General ACLS General Capnography (measurement of partial pressure of CO2 in the exhales breath over time) End-tidal CO2 Typically gradually rises with high-quality CPR Increase in CO w/ROSC will show a sudden rise in EtCO2 on capnography (Ex. 16 to 38) and is the earliest indicator of ROSC, even before a pulse is palpated EtCO2 of ≤10 mmHg after 20 minutes of CPR are highly unlikely to achieve ROSC Anemia IRONMAN : IV Iron not better than placebo did not change RBC transfusion during ICU stay Illness Severity Assessment Disease Specific Scoring Systems CURB65 sPESI (Pulmonary Embolism Severity Index) PSI ICU Delirium Mobilize pt, remove catheters, provide visual and hearing aids ICU Toxicology Oncologic Emergencies in the ICU Palliative Care in the ICU ICU-Acquired Weakness Evaluation Medical Research Council Muscle Scale (MRCMS) is a bedside tool used to evaluate weakness Critical Illness Myopathy RF: Steroids, Neuromuscular blocking agents, Sepsis Features Flaccid limbs Facial and respiratory weakness Normal sensation Normal to mild CK elevation (<2000) Critical Illness Polyneuropathy RF: Sepsis Features Flaccid limbs Respiratory weakness Distal sensory loss Normal CK Rhabdomyolysis RF: Infection, Medications, Serotonin Syndrome, Neuroleptic Malignant Syndrome Features Mild to moderate limb weakness Muscle swelling Myalgias DTRs intact Marked CK elevation (>5000) Guillain-Barre Syndrome RF: Infection Features Progressive and symmetric Normal CK Prolonged Neuromuscular Blockade RF: Prolonged paralytic agent use (days), often in renal or hepatic insufficiency Features Flaccid limbs Respiratory weakness Transient improvement after anticholinesterase Normal CK Hypothermia Symptoms Shivering, but as hypothermia progresses, shivering stops Moderate: Bradycardia, hypoventilation, lethargy, atrial arrhythmias, decreased shivering Severe: absent reflexes, ventricular arrhythmia, asystole, and apnea Diagnosis: Temperature Monitoring: Esophageal temperature probe Rectal and bladder temperatures will lag the rising core temperature during the rewarming process. Treatment Mild (> 35.0 °C (95.0 °F)) Moderate (28.0 - 35.0 °C (82.4 - 95.0 °F)) or (<28.0 °C (82.4 °F)) w/o coma or CV collapse 1) Active external warming Warming blankets and forced warm air, heating pads 2) Active internal warming Severe (<28.0 °C (82.4 °F)) in the setting of coma or cardiovascular collapse Cardiac Arrest: Extracorporeal support, including cardiopulmonary bypass, VA ECMO No Cardiac Arrest: Active internal rewarming (107F fluid) Infusion of heated intravenous crystalloid solution as well as lavage of the peritoneal or pleural cavities irrigation Other (Acid-Base Disturbances): HD Heat Stroke Strenuous activity during hot and humid weather Dehydration, poor acclimatization, lack of fitness Hyperthermia Core temp >104F (40C) immediately after collapse plus: CNS dysfunction: AMS, confusion, irritability, seizure Additional organ failure: DIC, Renal/Hepatic failure, ARDS Monitoring Rectal or esophageal probes Prognosis: Treatment Fluid resuscitation, electrolyte correction No antipyretic therapy Exertional: Ice water immersion Non-Exertional: Evaporative cooling (lukewarm water with fans), high-flow cool water dousing, ice/wet towel rotation, cold shower Ice Water immersion has increased mortality in elderly w/Non-Exertional Heat Stroke