ECG Interesting Cases
Presented by Professor Hassan Khaled at the Critical Care Center Journal Club
Author: Ecccp@scribe
Ventilator Wave-forms : Basic Interpretation and Analysis
Ventilator Wave-forms : Basic Interpretation and Analysis
Presentation by Dr Moataz El Hallage
Critical Care Center, Cairo University
Video Presentation: Stroke Heart Syndrome
Video Presentation: Stroke Heart Syndrome
Critical Care Medicine Department, Cairo University. Journal Club Lectures.
by Dr. Moataz Ahmed Hisham
Management of Benzodiazepine Poisoning
Key points in Critical Care Medicine
“Adapted from Oxford Textbook of Critical Care”
Management of Benzodiazepine Poisoning
- Benzodiazepines are the drugs most frequently involved in acute self-poisoning.
- Benzodiazepine overdose usually has a good prognosis. Most patients do well with careful observation and prevention of complications. Supportive care including oxygen, intubation, respiratory support, and fluid administration may be required in some cases.
- Care should be taken with elderly patients, or those with chronic obstructive pulmonary disease or liver disease. Fast- acting agents and ingestion of other central nervous system depressants, including alcohol, may present an additional risk.
- Early administration of activated charcoal in fully conscious patients who are able to protect their airway is only needed if there are co-ingestants.
- Flumazenil may help confirm the diagnosis, improve alertness, and prevent the need for respiratory support in some patients, especially after accidental poisoning in children. Contraindications include patients on long-term treatment and/or dependent on benzodiazepines, or those who have simultaneously ingested proconvulsant or prodysrhythmic substances, or at risk of increase intracranial pressure.
Epidemiology and pathophysiology of Traumatic Brain Injury
Key points in Critical Care Medicine
“Adapted from Oxford Textbook of Critical Care”
Epidemiology and pathophysiology of Traumatic Brain Injury
- Traumatic brain injury (TBI) is a devastating injury that causes a huge burden of disease around the world; approximately 1.6 million people suffer a TBI in the USA each year.
- TBI is a bimodal disease that affects young adults (15-34), the elderly (>75), and males more than females.
- Mechanism of injury, age, gender, and initial severity of injury are the most significant predictors of mortality.
- Harm from TBI arises from direct damage to the brain at the time of the initial injury (primary injury), which places the brain at risk of further harm secondary injury.
- Secondary injury may occur due to intracranial hypertension, hypotension, hypoxia, reduced cerebral perfusion, and inflammation.
Assessment of Traumatic Brain Injury
- Early assessment is based on a careful history, clinical assessment, and neurological imaging-usually a CT scan of the brain.
- An immediate CT scan of brain should be obtained in any adult patient at risk of harbouring intracranial pathology.
- In adult patients who have a Glasgow Coma Scale score below 15 and indications for a brain CT scan, the scan should include the cervical spine by scanning from the base of skull to T4.
- Establishing a reliable prognosis early after injury is notoriously difficult, but recent predictive models are readily accessible to clinicians via a web-based calculator to aid early clinical decision making and to allow better informed discussions with patient’s families.
Management of Traumatic Brain Injury
- Admission to a centre offering specialist neurological critical care and management of extracranial injuries improves outcome.
- Initial management priorities address the ‘ABCs’-airway with cervical spine control, breathing, and circulation. Neurological assessment using the Glasgow Coma Score and pupillary reaction should be repeated regularly to detect deterioration.
- Intracranial haematomas causing mass effect should be surgically evacuated without delay.
- Specific TBI management focuses on avoiding secondary cerebral insults by avoiding hypotension and hypoxia, controlling ICP, and maintaining cerebral perfusion pressure.
Extracorporeal liver support devices in the ICU.
Key points in Critical Care Medicine
Extracorporeal liver support devices in the ICU.
“Adapted from Oxford Textbook of Critical Care”
- There is an unmet need for a liver support system because of the increasing shortage of organs for transplantation and the complications associated with the procedure.
- In theory, acute liver failure and acute decompensation of chronic liver disease secondary to a precipitating event are potentially reversible. In this context, an extracorporeal liver support can temporarily substitute liver functionality to allow natural recovery through regeneration of hepatocytes and elimination of the precipitating event.
- Goals of liver support system are to provide all functions of the liver, including synthetic and metabolic functions, and to remove as well as reduce the production of pro-inflammatory mediators to attenuate the inflammatory process.
- Currently existing devices are either purely mechanical and/or cell-based. Detoxification is provided by both systems, but biological activities are limited only to the cell- based systems. Albumin dialysis is the major component of mechanical devices because albumin is irreversibly destroyed in liver failure.
- Cell-based or bio-artificial systems are essentially ‘mini-livers’, but their success is limited by the lack of a continuous and abundant supply of high-quality hepatocytes.
Pathophysiology, causes, and management of acute hepatic failure
Key points in Critical Care Medicine
Pathophysiology, causes, and management of acute hepatic failure
“Adapted from Oxford Textbook of Critical Care”
- Acute liver failure (ALF) is a rare, life-threatening clinical syndrome occurring in a person with no prior history of liver disease.
- Acute liver failure (ALF) occurs in patients with acute hepatic necrosis resulting in hepatic encephalopathy, jaundice, and coagulopathy.
- Acute liver failure is a multisystem disorder.
- Viral hepatitis is the most common cause of ALF worldwide, with drug-induced liver failure the most common in the developed world.
- ALF is a multi-system disorder resulting in encephalopathy, coagulopathy, systemic inflammatory response syndrome, and multi-organ failure.
- Patients can be prothrombotic or have balanced coagulation disorders.
- Several classifications exist incorporating time to encephalopathy from the onset of jaundice. O’Grady’s classification is the most widely used.
- The management is initially supportive. Intravenous N-acetylcysteine is recommended for all patients.
- Elective intubation is recommended for all patients who develop Grade III hepatic encephalopathy.
- Liver transplantation is an appropriate and viable treatment for ALF. Early and safe transfer to a transplant centre for transplant assessment is advised.
Classification Time of onset jaundice to encephalopathy
Hyper acute 0-1 weeks
Acute 1-4 weeks
Subacute 4-26 weeks
Causes
- Paracetamol, ischemia, recreational drugs, toxins (amanita)
- Hepatitis B,A, and E
- Non-paracetamol drug-induced liver injury, seronegative
- Hepatitis.
Factors affecting Quality of Life after the ICU
Factors affecting Quality of Life after the ICU
Lecture presented by Dr Lluis Blanch at the Egyptian African Critical care Summit.
Immunomodulation strategies in the critically ill
Immunomodulation strategies in the critically ill
- Severe sepsis is the result of an infectious stimulus that triggers a hyper-inflammatory response and results in multiple organ failure. This hyper immune response triggers a phase of immunoparalysis that results in the patient’s inability to resist and clear infections, causing the delayed mortality observed is some septic patients.
- The inflammatory and coagulation cascades are closely linked such that a significant aspect of the disease process is attributed to the activation of the coagulation cascade by circulating inflammatory mediators.
- Therapeutic approaches to sepsis have targeted the hyper-inflammatory response, inhibition of the subsequent coagulation cascade, and immunostimulation during the immunoparalysis phase.
- Proven beneficial therapies for sepsis are limited to the mechanical eradication of the source of infection, antibiotics to clear the organism, the judicious use of fluids to support organ perfusion, and oxygen supplementation. Studies evaluating immunotherapeutics for the treatment of severe sepsis have failed to show efficacy in clinical trials.
- Further research may demonstrate effectiveness using a strategy of targeting therapies based on an improved identification of the patient’s phase of sepsis, use of combination therapies, a better understanding and strategy aimed at specific host-organism interactions, and /or better specified therapies in relation to identified biomarkers.
Conclusion:
- Studies evaluating the use of immunotherapeutics for severe sepsis are plagued with multiple confounding factors including the pre-dominant phase of sepsis (hyperimmune versus hypoimmune), differing offending organisms, differing host-organism interactions, heterogeneity in the patient populations, and underpowered study designs.
- Perhaps the correct immunotherapy will need to be tailored in order to decrease the immune response in the hyperimmune phase and increase it during the hypoimmune phase. In order to do so, better markers of these phases of sepsis are needed. Further studies may also find more efficacy in using multiple therapies simultaneously to obtain best results.
- Finally, there exists a close interaction between in the immune and coagulation system. Further study of this link and therapies to temper the coagulation cascade many prove to be a successful modality of therapy in order to halt the body’s progression to multiple organ failure.
HIV in the critically ill
HIV in the critically ill
“Adapted from Oxford Textbook of Critical Care-Oxford University Press 2016”
- Human immunodeficiency virus (HIV) is increasingly a controllable disease in North America and life expectancy in patients adherent to combination antiretroviral therapy (cART) is similar to the general population.
- The majority of a admissions of HIV positive patients to the ICU are for reasons unrelated to their HIV, although presentations due to opportunistic infections and malignancies must be considered in those with previously undiagnosed infection or in those patients non-adherent to cART.
- The CD4 count is critical in determining the degree of immune suppression in a patient and should be checked in all critically ill HIV-infected patients to determine appropriate work-up and management of HIV- related infections/complications.
- It is important to involve an infectious disease specialist familiar with HIV in the care of a critically ill HIV-infected patient, particularly if therapy requires alterations or cessation of cART or if the patient is found to be significantly immunocompromised.
- Antiretroviral agents have many potential drug interactions and rare toxicities which must be evaluated throughout the ICU stay as concomitant medications are introduced.