Initial Management

Initial Management Guidelines for Medical Externs

First Step: Call for Response

• If no response and no pulse: Follow C-A-B as per ACLS .
• If no response but pulse is present: Proceed with A-B-C.
• If there is a response: Continue with A-B-C.

A: Airway Security

• Open the airway: Use techniques like Head tilt, Chin lift, or Jaw thrust.
• Alternative airway options: Nasopharyngeal (NP) or Oropharyngeal (OP) airway.
• Definitive airway indications for Endotracheal Tube (ETT) insertion include failure to maintain the airway, failure to improve oxygenation with mask and bag, impending respiratory failure, GCS < 8, inability to maintain airway by other measures, upper airway obstruction, need for aspiration prophylaxis, inhalation injury.

B: Breathing and Ventilation

• Endotracheal Intubation Steps (6 P’s):
• Preparation: Follow the SOAPME protocol.
  • Endotracheal Intubation Steps: Preparation (SOAPME Protocol)

• Suction: Ensure suction equipment is ready and functioning.
• Oxygen Mask with Ambu Bag: Prepare an oxygen mask and Ambu bag for preoxygenation.
• Alternative Airway/Advice: Have alternative airway devices handy and seek advice or assistance if needed.
• Position: Adjust the patient's position for optimal neck flexion and atlanto-occipital extension. Use a ramp position for obese patients.
• Equipment:
• Laryngoscope: Ensure the laryngoscope is functioning and the light is checked.
• Blade: Choose the appropriate laryngoscope blade size.
• Syringe: Have a syringe ready for inflating the ETT cuff.
• Endotracheal Tube (ETT) Sizes:
• For males, use a cuffed ETT size No. 7.5-8.
• For females, use a cuffed ETT size No. 7-7.5.
• Cuff Leak Check: Ensure the ETT cuff does not have any leaks.
• Stylet: Insert a stylet into the ETT, ensuring it does not extend beyond the end of the ETT.
• Preoxygenation: 100% O2 via mask with bag until deep inspiration (8 times) or 3-5 minutes of spontaneous breathing if SpO2 ≥90%.
• Preincubation Optimization: Use sedation drugs as per the patient's condition.
• Diazepam (Valium): 5-10 mg IV. The onset is slow but lasts longer.
• Midazolam (Dormicum): 1-5 mg IV, faster onset but shorter duration (30-60 min).
• Position: Adjust the patient's position for optimal neck flexion and atlanto-occipital extension. Ramp position for obese patients.
• Placement and Proof: Confirm ETT placement through auscultation, visualization, and CO2 detection. Remember, if in doubt, remove the tube.
• Post-intubation Care: Set ventilator settings and oxygen therapy as required.
  • Set ventilator settings and oxygen therapy as required.
  • Mark the ETT at the appropriate cm from the lips or teeth.
  • Adjust Bird’s ventilator settings based on patient requirements.
  • Administer Valium/Dormicum as needed during ETT insertion.
  • Order a portable chest X-ray (CXR) post-ETT insertion.
  • Obtain an arterial blood gas (ABG) analysis.

Ventilator Settings and Oxygen Therapy:

• Focus on PaO2 (monitored via SpO2) and PaCO2 (monitored via RR, ETO2).
• Adjust FiO2 based on the target SpO2 depending on the patient’s condition (e.g., ≥95% for normal lungs or pneumonia, 88-92% for COPD/ARDS, ≥90% for acute coronary syndrome).
• Gradually decrease FiO2 to prevent oxygen toxicity.

Oxygen Toxicity Prevention:

• Limit the duration of high FiO2 usage: 1.0 FiO2 for 1-2 hours, 0.8 FiO2 for 1-2 days, 0.6 FiO2 for 1-2 weeks, 0.4 FiO2 can be used continuously without significant risk.

These updates ensure the inclusion of specific medication dosages, aligning with the importance of precision in medical management.

C: Circulation SHOCK or HYPOTENSION

Several issues need to be assessed in patients, including:

• Cardiac arrest: Refer to ACLS guidelines.
• Tachyarrhythmia or bradyarrhythmia: Refer to ACLS guidelines.
• Shock or Hypotension: The main focus of this section. Situations include BP drop and hypotension, possibly extending to other signs of shock like altered consciousness and reduced urine output.
• Determining True Shock: It's important to remember that BP drop does not always equal shock. Recheck cuff size and BP, and consider baseline values. Clinically, shock is considered as SBP < 90 mmHg or MAP < 65 mmHg, along with signs of shock. In chronic HTN patients, criteria might include a MAP drop > 30 mmHg or a decrease of more than 20% from baseline.
• Causes of Shock: Evaluation involves history and physical examination (Hx & PE).
• For example, in cardiogenic shock, look for sudden onset, chest pain, listen for murmurs, and check EKG.
• In hypovolemic shock, consider history of volume loss, post-op, or trauma.
• For distributive shock, consider septic shock (fever and source of infection), neurogenic shock (spinal injury or tumor compression), anaphylactic shock (rash, BP drop, wheezing, GI symptoms), or adrenal insufficiency.
• Obstructive shock could be caused by tension pneumothorax, high PEEP, tamponade, or pulmonary embolism.
• Management of Shock:
• Initial Management: Follow the A-B-C concept and treat the specific cause. Send for lab work-up based on the suspected cause, including ABG, lactate, serum cortisol.
• Supportive Management: Begin with fluid therapy, opening 2 large bore IV accesses. Consider crystalloids before colloids. Be cautious of allergic reactions with colloids. Fluid responsiveness tests can help decide further management. Keep MAP > 65 mmHg, or 75-80 mmHg in chronic HTN patients. If fluid therapy is insufficient to maintain MAP, consider starting Inotropes.
• Observe Progression & Complications: Regularly assess signs of shock and macro/micro-circulation. Be aware of complications like pulmonary issues indicating fluid overload, and distal gangrene when using inotropes.

Specific Treatment of Shock Types:

• Cardiogenic Shock: Follow Acute Heart Failure ESC guidelines 2016. Differentiate between WET and DRY presentations. Address precipitating causes like MI, HTN Emergency, PE, Arrhythmia. Use diuretics like Furosemide. Choose Dobutamine or Dopamine before Norepinephrine for inotropes.
• Hypovolemic Shock: Use crystalloids like 0.9%NaCl or RLS. Prepare for blood component transfusion in case of bleeding.
• Distributive Shock: For septic shock, follow sepsis survival guideline 2018. Start empirical antibiotics within 1 hour of diagnosis. Hemodynamic support is crucial, involving fluid therapy, acceptable BP maintenance, and adequate tissue perfusion.
• Obstructive Shock: Focus on releasing obstruction, such as needle thoracentesis for tension pneumothorax, pericardiocentesis for cardiac tamponade.

Fluid Responsiveness Test

When BP remains low despite significant fluid administration, deciding whether to continue fluid therapy can be guided by the following methods. Some are outdated or require sophisticated equipment.

Static Method

• CVP Measurement:
• Normal in supine position: 0-8 mmHg or 0-10 cmH2O. However, this range is for normal individuals and not used for shock management.
• Shock state: In Classic Early Goal Directed Therapy, the goal is to keep CVP ≥ 8-12 mmHg or 10-15 cmH2O, but if the patient is on a ventilator, keep CVP 15-20 cmH2O.
• Latest data suggests that if CVP < 8-12 cmH20, further fluid administration can be considered.
• Pulmonary Capillary Wedge Pressure (PCWP):
• Usage has decreased, mainly seen in ICU or CVT settings due to complexity.

Dynamic Method

• Fluid Challenge Test:
• An older method, time-consuming but cost-effective and doesn't require extensive equipment.
• Process: Measure CVP initially. Load IV fluid based on the CVP level:
• Initial CVP < 8 cmH2O, PCWP < 10 mmHg: Load 200 ml/10min.
• Initial CVP 8-12 cmH2O, PCWP 10-14 mmHg: Load 100 ml/10min.
• Initial CVP ≥ 12 cmH2O, PCWP ≥ 14 mmHg: Load 50ml/10min.
• Monitor CVP regularly during fluid administration. Adjust based on changes in CVP.
• Legs Raising Test:
• Appears simple but challenging to measure. Involves elevating legs and monitoring cardiac output or stroke volume for increased fluid responsiveness.
• Respiratory Variation:
• IVC distensibility/collapsibility index: Use Ultrasound to measure IVC diameter near the right atrium. IVC starting < 2.5 cm suggests fluid responsiveness. Utilize M mode to monitor diameter changes.
• Indices:
• IVC Collapsibility index (IVC-CI) > 50% indicates fluid responsiveness when self-breathing.
• IVC Distensibility index (IVC-DI) > 18% indicates fluid responsiveness when on a ventilator.
• Pulse Pressure Variation (PPV) and Stroke Volume Variation (SSV) require an arterial line and are reliable in ventilated patients under specific conditions.

Limitations of Using Respiratory Variation (IVC-CI and IVC-DI):

• Operator dependent, requiring accurate measurement of IVC.
• Influenced by factors like tricuspid regurgitation, pulmonary hypertension, RV dysfunction.
• For IVC-CI, deep breathing by the patient can affect values.
• PPV and SSV:
• Require an arterial line.
• Accurate only in ventilated patients without spontaneous breathing.
• Must be used with caution in patients with severe lung disease or arrhythmias.