ICU Protocols

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Al-Azhar-Faculty of Medicine ICU Protocols 2014
FOREWORD:
A standardized approach to management is desirable for optimal patient care and
safety, improving communication and understanding between members of the ICU team
and associated specialties.
Management protocols have been shown to improve patient outcome and resource
utilization in the intensive care units and thus, are being used increasingly.
Different approaches in clinical management are expected, however, these protocols
are developed with the objective of improving patient care in the intensive care unit as
they are based on current best evidence. Clinicians must regularly review the protocols
in the light of new evidences and make the necessary changes to the protocols.
Staff must be familiar with these protocols before they are introduced in individual units.
ICU staff, Bab El Sharea University Hospital
Department of Anesthesiology and Intensive Care
Faculty of Medicine, Al- Azhar University
2014

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List of Contents
Admission and Discharge Policies -----------------------------------------------------------4
ICU Care: A Check List Approach ---------------------------------------------------------13
Management of critically-ill patients -------------------------------------------------------14
Stress Related Mucosal Disease Prophylaxis in ICU -------------------------------------15
Trauma Protocol in I.C.U --------------------------------------------------------------------16
Cardiovascular support Protocol (EGDT) -------------------------------------------------47
Septic shock protocol ------------------------------------------------------------------------49
Hypoxia: Diagnostic Approach-------------------------------------------------------------58
Hypoxia: Management ----------------------------------------------------------------------59
Initiation of Mechanical Ventilation ------------------------------------------------------60
Protective Ventilatory Strategy ------------------------------------------------------------51
Weaning - Extubation Protocol ------------------------------------------------------------66
Electrolyte Replacement Protocol ---------------------------------------------------------73
Acid-Base protocol --------------------------------------------------------------------------85
Diabetic Ketoacidosis protocol ------------------------------------------------------------90
IV Insulin Protocol --------------------------------------------------------------------------92
Acute Renal Failure in ICU ----------------------------------------------------------------96
Adult ICU Anemia Management Protocol -----------------------------------------------99
Adult ICU Hemostasis Protocol -------------------------------------------------------- 100

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Infection Management Protocol ---------------------------------------------------------104
Deep vein thrombosis (DVT) ------------------------------------------------------------111
Pulmonary Embolism (PE) ---------------------------------------------------------------115
Gastro-intestinal hemorrhage protocol --------------------------------------------------121
Nutritional support Protocol --------------------------------------------------------------122
Cardiac Arrest and Cardiopulmonary Resuscitation-----------------------------------130
Sedation, Analgesia and Muscle Relaxants---------------------------------------------144
Critical Care IV Medications Chart -----------------------------------------------------153
Appendices ---------------------------------------------------------------------------------157

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Admission and Discharge Policies
Introduction:
Principles:
ICU Admission Policy:
The Intensive Care Unit is an expensive resource area and ICU admission is reserved for
patients with actual or potential vital organ system failures, which appear reversible with
the provision of ICU support.
Organ System Failures include respiratory failure and cardiovascular instability.
The ICU support includes advanced monitoring, invasive procedures and intensive care
like mechanical ventilation and vaso - active drugs.

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ICU Admission Procedure:
 The request for admission must be made by the referring doctor.
 The ICU doctor on-duty must see and assess the referred patient.
 Resuscitation or admission must not be delayed where the presenting condition is
imminently life threatening, (eg profound shock or hypoxia).
 All admissions to ICU must be approved by the Duty Consultant Intensivist.
 All patients admitted to the ICU have to be under a primary Consultant.
 Patients admitted directly through the Emergency Department come under the name of
the admitting medical or surgical consultant of the day.
 Patients sent to the ICU from the wards must have their beds reserved.
 The patient is managed by the ICU staff during their stay in ICU.
 The primary Consultant/team may participate in the management through direct
communication with the ICU staff.
Admission Protocol: (organized by the ICU doctor on-duty):
1. Inform the ICU Charge Nurse to prepare for the admission.
2. Inform the Charge Nurse of the ward currently holding the patient.
3. On arrival to the ICU, attach monitors and record vital signs of the patient.
4. Resuscitation priorities MUST follow ACLS and ATLS GUIDELINES.
5. The ICU doctor must discuss the management with the duty ICU consultant.
6. The ICU doctor must write the admission doctor's orders.
7. The ICU doctor must write all the required medications in new drug charts.
8. The ICU doctor must complete pharmacy-required forms, investigations requests,
general consent form etc...
9. The ICU doctor must write a full admission note (history, physical exam, assessment
and the ICU management) in the progress sheet.

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ICU Discharge Policy:
Patients are discharged from ICU when the need for treatment or advanced monitoring is no longer
needed. The duty ICU consultant must approve the discharge.
ICU Discharge Procedure
 Inform and discuss with the referring Team.
 Inform the ICU nursing staff.
 Ensure a ward bed is available.
 The appropriate ward will be notified.
 Complete the doctor's orders AND discharge summary in the patient‟s notes.
 The patient will be informed of the transfer.
ADMISSION CRITERIA
Specific conditions or diseases requiring ICU admission:
I-Diagnosis Model:
A. Cardiac System:
1. Acute myocardial infarction with complications
2. Cardiogenic shock
3. Complex arrhythmias requiring close monitoring and intervention
4. Acute congestive heart failure with respiratory failure
5. Hypertensive emergencies
6. Unstable angina, particularly with dysrhythmias, hemodynamic instability
7. S/P cardiac arrest
8. Cardiac tamponade or constriction with hemodynamic instability
9. Dissecting aortic aneurysms
10. Complete heart block
B. Pulmonary System:
1. Acute respiratory failure requiring ventilatory support
2. Pulmonary emboli with hemodynamic instability
3. Patients in the wards who are demonstrating respiratory deterioration
4. Need for nursing/respiratory care not available in lesser care areas such as floor

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5. Massive hemoptysis
6. Respiratory failure with imminent intubation
C. Neurologic Disorders:
1. Acute stroke with altered mental status
2. Coma: metabolic, toxic, or anoxic
3. Intracranial hemorrhage with potential for herniation
4. Acute subarachnoid hemorrhage
5. Meningitis with altered mental status or respiratory compromise
6. Central nervous system or neuromuscular disorders with deteriorating neurologic or
pulmonary function
7. Status epilepticus
8. Brain dead or potentially brain dead patients
9. Vasospasm
10. Severe head injured patients
D. Renal:
1. Requirement for acute renal replacement therapies in an unstable patient
2. Acute rhabdomyolysis with renal insufficiency
E. Hematology:
1. Severe coagulopathy and/or bleeding diathesis
2. Severe anemia resulting in hemodynamic and/or respiratory compromise
3. Severe complications of sickle cell crisis
4. Hematological malignancies with multi-organ failure
F. Obstetric:
1. Medical conditions complicating pregnancy
2. Severe pregnancy induced hypertension/eclampsia
3. Obstetric hemorrhage
4. Amniotic fluid embolism
G. Drug Ingestion and Drug Overdose:
1. Hemodynamically unstable drug ingestion
2. Drug ingestion with significantly altered mental status with inadequate airway protection
3. Seizures following drug ingestion

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H. Gastrointestinal Disorders:
1. Life threatening gastrointestinal bleeding including hypotension, angina, continued bleeding,
or with comorbid conditions
2. Fulminant hepatic failure
3. Severe pancreatitis
4. Esophageal perforation with or without mediastinitis
J. Endocrine:
1. Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status,
respiratory insufficiency, or severe acidosis
2. Thyroid storm or myxedema coma with hemodynamic instability
3. Hyperosmolar state with coma and/or hemodynamic instability
4. Other endocrine problems such as adrenal crises with hemodynamic instability
5. Severe hypercalcemia with altered mental status
6. Hypo or hypernatremia with seizures, altered mental status
7. Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias
8. Hypo or hyperkalemia with dysrhythmias or muscular weakness
9. Hypophosphatemia with muscular weakness
K. Surgical:
Post-operative patients requiring:
 hemodynamic monitoring
 ventilatory support
 extensive nursing care
L. Miscellaneous:
1. Septic shock with hemodynamic instability
2. Hemodynamic monitoring
3. Clinical conditions requiring ICU level nursing care
4. Environmental injuries (lightning, near drowning, hypo/hyperthermia)
5. New/experimental therapies with potential for complications

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II- Objective Parameters Model:
Vital Signs:
* Pulse < 40 or > 150 beats/minute
* Systolic arterial pressure < 80 mm Hg
* Mean arterial pressure < 60 mm Hg
* Diastolic arterial pressure > 120 mm Hg
* Respiratory rate > 35 breaths/minute
Laboratory Values (newly discovered)
* Serum sodium < 110 mEq/L or > 170 mEq/L
* Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
* PaO2 < 50 mm Hg
* PH < 7.1 or > 7.7
* Serum glucose > 800 mg/dl
* Serum calcium > 15 mg/dl
* Toxic level of drug or other chemical substance in a hemodynamically or neurologically
compromised patient
Radiography/Ultrasonography/Tomography (newly discovered)
* Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered
mental status or focal neurological signs
* Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic
instability
* Dissecting aortic aneurysm
Electrocardiogram
* Myocardial infarction with complex arrhythmias, hemodynamic instability or
congestive heart failure
* Sustained ventricular tachycardia or ventricular fibrillation
* Complete heart block with hemodynamic instability

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Physical Findings (acute onset)
* Unequal pupils in an unconscious patient
* Burns covering > 10% BSA
* Anuria
* Airway obstruction
* Coma
* Continuous seizures
* Cyanosis
* Cardiac tamponade
Patients who are generally not appropriate for ICU admission
1. Irreversible brain damage
2. End stage cardiac, respiratory and liver disease with no options for transplant
3. Metastatic cancer unresponsive to chemotherapy and/or radiotherapy
4. Brain dead non-organ donors
5. Patients with non-traumatic coma leading to a persistent vegetative state

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DISCHARGE CRITERIA
The status of patients admitted to an ICU should be revised continuously to identify
patients who may no longer need ICU care.
A. When a patient's physiologic status has stabilized and the need for ICU
monitoring and care is no longer necessary
 Hemodynamically stable (of vaso-active drugs) for at least 12 hrs.
 No evidence of active bleeding
 Oxygen requirement is no more than FiO2 40% with SpO2 > 90%
 Acceptable pH
 Extubate for more than 6 hrs no evidence of upper airway obstruction
 Appropriate level of consciousness to protect the airway or has tracheostomy
B. When a patient's physiological status has deteriorated and active interventions
are no longer planned, discharge to a lower level of care is appropriate
TRIAGE
Due to the limited number of ICU beds, triaging may be necessary.
The following factors will be taken into consideration in triaging:
 Diagnosis
 Severity of illness
 Age and functional status
 Co-morbid disease
 Physiological reserve
 Prognosis
 Availability of suitable treatment
 Response to treatment to date
 Recent cardiopulmonary arrest
 Anticipated quality of life
The ultimate authority for ICU admission, discharge, and triage rests with the ICU
Director.

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Investigations and Microbiological Surveillance
No routine investigations are to be done for patients admitted to the ICU
Basic investigations on admission:
 Full blood count (includes hemoglobin, total white and differential counts, and platelet count)
 Serum creatinine, blood urea and electrolytes (including Na+, K+, Cl-, Ca2+, Mg2+,
Phosphate)
 Liver function test
 Prothrombin time (PT), activated partial thromboplastin time (APTT), coagulation screening
 Arterial blood gas
 Blood glucose level (hand held blood glucose analyzer is acceptable)
Additional tests on admission when indicated:
 Septic / microbiology screen as indicated
 CXR (after placement of appropriate lines e.g. central venous line, nasogastric tube)
 Patients requiring post-operative ventilation for a few hours may not require a routine
CXR
 ECG
Tests ordered daily:
 FBC: Hb, TWDC, platelet count
 BUSE, creatinine
 Other tests only when indicated
Microbiological Surveillance:
 MRSA screening (nasal swab only) on admission to ICU may be indicated in the
following:
 Patients who have been admitted for > 5 days in the ward
 Patients with previous positive cultures for MRSA either in the blood, tracheal
aspirate or urine
 Patients admitted from other hospital
 Patients admitted from long-term care institutions e.g. nursing homes
 Patients on chronic renal dialysis
 Tracheal aspirate for C&S; May be done once a week in intubated patients. (Note: not all
positive cultures on routine surveillance are infective)

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ICU Care: A Check List Approach

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Management of critically-ill patients
System Interventions
Respiratory Daily SBT☺ or safe ventilation: PVS
Cardiovascular Optimize flow & pressure: EGDT
Renal Electrolytes& acid-base/early CRRT
GIT Early TEN or TPN
CNS Daily sedation☺ interruption/titrateon
SIRS & ID Temp, WCB, CXR, lines & cultures
Metabolic Glucose control, low dose steroid
Hematology Packed RBCs only if Hb <7g/l
Drugs DVT & stress ulcer prophylaxis, Gut motility, antibiotics & others
Investigations Blood tests, imaging studies, ECG.
SBT=spontaneous breathing trial i.e. 30-120min CPAP, PVS=protective ventilation strategy
i.e. 6ml/kg PBW, high PEEP, PO2>7.5kPa, pH>7.25.
EGDT=early goal directed therapy,
CRRT=continuous renal replacement therapy, TEN=total enteral nutrition
Progress Note:
Problem-list List of the problems using diagnostic terms
Systems review* Transcribe the orders, clean-up drug charts
Active issues The problems for the night on-call
Assessment Overall condition
Prognosis Communicate with the consultant & families
* use the doctors' orders as a guide and minimize drugs, change IV to oral rout.

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Stress Related Mucosal Disease (SRMD) Prophylaxis in ICU
Introduction:
Principles:
SRMD Prophylaxis Protocol:

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SRMD Prophylaxis Algorithm

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Trauma Protocol in I.C.U
Airway
Chin lift
Bag-valve-mask assisted
with 100%O2
Intubation
Vocal response
Auscultation
Breathing
Circulation
Neurologic Disability
Exposure and
secondary survey
Mechanical Ventilation
Tube thoracostomy
Pulse Oximetry
Arterial blood
gases
Chest x-Ray
Vital signs
Capillary refill Response to
fluid bolus
CBC, coagulation profile, type
cross match, FAST, Pelvic
plain film
Determination of GCS
Motor and sensory
exam cervical spine
films
Head, neck, Spine CT
Adequate IV access
Fluid administration Pressure
on open wound Pelvic binder
Thoracotomy
Uncrossmatched blood
Surgery
Support of oxygenation and
perfusion
Emergency surgery
intracranial pressure
monitoring
Removal of all clothes
further surgical treatment as
indicated
Detailed review of all lab
and radio studies
Lab studies
ECG
Indicated plain Film and CT
scans
Detailed history

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Airway and C-spine protection

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INITIAL ASSESSMENT AND RESUSCITATION OF THE INJURED PATIENT
In severe trauma, assessment and resuscitation should be performed simultaneously. The purpose
of the initial evaluation and management is to diagnose and address life-threatening problems,
which can cause death or serious morbidity if not treated early. This is called Primary Survey.
PRIMARY SURVEY:
The primary survey includes 5 components, which should always be followed in strict order.
After the 5 main components of the Primary Survey, continue with F,G,H:
A. AIRWAY:
1. Clear the oropharynx of blood, mucus and foreign bodies.
2. Lift the angle of the jaw or the chin to prevent the tongue from falling back and obstructing the
airway. (Don't overextend the neck; the patient might have a spinal injury!).
3. If the above measures are not sufficient or if the patient is unconscious (GCS=<8), endotracheal
intubation is the next step. (Size 8 for adult males, size 7 for females, or the size of the patient's
small finger irrespective of age).
 Apply cricoid pressure during intubation to prevent aspiration. Keep applying the
pressure until the cuff of the tube has been inflated. Make sure that the tube is in the
A. Airway Maintenance with Cervical Spine Protection
B. Breathing and Ventilation
C. Circulation and Hemorrhage Control
D. Disability/Neurological Status
E. Exposure/Environmental Control
F. Foley Catheter
G. Gastric Tube
H. Hertz - Trauma

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 Make sure that the tube is in the correct place by checking for CO2 return, listening for
bilateral breath sounds and obtaining a chest x-ray.
 If endotracheal intubation is impossible (e.g. in severe facial trauma), the next step is a
cricothyroidotomy. In emergencies there is no place for tracheostomy. In patients with
short, fat necks, the procedure can be difficult.
Cervical Spine Protection:
o High index of suspicion depending on the history of the accident: (traffic accidents, falls,
certain sports).
o Avoid rough manipulation of the head and neck. Use hard collars to immobilize the neck.
Immobilize the whole body on a long spinal board.
o Obtain appropriate radiological evaluation. Symptomatic or unevaluable patients with
suspicious mechanisms of injury should be evaluated with CT scan of the cervical spine.
Radiological evaluation should be done only after the patient has been stabilized, if
necessary after an emergency operation. Clearance of the cervical spine is NOT an
emergency!
B. BREATHING AND VENTILATION
Inspect for symmetrical chest movements. Auscultate for breath sounds bilaterally.
Palpate the trachea for deviation and the chest wall for fractures or emphysema.
Life-threatening problems to be identified during primary survey:
1. Flail chest: Monitor pulse oximetry and blood gases, intubate and ventilate if there is
hypoxia or respiratory distress. Consider early intubation in elderly or severe multi-trauma
patients.
2. Open, sucking/blowing wound in the chest wall: Do not suture or pack before thoracostomy
tube insertion. Danger of tension pneumothorax! A Square gauze taped on only 3 sides can
be applied while preparing for chest tube insertion.
3. Tension pneumothorax: Initial decompression with needle insertion through the 2nd or 3rd
intercostal space anteriorly, mid-clavicular line then Thoracostomy tube

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C.CIRCULATION:
Resuscitation of trauma patient with ongoing blood loss should be considered in two
phases:
 Early, while active bleeding is still ongoing
 Late, once all hemorrhage has been controlled
Goal for Early resuscitation Goal for Late resuscitation
 Maintain systolic blood pressure 80-100 mm
Hg
 Maintain HCT at 25-30%
 Maintain PT and PTT at normal range
 Maintain platelet ≥50.000
 Maintain normal ionized calcium
 Maintain core temperature>35
 Prevent increase in serum lactate
 Prevent acidosis from worsening
 Fluid administration to limit hypoperfusion is
balanced against an increase in blood pressure
and thus bleeding
 Maintain systolic blood pressure >100
 Maintain HCT above transfusion threshold
 Normalize coagulation status
 Normalize Electrolyte balance
 Normalize body temperature
 Restore normal urine output
 Maximize cardiac output
 Reverse systemic acidosis
 Normalize serum lactate
 Fluid administration should be continued until
adequate perfusion is restored
Assessment Of hypovolemic Shock
Class of hypovolemia Class I Class II Class III Class IV
Blood Loss:
% Circulating volume
<15 15-30 30-40 >40
Blood Loss:
Volume (mls in adults)
<750 750-1500 1500-2000 >2000
Pulse Normal 100-120 bpm 120 bpm Weak >120 bpm Very
weak
Blood Pressure:
Systolic
Normal Normal Low Very Low
Blood Pressure:
Diastolic
Normal High Low Very Low
Capillary Refill Normal Slow Slow Absent
Mental State Alert Anxious Confused Lethargic
Respiratory Rate Normal Normal Tachypnoeic Tachy- pnoeic
Urine Output >30 mls/hr 20-30 mls/hr 5-20 mls/hr <5 mls/hr

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D. DISABILITY (NEURO EVALUATION AND MANAGEMENT):
1. Assess level of consciousness (Glasgow Coma Scale).
2. Assess pupils (size, reactivity).
E. EXPOSURE/ENVIRONMENT CONTROL:
1. Undress the patient completely for thorough examination.
2. Keep the patient warm with blankets and warm IV fluids. Trauma patients become
hypothermic very quickly. Severe blood loss, elderly patients and pediatric trauma
patients are at high risk for hypothermia.
Glasgow Coma Scale (GCS):
It is a scale used to assess the level of consciousness; the highest score is (15) and the
lowest score is (3).
Category Score
1-Eye opening:
-Spontaneous…………………………………………..
-To verbal command…………………………………..
-To pain………………………………………………..
-No response…………………………………………..
2-Best motor response:
-To verbal command: obeys………………………….....
-To pain -Localize pain……………………………….
-Flexion withdrawal………………………...
-Abnormal flexion (Decorticate rigidity)……
-Extensor response (Decelebrate rigidity)…...
-No response………………………………...
3-Best verbal response
-Oriented& converse…………………………………...
-Confused……………………………………………...
-Inappropriate words…………………………………..
-Incomprehensive sounds……………………………...
-No response…………………………………………...
4
3
2
1
6
5
4
3
2
1
5
4
3
2
1

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SECONDARY SURVEY:
1. The secondary survey is done only after the primary survey (ABC's) is completed
and resuscitation is initiated. Sometimes the secondary survey is performed after
operation for life-threatening injuries.
2. Complete examination from head to toe (head and neck, chest, abdomen, back,
rectal and vaginal examinations, and musculoskeletal).
EXPERT COMMENTS:
1. Examination of the trauma patient:
 Often this is very difficult because of intoxication, shock or head injury.
 Undress the patient completely and always examine the back. Serious injuries may
otherwise be missed. Cover the patient with warm blankets to prevent hypothermia.
 The presence of an obvious wound should not distract from another less obvious but
perhaps more dangerous injury elsewhere.
2. Head Injury:
 Correct any condition, which aggravates an existing brain injury (e.g. shock or hypoxia).
 Cervical spine injury is a commonly associated problem. Apply a semi-rigid collar, keep the
head and neck in a neutral position, and apply precautions during transportation, until a
cervical injury has been excluded. The cervical spine clearance is not an emergency as long
as protection is maintained.
 Closed head injuries alone rarely produce hypotension, except in the terminal stages or in
neonates. If the patient is in shock, look for a source of bleeding, cardiogenic shock or
associated cervical spine injury. Scalp lacerations can bleed profusely and may cause
hypotension.

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3. Fractures:
 Immobilize all severe fractures at an early stage, before moving the patient to CT
scan or other investigations. This will reduce pain, decrease bleeding, reduce fat
embolism, and minimize neurovascular damage.
 Fractures of the pelvis or the femur may be associated with significant blood loss.
 Early operative fixation of major fractures decreases morbidity, mortality, and
hospitalization. However, in the presence of severe associated head or chest trauma,
prior stabilization of the patient is advisable.

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MULTIPLE TRAUMA PROTOCOL

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CHEST TRAUMA

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CHEST TRAUMA
SIGNS AND SYMPTOMS
SIMPLE
PNEUMOTHORAX
OPEN
PNEUMOTHORAX
TENSION
PNEUMOTHORAX HEMOTHORAX
 Shortness of breath
 Dyspnea
 Tachypnea
 Cyanosis
 Chest pain
 Absent / Diminished
lung sounds on the
affected side
 Dyspnea
 Cyanosis
 Sucking chest wound
 Shock
lung sounds on
affected side
 Cyanosis
 Shock
 lung sounds
 Tracheal deviation
 Hypotension
 JVD
 Tachycardia
 Dyspnea (late sign)
 Dyspnea
 Cyanosis
 Dullness to
percussion sounds
 Flat neck veins
 Hypotension
 Shock
 Absent/Diminished
breath sounds
 Tachycardia
CARDIAC
TAMPONADE
TRAUMATIC
ASPHYXIA
FLAIL CHEST
 Hypotension
 Decreasing pulse pressure
Elevated neck veins
 Muffled heart tones
 Bruising over the sternum
 Tachycardia
 Bloodshot, bulging eyes
 Blue, bulging tongue
 JVD
 Cyanotic upper body
 Paradoxical chest wall
movement
 Asymmetric chest movement
upon inspiration
 Dyspnea
 Unstable chest segment
 Significant chest wall pain
KEY POINTS
 Thoracic injuries have been called the deadly dozen. The first six are obvious at the
primary assessment:
 Airway Obstruction
 Massive Hemothorax
 Flail Chest
 Open Pneumothorax
 Cardiac Tamponade
 Tension Pneumothorax
 The second six injuries may be more subtle and not easily found in the field:
 Traumatic Aortic Rupture
 Esophageal Injury
 Myocardial Contusion
 Diaphragmatic Tears
 Tracheal/Bronchial Tree Injury
 Pulmonary Contusion

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HEAD TRAUMA

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HEAD TRAUMA
HISTORY SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS
 Time of injury
 Mechanism: blunt /
penetrating
 Loss of consciousness
 Bleeding
 Medical history
 Medications
 Evidence of multi-trauma
 Helmet use or damage to
helmet
 Pain, swelling, bleeding
 Altered mental status
 Unconscious
 Respiratory distress / failure
 Vomiting
 Significant mechanism of
injury
 Skull fracture
 Brain injury (concussion,
contusion, hemorrhage, or
laceration)
 Epidural hematoma
 Subdural hematoma
 Subarachnoid hemorrhage
 Spinal injury
 Abuse

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Management of Traumatic Brain Injury
Trauma causes 150,000 deaths in the United States each year, about half due to fatal
head injuries. Not all neurologic damage occurs at the moment of injury; further injury
can occur over the ensuing hours and days.
Brain Injuries include :
1. Concussion: No gross pathology. Transient loss of consciousness. CT scan is normal.
2. Contusion: Bruising of the brain surface underneath a fracture or at the under-surface of
the frontal and temporal lobes, due to shearing forces. Diagnosed on CT scan.
3. Laceration: Tearing of the brain substance. Diagnosed by CT scan.
4. Brain edema: This is localized in the glial cells, myelin sheaths, and intercellular spaces.
It causes increased intracranial pressure, which may impair brain circulation, or result in
brain herniation. It may be missed in early CT scans. Later CT scans or MRI show
edema more reliably.
Brain damage is classified into:
1. Primary brain damage. It occurs at the time of injury and is irreversible (i.e. lacerations,
contusions, axonal injuries of the white matter due to shearing forces).
2. Secondary brain damage. It occurs at a later stage due to tissue hypoperfusion and may be
preventable and reversible. Conditions that may cause secondary brain damage:
 Extracranial causes: shock, hypoxia, and electrolyte abnormalities.
 Intracranial causes: hematoma, brain edema, infection, and hydrocephalus.
Cerebral Perfusion Pressure (CPP)
 CPP = mean arterial pressure (MAP) - intracranial pressure (ICP).
 Normal ICP is 5-15 cmH20
 A minimum CPP of 70 mm Hg (or >50 mmHg in young children)
 Is critical in maintaining adequate brain perfusion and minimizing secondary brain
damage.

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Planning of Therapies:
 Early goals of therapy are to evacuate surgically correctable intracranial mass lesions and
avoid secondary brain injury by protecting brain perfusion by meticulous critical care.
 A majority of patients with severe closed head injury can be managed with relatively
simple, but meticulous care. They will be referred to as 1st Tier Therapies (Table).
 Patients with more severe injury need more aggressive therapy. This will be called 2nd
Tier Therapies. (Figure) In patients who are not responding to therapy,
 Repeat CT scans early can be considered to detect delayed/ undiagnosed or evolving
injury.
Table: 1st Tier Therapy for Closed Head Injury:
 Endotracheal Intubation / Mechanical Ventilation. Target SaO2 > 90%, PaCO2 35-40
mmHg*
 Euvolemic Resuscitation – consider CVP / PA Catheter
 ICP Monitoring – EVD for drainage #
 Seizure Prophylaxis (Phenytoin 1g load, 300 mg/day x 7 days)
 Normothermia
 Euglycemia
 Stress ulcer, DVT prophylaxis
 Short-acting sedatives / analgesics
 Head of bed 30o
*There is no role for prophylactic or prolonged hyperventilation to decrease ICP.
Temporary hyperventilation may be considered in acute neurologic deterioration.
#Some patients with a GCS < 8 may not need an EVD. Young (age < 40), hemo-
dynamically stable (SBP > 90) patients with normal CT scans on admission can be
observed and followed clinically without an EVD.

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Specific Management:
1. All patients with skull fractures, history of loss of consciousness, seizures, significant headache,
amnesia, depressed level of consciousness, and focal deficits should be admitted. If in doubt, e.g.
when dealing with infants or drunken patients, admit.
2. Closed, uncomplicated fractures: Symptomatic management, observation for 2-3 days; no need
for antibiotics.
3. Compound fractures, uncomplicated: Observation for 2-3 days, single dose of antibiotic
prophylaxis, washout and closure.
4. Basilar fractures: Single dose antibiotic prophylaxis. Do not pack the nose or ears to stop CSF
leaking because of danger of meningitis. Put the patient in a semi-sitting position. If the CSF leak
persists for more than 10 days, consider surgical intervention.
5. Depressed fractures: If it is a compound fracture, elevation may decrease the incidence of sepsis.
Routine elevation is not recommended for closed depressed fractures. Elevation does not improve
the neurological outcome or risk of epilepsy.
6. Seizure prophylaxis in all patients with intracranial bleeding [Phenytoin loading dose 10-15
mg/Kg over 30-60 minutes, followed by 5 mg/Kg per day or Levetiracetam (Keppra) 500 mg
twice a day for 7 days]. Early seizures (within 7 days) do not warrant long-term prophylaxis.
Prolonged anticonvulsant prophylaxis does not prevent late epilepsy.
7. Evidence of brain stem dysfunction: (deteriorating level of consciousness, fixed dilated pupil,
localizing signs, bradycardia, high blood pressure): Give Mannitol if the patient is normotensive
(0.5g-l g/kg over 20 minutes) or hypertonic saline 3% (250 mls over 20 minutes), lower PaCO2 to
32-35 mmHg.
8. Elevated intracranial pressure: The normal ICP is <15 cm H20 (<5 in young children).
Treatment should be initiated if ICP >20 cm H20. High ICP is associated with poor outcome.
9. Nausea and vomiting are common in children. No prognostic significance. Treat
symptomatically.
10. Restlessness: Exclude pain, a distended bladder, tight casts, and hypoxia. If none of the above is
present, sedate the patient.
11. Gunshot wounds of the head: Poor survival, mortality exceeds 90%.

36
12. Diabetes Insipidus: Usually appears early within hours or days but it may manifest late after
injury. It occurs in about 15% of severe blunt and 40% of severe penetrating trauma. Characterized
by polyuria, high serum osmolality, and low urine osmolality. Treat with Desmopressin or
vasopressin and fluid replacement.
13. Inappropriate ADH secretion: low serum osmolality, high urine osmolality. Treat with fluid
restriction, hypertonic saline, and diuretics.
14. Disseminated Intravascular Coagulopathy (DIC): It is a very common complication in severe
head injuries, especially gunshot wounds. Monitor coagulation parameters very and start treating
early!
Intracranial hypertension:
The normal ICP is < 15 cm H20 (< 5 in young children). Treatment should be initiated if ICP > 20 cm
H20. High ICP is associated with poor outcome.
The intracranial hypertension is most severe in the first 2 to 3 days post-injury it can be managed by
a combination of the following therapeutic modalities:
General Measures Specific Measures
a) Correct any hypovolemia or hypoxia.
b) No tight tapes or C-collar around neck.
c) Adequate sedation and if necessary
paralysis.
d) Control of seizures
e) Keep head of bed elevated (15° - 30°),
provided the patient is euvolemic and has
no spinal trauma.
f) Keep the body temperature normal - this
reduces cerebral metabolism.
a) CSF drainage through an intraventricular catheter.
b) Mannitol 0.5-1.0 g/Kg over 20 minutes (keep
serum osmolality <320 m 0sm/L) provided that
the patient is hemodynamically stable. Hypertonic
saline (250 mls 3%) is an excellent alternative.
c) Lower pCO2 to 32-35 mmHg by means of
hyperventilation (hypocapnia causes constriction
of the cerebral vessels, thus decreasing the ICP).
d) Barbiturates for persistent intracranial
hypertension.
e) Always try to keep CPP > 70 mm Hg (>50 mmHg
in young children).
f) The following therapeutic modalities are reserved
for refractory intracranial hypertension:
Barbiturate coma, hypothermia, hypertensive CPP
treatment, and craniectomy.

37
Management of the Unconscious Patient:
1. Respiratory: Endotracheal intubation or tracheostomy if prolonged intubation is
anticipated. Regular suctioning of secretions. Humidified oxygen.
2. Fluids and electrolytes: Avoid over-hydration, dehydration or electrolytic disturbances,
especially in the critical first few days.
3. Nutrition: Consider early nasogastric or jejunal feeding. In adults about 1800 kcal and
1.5 g/Kg protein per day.
4. Bladder: Foley's catheter or condom drainage.
5. Prevent pressure sores: Special mattresses, good nutrition, and good hygiene.
6. Watch for complications such as pneumonia, UTI, meningitis, chronic subdural,
hydrocephalus, meningitis, diabetes insipidus, and inappropriate ADH secretion.
Late Complications:
1. Post-concussion syndrome: Headache, dizziness, poor concentration and memory. No
specific therapy. Most patients improve within days to months.
2. Chronic subdural hematoma: This may present weeks or months after the injury,
especially in elderly patients.
3. Subdural hygroma: Due to leakage and collection of CSF.
4. Hydrocephalus: This may follow a subarachnoid hemorrhage or intraventricular bleeding
because of obstruction of the CSF circulation.
5. Late CSF leaks: It may follow a basilar fracture and may present weeks or even years
after the injury.
6. Post-traumatic epilepsy: Common in bullet injuries, depressed fractures, intracranial
hematomas, meningitis, and early seizures. It usually occurs within the first year.
Prolonged prophylaxis does not reduce the risk of epilepsy.
7. Brain atrophy.

38
Spinal cord Injury Trauma

39
MANAGEMENT OF THE SPINAL TRAUMA PATIENT
SPINAL CORD INJURY PRECAUTIONS:
General Points:
 High index of suspicion for the diagnosis of spinal cord injuries.
 Strict spinal cord precautions / protection measures must be maintained until these injuries
can be excluded clinically or radiologically
 Many patients with a spinal fracture at one level will have a second injury at a higher or
lower level. For this reason, if one spinal fracture is found, full radiographic evaluation of
the spine is warranted
 If a patient is too unstable for complete evaluation of the spine, the patient should be
placed in full spinal precautions until diagnostic evaluation of the spine can be safely
performed
Guidelines for Evaluation for C-Spine Injury
Evaluable Patient:
If the patient is evaluable the C-spine can be cleared clinically (Patient must be alert, non-
intoxicated, without distracting injury, and without neurologic abnormality). If these criteria are
met, perform clinical evaluation of the spine, as follows:
1. Ask the patient about any pain in the cervical spine. If he/she reports pain, stop,
immobilize and obtain a CT scan from occiput to T1
2. In the absence of neck pain, loosen the collar and palpate the entire midline bony cervical
spine looking for tenderness or bony step off while maintaining manual neck
stabilization. If tender, replace collar and obtain a CT scan from occiput to T1.
3. If no pain press down on top of skull (axial loading)
4. If the patient is symptomatic and the CT proves normal, obtain MRI.

40
Unevaluable Patient:
If the patient is unevaluable (head injury, obtunded, intoxication, and distracting injury):
1. Obtain a CT scan from occiput to T1
2. If the CT scan is normal by neuroradiologist, there is no neurological deficit, and the
patient remains unevaluable, clear cervical spine (if suspicion for injury is low). Obtain
MRI of cervical spine (if suspicion is high and the patient can be transported safely to
MRI)
MANAGEMENT OF DIAGNOSED SPINAL CORD INJURY
1. Spine Surgery service notification
2. Steroid therapy
Steroid therapy:
a) NOT indicated in penetrating trauma
b) Its role in blunt trauma is controversial; decision is by trauma or neurosurgery
attending or fellow
c) If started within 3 hours of injury: Methylprednisolone 30 mg/kg bolus over one
hour, followed by continuous infusion 5.4 mg/kg/h for 23 hours
d) If started 3 – 8 hours after injury: Methylprednisolone 30 mg/kg bolus over one hour,
followed by continuous infusion 5.4 mg/kg/h for 47
e) After 8 hours – No steroid therapy

41
Algorithm for Evaluation of Penetrating Neck Injuries

42
PENETRATING INJURIES OF THE NECK
A. ANATOMICAL ZONES:
Penetrating injuries of the anterior neck are divided into 3 anatomical zones:
 Zone 1-between the clavicle and the cricoid cartilage,
 Zone 2-between the cricoid and the angle of the mandible, and
 Zone 3-between the angle of the mandible and the base of the skull.
B. OPERATION OR OBSERVATION:
 Criteria for emergency operation, usually without any specific investigation, include the
following “hard” signs and symptoms: severe hypovolemic shock, active bleeding, an
expanding or pulsatile hematoma, an absent or diminished peripheral pulse, bubbling of air
through the wound, or dyspnea.
 Other “soft” signs suggestive of significant injury are pain on swallowing, small
hematemesis, hoarseness, minor hemoptysis, and subcutaneous emphysema in the absence
of pneumothorax. These conditions require further investigation. The presence of an
isolated nerve injury is not an indication for an emergency operation.
 If there are no hard signs of significant injury and the investigations are normal the patient
is managed nonoperatively. Overall, only 15-20% of penetrating injuries of the neck require
an operation.
C. INITIAL ASSESSMENT AND MANAGEMENT:
1. Airway: Airway obstruction may be a problem in patients with a large neck hematoma or
extensive laryngotracheal injury. Intubation, preferably with a fiberoptic scope in stable
Patients or surgical airway placement in emergencies may be necessary. Pharmacological
paralysis may result in loss of airway if the cords cannot be visualized. During intubation
attempts the surgical team should be ready for cricothyroidotomy.
2. Bleeding: Apply external compression over the wound and put the patient in the
Trendelenburg position. These simple maneuvers also prevent air embolism in venous
Injuries. If the bleeding comes from a deep wound, inserting a Foley catheter and inflating
the balloon with sterile water can achieve control.
3. Intravenous Lines: Always insert the line on the opposite from a proximal venous injury

43
4. Local Examination: Check for active bleeding, an expanding or pulsatile hematoma, a
bruit, peripheral pulses, and blood in the sputum, air bubbling through the wound,
hoarseness, and subcutaneous emphysema. Exclude injury to the spinal cord, to the 7, 9, 10,
11 and 12 cranial nerves, to the brachial plexus, and to the sympathetic chain (Horner's
syndrome).
5. Central Nervous System: Carotid injuries are often associated with brain ischemia and
neurological signs. The neurological examination may be difficult in shocked or intoxicated
patients.
6. Cardiovascular Status: Check the blood pressure in the arm opposite to the injury.
7. Associated Injuries: The presence of a bleeding wound in the neck should not distract one
from looking for other dangerous injuries in the chest, abdomen, etc.
D. DIAGNOSTIC TESTS:
Diagnostic investigations should be done only on reasonably stable patients.
1. Chest and neck X-rays: Look for the following radiological signs:
a) A hemopneumothorax is a commonly associated problem (about 25% of cases).
b) Subcutaneous emphysema: This may be due to an associated pneumothorax,
injury to the trachea, larynx or esophagus, or due to air entering via the wound.
Patients with subcutaneous emphysema and a wound tract with a direction toward
the midline should be assessed by means of a Gastrografin swallow and endoscopy.
c) Widened upper mediastinum: This could be the result of injury to a major
mediastinal vessel. If the patient is in shock, an emergency operation is indicated. If
the patient is stable, an emergency CT angiogram should be performed to exclude
injury to the aorta and great vessels.
2. CT scan with intravenous contrast: It is an excellent investigation in hemodynamically
stable patients with gunshot wounds to the neck. It can reliably select patients who might
benefit from further evaluation by angiography or esophageal studies

44
3. Color Flow Doppler: This has become the investigation of choice in our center. It is
noninvasive, sensitive, specific, and cheap. It has some limitations in the evaluation of the
internal carotid artery near the base of the skull and in proximal subclavian vessels in obese
patients.
4. Angiography: There is no place for routine emergency angiography in the assessment of
penetrating injuries of the neck. In our center, it has been largely replaced by color flow
doppler and CT angiography. We advocate an emergency angiogram in fairly stable patients
with shotgun injuries, in suspicious CT scan findings, and in stable patients with an absent
or diminished peripheral pulse, or a bruit, provided the arm is not dangerously ischemic.
5. Gastrografin swallow: For suspected esophageal injuries. The patient should be awake
and alert.
6. Esophagoscopy: For suspected esophageal injuries preoperatively or intraoperatively.
7. Laryngo-tracheoscopy: For suspected injuries to the larynx and trachea.
E. NONOPERATIVE MANAGEMENT
Patients selected for nonoperative management are admitted for observation, and
frequent clinical reassessments.
If the patient develops signs suggestive of a serious neck injury, an operation is
performed. Otherwise, the patient is discharged within 24-48 hours.

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Reversal of Anticoagulation in Patients with Intracranial or Spinal Bleeding
In an effort to streamline emergency care of patients with neuro trauma who are on
wafarin (Coumadin®) and antiplatelet agents,
The following guidelines should be followed in the Emergency Department.
1. Neurosurgery or Spine should be informed of all CT scans demonstrating intracranial or
spinal trauma in patients taking warfarin or antiplatelet agents.
2. A STAT CBC, type and screen, and coagulation profile should be obtained.
3. For patients who are taking warfarin (Coumadin®):
a) The blood bank should be contacted and two units of AB FFP should be requested utilizing
the “Trauma AB plasma protocol” and the Emergency Release Form for Blood and Blood
Components should be completed.
b) The two units of “Trauma” FFP should be available for pick up in about 15-minutes.
c) Additional type specific FFP should be ordered and transfused at a dose of 15mL/kg (less
the volume of the two Trauma AB units). This infusion should take no more than 1 hour.
d) Vitamin K 10mg i.v. should be administered as soon as possible.
e) At the completion of the FFP infusion, repeat a STAT coagulation profile and calcium
level.
4. for patients who are on antiplatelet agents:
a) A 5-pack of platelets should be requested from the blood bank and administered as soon as
possible regardless of the measured platelet count. These agents induce thrombasthenia
which is a functional platelet defect NOT reflected by the platelet count!
b) Due to the long half-life of clopidogrel it may be necessary to give additional platelets in
1-2 hours for those patients undergoing invasive procedures.
c) Repeat platelet counts are not helpful but a bleeding time determination may be considered
if ongoing platelet dysfunction is suspected.

46
D.V.T. Prophylaxis in Trauma Patients
Guidelines:
1. For all major trauma patients, routine thromboprophylaxis is recommended
2. The following patients should be considered high risk for a thromboembolic disease.
a. Prolonged immobilization (> 72 hrs.)
b. Severe head injury (GCS<8)
c. Spinal cord injury
d. Pelvic fracture
e. Spinal fracture (requiring fixation or bracing)
f. Lower extremity fracture
g. Femoral venous line or major venous repair
h. Hypercoagulable state
3. The following prophylaxis should be considered:
a. Mobilize all patients as soon as possible.
b. Low molecular weight heparin (LMWH) Enoxaparin 40 mg every 24 hr
c. Contraindications to LMWH are:
• Severe head injury (first 72 hours)
• Spinal cord injury (first 2-3 days)
• Bleeding diathesis (first 2-3 days)
• Uncorrected coagulopathy
d. Sequential compression devices SCD‟s for all patients in who anti-coagulation is
contraindicated.
4. If a DVT is detected, start systemic heparin according to the ICU Protocol if no contraindications
exist.
5. For patients undergoing rehabilitation following acute spinal cord injury, the continuation of LMWH
thromboprophylaxis or conversion to oral anticoagulant (INR target, 2.5; range, 2.0 to 3.0) is
recommended.

47
Cardiovascular support Protocol
Early Goal Directed Therapy (EGDT)
Inclusion Criteria:
Shock as evident by the followings:
1. Systolic BP < 90 mmHg
2. Mean Arterial Pressure MAP < 65 mmHg
3. Tachycardia and tachypnea
4. Arterial lactate ≥ 4.0 mmol/L
5. Urine output < 0.5ml/kg/hr
6. Acute confusion
Required Monitoring:
1. Vital signs (noninvasive BP, heart rate, respiratory rate, temperature)
2. Pulse oximetry
3. Cardiac monitoring (continuous ECG monitor)
4. Urinary indwelling catheter
5. Arterial line for invasive BP monitoring and lactate
6. Central venous line for CVP monitoring
7. Central venous line for ScVO2 monitoring (central venous saturation)
8. Pulmonary Artery Catheter (optional)
Early Goal Directed Therapy:
 Early and quickly Resuscitation is lifesaving.
 The GOALS should be achieved within 6 hours from shock recognition.
 These 6 hours are the GOLDEN HOURS.
 DO NOT WASTE the GOLDEN HOURS.
 Inadequate resuscitation leads to IRREVERSIBLE SHOCK.
 At irreversible shock stage, resuscitation is costly and of very little value
Goals:
1. MAP ≥ 65 mmHg AND Systolic BP ≥ 90mmHg
2. CVP = 8-12 mmHg
3. Urine ≥ 0.5 ml/kg/hr
4. ScVO2 ≥ 70% (central venous saturation)
Therapies
1. Respiratory support (supplemental oxygen / mechanical ventilation)
2. Fluid boluses as 500ml over 15-30 minutes if CVP ≤ 12 mmHg
3. Norepinephrine infusion if systolic BP < 90 mmHg or MAP < 65 mmHg
4. Packed RBCs boluses if hemoglobin <10gm/dl AND ScVO2 < 70%
5. Dobutamine infusion if hemoglobin ≥10gm/dl AND ScVO2 < 70%

48
GOLDEN HOURS Fluid Therapy
 Adequate fluid resuscitation is the cornerstone of EGDT in all types of shock.
 During the golden hours, 4-8 liters of fluid boluses is quite common.
 Never use fluid balance chart to limit volume resuscitation.
 Crystalloid fluids (isotonic saline, Ringer lactate) are given over 15-30 minutes.
 Colloid fluids (blood products) are given over 30 minutes.

49
Septic shock protocol
Definitions
Sepsis is defined as the presence (probable or documented) of infection together with
systemic manifestations of infection.
Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue
hypoperfusion
Sepsis-induced hypotension is defined as a systolic blood pressure (SBP) < 90 mm Hg or
mean arterial pressure (MAP) < 70 mm Hg or a SBP decrease > 40 mm Hg or less than two
standard deviations below normal for age in the absence of other causes of hypotension.
Septic shock is defined as sepsis-induced hypotension persisting despite adequate fluid
resuscitation.
Sepsis-induced tissue hypo-perfusion is defined as infection-induced hypotension,
elevated lactate, or oliguria.

50
Interrelationship between systemic inflammatory response (SIRS), Sepsis and Infection
Diagnostic Criteria for Sepsis
Infection, documented or suspected, and some of the following:
General variables
• Fever (> 38.3°C)
• Hypothermia (core temperature < 36°C)
• Heart rate > 90/min–1 or more than two SD above the normal value for age
• Tachypnea
• Altered mental status
• Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
• Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
• Leukocytosis (WBC count > 12,000 μL–1)
• Leukopenia (WBC count < 4000 μL–1)
• Normal WBC count with greater than 10% immature forms
• Plasma C-reactive protein more than two sd above the normal value
• Plasma procalcitonin more than two SD above the normal value

51
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP decrease > 40 mm
Hg in adults or less than two SD below normal for age)
Organ dysfunction variables
• Arterial hypoxemia (Pao2/Fio2 < 300)
• Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite adequate fluid
resuscitation)
• Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
• Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
• Ileus (absent bowel sounds)
• Thrombocytopenia (platelet count < 100,000 μL–1)
• Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Severe Sepsis
Severe sepsis definition = sepsis-induced tissue hypoperfusion or organ dysfunction (any of the
following thought to be due to the infection)
• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal
• Urine output < 0.5 mL/kg/hr for more than 2 hrs despite adequate fluid resuscitation
• Acute lung injury with Pao2/Fio2 < 250 in the absence of pneumonia as infection source
• Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection
source
• Creatinine > 2.0 mg/dL (176.8 μmol/L)
• Bilirubin > 2 mg/dL (34.2 μmol/L)
• Platelet count < 100,000 μL
• Coagulopathy (international normalized ratio > 1.5)

52
Overview of Patient Enrollment and Hemodynamic Support:

53
SURVIVING SEPSIS BUNDLES
TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4mmol/L
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to
maintain a mean arterial pressure (MAP) ≥ 65 mm Hg
6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock)
or initial lactate ≥ 4 mmol/L (36 mg/dL):
- Measure central venous pressure (CVP)
- Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated
Recommendations: Initial Resuscitation and Infection Issues
A. Initial Resuscitation
1. Protocolized, quantitative resuscitation of patients with sepsis- induced tissue
hypoperfusion
Goals during the first 6 hrs of resuscitation:
a) Central venous pressure 8–12 mm Hg
b) Mean arterial pressure (MAP) ≥ 65 mm Hg
c) Urine output ≥ 0.5 mL/kg/hr
d) Central venous (superior vena cava) or mixed venous oxygen saturation 70% or 65%,
respectively.
2. In patients with elevated lactate levels targeting resuscitation to normalize lactate.
B. Screening for Sepsis and Performance Improvement
1. Routine screening of potentially infected seriously ill patients for severe sepsis to allow
earlier implementation of therapy.
C. Diagnosis
1. Cultures as clinically appropriate before antimicrobial therapy if no significant delay (>
45 mins) in the start of antimicrobial(s). At least 2 sets of blood cultures (both aerobic

54
and anaerobic bottles) be obtained before antimicrobial therapy with at least 1 drawn
percutaneously and 1 drawn through each vascular access device, unless the device was
recently (<48 hrs) inserted.
2. Imaging studies performed promptly to confirm a potential source of infection.
D. Antimicrobial Therapy
1. Administration of effective intravenous antimicrobials within the first hour of
recognition of septic shock and severe sepsis without septic shock as the goal of therapy.
2. Initial empiric anti-infective therapy of one or more drugs that have activity against all
likely pathogens (bacterial and/or fungal or viral) and that penetrate in adequate
concentrations into tissues presumed to be the source of sepsis.
3. Antimicrobial regimen should be reassessed daily for potential deescalation.
4. Combination empirical therapy for neutropenic patients with severe sepsis and for
patients with difficult-to-treat, multidrug-resistant bacterial pathogens such as
Acinetobacter and Pseudomonas spp. For patients with severe infections associated
with respiratory failure and septic shock, combination therapy with an extended
spectrum beta-lactam and either an Aminoglycoside or a fluoroquinolone is for P.
aeruginosa bacteremia. A combination of beta-lactam and macrolide for patients with
septic shock from bacteremic Streptococcus pneumoniae infections.
5. Empiric combination therapy should not be administered for more than 3–5 days.
Deescalation to the most appropriate single therapy should be performed as soon as the
susceptibility profile is known.
6. Duration of therapy typically 7–10 days; longer courses may be appropriate in patients
who have a slow clinical response, undrainable foci of infection, bacteremia with S.
aureus; some fungal and viral infections or immunologic deficiencies, including
neutropenia.
7. Antiviral therapy initiated as early as possible in patients with severe sepsis or septic
shock of viral origin.
8. Antimicrobial agents should not be used in patients with severe inflammatory states
determined to be of noninfectious cause
E. Source Control
1. A specific anatomical diagnosis of infection requiring consideration for emergent source
control be sought and diagnosed or excluded as rapidly as possible, and intervention be

55
undertaken for source control within the first 12 hr after the diagnosis is made, if
feasible.
2. When infected peripancreatic necrosis is identified as a potential source of infection,
definitive intervention is best delayed until adequate demarcation of viable and
nonviable tissues has occurred.
3. When source control in a severely septic patient is required, the effective intervention
associated with the least physiologic insult should be used (eg, percutaneous rather than
surgical drainage of an abscess).
4. If intravascular access devices are a possible source of severe sepsis or septic shock, they
should be removed promptly after other vascular access has been established (UG).
F. Infection Prevention
1. Selective oral decontamination and selective digestive decontamination should be
introduced and investigated as a method to reduce the incidence of ventilator-associated
pneumonia.
2. Oral chlorhexidine gluconate be used as a form of oropharyngeal decontamination to
reduce the risk of ventilator-associated pneumonia in ICU patients with severe sepsis
Recommendations: Hemodynamic Support and Adjunctive Therapy
G. Fluid Therapy of Severe Sepsis
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis and septic
shock.
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe sepsis and
septic shock.
3. Albumin in the fluid resuscitation of severe sepsis and septic shock when patients
require substantial amounts of crystalloids.
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion with
suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (a portion
of this may be albumin equivalent). More rapid administration and greater amounts of
fluid may be needed in some patients.

56
H. Vasopressors
1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65 mm Hg
(grade.
2. Norepinephrine as the first choice vasopressor.
3. Epinephrine (added to and potentially substituted for norepinephrine) when an additional
agent is needed to maintain adequate blood pressure.
4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with intent of either
raising MAP or decreasing NE dosage.
5. Low dose vasopressin is not recommended as the single initial vasopressor for treatment
of sepsis-induced hypotension and vasopressin doses higher than 0.03-0.04 units/minute
should be reserved for salvage therapy (failure to achieve adequate MAP with other
vasopressor agents).
6. Dopamine as an alternative vasopressor agent to norepinephrine only in highly selected
patients (eg, patients with low risk of tachyarrhythmias and absolute or relative
bradycardia).
7. Phenylephrine is not recommended in the treatment of septic shock except in
circumstances where
(a) norepinephrine is associated with serious arrhythmias,
(b) cardiac output is known to be high and blood pressure persistently low or
(c) As salvage therapy when combined inotrope/vasopressor drugs and low dose
vasopressin have failed to achieve MAP target.
8. Low-dose dopamine should not be used for renal protection.
9. All patients requiring vasopressors have an arterial catheter placed as soon as practical if
resources are available.
I. Inotropic Therapy
1. A trial of dobutamine infusion up to 20 micrograms/kg/min be administered or added to
vasopressor (if in use) in the presence of
(a) myocardial dysfunction as suggested by elevated cardiac filling pressures and
low cardiac output, or
(b) Ongoing signs of hypoperfusion, despite achieving adequate intravascular
volume and adequate MAP.
2. Not using a strategy to increase cardiac index to predetermined supranormal levels.

57
J. Corticosteroids
1. Not using intravenous hydrocortisone to treat adult septic shock patients if adequate
fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability
(see goals for Initial Resuscitation). In case this is not achievable, we suggest
intravenous hydrocortisone alone at a dose of 200 mg per day.
2. Corticosteroids not be administered for the treatment of sepsis in the absence of shock.
Recommendations: Other Supportive Therapy of Severe Sepsis:
K. Blood Product Administration
1. Once tissue hypoperfusion has resolved and in the absence of extenuating circumstances,
such as myocardial ischemia, severe hypoxemia, acute hemorrhage, or ischemic heart
disease, we recommend that red blood cell transfusion occur only when hemoglobin
concentration decreases to <7.0 g/dL to target a hemoglobin concentration of 7.0- 9.0 g/dL
in adults.
2. Not using erythropoietin as a specific treatment of anemia associated with severe sepsis
3. Fresh frozen plasma not be used to correct laboratory clotting abnormalities in the absence
of bleeding or planned invasive procedures.
4. Not using antithrombin for the treatment of severe sepsis and septic shock.
5. In patients with severe sepsis, administer platelets prophylactically when counts are
<10,000/mm3 (10 x 109/L) in the absence of apparent bleeding. We suggest prophylactic
platelet transfusion when counts are < 20,000/mm3 (20 x 109/L) if the patient has a
significant risk of bleeding. Higher platelet counts (≥50,000/mm3 [50 x 109/L]) are
advised for active bleeding, surgery, or invasive procedures.
O. Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)
1. Protective Ventilatory Strategy protocol
2. Prone positioning be used in sepsis-induced ARDS patients with a Pao2/Fio2 ratio ≤ 100
mm Hg in facilities that have experience with such practices.
3. That mechanically ventilated sepsis patients be maintained with the head of the bed
elevated to 30-45 degrees to limit aspiration risk and to prevent the development of
ventilator-associated pneumonia.

58
HYPOXIA: DIAGNOSTIC APPROACH

59
HYPOXIA: MANAGEMENT

60
Initiation of Mechanical Ventilation

61
Protective Ventilatory Strategy
Policy:
Introduction
Although invasive positive pressure ventilation (IPPV) saves lives, it could cause serious
adverse effects. These complications are either due to the presence of an invasive airway
(endotracheal tube or tracheostomy tube) or related to the positive pressure ventilation. The
latter has been called: ventilator-induced lung injury (VILI). Minimizing IPPV adverse effects
rely on the adoption of protective ventilatory strategy (PVS) and timely liberation from
mechanical ventilation. This document focuses on VILI and PVS. An evidence-based strategy
to expedite the liberation from mechanical ventilation (weaning protocol) will be discussed
separately.
Ventilator-induced lung injury (VILI)
Although the pathogenesis of VILI is incompletely understood, current data support several
injurious mechanisms. These include volutrauma, atelectrauma, barotrauma and biotrauma.
Volutrauma is the injuries caused by alveolar wall overstretch. Atelectrauma is due to cyclical
closing and reopening of the alveoli. Barotrauma includes hemodynamic adverse changes on
venous return and cardiac output as well as direct injuries like pneumothorax,
pneumomediastinum and surgical emphysema. Finally, biotrauma refers to the contribution of
VILI to systemic inflammation. Biotrauma is the common pathway where VILI lead to
production of systemic inflammatory mediators and consequently multiple-organ dysfunction
and death.
Protective ventilatory strategy (PVS)
This aim of this strategy is to mitigate VILI. In this strategy, low tidal volume takes precedence
over normal CO2 (permissive hypercapnia). Also, low normal PO2 and SaO2 are acceptable.
Normalization of arterial blood gases is of secondary importance in PVS. PVS has four major
components:
1. Low tidal volume.(6 ml/kg PBW).
2. Low inspiratory plateau airway pressure. (Max 30 cm H2O).
3. Appropriate FiO2 and positive end-expiratory pressure (PEEP).
4. Arterial pH management.

62
Procedures:
1. Low tidal volume
Tidal volume goal= 6 ml/kg PBW if PO2/FiO2 < 300mmHg
Calculate predicted body weight (PBW):
 Male = 50 kg + 0.91 [height (cm) - 152.4]
 Female = 45.5 kg + 0.91 [height (cm) - 152.4]
Target tidal volume (Vt) according to PBW:
 Vt= 6 ml/kg PBW if PO2/FiO2 < 300mmHg
 Vt= 8 ml/kg PBW if PO2/FiO2 > 300mmHg
Mode choices:
 AC pressure regulated volume controlled AC/PRVC OR SIMV/ PRVC
 AC pressure controlled AC/PC OR SIMV/PC
 AC volume controlled AC/VC OR SIMV/VC
Minute Ventilation:
 Set initial tidal volume to 8 ml/kg PBW
 Reduce tidal volume to 7 ml/kg after 1-2 hours and then to 6 ml/kg PBW after 1-2 hours
 Set initial ventilator rate to maintain baseline minute ventilation of 10 L/min (not > 35
bpm).
I: E ratio goal is 1:1.0 - 1:3.0
Adjust flow rate and inspiratory flow wave-form to achieve this goal.
2. Low plateau pressure:
Plateau Pressure Goal: ≤ 30 cmH2O
Check inspiratory plateau pressure (Pplat) with 0.5 second inspiratory pause at least every six
hours and after each change in PEEP or tidal volume.
 If Pplat > 30 cmH2O: Decrease to Vt = 5 ml/kg PBW or if necessary to Vt =4 ml/kg PBW

63
 If Pplat < 25 cmH2O & Vt < 6 ml/kg: increase Vt= 5 to 6 ml/kg PBW until Pplat > 25
cmH2O
 If breath stacking or severe dyspnea: Vt = 7 to 8 ml/kg PBW if Pplat remains ≤ 30 cmH2O
3. FiO2 and PEEP:
Arterial oxygenation goal: PaO2 55-80 mm Hg or SpO2 88-95%
Use these FiO2/PEEP combinations to achieve oxygenation goal.
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 20-
24

64
4. Arterial pH management
Arterial pH goal: 7.30-7.45
 Acidosis Management:
1. If pH 7.15-7.30:
Increase set RR until pH > 7.30 or PaCO2 < 25 (Maximum Set RR =35)
If set RR = 35 and pH < 7.30, NaHCO3 may be given (not required)
2. If pH < 7.15:
 Increase set RR to 35.
 If set RR = 35 and pH < 7.15 and NaHCO3 has been considered,
VT may be increased in 1 ml/kg PBW steps until pH > 7.15 (Pplat target may be
exceeded).
 Alkalosis Management:
 If pH > 7.45:
Decrease set RR until patient RR > set RR. Minimum set RR = 6/min

65
Height (inches) PBW(kg) VT @
6mls/kg
7mls/kg 8mls/kg 9mls/kg 10mls/kg
Male= 50 + 2.3 [height (inches) - 60] or 50 + 0.91 [height (cm) - 152.4]
155 61 52.3 313.8 366.1 418.4 470.7 523
157 62 54.6 327.6 382.2 436.8 491.4 546
160 63 56.9 341.4 398.3 455.2 512.1 569
163 64 59.2 355.2 414.4 473.6 532.8 592
165 65 61.5 369 430.5 492 553.5 615
168 66 63.8 382.8 446.6 510.4 574.2 638
170 67 66.1 396.6 462.7 528.8 594.9 661
173 68 68.4 410.4 478.8 547.2 615.6 684
175 69 70.7 424.2 494.9 565.6 636.3 707
178 70 73 438 511 584 657 730
180 71 75.3 451.8 527.1 602.4 677.7 753
183 72 77.6 465.6 543.2 620.8 698.4 776
185 73 79.9 479.4 559.3 639.2 719.1 799
188 74 82.2 493.2 575.4 657.6 739.8 822
191 75 84.5 507 591.5 676 760.5 845
193 76 86.8 520.8 607.6 694.4 781.2 868
196 77 89.1 534.6 623.7 712.8 801.9 891
198 78 91.4 548.4 639.8 731.2 822.6 914
201 79 93.7 562.2 655.9 749.6 843.3 937
Height(cm) Height (inches) PBW(kg) VT @
6mls/kg
7mls/kg 8mls/kg 9mls/kg 10mls/kg
Female= 45.5 + 2.3 [height (inches) - 60] or 45.5 + 0.91 [height (cm) - 152.4]
155 61 47.8 286.8 334.6 382.4 430.2 478
157 62 50.1 300.6 350.7 400.8 450.9 501
160 63 52.4 314.4 366.8 419.2 471.6 524
163 64 54.7 328.2 382.9 437.6 492.3 547
165 65 57 342 399 456 513 570
168 66 59.3 355.8 415.1 474.4 533.7 593
170 67 61.6 369.6 431.2 492.8 554.4 616
173 68 63.9 383.4 447.3 511.2 575.1 639
175 69 66.2 397.2 463.4 529.6 595.8 662
178 70 68.5 411 479.5 548 616.5 685
180 71 70.8 424.8 495.6 566.4 637.2 708
183 72 73.1 438.6 511.7 584.8 657.9 731
185 73 75.4 452.4 527.8 603.2 678.6 754
188 74 77.7 466.2 543.9 621.6 699.3 777
191 75 80 480 560 640 720 800
193 76 82.3 493.8 576.1 658.4 740.7 823
196 77 84.6 507.6 592.2 676.8 761.4 846
198 78 86.9 521.4 608.3 695.2 782.1 869
201 79 89.2 535.2 624.4 713.6 802.8 892

66
Extubation Protocol
Policy:
All mechanical ventilated patients must be assessed daily for Extubation. The
assessment method must be objective using well-defined criteria. Implementation of this
protocol ensures early and appropriate liberation from mechanical ventilation.
Procedures:
STEP 1: Assess readiness for SBT
(Screening at 7:00-8:00am)
1. PaO2/FiO2 ≥ 200mmHg OR SpO2 ≥ 95 % on FiO2 ≤ 0.4.
2. PEEP ≤ 5 cmH2O.
3. Awake, with minimal secretions and effective cough reflex.
4. No Vasoactive agents.
5. Temperature ≤38.0
6. Rapid Shallow Breathing Index (RSBI) ≤ 105
RSBI (f/VT) = Frequency of breathing in 1 min/ averaged Tidal Volume in 1 min
This is done as 1 min CPAP 5 cmH2O.
STEP 2: Spontaneous Breathing Trial (SBT)
Perform 30 minutes trial of spontaneous breathing using either
a) Automatic tube compensation: 100% ATC
OR
b) T-piece system

67
STEP 3: Assessment of SBT success
Signs of poor tolerance (SBT failure) are the followings:
1. Respiratory rate > 35 Breath per min.
2. SpO2 < 90%.
3. Heart rate >140 per min.
4. Systolic BP >180mmHg OR <90mmHg.
5. Somnolence, agitation, diaphoresis, anxiety
6. Paradoxical chest movement.
STEP 4: Extubation order
If no signs of SBT failure, extubate the patient preferably before 10:00 am
The Respiratory Therapist RT initiates and monitors all steps.
The RT must inform the ICU doctor and the designated nurse before Extubation.

68
Cuff Leak Test

69
Causes of Failed SBT/Weaning Failure

70

71
Agitation in Intubated Patients

72
Agitation in the Non-intubated Patient

73
Electrolyte Replacement Protocol

74
MANAGEMENT OF HYPERKALEMIA
If serum K+ rises above 6.5 mEq/L or if the ECG shows conduction abnormalities, urgent
treatment to lower the serum K+ should be initiated. The goals of treatment of acute hyperkalemia
are to stabilize the cardiac Myocyte cellular membrane with calcium and decrease the serum K+,
either temporarily through cellular shifts with insulin and glucose or permanently via diuresis or
K+-binding medications. Inhaled albuterol can be used to shift K+ intracellularly if intravenous
access is not available (however, this has failed in 40% of patients on hemodialysis).
TREATMENT OF HYPERKALEMIA:
EMERGENT TREATMENT:
Intervention Change in [K+] Response
Time
Duration
Calcium gluconate or chloride (10 ml of 10%
solution).
Note: Intravenous calcium should not be
given in the setting of digoxin toxicity.
No effect on serum
K+
Immediate 15–30 min
Glucose (50 ml of 50% solution) + regular
insulin 10 U intravenously.
0.5–1.2 mmol/L 10–20 min 2–3 hr
Albuterol 10–20 mg by inhaler over 10 min. 0.9–1.4 mmol/L 20–30 min 2–3 hr
NaHCO3-, only if metabolic acidosis present. Delayed
Kayexalate 15–30 g with sorbitol:
 By mouth.
 As retention enema.
Binds 0.5–1.2 mEq
K+ in exchange for
2–3 mEq Na+
 4–6 hr
 1 hr
Permanent
Loop diuretic (intravenous). Variable 1 hr Permanent
Hemodialysis 1.2–1.5 mmol/L
during the 1st hour
15–30 min
Permanent
LONG-TERM MANAGEMENT:
Dietary K+ restriction 2–3 g/d (avoid orange juice, melons, bananas, tomatoes)
Discontinue supplemental K+ (salt substitutes)
Discontinue drugs that interfere with K+ homeostasis
Augment K+ excretion
Loop, thiazide diuretics
Fludrocortisone, if hypoaldosteronism present
Chronic sodium polystyrene sulfonate therapy (in patients without gastrointestinal disease)

75
Hypokalemia

76
POTASSIUM REPLACEMENT PROTOCOL
Contraindications to using this electrolyte replacement protocol:
1. Renal insufficiency with creatinine ≥ 200 micro mol/L.
2. Severe oliguria (< 30ml/h) or anuria.
3. Chronic renal failure on renal replacement therapy.
4. Severe Hypokalemia < 2.5 mmol/L; call the ICU doctor STAT
POTASSIUM REPLACEMENT PROTOCOL – INTRAVENOUS
 Recommended rate of infusion is 10 mEq/h
 Maximum rate of intravenous replacement is 20 mEq/h with continuous ECG
monitoring (the maximum rate may be increased to 40 mEq/h in emergency situations
 Maximum Concentration for Central IV administration = 20 mEq/50 Ml
 Maximum Concentration for Peripheral IV administration = 10 mEq/50 mL
Current Serum
Potassium
Level
Central IV
Administration
Peripheral IV
Administration Monitoring
3.6 – 3.9
mEq/L
20 mEq IV over 2 HR x 1 10 mEq IV over 1 HR
x 2
No additional action
3.4 – 3.5
mEq/L
20 mEq IV over 2 HR x 1
AND
10 mEq IV over 1 HR
x 3
3.1 – 3.3
mEq/L
20 mEq IV over 2 HR x 2 10 mEq IV over 1
HRx 4
Recheck serum
potassium level 2
hours after infusion
complete
2.6 – 3
mEq/L
AND
10 mEq IV over 1 HR
x 5
Recheck serum
potassium level 2
complete
2.3 – 2.5
mEq/L
20 mEq IV over 2 HR x 3 10 mEq IV over 1 HR
x 6
Recheck serum
potassium level 2
complete
< 2.3 mEq/L Call Physician AND
Call Physician AND
10 mEq IV over 1 HR
x 6
Recheck serum
potassium level 2
complete

77
If both potassium and phosphorus replacement required, subtract the mEq of
potassium given as potassium phosphate from total amount of potassium required.
(Conversion: 3 mmols KPO = 4.4 mEq K+)
POTASSIUM REPLACEMENT PROTOCOL – ORAL or ENTERAL (PT)
 Standard dosage forms: KCl 20mEQ tablet or KCl 10% solution (20 mEq/15 mL)
Current Serum Potassium Total Potassium Replacement Monitoring
3.7 – 3.9 mEq/L 20 mEq KCl PO/Per feeding
tube x 1 dose
tube Q2H x 2 doses
tube Q2H x 3 doses
Recheck serum potassium level 4
hours after last oral dose
tube Q2H x 4 doses
< 3.1 mEq/L 20 mEq KCl PO/Per feeding
tube Q2H x 4 doses

78
HYPERNATREMIA

79
Hyponatremia (Na < 135 meq/L)

80
Treatment of Hyponatremia Dose Calculator

81
Hypomagnesemia

82
MAGNESIUM REPLACEMENT PROTOCOL
 Infusions should be no faster than 1gm of magnesium sulfate every 30 minutes.
 Standard Concentrations: 1 gm/100 mL and 2 gm/50 mL
Current Serum
Magnesium Level
Total Magnesium Replacement Monitoring
1.5 – 2 mEq/L 2 grams Magnesium Sulfate IV over 1 HR No additional action
0.9 – 1.4 mEq/L 2 grams Magnesium Sulfate IV over 1 HR
x 2 doses
Recheck serum magnesium
level 2 hours after infusion
complete
< 0.9 mEq/L Call Physician AND
2 grams Magnesium Sulfate IV over 1 HR
x 2 doses
Recheck serum magnesium
level 2 hours after infusion
complete

83
Hypercalcemia

84
CALCIUM REPLACEMENT PROTOCOL
You must specify the salt form (gluconate or chloride)
Calcium chloride:
 Reserved for Level I areas only
 Must be administered via a central line
 Maximum rate = 1 gm IV over 10 minutes
Calcium gluconate:
 May be used in all levels of care
 Administration via a central line is preferred; however, it may be given
peripherally with adequate IV access.
 Maximum rate = 3 gm IV over 10 minutes
Standard concentrations:
Calcium chloride: 1 gm/50 mL, 2 gm/100 mL, 3 gm/150 mL
Calcium gluconate: 1 gm/50 mL, 2 gm/100 mL
Current Ionized
Calcium Level
Total Calcium
GLUCONATE
Replacement
Total Calcium
CHLORIDE
Replacement
Monitoring
1 – 1.1 mmol/L 1 gram IV over 1 HR 1 gram IV over 1 HR No additional action
0.85 – 0.99 mmol/L 2 grams IV over 1HR 2 grams IV over 1HR
Recheck serum ionized
calcium 2 hours after
infusion complete
< 0.85 mmol/L Call Physician AND
2 grams IV over 1HR
Call Physician AND
3 grams IV over 1HR
Recheck serum ionized
calcium 2 hours after
infusion complete

85
Hypophosphatemia

86
PHOSPHORUS REPLACEMENT PROTOCOL
 Replacement must be ordered in mmol of phosphorus.
 Recommended rate = 3mmol/hr (= 4.4 mEq/h of K)
 Maximum rate = 10 mmol/hr (= 15 mEq/h of K)
 Use SODIUM phosphate for patients with serum potassium > 4.5 mEq/L and serum
sodium <145 mEq/L
 Standard Concentrations:
 Potassium Phosphate: 15 mmol/250 mL and 21 mmol/250 mL
 Sodium Phosphate: 15 mmol/250 mL, 21 mmol/250 mL, and 30 mmol/250 mL
Current Serum
Phosphorus Level
Total Phosphorus Replacement Monitoring
2 – 2.5 mg/dL 15 mmol Potassium Phosphate IV
over 4 HR
1 – 1.9 mg/dL 21 mmol Potassium Phosphate IV
over 4 HR
Recheck serum phosphorus level 2
hours after infusion complete
< 1 mg/dL 30 mmol potassium Phosphate IV
over 4 HR
(Administered as: 15 mmol
Potassium Phosphate IV Q2H x 2
doses)
Recheck serum phosphorus level 2
hours after infusion complete
If both potassium and phosphorus replacement required, subtract the mEq of potassium given
as potassium phosphate from total amount of potassium required. (Conversion: 3 mmols KPO4
= 4.4 mEq K+)

87
Acid-Base protocol
Diagnostic Approach to Acid Base

88
Acidosis protocol

89
Alkalosis protocol

90
Metabolic Acidosis in ICU Patient

91
Diabetic Ketoacidosis

92
Diabetic Ketoacidosis
INITIAL CARE
ENSURE:
- Secure airway and adequate ventilation/oxygenation
PLACE:
- Adequate IV access (may require 3 ports)
- Foley catheter
MONITOR:
- Orthostatic hypotension (If not hypotensive)
- Continuous EKG monitoring
- Urine output
- Frequent Vital signs
CALCULATE:
- Anion Gap
- Serum Osmolality
- Free Water Deficit
- Corrected Serum Sodium
LABS:
- Basic metabolic panel, Serum phosphate level,
hepatic enzymes, A1C
- beta-HCG. Urine (for women of child bearing age)
- CBC w/differential
- Cardiac enzymes
- Serum ketones/acetone/Beta-hydroxybutyrate
- PT/PTT
- Venous/Arterial blood gas
- UA/Urine micro/Urine culture
ORDER:
- EKG, CXR
- Venous thromboembolism prophylaxis: Heparin
5,000 units SQ BID or TID (unless
contraindicated)
CONSIDER, as indicated:
- Further Infectious work up
- Amylase/Lipase to rule out pancreatitis
- Head CT/LP if encephalopathic
– Consider Central access
POTASSIUM REPLACEMENT: (Serum Chemistry q 2-4 hours)
Serum K+1 Total Replacement Dose Maximum Rate of Infusion
< 3 mEq/L HOLD INSULIN - Peripheral Line: 10 mEq/hour
- Central Line: 20 mEq/hour
 Check Serum K+ every 2 hours If
 acidemic, serum K+ may underestimate
potassium deficiency
40 - 80 mEq
3.1 – 3.4 mEq/L 40 - 60 mEq
3.5 – 3.9 mEq/L 20 - 40 mEq
4 – 5 mEq/ L4 Add KCl 20 mEq to each
liter of IVF
> 5.5 mEq/L No Potassium Replacement
GOALS OF TREATMENT
-Replace volume deficit
- Correct ketosis and acidosis with continuous insulin
- Replace electrolyte deficits
- Replace free water deficit
- Prevent hypoglycemia
- Determine inciting condition for the DKA
- Correct hyperglycemia (secondary goal)
- When DKA resolved: begin appropriate SQ insulin
before stopping Insulin drip
CALCULATIONS
-Anion Gap (AG) [<12-16]:
AG = [Na+] – [Cl- + HCO3-]
-Serum Osmolality [275-295 mOsm/L]:
= 2 X Serum Na+ (mEq/L) + [Glucose
(mg/dL)/18] + [BUN (mg/dL)/2.8]
- Free Water Deficit:= Dosing Factor X wt
(Kg) X [(Serum Na+/140) – 1]
{Dosing Factor = 0.6 (Male) and
0.5(Female)}
- Corrected Serum Sodium:
Corrected Na+ = Serum Na+ mEq/L + (1.6
mEq/L for each 100 mg/dLglucose > 100
mg/dL)

93
Insulin Therapy in DKA
- Finger sticks (FS BG) q 1 hour until BG < 250 mg/dl, stable and no change > 10 % for 3
hours, then FS BG q 2 hour, Serum Chemistry every 4 hours
Regular Insulin: 0.15 Units/Kg as IV Bolus; Then IV infusion @ 0.1 Units/Kg/hr
- If Serum Glucose does not fall by 50 -70 mg/dl in the next hour:
Serum Glucose Reaches 250 mg/dL
-Add Dextrose (D5½NS* or D5NS) to IVF @ 150 –250 mL/h to maintain serum glucose
150 – 200 mg/dL and continue insulin at same rate
- Titrate insulin to a minimum 0.1 Units/kg/hr and glucose goal between 150 – 200 mg/dL
until ketosis and anion gap resolves.
- If patient can tolerate PO, encourage consistent carbohydrate diet
Normal Anion Gap (AG), Ketosis resolved
Ketoacidosis/ AG persist & FS BG < 70
mg/dL:
- Hold insulin X 15 min & Bolus 1 AMP D50 IVP
- Recheck FS BG if < 70, retreat w/ 1 AMP D50
IVP and repeat FS BG
- Once FS BG > 70 mg/dL, restart Insulin @ ½
prior infusion rate
- Start D10W or D10NS (If volume depleted) @
150 – 250 mL/h
- Keep Serum glucose between 150 –200 mg/dL
- If cannot maintain glucose > 150 mg/dL despite
D10 and diet then titrate insulin down to a
minimum of 0.5 unit/hr
Ketoacidosis/ AG persists & FS BG 70 to 150 mg/dL
Ketoacidosis/ AG persists & FS BG 70 to 150
mg/dL:
- Start D10W or D10NS @ 150 - 250 mL/h
and/or consider reducing insulin rate by½.
- Keep Serum glucose between 150 -200mg/dL
- If cannot maintain glucose > 150 mg/dL
despite D10 and diet then titrate insulin down to a
minimum of 0.5 unit/hr
Ketoacidosis/ AG persists & FS BG < 70 mg/dL
If tolerating oral feeds:
- Discontinue insulin drip 2 hours after
administering multidose regimen of short-
acting OR long-acting SQ insulin
- Calculate total daily dose (TDD): 0.3
Units/kg/day (type 1 & Renal pts) or 0.5
Units/kg/day (type 2)
Gap closed and not eating reliably:
- Switch to “Insulin drip: Adult General
Care Floor: Goal BG 120- 180

94
IV INSULIN PROTOCOL
* Start IV insulin when BG above 7.8mmol/L: see algorithm 1
* Stop IV insulin when BG below 7.8 mmol/L: see algorithm 1
* Give IV D50%W when BG below 3.3 mmol/L
1. Starting Insulin Protocol:
 Start the nutritional support (enteral tube feed, TPN or IV Dextrose)
 Add 50 U reg. Insulin in 50mL 0.9 NaCl (using 50mL syringe)
 Start insulin infusion via a syringe pump according to algorithm
Algorithm 1 Algorithm 2
BG mmol/L mL/hr BG mmol/L mL/hr
G
O
A
L
<4.4 Off <4.4 Off
4.4-5.5 0.2 4.4-5.5 0.5
5.6-6.6 0.5 5.6-6.6 1.0
6.7-7.8 1.0 6.7-7.8 1.5
7.9-8.3 1.5 7.9-8.3 2.0
8.4-9.9 1.5 8.4-9.9 2.0
10-11.6 2.0 10-11.6 3.0
11.7-13.3 2.0 11.7-13.3 4.0
13.4-14.9 3.0 13.4-14.9 5.0
15-16.6 3.0 15-16.6 6.0
16.7-18.3 4.0 16.7-18.3 7.0
18.4-20 4.0 18.4-20 8.0
>20 6 >20 12
Goal Blood Glucose (BG) = 4.4-7.8 mmol/L (generally -6.1 mmol/L)

95
2. Adjusting the infusion:
 Algorithn 1: Start here for all patients.
 Moving Up from Algorithm 1 to Algorithm 2
 BG outside the GOAL (80-140mg/dL) AND
 BG change is less than 60mg/dL per hour.
 Moving Down from Algorithm to Algorithm
 BG change is more than 180 mg/dL per hour or
 if BG less than 80 mg/dL
3. Patient Monitoring:
Check BG Q hour until it is with in goal range for 4 hrs (4 readings), then Q 2 for 4 hrs (2
readings), and if remains stable Q 4 hrs.
Resume of hourly BG monitoring for a significant changes in clinical condition.
4. Treatment of Hypoglycemia (BG <60mg/dL)
Discontinue Insulin Drip and give D50%W IV bolus 12.5g (25mL) if BG 49-60mg/dL or
25 g (50mL) if BG less than 40mg/dL. Recheck BG q 15-30 minutes and repeat D50%w
IV if needed. Restart drip once BG > 80mg/dL x 2 readings with lower algorithm.
5. Notify the physician:
For patient not responding to Algorithm 2 or persistent hypoglycemia

96
Acute Renal Failure in ICU

97
Management
General Measures:
Nephrotoxic drugs should be stopped. The dose of all drugs excreted by the kidneys (e.g. digoxin,
some antibiotics) should be adjusted; serum levels are useful.
Fluid Balance:
If the patient is fluid overloaded, daily water intake is restricted to a volume equal to the previous
day's urine output plus measured extrarenal losses (e.g. vomit) plus 500 mL/day for insensible loss.
Water intake may need to be increased in a dry patient, especially if hypernatraemic.
Nutrition:
Na and K intake should be minimized in most patients. Don‟t forget the importance of nutritional
support to patients with AKI. They will often be hypercatabolic with high nutritional requirements.
Elderly patients are at particular risk of malnutrition. An adequate diet should be provided, including
daily protein intake of about 0.8-1 g/kg.
Calcium and Phosphate:
Calcium salts (carbonate, acetate) before meals help maintain serum phosphate at < 1.8 mmol/L.
Urinary Catheter- exclude obstruction and monitor urine output:
An indwelling bladder catheter is often needed, accepting the risks of UTI and urosepsis. It should be
removed as soon as possible.
Oxygenation up to mechanical ventilation:
Specific Management:
 Treat underlying cause
 Diuresis in Recovery Phase of ATN and Obstruction
 Maintain BP
 Correct hyperkalemia and metabolic acidosis
 Does this patient need dialysis?
Indications for Kidney Replacement Therapy
 Acidosis(pH <7.2) unresponsive to medical therapy
 Acute, severe, refractory electrolyte changes (e.g., hyperkalemia > 6.5 mmol/L)
 Encephalopathy
 Significant azotemia (blood urea nitrogen level >100 mg per dL [36 mmol per L])
 Significant bleeding
 Uremic pericarditis
 Volume overload

98
Diuretics in acute renal failure:
 Restoration of perfusion pressure and hemodynamics, normalization of volume status, and
exclusion of post- and prerenal azotemia are the first steps in the approach to the patient with
oliguric acute renal failure (ARF). High-dose loop diuretics are used in an attempt to convert an
oliguric into a non-oliguric ARF.
 Loop diuretics are the most powerful available and are the diuretics of choice in renal failure. The
maximal renal response to a loop diuretic is excretion of 20% of the filtered load of sodium.
Decreased glomerular filtration rate (GFR) leads to decreased delivery of loop diuretic to the TAL,
thus reducing the diuretic response and creating the need for higher doses of therapy.
Therapeutic regimens for loop diuretics in patients with diminished responses to initial therapy.
Factor Renal insufficiency Preserved renal function
Moderate Severe Nephrotic syndrome Cirrhosis Congestive
Mechanism of
diminished
response
Impaired delivery to
site of action
Diminished nephron
response, binding of
diuretic to urinary
protein
Diminished
nephron
response
Diminished
nephron response
Therapeutic
approach
Administration of
sufficiently high dose
to attain diuretic at
site of action
Administration of
sufficiently high
dose to attain
effective amount of
unbound diuretic at
site of action, more
frequent
administration of
effective dose
More frequent
administration
of effective
dose
More frequent
administration of
effective
Maximal IV (mg)
Furosemide 80–160 160–200 80–120 40 40–80
Bumetanide 4–8 8–10 2–3 1 1–2
Torsemide 20–50 50–100 20–50 10 10–20
Doses for continuous intravenous infusion of loop diuretics:
Diuretic Intravenous
loading dose (mg)
Infusion rate (mg/h)
Creatinine
clearance
< 25 mL/min
Creatinine
clearance
25–75 mL/min
Creatinine clearance
>75 mL/min
Furosemide 40 20 then 40 10 then 20 10
Bumetanide 1 1 then 2 0.5 then 1 0.5
Torsemide 20 10 then 20 5 then 10 5

99
Adult ICU Anemia Management Protocol
Policy:
Critically-ill patients commonly suffer from anemia. Anemia can cause prolonged ICU stays,
increase the costs of healthcare, and lead to other negative patient outcomes. Strategies for the
management of anemia in the critically ill include blood conservation, defining transfusion
triggers, and identifying effective adjunctive treatments like EPO, iron supplement, vitamins
B12 and folate.
Procedures:
Blood Conservative Strategies:
 Minimize blood tests to the actual need; avoid so called routine daily tests.
 Use small (pediatric) blood tubes if available.
 Minimize the discarded blood after sampling.
Transfusion of Packed RBCs:
Description:
One unit of red blood cells (RBC) contains ~200mL RBCs, 100 mL AS-5 (Optisol ®, a nutrient solution
added to extend shelf life to 42 days) and ~30mL plasma. RBC must be stored between 1-6° C.
Therapeutic Effect:
In a 70 kilogram adult, each RBC unit should increase the hematocrit by 3-4%.
Indications:
To receive PRBCs, patients must meet one of three criteria presented in Table 1.
Table 1: Indication for Transfusion of Packed RBCs
 Evidence of significant blood loss
(Systolic BP < 90 mmHg with obvious hemorrhagic shock)
 Hemoglobin < 10 g/dL (Hct < 30 %) with clinical sequelae including:
1. Hemorrhagic Shock.
2. Acute Septic Shock with poor oxygen delivery (Central venous saturation ScVO2 < 70%)
3. Acute myocardial ischemia.
 Hemoglobin < 7g/dL (Hct < 21%)

100
Administration of EPO (Erythropoietin)
Adjunctive Medications:
Patients being treated for anemia should also receive:
Folic acid 1 mg orally/per tube daily.
Vitamin B12 500 mcg orally/ per tube daily for five days, then weekly.
Adult ICU Hemostasis Protocol
Policy:
Blood products could be given only when absolutely necessary. Clinical indications include
either prophylactic or therapeutic transfusions. Adherence to this protocol is important to avoid
unnecessary transfusions.
Procedures:
Platelets
Description:
Platelets are essential for the initial phase of hemostasis. All platelet units contain plasma, a small
numbers of RBCs, and leukocytes. Platelet units must be maintained at room temperature and
agitated during storage.
Platelets provided in two different formats, a pooled product from multiple donors and an apheresis
unit from a single donor:
 Pooled platelet units are prepared from platelets that have been harvested after centrifuging whole
blood (WB) units from separate, random donors.One pooled platelet product is often called a “six
pack” because platelets from 6 whole blood units were traditionally pooled to make the pooled
product.
 Apheresis platelet units are collected from a single donor and are equivalent to a pooled platelet
unit containing ~4-6 pooled units; an apheresis platelet unit contains 200-400mL of plasma
Table 2: Criteria for the Use of EPO
1. Expected to have at least four days ICU stayAND
2. Hemoglobin < 10 (Hct < 30%) on Day 3 or prior to blood transfusion
Table 3: Dosing Recommendations for EPO
 Initiate therapy on ICU day 3.
 Dose EPO at 40,000 units subcutaneously, weekly on days 3, 10, 17, 24 while in the
ICU. EPO will be discontinued upon transfer from the ICU.
 Ferrous sulfate 325 mg orally/per tube daily unless contraindicated.

101
Indications for Platelet transfusion
a) Prophylactic transfusion:
Before surgery or other invasive procedure that could result in bleeding:
 Platelet count < 50 × 109
/L
 Platelet count > 50 × 109
/L; with evidence of platelet dysfunction.
 For high-risk procedures, such as neurologic or ophthalmologic surgeries, 100,000/μL is
recommended
b) Prophylactic transfusion in marrow failure:
/L
 May be given at higher levels with clinical evidence of bleeding
c) Therapeutic transfusion for uncontrolled hemorrhage:
/L
 ITP only if life-threatening bleeding is present.
Therapeutic Effect: Expected Platelet Increment
1 unit
1.0 X 1011
4 units
4.0 X 1011
6 units
6.0 X 1011
50 lb/23 kg 22,000/uL 88,000/uL 132,000/uL
100 lb/45 kg 11,000 45,000 66,000
150 lb/68 kg 7,400 30,000 44,000
200 lb/91 kg 5,500 22,000 33,000
In pediatric patients, the usual platelet dose is 1 unit whole blood platelet per 10 kg patient weight or
5-10 mL/kg. A 50,000/μL rise in platelet count is expected with each dose.
Fresh Frozen Plasma (FFP)
Description
 Plasma is the liquid component of blood and is free of RBCs, leukocytes and platelets. One unit of
plasma is the plasma taken from one unit of whole blood and is ~250mL.
 FFP is frozen within eight hours of whole blood collection and contains all coagulation factors in
normal concentrations.
 After FFP is thawed (“thawed plasma”), it may be transfused up to 5 days later, but contains
slightly decreased levels of Factor V (66 ± 9%) and decreased Factor VIII levels (41 ± 8%).

102
Indications for Plasma Transfusion
a) Prophylactic transfusion
1-Before surgery or other invasive procedure that could result in bleeding:
 Urgent correction of prolonged INR in warfarin therapy
 Correction of prolonged INR or APTT in liver disease
 Correction of inherited coagulation factor deficiencies
2-Massive transfusion with INR > 1.5 or APTT > 40 seconds
c) Therapeutic transfusion for uncontrolled hemorrhage
 Warfarin overdose
 Liver disease
 Vitamin K deficiency
 DIC
 Inherited coagulation factor deficiencies
c) Plasma exchange
 Thrombotic Thrombocytopenic Purpura TTP
 Hemolytic Uremic Syndrome HUS
Therapeutic Effect: FFP Dosing
 1FFP unit (200-250 mL) contains roughly 220U coagulation factors A dose of 10 mL/kg
of body weight increases factor levels by 10-15%
 To raise coagulation factors by 10%: (Body Weight (in kg)*10 mL/kg) / (200
mL/plasma unit) = No. of FFP units
 Pediatric patients dosing is 10-15mL/kg, to provide ~15-20% rise in factor levels
 Usually a 10% increase in factor levels is needed for any significant improvement in
coagulation status. The usual dose is four units, but the amount will vary depending on
the patient's size, actual clotting factor levels, and procedures that a patient will undergo
CRYOPRECIPITATE (CRYO)
Description
 Cryoprecipitate is prepared from plasma and contains fibrinogen, von Willebrand factor,
factor VIII, factor XIII and fibronectin.
 Cryoprecipitate is available in pre-pooled concentrates of six units or singly. Each unit
from a separate donor is suspended in 15 mL plasma prior to pooling.
 Each unit provides about 350 mg of fibrinogen.

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