Articles: critical-care.
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Emerg. Med. Clin. North Am. · Nov 1986
Review Comparative StudyResuscitation of the critically ill patient. Use of branched-chain decision trees to improve outcome.
The algorithm approach provides criteria based on decision rules for expeditious monitoring, diagnostic and therapeutic decisions; algorithms are particularly useful in crisis situations, in which time is of great importance, for example, in the resuscitation of emergency patients. Because of its objectivity and usefulness as a teaching tool, this algorithmic approach is of practical benefit in the training of residents and students in teaching hospitals, as well as in the community hospital where less experienced physicians manage hypotensive emergency patients more infrequently. In a few instances there has been some reluctance to use the algorithm, but most often it was found to be useful in organizing the work-up and establishing therapeutic priorities. ⋯ The underlying premise under these conditions was to evaluate increments of volume therapy without exceeding safe CVP pressures (less than 18 mm Hg) in order to obviate fluid overloading. A third algorithm for ICU patients with pulmonary artery catheters was developed from decision rules based on objective physiologic, heuristic, survival data as the criteria for post-trauma and postoperative patients who were critically ill despite apparent success with the initial resuscitation and CVP algorithms. The improved mortality in prospective studies supports the hypothesis that compensatory responses of the survivors are the major determinants of outcome.
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A basic understanding of respiratory physiology and ventilator-patient interaction is critical for the initiation of ventilatory support and management of the ventilated patient. A brief review of these subjects is incorporated in this outline of the approach to the patient requiring mechanical ventilation.
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Respiratory rate is a sensitive clinical parameter in a multitude of pulmonary diseases, especially in the critical care setting. In order to validate the routine recording of the respiratory rate in the intensive care unit, we compared the values obtained from the nursing records with the breathing frequency continuously recorded by a prototype microprocessor system using respiratory inductive plethysmography. We found a significant (greater than or equal to 20 percent) error in the staff's monitoring of respiratory rate one third of the time. In addition, we demonstrated the ease and reliability of using this prototype system as a continuous, noninvasive, long-term respiratory monitor in the intensive care unit.
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Hyperthermia (temperature of at least 40.5 degrees C for at least one hour) associated with drug intoxication was identified in 12 patients over a 5-yr period. Intoxication was due to anticholinergic drugs (tricyclic antidepressants, antipsychotics, antihistamines), CNS stimulants (phencyclidine, cocaine, 3,4-methylene dioxyamphetamine, mescaline, lysergic acid diethylamide), salicylates, or combinations of these. Hyperthermia was present in four patients on admission, but its onset was delayed up to 12 h in the remainder. ⋯ Five patients suffered seizures, and four did not respond to anticonvulsant medication until body temperature was lowered. Cooling did not appear to favorably affect the outcome after body temperature had remained above 40.5 degrees C for a prolonged period. Prevention of death or neurologic sequelae from drug-induced hyperthermia depends upon the recognition of risk factors and the prompt treatment of hyperthermia.