Patient's Guide to ICU
Dr. Vipin Malik practices Pulmonary, Critical Care and Sleep Medicine in Denver, CO. A pulmonologist is a physician who possesses specialized knowledge and skill in the diagnosis and treatment of pulmonary conditions and diseases. Dr. Malik manages patients who need life support and mechanical ventilation, and is specially... more
I have developed this document to help patients and their families navigate critical care processes and vocabulary. It is not comprehensive and can be modified/corrected as/if needed. Direct expert/specialist opinion/consultation should be obtained if there is any confusion or questions that arise from reviewing this document. This document should/does not override expert opinion/advice.
Introduction
Patient bill of rights
Critical Care structure
- ED
- Critical Care units
ICU workflow
- ED to ICU
- ICU to step-down unit or floor
- ICU to LTAC
- ICU to home
Procedures
- Endotracheal intubation
- Mechanical ventilation- invasive versus non-invasive
- Central venous lines
- Arterial lines
- Feeding tube (nasogastric/orogastric)
- Foley catheter
- Rectal tube
- SCDs
- Chest tubes
- Post-surgical drains
- Percutaneous cholecystostomy
- Percutaneous tracheostomy
- Coronary angiogram (Left heart catheterization)
- Right heart catheterization
- Pulmonary artery catheter
- Craniotomy
- EVD
- ICP monitoring
- Bronchoscopy
- UGI endoscopy
- Colonoscopy
- Blood product transfusion
- Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- Percutaneous Entero-Gastrostomy/Jejunostomy tube (PEG/PEJ)
- EEG monitoring
- Exploratory laparotomy
- Spontaneous breathing trial
- Spontaneous awakening trial
- Early mobilization/PT/OT/Speech therapy
- Imaging studies- MRI/MRA/CTA/HRCT/USG/echocardiogram
- ECMO
- LVAD
- Hemodialysis/CRRT
- Temporary pacemaker
- NICOM monitoring
- Fasciotomy
- Lumbar puncture
- IABP
Medications
- Intravenous fluids
- Inotropic agents/vasopressors
- Sedatives
- Narcotics
- Psychotropic medications
- Antimicrobials
- Antihypertensives
- Diabetes medications
- Anti-seizure medications
- Blood thinners
- Acid reducing medications
- Nitric Oxide
- Heliox
- tPA- intra-arterial/intravenous
Medical conditions
- Heart
i. Shock
ii. Myocardial Infarction
iii. Hypertensive crisis
iv. Pericardial effusion/tamponade, pericarditis
v. Right heart/left heart failure
Lungs
i. Respiratory failure
ii. Pulmonary embolism
iii. Pleural effusion/empyema
iv. Pneumonia-VAP/HCAP/CAP/Opportunistic
Abdomen
i. Peritonitis
ii. Kidney failure and electrolyte abnormalities
iii. Colitis (C diff infection, ischemia)
iv. UTI
v. Gastrointestinal bleeding (GIB)
vi. Intra-abdominal hypertension/compartment syndrome
Neurology
i. Stroke
ii. Seizures
iii. Delirium
Endocrine
i. Diabetic Ketoacidosis
ii. Thyrotoxicosis/Myxedema
Extremities
i. Gangrene
ii. Compartment syndrome
Dermatology
i. Decubitus ulcers
ii. Stevens Johnson Syndrome
iii. Drug reactions
Medical jargon
- QD, BID, TID, QAC, QHS, TIPS, CATH, Foley, vent, Fio2, PEEP, HRCT, CTA, MRI/MRA, PRBC, FFP, TPA, Cryo,10 pack, PCC, EVD, ICP, MAP, SBP, DBP, Tachy, Brady, Swan-Ganz/PA catheter, PPM, PT/OT, Pressors, ICH, SAH, ICP monitoring, PT/OT, Restraints, AEDs, SCDs, PPI, H2 blockers, beta blockers, ACE inhibitors, SBT/SAT, vent wean, tube feeds, H/H, bicarb, pH, electrolyte abnormalities, inflammations-itis, migs/kigs, p.r.n, HIPPA
Introduction
Critical illness of a family member is a time filled with anxiety and uncertainty that requires caretakers to have better understanding of the structure and functioning of critical care units.
This post will provide basic information on general ICU structure and workflow, common medical conditions, procedures and medications along with medical terms commonly used by critical care providers to communicate with each other. Please note that this a dynamic document and more information can be added as needed/requested.
Patient's Bill of Rights
American Hospital Association (1973, revised 1992)
Introduction
Effective health care requires collaboration between patients and physicians and other health care professionals. Open and honest communication, respect for personal and professional values, and sensitivity to differences are integral to optimal patient care. As the setting for the provision of health services, hospitals must provide a foundation for understanding and respecting the rights and responsibilities of patients, their families, physicians, and other caregivers. Hospitals must ensure a health care ethic that respects the role of patients in decision-making about treatment choices and other aspects of their care. Hospitals must be sensitive to cultural, racial, linguistic, religious, age, gender, and other differences as well as the needs of persons with disabilities.
The American Hospital Association presents A Patient's Bill of Rights with the expectation that it will contribute to more effective patient care and be supported by the hospital on behalf of the institution, its medical staff, employees, and patients. The American Hospital Association encourages health care institutions to tailor this bill of rights to their patient community by translating and/or simplifying the language of this bill of rights as may be necessary to ensure that patients and their families understand their rights and responsibilities.
Bill of Rights
The patient has the right to considerate and respectful care.
2. The patient has the right to and is encouraged to obtain from physicians and their direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the medically reasonable alternatives and their ac-companying risks and benefits.
Patients have the right to know the identity of physicians, nurses, and others involved in their care, as well as when those involved are students, residents, or other trainees. The patient also has the right to know the immediate and long-term financial implications of treatment choices, insofar as they are known.
3. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of the medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.
4. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment or designating a surrogate decision maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy.
Health care institutions must advise patients of their rights under state law and hospital policy to make informed medical choices, ask if the patient has an advance directive, and include that information in patient records. The patient has the right to timely information about hospital policy that may limit its ability to implement fully a legally valid advance directive.
5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient's privacy.
6. The patient has the right to expect that all communications and records pertaining to his/her are/will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records.
7. The patient has the right to review the records pertaining to his/her medical care and to have the information explained or interpreted as necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacity and policies, a hospital will make reasonable response to the request of a patient for appropriate and medically indicated care and services. The hospital must provide evaluation, service, and/or referral as indicated by the urgency of the case. When medically appropriate and legally permissible, or when a patient has so requested, a patient may be transferred to another facility. The institution to which the patient is to be transferred must first have accepted the patient for transfer. The patient must also have the benefit of complete information and explanation concerning the need for, risks, benefits, and alternatives to such a transfer.
9. The patient has the right to ask and to be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient's treatment and care.
10. The patient has the right to consent to or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide.
11. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospital's charges for services and available payment methods.
The collaborative nature of health care requires that patients, or their families/surrogates, participate in their care. The effectiveness of care and patient satisfaction with the course of treatment depends, in part, on the patient fulfilling certain responsibilities. Patients are responsible for providing information about past illnesses, hospitalizations, medications, and other matters related to health status. To participate effectively in decision-making, patients must be encouraged to take responsibility for requesting additional information or clarification about their health status or treatment when they do not fully understand information and instructions. Patients are also responsible for ensuring that the health care institution has a copy of their written advance directive if they have one. Patients are responsible for informing their physicians and other caregivers if they anticipate problems in following prescribed treatment.
Patients should also be aware of the hospital's obligation to be reasonably efficient and equitable in providing care to other patients and the community. The hospital's rules and regulations are designed to help the hospital meet this obligation. Patients and their families are responsible for making reasonable accommodations to the needs of the hospital, other patients, medical staff, and hospital employees. Patients are responsible for providing necessary information for insurance claims and for working with the hospital to make payment arrangements, when necessary.
A person's health depends on much more than health care services. Patients are responsible for recognizing the impact of their life-style on their personal health.
Conclusion
Hospitals have many functions to perform, including the enhancement of health status, health promotion, and the prevention and treatment of injury and disease; the immediate and ongoing care and rehabilitation of patients; the education of health professionals, patients, and the community; and research. All these activities must be conducted with an overriding concern for the values and dignity of patients.
Critical Care Structure
Emergency Department
Patients present to Emergency Department (ED) for acute issues such as shortness of breath, chest pain and traumatic injuries and are evaluated and stabilized by physicians who have been trained in Emergency Medicine. After initial testing, if patient meets criteria for admission to a critical care unit such as low blood pressure, uncontrolled bleeding, worsening breathing difficulty, advanced infections among others, emergency physicians request critical care consultation from physicians who have received training in Critical Care Medicine. Consultations from specialists such as surgeons, gastroenterologists, neurosurgeons, interventional radiologists, neurologists, trauma surgeons and other disciplines may also be needed while in Emergency Department. If the physicians are in agreement, patient is formally admitted to illness specific Intensive Care Unit (ICU)/Critical Care Unit (CCU).
Critical Care/Intensive Care Units
Critical care can be provided in any designated critical care units. Critical care providers such as physicians, nurses, respiratory therapists and pharmacists have specific expertise and experience in treating critically ill patients. Critical care units are classified based on specialized care provided by treating physicians and include:
Cardiothoracic ICU (CTICU) – heart bypass (CABG), vascular surgery, etc.
Cardiac Care Unit (CCU – confusing!) – heart attack (MI), heart failure, rhythm problems
Surgical Intensive Care Unit (SICU) – general surgeries
Trauma Intensive Care Unit – any trauma related post-operative management
Neurocritical Care Unit- strokes, seizures
Neurosurgical Intensive Care Unit- brain bleed, brain tumor surgeries, etc.
Neonatal Intensive Care Unit (NICU)- post-delivery infant care
Pediatric Intensive Care Unit (PICU)- children’s critical care
ICU workflow
ED to ICU
Once a decision is made to admit the patient to ICU after physician consultations, nurse from ED transfers the patient to the assigned ICU bed with monitoring equipment. ICU team including physicians, nurses, pharmacists and respiratory therapists are alerted followed by face-to-face hand-off of the patient between teams. Family members are directed to waiting room that is generally adjacent to the ICU. Several members of ICU staff connect patient to all the monitoring and treatment equipment, while treating physicians perform necessary procedures needed to treat and stabilize patient. Patient might need emergency procedures including mechanical ventilation, central venous line placement, hemodialysis catheter, chest tube placement or emergency operations. The ICU providers invite family members to patient’s bedside after initial evaluation and treatment to provide update regarding differential diagnosis, necessary testing/therapy needed and overall prognosis if discernible.
ICU care
Critical care physicians staff most ICUs around the clock. Every morning a multidisciplinary team gets together at patients’ bedside to discuss events over past 24 hours and discuss treatment plan for next 24 hours. This team is led by critical care physician and includes bedside nurse, respiratory therapist, pharmacist, nutritionist, social worker and often chaplain, physical/occupational therapists join the rounds. Patients’ regular physicians, other treating specialists and family members are encouraged to attend these multidisciplinary rounds. Critical care team continues to monitor and treat patients throughout the day and update families on any clinical changes during the day.
Family members can call the ICU to get updates at any time of the day or night. Most ICUs provide specific code to the family members for phone inquiries to prevent violation of privacy (HIPPA) rules
ICU to step down unit or floor
After meeting clinical criteria for transfer out of the ICU, decision is made to transfer the patient either to regular floor or progressive care unit bed - depending on care needed post transfer. In ICU, patient to nurse ratio is 2:1, while in progressive care units, it can be 4:1 and 8:1 on regular floors. Monitoring systems in progressive care units are similar to the ICU and patient can be transferred to the ICU if patient’s condition deteriorates. Alternatively, patient is moved to regular floor as patient’s condition stabilizes.
ICU to LTAC
Patient can be transferred to Long Term Acute Care Facility, if long-term critical care is needed such as patients who need ongoing support with mechanical ventilation for chronic respiratory failure. This can be seen in patients with severe lung disease, severe neurological deficits among other conditions that prevent the patient to breathe effectively or have inability to protect their airway. Most of these patients have a tracheostomy i.e. airway in lower neck and a feeding tube in the stomach. LTAC facilities have expertise in ventilator weaning protocols and are able to facilitate early transition of patients to home, in most patients.
ICU to home
Small percentage of patients can be discharged to go home from ICU and include patients being observed postoperatively after elective procedures, simple electrolyte and fluid imbalances, etc.
PROCEDURES
Endotracheal intubation
Placement of breathing tube through the mouth into the windpipe. Tube is then connected to a machine (ventilator) that can support work of breathing for the patient partially or completely and provide higher level of respiratory support with pure oxygen while preventing collapse of smallest breathing units in the lungs.
Mechanical ventilation- invasive versus non-invasive
Refers to breathing support provided by a machine that blows air/oxygen mix into the lungs to maintain adequate oxygenation and supports patients’ work of breathing. Invasive ventilation is provided through an endotracheal tube while non-invasive ventilation is provided through a tight fitting facemask that covers the nose and mouth and is secured around the head.
Central venous lines
Intravenous catheters are placed in a large vein that drains blood closer to the heart instead of small veins of extremities used commonly. Generally internal jugular veins (sides of the neck), subclavian veins (under the collar bones) or femoral veins (in the groins) are used. These are considered invasive procedures and catheters are placed using portable ultrasound machines under direct visualization. Most common risks associated with these procedures include introduction of infection, bleeding from accidental arterial puncture and lung collapse associated with internal jugular and subclavian veins although use of ultrasound machine and sterile techniques, to place these catheters has reduced major risks dramatically.
Arterial lines
Small catheter is placed in an artery to monitor blood pressure invasively and more accurately. Most commonly radial artery located in the wrist is used. Other sites include the femoral artery located in the groin next to the femoral vein and axillary artery located in the axilla (underarm). Patients who have very high or very low blood pressure that requires special medications to bring blood pressure within acceptable limits generally need to have invasive monitoring with arterial lines.
Feeding tube (nasogastric/orogastric)
Non-surgical placement of a small tube into the stomach through the nose or mouth. Feeding tube is placed to provide nutrition to patients who are not able to meet their nutritional demands/goals due to inability to swallow safely or critically ill.
Foley catheter
Catheter is placed into the urinary bladder to accurately measure urine output or to maintain adequate hygiene in patients who are not able control their bladder.
Rectal tube
Catheter is placed into the rectum to maintain adequate hygiene in patients with diarrhea. This can also facilitate diversion of fecal material away from any skin breakdown or surgical incisions in the local area, to promote healing without infections.
Sequential Compression Devices
Hospitalized patients, especially in ICU, are prone to having blood clots in their legs that can be fatal if they travel to the lungs. Compression pneumatic stockings are wrapped around the calves that are pumped with air by a mini-air compressor periodically to keep blood circulating in the lower extremities.
Chest tubes
Two thick membranes line lungs called visceral (attached to the lung tissue) and parietal pleura (attached to the chest wall) and space between them is called pleural space. Pleural space has very small amount of pleural fluid that acts as a lubricant to facilitate sliding between the pleural membranes during breathing.
Tubes are placed in the pleural space to drain any excess amount of fluid accumulation (pleural effusions) caused by various medical conditions such a heart failure, pneumonia, surgeries involving the chest, cancer etc. or air (pneumothorax) that can be introduced accidentally during a procedure including central line placement, chest wall surgeries, mechanical ventilation, trauma, etc.
Post-surgical drains
Catheters are places after surgical procedures to prevent collection of fluids in the remaining space that could delay healing and increased risk for infection. Most often these catheters are connected to suction devices including suction bulbs and small vacuum devices. They are removed within a few days depending on the rate of healing and size of the incisional gap.
Pulmonary artery/Right heart catheterization
Long catheter is placed in the right side of the heart invasively using one of the central veins i.e. internal jugular (preferred), subclavian or femoral veins, to measure pressures that can guide treatment of various medical conditions including heart failure and low blood pressures caused by infection, heart attack, and blood clot traveling to the lungs. This procedure is done infrequently due to equivocal efficacy and association with several complications.
Percutaneous cholecystostomy
Catheter is placed from the right side of the abdomen, through the liver, passing directly into the gall bladder to drain infected bile. It is indicated in patients who are at high risk for having gall bladder removed with open or laparoscopic procedures. Catheters remain in place, till the patient is stable enough to get the gallbladder removed by either procedure.
Spontaneous breathing trial
Normally combined with spontaneous of awakening trial and involves placing the patient on a mode of ventilation that tests patients’ ability to sustain spontaneous breathing with minimal support from the ventilator.
Spontaneous awakening trial
Critically ill patient who require mechanical ventilation are routinely sedated intravenously to minimize discomfort and pain from therapeutic interventions including endotracheal intubation. Current treatment guidelines support stopping all sedatives in the morning to facilitate awake state such that patient is able to open eyes spontaneously and follow simple commands. This allows washout period for sedatives from patients’ body and prevents prolonged periods of sedation that can are associated with poor critical care outcomes including length of stay in the ICU/hospital. It is combined with spontaneous awakening trial as noted above.
Percutaneous tracheostomy
An L-shaped small breathing tube is surgically placed in the lower neck for mechanical ventilation in patients who are unable or are unlikely to breathe spontaneously without endotracheal tube placed through the mouth and fail daily spontaneous breathing trials. Tracheostomy tubes are discontinued once patients are able to wean off mechanical ventilation and are able to demonstrate ability to breathe effectively without ventilatory support. Most often patients are able to speak with tracheostomy tube in place, 2-3 weeks after placement, using speech valve. Patients who need tracheostomy in place for long time are also able to eat and swallow food without complications.
Early mobilization/PT/OT/Speech therapy
Rehabilitation specialist are consulted to provide guidance/instructions needed to perform exercises that involve physical activity in critically ill patients after ensuring minimal risk to the patient. Speech-Language specialist can assess safety of patients’ swallowing mechanisms and recommend special diet consistencies to reduce risk of aspiration (entry of food into windpipe).
Lumbar puncture
Patients with suspected meningitis need lumbar puncture to get 10-15 mL of spinal fluid surrounding the spinal cord and brain to test for infection. This procedure involves placing the patient on their side (or in sitting position) and passing a hollow needle in between lower lumbar vertebrae to access the space between the membranes surrounding the spinal cord that contains spinal fluid. Regular bandage is placed at the skin puncture site after the needle is withdrawn. Patients are recommended to lie on their backs for 1-2 hours to reduce the risk of headache after the procedure. Complications include infection, bleeding, nerve/spinal cord damage resulting in acute/chronic pain or lower extremity numbness/weakness or paralysis in extreme cases.
Hemodialysis/Continuous Renal Replacement Therapy (CRRT)
When kidneys are unable to clear the toxins, high level of acids, potassium or water content from the blood, dialysis machines are used to correct the abnormalities. A dual lumen catheter is placed in one of the central veins (preferably internal jugular vein), one lumen takes blood from the body to the machine for purification or removal of excess water and the other one brings purified blood from the machine back to the body over a 3-hour period. CRRT refers to continuous circulation of blood through a specialized dialysis machine that primarily removes excess water from the body and is preferred in critically ill patient with low blood pressures.
Coronary angiogram (Left heart catheterization)
Catheter is passed through either the femoral artery (in the groin) or redial artery (in the wrist) and advanced in to the left side of the heart. Coronary arteries that supply the heart muscle with oxygenated blood are located at the base of aorta (largest artery in the body) and injected with contrast dye to assess patency of the blood vessels that can facilitate procedures to unblock any obstruction with balloon dilation and stent placement.
Craniotomy
In patients with hemorrhagic stroke, head trauma or procedural complications from blood clot busters, bleeding inside the head can cause significant compression of the brain tissue and result in permanent brain damage or fatal complications. Since skull is a rigid closed compartment, craniotomy is done to remove one of the skull bones/plates (depending on location of bleeding) to relieve pressure and avoid brain damage. Bone flap is replaced once brain swelling improves.
EVD
An external ventricular drain or ventriculostomy involves placing a catheter through a small opening in the skull and advanced into a small space in the brain (ventricle) that relieves elevated pressure inside the skull when flow of cerebrospinal fluid around the brain is obstructed. EVD can also be used for intracranial pressure monitoring (ICP monitoring) to provide accurate pressure inside the skull and guide therapy to improve blood circulation to the brain tissue.
Bronchoscopy
Invasive direct visualization of the lungs from the inside and take cells and tissue samples using a bronchoscope is needed in patients with lung related illness including infections, inflammation, bleeding (coughing up blood) and cancer. Procedure can be done under conscious sedation using intravenous medications to relax and block pain while the flexible bronchoscope is passed through the nose or mouth into the lungs through past the back of the throat. Once inside, flexible forceps can be passed through a special channel in the bronchoscope to take small tissue samples for testing. Complications are uncommon and include infection, bleeding and pneumothorax (deflation of the lung from puncturing of pleura)
UGI endoscopy
Invasive direct visualization of the food pipe (esophagus) and stomach to investigate the source of bleeding in the stomach when patient vomits blood or esophagus or causes of food pipe related symptoms including heartburn, chest pain, etc. This procedure is also done under conscious sedation and complications although uncommon include bleeding, perforation of stomach or esophageal wall and blood stream infections.
Colonoscopy
Invasive direct visualization of the lower gastrointestinal tract including rectum and colon to investigate the source of bleeding when patient notices blood in stools or black/maroon stools. This procedure is also done under conscious sedation and requires bowel preparation by drinking a gallon of laxative solution to flush out stool from the colon for clear visualization. Physician might decide to inject bleeding vessel with alcohol solution to initiate clotting to prevent bleeding. Patient could also need surgical intervention with colon resection if bleeding is brisk and endoscopic procedure does not work.
Blood product transfusion
In cases of severe anemia associated with active bleeding, low blood pressure or active heart attack, patient can be given packed red blood cells intravenously to improve oxygen carrying capacity of blood and stabilize blood pressures. If patient had problems with blood clotting or platelet function the patient would need transfusion of fresh frozen plasma (after thawing) or platelets.
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Patients with end-stage liver disease, develop elevated portal pressures i.e. circulation between liver and intestines. This predisposes them to development of ascites (fluid collection in the abdominal cavity) and esophageal varices (dilated veins in food pipe). Ascites can be associated with respiratory compromise and septic shock. Varices can start bleeding and cause patient to vomit blood. Portal pressures can be lowered by placing a small tube in the liver that opens up connections between portal and systemic circulation like a gasket. This procedure involves passing a catheter from internal jugular vein that deploys the catheter into the liver using hepatic (liver) veins.
Percutaneous Entero-Gastrostomy/Jejunostomy tube (PEG/PEJ)
Critically ill patients or patients who are unable to eat food, are provided liquid nutrition through a catheter placed directly into the stomach or early part of small intestine (jejunum). Surgeon, gastroenterologist or interventional radiologist (most commonly) can place these feeding catheters/tubes into the desired location through the abdominal wall under endoscopic or fluoroscopic guidance.
EEG monitoring
Electrical leads are connected to the scalp with gel and tape to monitor electrical activities of the brain for patients having seizures or unresponsive patients for diagnostic purposes. It is similar to EKG that monitors electrical activity of the heart with leads connected to the chest.
Exploratory laparotomy
In patients suspected of infection, bleeding or intestinal infarction (death of intestines due to lack of circulation) surgeons make an incision into the abdominal wall to enter the cavity for a direct inspection/exploration of abdominal contents and definitive therapy.
Imaging studies- MRI/MRA/CTA/HRCT/USG/echocardiogram
Magnetic Resonance Imaging uses strong magnetic fields to orient water molecules in human cells to point in North-South direction followed by release off the magnetic pull at short intervals. Since human tissues have variable amount of water, variable energy released generates digital image with high definition contrast images. MRI does not involve radiation but is contraindicated in patients with any metallic implants that can cause significant soft tissue damage/burns. Intravenous contrast is needed to study blood vessels/circulation of tissues such as brain and heart.
Computerized Tomography uses radiation to generate digital images similar to MRI. Tissues with air such as lungs are better visualized by CT imaging. Precautions are needed in pregnant women and children. Radiation dose can accumulate over lifetime and low dose CT imaging is preferred where available.
Ultrasound uses reflection of sound wave from tissues with variable densities (air-liquid-solid contrast) to generate images. It is safe at all stages of life.
ECMO - Extra-Corporeal Membrane Oxygenation
Life support machine used in patients with severe lungs or heart failure that pumps blood from the heart (right side in VV-ECMO or left side in AV-ECMO) to a machine that oxygenates the blood and removes carbon dioxide before returning to left side of the heart. It can give time for heart or lungs to rest while aggressive treatment measures are put in place.
IABP (Intra-aortic balloon counter pulsation)
This is a special catheter placed in the aorta (biggest artery in human body) to facilitate better circulation in the coronary arteries that supply blood to the heart.
Temporary pacemaker
Special catheter is placed through the right internal jugular vein (most commonly) into the right ventricle to provide electrical stimulation in patients with very slow heart rate causing hemodynamic instability
Ulcer debridement
In patients who develop bedsores with undermined margins with dead skin tissue, surgical debridement is necessary to promote healing. Occasionally, skin grafting is required.
Fasciotomy
Limbs have compartments, separated by fascia (thick membranes), that are occupied by muscles, blood vessels and nerves. Blunt trauma can result in significant damage to muscles, resulting in swelling and increased pressure that can further worsen tissue damage. In this emergent situation, surgeons have to relieve the pressure by cutting open the skin down to the fascia to prevent permanent damage.
MEDICATIONS (Commonly used in ICU)
Intravenous (IV) fluids: Fluids given through a blood vessel, usually a vein, to expand volume. The two broad classes of IV fluids are crystalloids (like saline) and colloids (like albumin)
Inotropic agents/vasopressors: Inotropes are medications that increase the force of myocardial (heart) contractions, while vasopressors constrict arterial smooth muscle causing an increase in blood pressure.
Sedatives: Medications that depress the central nervous system to cause calmness, drowsiness, and sleep.
Narcotics: a controlled substance that either dulls the senses, relieves pain or induces sleep.
Psychotropic medications: Any medication producing a change in mental/emotional status or behavior. Includes antianxiety medications, antidepressants, antipsychotics, and other medications.
Antimicrobials: Any medication used to treat a known or suspected microbial infection, including antibiotics, antifungals, antiprotozoals, and antivirals.
Antihypertensives: Any medication used for the purpose of lowering blood pressure. Includes angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), renin inhibitors, beta-blockers, calcium channel blockers (CCBs), and diuretics, among others.
Diabetes medications: Medications used to control blood glucose levels. Includes insulin, insulin sensitizers (metformin, thiazolidinediones), insulin secretagogues (sulfonylureas, meglitinides), alpha-glucosidase inhibitors, glucagon-like peptide (GLP-1) agonists, dipeptidyl peptidase (DPP-4) inhibitors, and amylin analogues.
Anti-seizure medications (also known as anticonvulsants): Medications that suppress abnormal electrical activity in the CNS to prevent or inhibit seizures.
Blood thinners (also known as anticoagulants): Medications that interfere, directly or indirectly, at various points in the coagulation pathway to prevent blood clots. Agents include heparins (unfractionated and low molecular weight), vitamin K antagonists (warfarin), direct thrombin inhibitors, and factor Xa inhibitors.
Acid reducing medications: Medications that reduce the secretion of gastric (stomach) acid. Agents include H2 receptor antagonists, and proton pump inhibitors.
Nitric Oxide: Inhaled gas that causes pulmonary (lung) vasodilation, used to treat certain pulmonary disease states.
Heliox: A mixture of helium and oxygen used to improve ventilation. The low density of this gas mixture reduces resistance in the lungs.
tPA- intra-arterial/intravenous: Tissue plasminogen activator is an intravenous or intra-arterial thrombolytic (clot disrupter). Often used to dissolve a clot in a stroke patient and helps improve blood flow to the part of the brain where the clot occurred.
Medical conditions
Heart
i. Shock – Very low blood pressure causing damage to internal organs due to poor blood/oxygen supply.
ii. Myocardial Infarction- “heart attack”:decrease or no blood flow to the heart muscle due to blockage of coronary arteries that supply the heart muscle.
iii. Hypertensive crisis- Significant elevation of blood pressure causing internal organ damage.
iv. Pericardial effusion/tamponade, pericarditis: Increase in fluid collection in the sac that surrounds the heart called a pericardial effusion. When this collection impairs heart function due to compression of chambers it can lead to decreased blood pressure and cause fatality. Inflammation of the sac surrounding the heart is called pericarditis and can cause significant chest pain similar to a heart attack.
v. Right heart/left heart failure- Decrease squeeze of heart muscle of the lower chambers of the heart (ventricles- left or right) is called heart failure.
Lungs
i. Respiratory failure: Inability to breathe or oxygenate is called respiratory failure and can be due to many different reasons.
ii. Pulmonary embolism: Blood clot in the blood vessels that carry blood from the right side of the heart into the lungs (pulmonary arteries) and has high risk of mortality. Most often this results from blood clot traveling from legs to the heart.
iii. Pleural effusion/empyema: Fluid collection in the sac that surrounds each lung is called pleural effusion. When this fluid is rich in pus like material, it is called empyema and is most often from an infection.
iv. Pneumonia-VAP/HCAP/CAP/Opportunistic: Generally, infection of lung tissue is called pneumonia. It is often confused with pneumonitis that refers to inflammation of the lung tissue and can be from infection or inflammation as seen in auto-immune diseases such as lupus, etc.
Abdomen
i. Peritonitis: Inflammation of the sac that encloses abdominal contents. It is most commonly caused by infection of any abdominal organs but can results from inflammation from auto-immune diseases such as lupus, etc.
ii. Kidney failure and electrolyte abnormalities: Most important functions of kidneys are water balance (filter blood to make urine), excrete breakdown products such as urea and regulate electrolytes such as sodium, potassium, calcium, etc.. In kidney failure any of these functions could be affected. Conservative treatment is based on type of abnormality but most effective, end stage treatment is hemodialysis during which hemodialysis machine serves as artificial kidney.
iii. Colitis (C diff infection, ischemia): Large intestines are called colon and any inflammation of colon is termed colitis. Most common cause is infection caused by bacteria or viruses. Opportunistic bacteria called Clostridium difficile that naturally occurs in the colon and normally suppressed by natural bacteria in the colon causes antibiotic associated colitis or “C diff colitis”. If natural bacteria in the colon is suppressed by antibiotics then C difficile can start an infection that needs specific antibiotic therapy. Lack or decrease of blood to colon (colonic ischemia) can also cause inflammation and damage to colon wall that can result in rupture and spilling of colon contents into sterile abdominal cavity. Most often surgical treatment with antibiotic therapy is required.
iv. UTI: Infection of urine anywhere in the urinary tract from kidneys, bladder to urethra.
v. Gastrointestinal bleeding (GIB): Loss of blood from any part of the digestive tract. Classified as Upper GI bleed (UGIB) if patient is vomiting blood or Lower GI bleed (LGIB) if patient has fresh blood or digested blood (that appears like black tar) from the rectum. Generally considered an emergency and requires endoscopy by a gastroenterologist (GI specialist).
vi. Intra-abdominal hypertension/compartment syndrome: Increase in pressure inside the abdominal cavity due to any reason (most commonly trauma, lack of blood supply to abdominal organs such as colon or infection/inflammation) is called intra-abdominal hypertension. Any worsening damage to abdominal organs from intra-abdominal hypertension is called intra-abdominal compartment syndrome and needs urgent surgical intervention to open abdominal cavity and relieve pressure.
Neurology
i. Stroke: Damage to brain tissue caused by either- lack of blood supply due to blockage of arteries feeding the brain (also called ischemic stroke and could be treated with clot busters) or due to bleeding in the brain (also called hemorrhagic stroke)
ii. Seizures: Electrical storm in the brain that can cause generalized or focal muscle contractions. It is a neurologic emergency and is treated with intravenous medications.
iii. Delirium: Also called acute brain dysfunction and is associated with fluctuating mental status and disorientation. Can be associated with medications, illicit drugs, medical illnesses, hospitalization (especially in critically ill elderly patients).
Endocrine
i. Diabetic Ketoacidosis: Production of keto-acids as a result of altered metabolism due to lack of insulin in patients with diabetes mellitus. This causes blood to become acidic and can result in acute deterioration of mental status, nausea/vomiting, abdominal pain and requires hospitalization with intravenous insulin infusion.
ii. Thyrotoxicosis/Myxedema: Dysregulation of thyroid hormone production that can lead to excessively high thyroid hormone (also called thyrotoxicosis- associated with high blood pressure, palpitations, fever, chest pain, nausea/vomiting, etc.) or excessively low thyroid hormone (also called myxedema –associated with lethargy, decreased body temperature, slow heart rate with drop in blood pressure, mental status changes, etc.).
Extremities
i. Gangrene: Death/destruction of any tissue due to lack of blood supply. Generally, discussed in context of damage to skin, muscle, bones, etc.
ii. Compartment syndrome: Blunt injury to the extremities can result in swelling of muscle and lead to
Dermatology
i. Decubitus ulcers
ii. Stevens Johnson Syndrome
iii. Drug reactions
MEDICAL JARGON
QD: every day or once per day
BID: twice daily
TID: three times daily
QAC: before every meal
QHS: every night at bedtime
TIPS: Transjugular intrahepatic portosystemic shunt
CATH: catheter
Foley: catheter in bladder
Vent: ventilator
FiO2: Oxygen flow in liters/minute
PEEP: Positive End-Expiratory Pressure
PF ratio: Partial pressure of Oxygen divided by inspired oxygen fraction
HRCT: High Resolution CT scan
CTA: CT Angiography
MRI/MRA: Magnetic Resonance Imaging/ Magnetic Resonance Angiography
PRBC: Packed Red Blood Cells
FFP: Fresh Frozen Plasma
TPA: Tissue Plasminogen Activator
Cryo: Cryoprecipitate
10 pack: Bag of platelets
PCC: prothrombin concentrate complex
EVD: Extra Ventricular Drain
ICP: Intra-Cranial Pressure
MAP: Mean Arterial Pressure
SBP/DBP: Systolic Blood Pressure/Diastolic Blood Pressure
Tachy/Brady: Tachycardia/Bradycardia
Swan-Ganz/PA catheter: Pulmonary Artery Catheter
PPM: Permanent Pacemaker
PT/OT: physical therapy/occupational therapy
Pressors: IV medications that increase blood pressure
ICH: intracranial hemorrhage
ICP monitoring: intracranial pressure monitoring
PT/OT, Restraints,
AEDs: antiepileptic drugs
SCDs: sequential compression devices
PPI: proton pump inhibitor
H2 blockers: Histamine receptor antagonists
beta blockers: class of medications that work by blocking beta receptors
ACE inhibitors: angiotensin-converting enzyme inhibitors
SBT/SAT: Spontaneous Breathing Trial/Spontaneous Awakening Trial
Vent wean: Ventilator Weaning
H/H: Hemoglobin/Hematocrit
Bicarb: Bicarbonate
migs/kigs: Milligram(medication) per Kilogram(body weight)
p.r.n: as needed
ECMO: Extracorporeal Membrane Oxygenation
HIPPA: Health insurance portability and accountability act
