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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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DNC Assessment
59
3 criteria to confirm DNC
1. Absence of consciousness – no wakefulness or response to stimuli
2. Absence of brainstem function – no brainstem reflexes
3. Absence of capacity to breathe
Shemie et al., Can J Anesth (2023) 70:483–557
1. Motor examination
- Central stimulation (supraorbital notch)
- Peripheral stimulation
2. Brainstem Reflexes
- Pupillary response to light
- Corneal response
- Cough
- Gag
- Vestibulo-ocular (cold calorics.
Don’t use oculo-cephalic – dolls
eyes)
3. Apnea testing
- No respiratory effort
- pH < 7.28, pCO2 > 60 AND
pCO2 increase ≥20
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Apnea Testing
• Pre-oxygenate and obtain ABG (Trillium Gift of Life Network
recommends baseline ABG PaCO2 35-45, pH = 7.35-7.45)
• Several options for apnea testing
– CPAP
– Passive oxygenation (O2 tubing down ETT, disconnected from ventilator)
– Exogenous CO2 or Reduce minute ventilation by 50% if high risk of failing (i.e.
from Hypoxaemia)
• Monitor for respiratory efforts
• Serial ABGs at 0, 5, 10 and 15min
Thresholds for completion: PaCO2 > 60 mmHg AND
> 20 mmHg above
the pre-apnea baseline AND
pH ≤ 7.28.
60
BONUS
Read on own
Shemie et al., Can J Anesth (2023) 70:483–557
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DNC: Ancillary Testing
• Required if DNC examination cannot be completed
(i.e. confounder cannot
be reversed, trauma to one eye prevents pupillary/corneal/vestibulo-ocular reflex testing)
• Ancillary tests used to support theory of cessation of brain function
• Several modalities can be used
– CT angiography (CTA)
– CT perfusion (CTP)
– Transcranial Doppler
– Radionuclide lipophillic perfusion study
• Don’t use: EEG, MRI, 4 vessel angiography, SSEP, BAEP, radionuclide
liphophobic perfusion study
61
BONUS
Read on own
Shemie et al., Can J Anesth (2023) 70:483–557
SSEPs = somatosensory evoked potentials, BAEP = brainstem
auditory evoked potentials
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Donation Organ Support
62
BONUS
Read on own
Ball et al., CMAJ 2020 April 6;192:E3619.
• Respiratory: Vt 6-8ml/kg, PEEP ≥8, Recruitment manoeuvres
• Cardiovascular: MAP > 65, inotropes (1
st
Vaso, 2
nd
Norepi, NO
dopamine), crystalloids for fluid resuscitation
• Endocrine: Steroids if on vasopressors, no recommendation for
levothyroxine, glucose 6-10
• Diabetes insipidus: Na target 135-155, use vaso or DDAVP
• GI: Continue enteral feeding
• Core temperature 34-35 kidneys being considered
• Coronary angiography if heart being considered
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Management of Neurological Injuries
Types: traumatic brain injuries, subarachnoid hemorrhages, stroke, hypoxic injuries, etc.
Principles of ICU management (Neuro lecture for specifics):
• Intubation for airway protection (if GCS < 8)
• Keep head of bed > 45 degrees
• Targ et n or mo th er mi a, eu gl yc em ia , n or mo ca pn ia
• Preferentially use normal saline for fluid management to avoid significant sodium
shifts and avoid hyponatremia
Increased ICP management: (in addition to above)
• Hypertonic 3% saline (250 cc bolus) or mannitol (0.25 – 1 g/kg/dose, may repeat
every 6-8 hrs)
• Hyperventilation (target CO2 of 26 – 30)
• ICP monitoring (goal to keep ICP < 20 mmHg)
• Increase sedation (make sure airway is secured)
• Blood pressure control (to maintain cerebral perfusion pressure > 60)
• Avoid restrictive neck taping or excessive rotation/flexion of the neck
• Treat seizures with anticonvulsant therapy if s uspected
• Surgical consultation for consideration of EVD placement (if hydrocephalus) or
decompressive craniectomy
63
Devastating Brain Injury:
*Incompatible with life or
unlikely to make a meaningful
recovery.
CCCS 2020 Position Statement
recommends waiting at least 72
hours before consideration of
withdrawal of life support to
establish greater confidence
and accuracy in prognostication
and recovery. This also allows
time for conversations around
and consideration of organ
donation. Always remember to
call Trillium Gift of Life!
Healey et al. Can Journal of ED
Medicine 2020; 22(5): 658-660.
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Critical Illness Associated Weakness
64
Critical illness myopathy Critical illness polyneuropathy Glucocorticoid-induced myopathy
Motor
Flaccid quadriparesis, proximal
> distal muscles, failure to
wean, normal CNs, weak facial
muscles
Flaccid quadriparesis, failure to wean,
normal CNs
-Gradual onset 1-3 months after starting
steroids
-Proximal muscle Lower>upper weakness,
followed by atrophy of proximal muscle
groups
-Lower occurs before upper extremity
weakness and is more severe
Sensory Spared Decreased pin prick/touch in distal
extremities
Normal
Reflex Normal or low Low Normal
Other CK may be elevated
Strongly associated with
steroid use (starts several days
after steroids)
-Diagnose with nerve
conduction studies/EMGs
-No tx
Severe sepsis is the strongest risk factor -Will get Cushing’s like syndrome with , DM,
mood alteration, skin fragility, osteoperosis
-
Definitive dx=decrease steroid dose and see if
improves in 3-4 weeks
BONUS
Read on own
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TOXICOLOGY TIME!
• Toxicology
– Approach
– TCA
– Toxic A lc oh ols
– Salicylate
– Acetaminophen
– Carbon Monoxide, Cyanide
– Methemoglobinaemia
– Lithium
– Hyperthermic Toxidromes
• Extra slides for your reference:
– Acute hypoxia in the ICU
– Gas trapping
– Maternal cardiac arrest
– Liver failure guidelines
– Hyperthermia & Hypothermia
– Bonus MCQs
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MCQ 4 2024
A 50 year old female presents to the emergency department after starting a new
antibiotic for a UTI. She has a headache, dizziness, shortness of breath and confusion.
On assessment vitals show BP 110/70, HR 110, RR 28, Sat 87%, temp 36.5. She appears
cyanotic, tachypneic and drowsy. She is placed on a non-rebreather mask at 15L/min.
Laboratory investigations show Hb 115, WBC 8, Plt 250, Cr 120, Na 137, K 4.8, Cl 105,
bicarb 21, lactate 2.3, ABG 7.44, CO2 35, PaO2 170, SaO2 56%.
What is the definitive next step in management?
a. Hydroxycobalamin 5g IV
b. Place on high-flow nasal cannula at FiO2 1.0
c. Methylene blue 2mg/kg IV
d. CT head
e. Transfuse 1 unit RBCs
66
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Tox Quick Approach
• History:
– What did the patient take? How long ago? How much?
• Co-ingestions (EtOH? ASA? Acetaminophen? Toxic alcohols?)
– Environmental exposures : Carbon monoxide risk factors
– Past Medical History, Meds, Allergies, Social
• Physical: look for toxidromes
– Vitals, GCS, capillary blood glucose
– Pupils (mydriasis, mioisis)
– Neuro (Reflexes, clonus, rigidity)
– Skin (dry, sweating, hot)
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Tox Quick Approach
STAT Investigations
– CBC, Na, K, Cl, bicarb, BUN, Cr, Ca, Mg, PO4, LFTs, CK, troponin, glucose
– ABG, lactate
– Serum osmolality, urea
– BHCG (if young female)
– Urine/Serum Tox
• ALWAYS ask for acetaminophen, salicylates, and EtOH level
– 12-Lead ECG
– Urinalysis (for pH), R+M (for crystals)
– Consider CT head
AND SOME QUICK MENTAL CALCULATIONS:
- Anion gap= Na-Cl-Bicarb (normal < 12 with normal albumin)
- Osmolar gap=Sosm-CalcOsm (normal < 10) --> if elevated, order toxic alcohols +
start empiric treatment if high suspicion, not explained by ETOH level
-Calc Osm=2Na+gluc+BUN (“2 salts and a sugar BUN”)
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