. Our open architecture approach reduces your total cost of ownership and gives you the freedom to build a custom solution.



Epic II Critical Care Hospital Bed

Facilitate and complement clinicians’ care for their patients.

Features & Benefits

Zoom Drive System

This optional system minimizes the effort needed for patient transport and encourages proper ergonomic posture.

Chaperone Bed Exit System

Accurately senses body position by constantly tracking the patient’s center of gravity in three zones. If 50% of the patient’s weight exits the zone, it sounds an alarm to alert the caregiver.

Intuitive and Efficient Patient Care

Epic II can help support the most rigorous critical care therapies and handle complex ICU situations. Epic II intuitively and efficiently facilitates patient care while complementing caregiver expertise.

Admissions to CCUs may be categorized under two headings: unplanned (emergency) and planned (elective). The length of stay (LoS) in the CCU is heavily dependent on the admission category: unplanned admissions have a much longer LoS on average than elective patients.

Equipment Used in an Intensive Care Unit
How have the computer and Internet changed the way work is done?
A computer with Internet service at a home office can accomplish better work than any other office.
Desktop computer with Internet should be number one on the list of health care medical equipment.
Here are further guidelines.
  1. Arterial Line

  2. Brain Stem Evoked Response Equipment

  3. Catheter

  4. Central Venous Pressure (CVP) Line

  5. Chest Tubes

  6. Electrocardiogram (ECG/EKG)

  7. Endotracheal Tube (E.T. Tube)

  8. Eye Tape

  9. Foley Catheter

  10. GI Tube

  11. Intracranial Pressure (ICP) Monitor

  12. Intravenous (IV)

  13. Intravenous (IV) Board

  14. Jejunostomy Tube (J Tube)

  15. Leg Bag

  16. Monitor, Intensive Care

  17. Nasogastric Tube (NG Tube)

  18. Respirator/Ventilator

  19. Posey Vest/Houdini Jacket

  20. Shunt

  21. "Space Boots" (Spenco Boots)

  22. Subarachnoid Screw

  23. Support Hose/TEDS

  24. Swan-Ganz Catheter

  25. Tracheostomy Tube

  26. Traction

  27. Transducer

Arterial Line

A very thin tube (catheter) is inserted into one of the patient's arteries (usually in the arm) to allow direct measurement of the blood pressure and to measure the concentration of oxygen and carbon dioxide in the blood. Arteries carry oxygen and nutrient-rich blood from the heart to tissues and organs throughout the body. Veins carry blood that is higher in waste products and carbon dioxide back to the heart and lungs. The arterial line allows nurses and doctors to monitor these levels at regular intervals. The arterial line is attached to a monitor.

Brain Stem Evoked Response Equipment

Auditory brain stem responses evoked by stimulating the brain stem with painless sound waves using headphones. These sound waves are received by the brain, and a machine is used to test whether the brain stem has received the signals.

The quality of the brain stem's functioning in a comatose patient is thought to be an important indicator of the degree and location of brain injury. This highly specialized equipment is not available in all hospitals.

Catheter

A flexible plastic tube of varying sizes for withdrawing fluids from, or introducing fluids into, a cavity of the body. Frequently used to drain the urinary bladder.

Central Venous (CVP) Line

A very thin tube which is inserted into a vein to measure the venous blood pressure (the pressure of the blood as it returns to the heart). CVP lines are inserted into veins in either the arm or the chest just below the shoulder, or occasionally on the side of the neck. The CVP line is connected to a monitor.

Chest Tubes

Tubes inserted into the chest between the lung and ribs to allow fluid and air to drain from the area surrounding the lungs. Removing this fluid and air from around the lungs allows them to more fully expand. An accumulation of fluid and air in the lung cavity can cause the lung to collapse. Chest tubes drain into a large plastic container near the foot of the patient's bed. The patient may have one or more of these tubes in place. Nurses will monitor the comatose patient for non-verbal signs of pain.

Electrocardiogram (ECG/EKG)

The recording made by small, round electrode pads located on the patient's chest to monitor heart rate and rhythm. These are connected to a monitor and uses routinely in the intensive care unit.

Endotracheal Tube (E.T. Tube)

A tube that serves as an artificial airway inserted through the patient's nose or mouth. It passes down the throat and into the air passages to help breathing. To do this, it must also pass through the vocal chords. The patient will be unable to speak as long as the endotracheal tube is in place. It is this tube that connects the respirator to the patient.

Eye Tape

Tape used to close the patient's eyes. It is important that the eyes be kept moist. We do this naturally when we blink our eyes. This reflex is lost in the patient who is unresponsive but has open eyes. To protect the eyes and to prevent them from drying out, eye drops may be put into the eyes and eye tapes may be used to close them.

Foley Catheter

This is a tube (catheter) inserted into the urinary bladder for drainage of urine. This helps to monitor the patient's fluid status and kidney function. The urine drains through the tube into a plastic bag hanging low by the foot of the bed.

GI Tube

A tube inserted through a surgical opening into the stomach. It is used to introduce liquids, food, or medication into the stomach when the patient is unable to take these substances by mouth.

Intracranial Pressure (ICP) Monitor

A monitoring device to determine the pressure within the brain. It consists of a small tube (catheter) attached to the patient's skull by either a ventriculostomy, subarachnoid bolt or screw and is then connected to a transducer, which registers the pressure.

Ventriculostomy is a procedure for measuring intracranial pressure by placing an ICP monitor within one of the fluid-filled, hollow chambers of the brain, called ventricles. These four natural cavities are filled with cerebrospinal fluid (CSF), which also surrounds the brain and spinal chord.

Intravenous (IV)

Tubing inserted into a vein through which fluids and medications can be given.

Intravenous Board

A simple wooden or plastic board usually attached with tape to the patient's forearm. It prevents bending and dislocation of the intravenous (IV), arterial or CVP lines.

Jejunostomy Tube (J Tube)

A type of feeding tube surgically inserted into the small intestine.

Leg Bag

A small, thick plastic bag that can be tied to the leg and collects urine. It is connected by tubing to a catheter inserted into the urinary bladder.

Monitor, Intensive Care

A TV-like screen with a continuous display of different wave forms representing different pressures and activities in the body such as blood pressure, intracranial pressure, and EKG. It may also show a corresponding number for them (digital readout).

Nasogastric Tube (NG Tube)

A tube that passes through the patient's nose and throat and ends in the patient's stomach. This tube allows for direct "tube feeding" to maintain the nutritional status of the patient or removal of stomach acids.

Posey Vest/Houdini Jacket

A vest worn to keep the patient stationary. This is for the patient's safety.

Respirator/Ventilator

A machine that does the breathing work for the unresponsive patient. It serves to deliver air in the appropriate percentage of oxygen and at the appropriate rate. The air is also humidified by the respirator.

Shunt

A procedure to draw off excessive fluid in the brain. A surgically-placed tube running from the ventricles which deposits fluids into either the abdominal cavity, heart or large veins of the neck.

"Space Boots" (Spenco Boots)

Padded support devices made of lamb's wool used to position the feet and ankles of the patient. Without this support and alignment, patients who are unconscious for long periods may develop deformities limiting future movement.

Subarachnoid Screw

Also Subarachnoid Bolt. A device for measuring intracranial pressure which is screwed through a hole in the skull and rests on the surface of the brain.

Support Hose/TEDS

Anti-embolic stockings. Tight knee or thigh-high stockings that support the leg muscles and thus help prevent pooling of blood in veins of legs.

Swan-Ganz Monitor

A catheter (tube) similar to the Central Venous Pressure (CVP) Line. It is used to measure blood pressure and blood gas concentrations in the right side of the heart, in vessels of the lungs and in the left side of the heart.

Tracheostomy Tube

A tube inserted into a temporary surgical opening at the front of the throat providing access to the trachea and windpipe to assist in breathing.

Traction

A weighted traction setup composed of pulleys and lines used in the care of the patient with broken leg or spine. After repair of the fractures and application of the appropriate casts, weights are used to keep the bones in alignment. Transducer

A sensitive electronic device which detects bodily functions, such as heart rate and blood pressure, and transmits signals representing those functions to a monitor so that the can be observed.

What is a critical care patient?
Critical care is medical care for patients whose illness requires close, constant watch by a team of specially trained caregivers. Most critical care takes place in an intensive care unit (ICU) or a trauma center.

What are the categories of critical care equipment?

Patient monitoring equipment
Central oxygen and suction equipments.
Critical Care Medical Cart
Defibrillators.
Diagnostic equipment
E.C.G. machines
I.V. pumps.
I.V. syringe pumps.
Inter-com, and wireless communication systems for internal & external care of emergency cases throughout the Area. Life support and emergency resuscitative equipment
Portable ventilators.
Pulse oxymeters.
Ventilators.
Vital signs monitors (Dynamaps).

Other ICU equipment

Disposable ICU equipment includes urinary (Foley) catheters, catheters used for arterial and central venous lines, Swan-Ganz catheters, chest and endotracheal tubes, gastrointestinal and nasogastric feeding tubes, and monitoring electrodes. Some patients may be wearing a posey vest, also called a Houdini jacket for safety; the purpose is to keep the patient stationary. Spenco boots are padded support devices made of lamb's wool to position the feet and ankles of the patient. Support hose may also be placed on the patient's legs to support the leg muscles and aid circulation.

Protocols & Guidelines
Appendix 1 Administration via enteral feeding tubes
Appendix 2 Warfarin reversal guidelines
Appendix 3 Paracetamol poisoning nomogram
Appendix 4 Therapeutic drug level monitoring
Appendix 5 Antibiotic sensitivity overview
Appendix 6 Opioid dose equivalence
Appendix 7 Intravenous vs enteral medication

Critical Care Drug Manual
Antibiotics
A
  1. Acetazolamide

  2. Acetylcysteine

  3. Acyclovir

  4. Adenosine

  5. Adrenaline

  6. Allopurinol

  7. Aminophylline

  8. Amiodarone

  9. Amitriptylline

  10. Amlodipine

  11. Amoxicillin / Amoxycillin

  12. Amoxicillin-Clavulanic Acid

  13. Amphotericin B (Liposomal)

  14. Aspirin

  15. Atenolol

  16. Atorvastatin

  17. Atracurium

  18. Atropine

  19. Azathioprine

  20. B
    C
  21. Caffeine

  22. Calcitriol

  23. Calcium Carbonate

  24. Calcium Chloride

  25. Calcium Gluconate

  26. Candesartan

  27. Captopril

  28. Carbamazepine

  29. Carvedilol

  30. Caspofungin

  31. Cefaclor

  32. Cefazolin / Cephazolin

  33. Cefotaxime

  34. Ceftazidime

  35. Ceftriaxone

  36. Cefuroxime

  37. Celiprolol

  38. Charcoal

  39. Chloral Hydrate

  40. Chlorpromazine

  41. Cilazapril

  42. Ciprofloxacin

  43. Citalopram

  44. Clarithromycin

  45. Clindamycin

  46. Clonazepam

  47. Clonidine

  48. Clopidogrel

  49. Clozapine

  50. Codeine Phosphate

  51. Colchicine

  52. Coloxyl with Senna

  53. Co-trimoxazole

  54. Cyclizine

  55. Cyclosporin

  56. D
  57. Dantrolene

  58. Dexamethasone

  59. Diazepam

  60. Digoxin

  61. Dipyridamole

  62. Dopamine

  63. Desmopressin/DDAVP

  64. Dexmedetomidine

  65. Diclofenac

  66. Diltiazem

  67. Dobutamine

  68. Doxazosin

  69. E
  70. Enalapril

  71. Ephedrine

  72. Esmolol

  73. Enoxaparin

  74. Erythromycin

  75. Etomidate

  76. F
  77. Felodipine

  78. Flucloxacillin

  79. Flumazenil

  80. Frusemide

  81. Fentanyl

  82. Fluconazole

  83. Fluoxetine

  84. G
  85. Gabapentin

  86. Gentamicin

  87. Glyceryl Trinitrate

  88. Ganciclovir

  89. Glucagon

  90. Glycopyrrolate

  91. H
  92. Haloperidol

  93. Hydralazine

  94. Hyoscine Butylbromide

  95. Heparin

  96. Hydrocortisone

  97. Hyoscine Hydrobromide

  98. I
  99. Ibuprofen

  100. Imipenem

  101. Isoprenaline

  102. Iloprost

  103. Ipratropium

  104. K
  105. Ketamine

  106. L
  107. Labetalol

  108. Levosimendan

  109. Loperamide

  110. Lactulose

  111. Lithium

  112. Losartan

  113. M
  114. Magnesium Sulphate

  115. Meropenem

  116. Metformin

  117. Methylene Blue

  118. Metoclopramide

  119. Metronidazole

  120. Milrinone

  121. Moxifloxacin

  122. Mannitol

  123. Metaraminol

  124. Methadone

  125. Methylprednisolone

  126. Metoprolol

  127. Midazolam

  128. Morphine

  129. N
  130. Naloxone

  131. Nicotine

  132. Noradrenaline

  133. Neostigmine

  134. Nimodipine

  135. O
  136. Octreotide

  137. Omeprazole

  138. Oxycodone

  139. Olanzapine

  140. Ondansetron

  141. Q
  142. Quinapril

  143. S
  144. Sodium Chloride (Hypertonic)

  145. W
  146. Warfarin

  147. Z
  148. Zopiclone

  149. Here are further facts.

Refusing to eat/drink
An elder refuses to eat: what should a caregiver do?
Refusing to eat/drink

Refusal to Eat in the Elderly

Refusal to eat by the elderly, and subsequent malnutrition, occurs in both institutional and community settings. Causes include physiologic changes associated with aging, mental disorders such as dementia and depression, and medical, social, and environmental factors. Treatment approaches call for management of these causes while considering the roles that medicine, ethics, and culture play in the process.

An elder refuses to eat: what should a caregiver do?

First, Do No Harm

So, what needs to happen on those on-again, off-again days where elders refuse to eat, or constantly spit-out food? My practice is, if at first I don't succeed, I'll try, try again.

Without forcing your loved one to eat, or making meal times unpleasant by nagging, there are a few things you may want to consider short of waving the white flag of caregiver surrender.

•Serve smaller meal portions on smaller plates, including your own.

•Make sure the food is soft enough to comfortably eat, chew and swallow. Now is not the time for fried chicken or stringy asparagus stalks. Try polenta with a large flake of broiled salmon on top. Forget the salmon fillet service!

•Skip herbal garnishes that may look like tiny insects crawling in food.

•Sometimes a light and smooth sauce or greater moisture in meals helps elders to better eat, chew, swallow and enjoy foods that might otherwise be too dry for them to handle comfortably. •Verbally recognize and celebrate any food portions eaten with praise. I often remind my mother that we eat to live, not live to eat. ""I'm proud of you for eating a little something, Mom!"" She is visibly relieved whenever I make that comment.

•Remove plates and uneaten food as soon as it becomes clear that your loved one has eaten as much as he or she can at that meal serving. Leftover food that remains visible may inadvertently reinforce not eating, guilty feelings, unappetizing meals, and may contribute to feelings of nausea for chronically ill individuals.

•Before the next meal serving, casually serve a light snack like chilled or frozen grapes, biscotti for dunking in a hot cup of tea, a small cup of applesauce, or yogurt with rolled oats mixed-in.

•Ask, before preparing and serving meals, whether your elder is hungry or not. Get a feel for what your elder's answers really mean. Sometimes it helps to go five to ten or more minutes past regularly scheduled meal-serving times to ensure that some food will be eaten. Allowing an elder to own his or her meal service schedule is more effective than rigid clockwork meals with no flexibility for normal individual appetite quirks.

•Refusal to eat one meal does not a disaster make - not necessarily, that is. Hang loose to see what happens at the next meal. Sometimes, by the time the next meal is served some hunger pangs will have kicked-in. Other times, real appetite picks back up no later than the following morning when it's time to break the night's fast (breakfast). Late night hunger also may be part of the bigger care picture. Have something light to snack on for those wee hours of the morning hunger pangs. •Many individuals have a favorite meal of the day. Elders are no different. If you can determine which meal is your elder's favorite, try to pack the day's best nutritional punch into that one meal. It may be your best - sometimes only - shot at balancing your elder's nutrition for the entire day. My mother loves her first meal of the day, thankfully. •Be sure to track elder snacking throughout the day. Some elders sneak snacks in between meals that diminish their appetite when regular meals are served.

TECHNIQUES FOR APPROACHING SWALLOWING DIFFICULTIES

Difficulty swallowing (dysphagia) can arise from a number of problems—physical, cognitive, and perceptual. The following techniques can help alleviate swallowing difficulties:

•Maintain an upright position during meals and for at least 30 minutes after meals in order to prevent reflux. •Do not tilt the head back. Tilting the head back increases the risk of aspirating food into the lungs.

•Do not use syringes or straws to deliver solids. Syringes and straws force food into the back of the throat, increasing the risk of aspiration. Use of syringes may also be perceived as demeaning and reduce the dignity of the client. •Focus on the client. The person doing the feeding should not engage in conversation with other staff members or talk on the phone while feeding. These actions objectify the person being fed rather than include them in the process. Caregiver distraction may also increase risk of overlooking signs of possible aspiration.

•Check for pocketing. Clients with swallowing and food manipulation difficulties may “pocket” food in their cheeks, which might then be aspirated later. Check for pocketing to make sure that food doesn’t remain in the mouth. A mirror can be helpful for the client to check for pocketed food together with the caregiver in order to reduce the feelings of infantilization.

•Offer small bites and liquid. Liquids should be alternated with solids in order to promote safe swallowing. Do not offer liquids, however, when there is still food in the mouth. Trying to “wash down” foods with liquids can result in choking, as food that has not been sufficiently chewed can end up going down the throat.

•Avoid foods that combine textures. For example, soup can contain both thin liquids and chunks; this kind of food may be difficult to manipulate. Offering a variety of textures one at a time, however, may work well to stimulate the appetite.

Feeding problems
In a nursing home or hospital ward several patients may need to be fed individually. Some may also have difficulty swallowing. Often a student nurse or junior care assistant is asked to feed these patients.

The loss of teeth and ill-fitting dentures can make chewing uncomfortable.

Important considerations

Some patients may need smaller, more frequent meals. The person’s sensory abilities also need to be assessed.

Feeding

Posture is important when eating. People should be sitting upright, with their heads inclined forwards. They should be encouraged to remain seated for 15 minutes after eating in case of regurgitation. Some people will have difficulty transferring the food to their mouths.

Swallowing

If food needs to be adjusted, four main factors need to be considered: flavour, texture, density and temperature.

Conclusion

Many people assume that anyone can assist another to eat. However, feeding a patient is not a simple procedure that can be assigned to a junior member of staff without experience. Nurses need to be taught how to do it, what the problems are and how they might be overcome. Most importantly, they need to know the danger signs and when help is needed.

Spoon Feeding Alzheimers Patient MLO

Acute Vision Loss
  1. Frequently Used Terms to Express Visual Acuity

  2. Questions that need to be answered.

  3. Annotation or definition

  4. History

  5. Pathophysiology

  6. Etiology

  7. Differential Diagnosis: Acute Vision Loss based on pain

  8. Evaluation

  9. Treatment

Questions that need to be answered.

What is it?
What causes it?
What are the risk factors?
What's normal?
How do you differentiate this medical condition from other medical conditions?
How is it diagnosed?
What are the symptoms?
What are the signs?
What are the clinical findings?
What are the lab or investigation findings?
What are the workable treatment options?
How could this be prevented?



Acute visual loss is defined by visual deficit lasting less than 24 hours upon evaluation. Persistent visual loss is dysfunction lasting greater than 24 hours.

To best evaluate vision loss and the multitude of causes, providers must understand the visual pathway. Three major anatomic areas including the media, retina, and neural pathways may be affected, resulting in visual deficits.

– Media: These include keratopathy, vitreous hemorrhage, uveitis, endophthalmitis, hyphema, and lens pathology.

– Retina: These include retinal detachment, vascular occlusion, and acute maculopathy.

– Neural Pathway: Malfunction in this category may occur at the optic nerve, optic chiasm, and retrochiasm, including posterior occipital lobe.

Acute loss of vision without eye pain
Acute loss of vision with eye pain

A second, and more common, means of differentiation include painful and painless sudden loss of vision.

– Painful includes acute glaucoma, optic neuritis, giant cell arteritis (GCA), uveitis, and migraine headache.

– Painless includes central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), ischemic optic neuropathy, cataract, vitreous hemorrhage, amaurosis fugax, TIA, cortical blindness, retinal detachment, macular degeneration, diabetic retinopathy, CMV retinitis, methanol intoxication, and functional visual loss.

Before we explore this large differential diagnosis, a systematic approach should be followed with history and physical examination. Similar to many conditions managed in emergency medicine, the history and physical examination often will lead to the diagnosis.

History

Where is the patient now?
What seems to be the issue or issues?
What is the name of the patient?
What is the gender of the patient?
What is the date of birth of the patient?
What is the mailing address of the patient?
How long have you stayed at this location?
How old is the patient?
Is there a history of trauma?
Where, when, and how did the trauma occur?


Pathophysiology

Acute loss of vision has 3 general causes:
•Opacification of normally transparent structures through which light rays pass to reach the retina (eg, cornea, vitreous)
•Retinal abnormalities
•Abnormalities affecting the optic nerve or visual pathways

Etiology

The most common causes of acute loss of vision are
•Vascular occlusions of the retina ( central retinal artery occlusion, central retinal vein occlusion)
•Ischemic optic neuropathy (often in patients with temporal arteritis)
•Vitreous hemorrhage (caused by diabetic retinopathy or trauma)
•Trauma

In addition, sudden recognition of loss of vision (pseudo-sudden loss of vision) may manifest initially as sudden onset. For example, a patient with long-standing reduced vision in one eye (possibly caused by a dense cataract) suddenly is aware of the reduced vision in the affected eye when covering the unaffected eye.

Presence or absence of pain helps categorize loss of vision (see Table: Some Causes of Acute Vision Loss).

Most disorders that cause total loss of vision when they affect the entire eye may affect only part of the eye and cause only a visual field defect (eg, branch occlusion of the retinal artery or retinal vein, local retinal detachment).

Less common causes of acute loss of vision include

• Anterior uveitis (a common disorder, but one that usually causes eye pain severe enough to trigger evaluation before vision is lost)

•Aggressive retinitis
•Certain drugs (eg, methanol, salicylates, ergot alkaloids, quinine)

Evaluation

History

History of present illness should describe loss of vision in terms of onset, duration, progression, and location (whether it is monocular or binocular and whether it involves the entire visual field or a specific part and which part). Important associated visual symptoms include floaters, flashing lights, halos around lights, distorted color vision, and jagged or mosaic patterns (scintillating scotomata). The patient should be asked about eye pain and whether it is constant or occurs only with eye movement.

Review of systems should seek extraocular symptoms of possible causes, including jaw or tongue claudication, temporal headache, proximal muscle pain, and stiffness (giant cell arteritis); and headaches (ocular migraine).

Past medical history should seek known risk factors for eye disorders (eg, contact lens use, severe myopia, recent eye surgery or injury), risk factors for vascular disease (eg, diabetes, hypertension), and hematologic disorders (eg, sickle cell anemia or disorders such as Waldenström macroglobulinemia or multiple myeloma that could cause a hyperviscosity syndrome).

Family history should note any family history of migraine headaches.

Physical examination

Vital signs, including temperature, are measured.

If the diagnosis of a transient ischemic attack is under consideration, a complete neurologic examination is done. The temples are palpated for pulses, tenderness, or nodularity over the course of the temporal artery. However, most of the examination focuses on the eye.

Eye examination includes the following:

•Visual acuity is measured.

•Peripheral visual fields are assessed by confrontation.

•Central visual fields are assessed by Amsler grid.

•Direct and consensual pupillary light reflexes are examined using the swinging flashlight test.

•Ocular motility is assessed.

•Color vision is tested with color plates.

•The eyelids, sclera, and conjunctiva are examined using a slit lamp if possible.

•The cornea is examined with fluorescein staining.

•The anterior chamber is examined for cells and flare in patients who have eye pain or conjunctival injection.

•The lens is checked for cataracts using a direct ophthalmoscope, slit lamp, or both.

•Intraocular pressure is measured.

•Ophthalmoscopy is done, preferably after dilating the pupil with a drop of a sympathomimetic (eg, 2.5% phenylephrine), cycloplegic (eg, 1% cyclopentolate or 1% tropicamide), or both; dilation is nearly full after about 20 min. The entire fundus, including the retina, macula, fovea, vessels, and optic disk and its margins, is examined.

•If pupillary light responses are normal and functional loss of vision is suspected (rarely), optokinetic nystagmus is checked. If an optokinetic drum is unavailable, a mirror can be held near the patient’s eye and slowly moved. If the patient can see, the eyes usually track movement of the mirror (considered to be the presence of optokinetic nystagmus).

Red flags

Acute loss of vision is itself a red flag; most causes are serious.

Interpretation of findings

Diagnosis of acute vision loss can be begun systematically. Specific patterns of visual field deficit help suggest a cause. Other clinical findings also help suggest a cause for acute vision loss:

•Difficulty seeing the red reflex during ophthalmoscopy suggests opacification of transparent structures (eg, caused by corneal ulcer, vitreous hemorrhage, or severe endophthalmitis).

•Retinal abnormalities that are severe enough to cause acute loss of vision are detectable during ophthalmoscopy, particularly if the pupils are dilated. Retinal detachment may show retinal folds; retinal vein occlusion may show marked retinal hemorrhages; and retinal artery occlusion may show pale retina with a cherry-red fovea.

•An afferent pupillary defect (absence of a direct pupillary light response but a normal consensual response) with an otherwise normal examination (except sometimes an abnormal optic disk) suggests an abnormality of the optic nerve or retina (ie, anterior to the chiasm).

In addition, the following facts may help:

•Monocular symptoms suggest a lesion anterior to the optic chiasm.

•Bilateral, symmetric (homonymous) visual field defects suggest a lesion posterior to the chiasm.

•Constant eye pain suggests a corneal lesion (ulcer or abrasion), anterior chamber inflammation, or increased intraocular pressure, whereas eye pain with movement suggests optic neuritis.

•Temporal headaches suggest giant cell arteritis or migraine.

Testing

ESR, C-reactive protein, and platelet count are done for all patients with symptoms (eg, temporal headaches, jaw claudication, proximal myalgias, stiffness) or signs (eg, temporal artery tenderness or induration, pale retina, papilledema) suggesting optic nerve or retinal ischemia to exclude giant cell arteritis.

Other testing is listed in Some Causes of Acute Vision Loss. The following are of particular importance:

•Ultrasonography is done to view the retina if the retina is not clearly visible with pupillary dilation and indirect ophthalmoscopy done by an ophthalmologist.

•Gadolinium-enhanced MRI is done for patients who have eye pain with movement or afferent pupillary defect, particularly with optic nerve swelling on ophthalmoscopy, to diagnose multiple sclerosis.

II. Differential Diagnosis: Acute Vision Loss based on pain

III. Differential Diagnosis: Acute unilateral Vision Loss

IV. Differential Diagnosis: Acute bilateral Vision Loss

V. Risk Factors: Acute Vision Loss predisposing factors

  1. Diabetes Mellitus
  2. Hypertension
  3. Hyperlipidemia
  4. Hypercoagulable States
  5. Cardiac arrhythmias
  6. Carotid Insufficiency
  7. Glaucoma
  8. Migraine Headaches

VI. History

  1. Timing: Red flags for urgent referral
    1. Very recent onset of Vision Loss (hours)
    2. Progressive symptoms
    3. First episode
    4. Sudden onset (Hemorrhage, ischemia)
  2. Lesion localization
    1. Monocular or binocular?
      1. Monocular: Ocular or Optic Nerve lesion
      2. Binocular: Optic Chiasm and posterior back to Occipital Lobe lesion
    2. Focal visual field deficit?
      1. Retina and posterior back through Optic Nerve and Occipital Lobe
    3. Periocular pain?
      1. Anterior eye or Optic Nerve lesion (requires Trigeminal Nerve sensitization)
  3. Associated symptoms
    1. Nausea or Vomiting with Eye Pain
      1. Acute angle closure Glaucoma
    2. Flashes or Floaters
      1. Vitreous Hemorrhage
      2. Retinal Detachment
    3. Associated neurologic deficits
      1. Cerebrovascular Accident or other systemic cause
Treatment

Causative disorders are treated. Treatment should usually commence immediately if the cause is treatable. In many cases (eg, vascular disorders), treatment is unlikely to salvage the affected eye but can decrease the risk of the same process occurring in the contralateral eye or of a complication caused by the same process (eg, ischemic stroke).

Frequently Used Terms to Express Visual Acuity
A or Acc: Accommodation; mechanism by which eye spontaneously adjusts to objects at different distances to achieve a clear image.
C, CC: With correction; wearing prescribed lenses with glasses.
CF: Counting fingers; low visual acuity; used in conjunction with distance. For example, CF at I foot - the individual can count fingers at a distance of one foot.
D: Diopter; lens strength.
EOM: Extraocular muscles. A check to see if the individuals eye can move normally in different fields.
ET or ST: Esotropia; inward deviation of eye, towards nose.
FA: Fluorescein angiogram; a dye test. Dye is injected into blood and a picture is taken of the retina.
Fundi: Behind the lens. Examination of the eye to check what is behind the lens.
HM: Hand motion (also known as hand movement); used in conjunction with distance. For example, HM at 1 foot means the individual can see hand movement at one foot.
IOP: Intraocular pressure; the pressure of aqueous humor within the eye.
Jl, J2, J3: Jaeger test; a test for near vision. Lines of reading matter printed in a series of various sizes of type.
LP: Light perception; ability to distinguish light from dark.
LPP: Light projection; the ability to perceive and localize light.
MB: Muscle balance; how eyes line up.
NLP: No light perception; inability to distinguish light from dark.
OD: Right eye; oculus dexter.
OS: Left eye; oculus sinister.
OU: Both eyes together; oculi unitas.
PERRL: Pupils; equally round and reactive to light. If optic nerve is damaged the pupils will not respond normally.
PLL: Perceives and localizes light in one or more quadrants.
PR: Presbyopia; a gradual lessening of the power of accommodation due to a physiological change which affects eyes after the age of forty.
SS, S, or SC: Without correction; not wearing glasses.
V, Va, or VA: Visual acuity; the ability of the eye to perceive the shape of objects in the direct line of sight. Visual acuity is measured by viewing standardized letters of varying sizes and is expressed as a fraction such as 20/20.
VF: Visual field; entire area which can be seen without moving the gaze, normally 180 degrees.
XT: Exotropia; outward deviation of eye, away from nose.
20/20 Vision: Normal visual acuity; ability to correctly perceive an object or letter of a designated size from a distance of 20 feet.
20/70 Vision: Visual acuity notation; ability to see at 20 feet what others with normal acuity are able to see at 70 feet. Visually impaired.
20/200 Vision: Visual acuity notation; ability to see at 20 feet what others with normal acuity are able to see at 200 feet. Legally blind.
+: Plus or convex; farsighted.
-: Minus or concave lens; nearsighted.

Negligent death in the intensive care unit
How do you investigate a negligent death in the intensive care unit?

Let's investigate this.
On October 20, 2014, a policeman injured in a stone pelting died at SKIMS, Soura, in Kashmir, Asia. Waseem Ahmad Bhat was injured in a stone pelting incident at Duck Park, Fore Shore Road, Nigeen Hazratbal, on July 29, 2014, when locals clashed with a police party.

Where had the physicians been educated who did the assessment and treated the injured on the spot, in the intensive care unit, and during the stay in hospital?
Their educational resource needs to be reminded they did not teach them to do a proper assessment of patients in various healthcare settings.

Questions that need to be answered.

What exactly happened on July 29, 2014, at Duck Park, Fore Shore Road, Nigeen Hazratbal, Srinagar, Kashmir, in which policeman Waseem Ahmad Bhat was injured – minute by minute, second by second?
How many total police officers were present at that point and how many stone pelters were there?
What were the issues?
What is the profile of the physicians who treated him from July 29 to October 20, 2014?
What physicians assessed Waseem Ahmad Bhat on the spot on July 29, 2014?
What physicians assessed Waseem Ahmad Bhat on arrival at the SKIMS intensive care unit on July 29, 2014?
What was the condition of Waseem Ahmad Bhat when the injury occurred?
What was the condition of Waseem Ahmad Bhat when he was received in the intensive care unit?
What treatment was given from July 29 to October 20, 2014 to Waseem Ahmad Bhat?
What senior physicians supervised the treatment?
Who was supervising the intensive care unit at SKIMS Srinagar, Kashmir, from 1994 to 2014?
How did this individual or individuals supervise the intensive care unit at SKIMS Srinagar, Kashmir, from 1994 to 2014 and how did this individual contribute intellectually to enhance the intensive care unit, Kashmir?


State police empowered by other departments in the state and outside the state should get answers to these questions.
Termination of services with further punishments of physicians and those who harmed must go ahead.

Place two police officers around the clock at SKIMS Intensive care unit with everyday reporting.

Computerize all the intensive care records under supervision of state police and the court.

Questions must be answered before sending patients home from the critical care unit of a hospital in the state.
How long was the person in the critical care unit, including the name of the hospital’s critical care unit specific dates and time?

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Why was the patient admitted and how did he/she get to the critical care unit?

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What was the diagnosis?

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What were the patient’s main symptoms?

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What treatment was given in the critical care unit?

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How did the patient seem to react to his/her critical care unit stay?

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What is the mailing address of the patient?

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Is it safe?

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What other facts need to be included in the record for future reference to help others understand and make sense of the treatment of this person in critical care?

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Can the patient spontaneously open his/her eyes, as appropriate for his/her age?

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Can the patient talk or make some noises relevant to his/her age?

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Can the patient move both upper and lower limbs, as appropriate for his/her age?

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Is the patient’s level of consciousness, oxygen saturation by pulse oximetry, pulse, respiratory rate, blood pressure, temperature, input output, blood biochemistry, and arterial blood gases normal, as appropriate for his/her age?

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What is the profile of activities of daily living of the person, relevant to his/her age?


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Is there any abnormality in activities of daily living of the person, relevant to his/her age?


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What best describes any complaints and/or issues that need to be fixed before sending a patient home from a hospital’s critical care unit?

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Do not send a patient home without answering these questions and fixing any abnormal issues relevant to the age of the patient.

What needs to be accomplished?
Activities of daily living should be monitored in acute and chronic conditions.
Normal activities of daily living should slowly be restored in acute and chronic conditions.

If a woman is 85 years old, we do not expect her to do running exercises.
Walking slowly within the home, with support (to prevent wandering or self-injury) or without support, is acceptable.

What type of home care does this person need?
  1. Assisted living care at home is usually provided to a senior who does not need the level of care offered by a nursing home but who needs some assistance in day-to-day living.

  2. Supportive living with resident services

  3. Independent living with resident services

  4. Other human services described

Do not send patient home if the Glasgow coma scale, vitals, and/or activities of daily living are not normal, relevant to the age of the person.

Existing Patients in Critical Care
Sameer Ahmad, 17 years old on June 9, 2017

What is the recent case history (past 12 days) as well as profile of this patient?
Age of patient: 17 years on June 9, 2017.
Name of patient: Sameer Ahmad
Location pf patient on June 9, 2017: Critical care unit, King Hospital (formerly SMHS Hospital), Srinagar, Kashmir.
Circumstances of harms:
On May 30, 2017, troops from the nearby CRPF camp barged into the school premises and roughed up the students, including girls and faculty members. According to one student, one of the female teachers was injured after being hit by a stone thrown by the CRPF men.
The student said that Sameer was standing with his friends when the CRPF troops fired bullets at him. “When the forces saw the group of students standing separately, they target fired at the group. A bullet hit Sameer’s head,” the student said.

CRPF supervisor: What is your answer to these facts?
If you cannot explain these actions, CRPF has to be banned, including BSF and Rashtriya Rifles.

When did I first come across this patient?
Friday June 9, 2017, at 3:30 PM. I was in Chicago, Illinois.
At that time, the patient was in Srinagar, Kashmir.

How did I come across this patient?
Internet news

What is the diagnosis of this patient at this point?
Traumatic brain injury.
Coma
Coma after a bullet injury to the head on May 30, 2017.

What treatment should this patient get?
A team of critical care physicians must maintain rotations 24 hours a days, 7 days a week.
8-hour on-site duty for critical care physicians.
Maintain oxygen saturation above 95%.
Record eye movement, noises or talk, and movement in the extremities every 2 hours.
Parental nutrition through a Nasogastric (Ryles) Tube.
Change clothing and bed sheets every 24 hours or as required.
Intravenous line with normal saline at 12 drops per minute.
Empty the Foleys catheter every 12 hours.
Monitor the critical care provided 24 hours a day, 7 days a week, and provide regular updates via the Internet.

How could this be prevented?
Ban on entities causing intentional, willful harm.

Treatment of a Patient in a Coma
Verification of facts.

Who verified the patient is in a coma?

How do you treat a patient in a coma in the critical care unit?
A team of critical care physicians must maintain rotations 24 hours a days, 7 days a week.
Each critical care physician must work 8-hour on-site rotations.
Maintain the oxygen saturation above 95%.
Record eye movement, noises or talk, and movement in the extremities every 2 hours.
Record pulse, blood pressure, temperature, and input/output every 2 hours.
Administer water through a nasogastric tube as per body weight.
Provide parental nutrition through a nasogastric (Ryles) tube.
Change clothing and bed sheets every 24 hours or as required.
Administer an intravenous line with normal saline at 12 drops per minute.
Empty the Foleys catheter every 12 hours.
Monitor the critical care provided 24 hours a day, 7 days a week, and provide regular updates via the Internet.

How much water will you give this patient through a nasogastric tube?

What food and how much food will you give this patient through a nasogastric tube?

What will happen if you give less than the required amount of water to the patient?

How do you calculate the amount of water required to be given through a nasogastric tube for a patient in a coma?

How do you calculate the amount of food required to be given through a nasogastric tube for a patient in a coma?


What is the underlying cause of the coma?
Treat the underlying cause in addition to following the mentioned guidelines.

Profiles of physicians in the critical care unit.

What is the name and state of the critical care unit?
Government medical college in Srinagar and associated critical care unit of King Hospital (former SMHS Hospital)

King Fahed Hospital Medina critical care unit staff.

Who’s who at this critical care unit among those who have duties on the spot at this point?
Who is on the roster of physicians in the critical care unit at this point for the next year?
Who is on the roster of aspiring physicians in the critical care unit at this point for the next year?
Last Updated: June 15, 2017