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The Critically Ill Patient

The Critically Ill Patient. Stuart Conquer Advanced Physiotherapist Paediatric ICU, Surgery & Medicine Sheffield Children’s Hospital. Aims of session. Recap of essentials of assessment: Respiratory Failure Auscultation CXR FBC Review of treatment options: Positioning

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The Critically Ill Patient

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  1. The Critically Ill Patient Stuart Conquer Advanced Physiotherapist Paediatric ICU, Surgery & Medicine Sheffield Children’s Hospital

  2. Aims of session • Recap of essentials of assessment: • Respiratory Failure • Auscultation • CXR • FBC • Review of treatment options: • Positioning • Breathing Techniques • Secretion clearance • Adjuncts • On call: • Case Studies • Appropriate/inappropriate • Questions to ask

  3. Assessment

  4. Definitions Ventilation: Respiratory Failure: Ventilation is the drive to get CO2 out not to get O2 in “An inability to sufficiently eliminate carbon dioxide from, or provide oxygen to the organ systems during spontaneous respiration.” • Can’t get oxygen in +/- • Can’t get carbon dioxide out

  5. Inability to get oxygen in Hypoxaemia Cardiac: Resp: Inability to get carbon dioxide out Hypercapnoea Causes: Respiratory Failure Type I Type II • Pulmonary Oedema • Embolism • Pneumonia • Asthma • ARDS • Fibrosis • Airway obstruction • Chest injury • Neurological lesions • Muscle/neuromuscular junction problems • Chronic lung disease

  6. Auscultation Thyroid cartilage Cricoid cartilage Tracheal cartilage Right upper lobe Left upper lobe Right main bronchus Left main bronchus Horizontal fissure Oblique fissure Right middle lobe Oblique fissure Bronchioles Right lower lobe Left lower lobe

  7. Auscultation Bronchial Vesicular • Breath sounds: • Normal • Equal • Complete • Crackles: • Inspiratory/Expiratory • Coarse/Fine • All or part • Where is it? • Wheeze: • Inspiratory/Expiratory • All or part • Monophonic/Polyphonic • Where is it?

  8. Be methodical Demographics Type of film Exposure Position Heart Lungs Ribs Anything Added Abnormal: Too white Too Dark Too Big/small In the wrong place Chest X-rays

  9. Left upper lobe Left lower lobe Right upper lobe Right middle lobe Right lower lobe

  10. Hb WCC: Royal Marines: Royal Marine Commandos: SAS: SBS: CRP Platelets Urea Creatinine Albumin Lactate Sodium Potassium Others at a later date if required Blood Count Neutrophils Lymphocytes Macrophages Eosinophils

  11. Treatment

  12. Options • Positioning • Breathing Techniques • Secretion Clearance Techniques • Adjuncts • BE METHODICAL

  13. On call TREAT? MANUAL TECHNIQUES? RUN? COMPUTER SAYS NO! SLEEP

  14. Appropriate Inappropriate

  15. Case Study 1 • Capt. C Caveman • Retired Colonel BAF • ICU admission with AAA repair (emergency) • CV Instability post-op • Reduced air entry L LZ’s • Type I respiratory failure • Secretion retention

  16. Case Study 2 • Ms P Pittstop • Racing Driver • Crash sustaining # Ribs and pneumothorax L • Blood Stained secretions • Pain++ • Oxygen requirement

  17. Case Study 3 • Mr H K Phooey • Janitor (mild Mannered of course!) • Keeps exotic birds • Atypical pneumonia • Increased WOB • Secretion Retention

  18. Case Study 4 • Dame Crystal Tipps • 85 year old millionaire • Smokes 60 park-drive/day • COPD • Increased WOB • Thick green secretions • Type II respiratory failure

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