UNIT 3

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1. Define shock, categorize it based upon type, explain the etiology and pathophysiology of each type of shock:

a. Cardiogenic

b. Hypovolemic

c. Distributive (septic, anaphylactic, neurogenic, and adrenal insufficiency mediated)

d. Obstructive (cardiac tamponade, tension pneumothorax, pulmonary embolus)

2. Summarize the clinical presentation and hemodynamic parameters associated with each type of shock using clinical terms, such as heart rate, respiratory rate, and blood pressure and filling pressures.

3. Propose an algorithm for diagnosing and initiating treatment for each shock type.

a. Cardiogenic

b. Hypovolemic

c. Distributive (septic, anaphylactic, neurogenic, and adrenal insufficiency mediated)

d. Obstructive (cardiac tamponade, tension pneumothorax, pulmonary embolus)

4. Discuss the pathophysiology, including the mechanism of arrest, for each of the following situations:

a. Acute myocardial infarction

b. Acute dysrhythmia

c. Congestive heart failure

d. Hypovolemic shock (blood loss, dehydration)

e. Burns

f. Hemorrhagic shock (non-traumatic)

g. Septic shock

h. Anaphylactic shock (envenomation, drug related)

i. Acute adrenal insufficiency

j. Penetrating or blunt trauma

(1) Tension pneumothorax

(2) Pericardial tamponade

(3) Hemorrhagic shock

k. Hypothermia

l. Substance abuse

m. Electrical injury

n. Suffocation

o. Acute stroke

5. Explain the indications for and the pharmacokinetics of each of the following drugs:

a. Lidocaine j. Vasopressin

b. Digoxin k. Nitroglycerin

c. Metoprolol l. Amrinone

d. Diltiazem m. Milrinone

e. Pronestyl n. Levophed

f. Amiodarone o. Phenylephrine

g. Dopamine p. Epinephrine

h. Dobutamine

i. Adenosine(Adenocard®)

6. Summarize the indication and appropriate technique for cardiac support, pressors, and Circulatory Assist Devices (IABP, LVAD, RVAD).

7. Outline the signs and symptoms of acute airway obstruction and define the appropriate intervention in adult and pediatric patients.

8. Outline the surgical housestaff role on the "code team."

9. Explain the physiological impact of mechanically assisted ventilation on the cardiovascular/respiratory system.

10. Analyze methods for initiating and maintaining ventilator/ weaning support.

11. Describe the indications and potential complications for the following surgical interventions:

a. Bag mask ventilation, endotracheal intubation (oral and nasal)

b. Cricothyrotomy

c. Thoracostomy tube

d. Central venous catheter

e. Peripheral vein cutdown

f. Arterial line

g. Pulmonary artery catheter

h. Diagnostic peritoneal lavage (DPL)

i. Resuscitative thoracotomy

j. Pericardiocentesis

k. Thoracentesis

l. Ultrasound

m. Wound exploration

12. Review the importance of serial physical examinations, hemodynamic monitoring, and serial laboratory evaluations, including urine output and lactic acidosis, in assessing patient response to specific resuscitation treatment.

13. Outline the clinical and laboratory indications for transfusion of the following blood products:

a. Packed red cells

b. Fresh frozen plasma

c. Platelets

d. Cryoprecipitate

e. Whole blood

f. Specific clotting factor concentrates (VIII, IX, XII)

g. Recombinant erythropoietin

14. Analyze the potential complications from use of the above products.

15. Older patients represent a special population, presenting key differences in emergency situations. Analyze and use examples to describe the significance of the following characteristics that are more frequent in the older patient:

a. Vague, imprecise symptoms

b. Atypical disease presentation

c. Co-morbidity

d. Polypharmacy (multiple organ specific physician input)

e. Possibility of cognitive impairment

f. Diagnostic tests with different normal values (age adjustments for normal values)

g. Likelihood of decreased functional reserve

h. Inadequate social support systems

16. Describe the role and indications (if any) for the following products in acute resuscitation:

a. Recombinant activated Protein C c. Albumin

b. Hespan and similar products

17. Assess the indications, guidelines, and potential complications of the following cardiovascular drugs:

a. Dopamine

b. Dobutamine

c. Phenylephrine

d. Vasopressin

e. Epinephrine

f. Norepinephrine

g. Amrinone

h. Nitroglycerine

i. Esmolol

j. Nipride

k. Diltiazem

18. Analyze and explain factors involved in blood pressure overestimation in the older patient (pseudohypertension, arteriosclerosis, arm size cuff discrepancies).

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

1. Complete and pass Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS), and Fundamentals of Critical Care Support (FCCS) training.

2. Manage the unconscious patient (seizure).

3. Serve on the code team and the trauma team.

4. Recognize and manage airway obstruction.

5. Perform endotracheal and nasotracheal intubation.

6. Use disposable airway equipment, (e.g., bags, gloves) as transmissible infection precautions.

7. Perform cricothyrotomy and tracheostomy.

8. Manage mechanical ventilator equipment.

9. Manage flail chest (pneumothorax, hemothorax, obstructive shock states).

10. Manage carbon monoxide poisoning.

11. Diagnose cardiac arrest and rhythm disturbances

12. Apply closed chest cardiac massage (CPR).

13. Perform closed chest defibrillation.

14. Perform venous access procedures, including subclavian and jugular and femoral vein catheterizations and saphenous vein cutdown.

15. Determine the indication, dosage, contraindications, and method of administration of the following medications:

a. Morphine

b. Lidocaine and Procainamide

c. Propranolol

d. Atropine

e. Diltiazem

f. Epinephrine and norepinephrine

g. Dopamine and dobutamine

h. Amrinone

i. Adenosine (Adenocard ®)

j. Cardiac glycosides

k. Nitroglycerin and nitroprusside

l. Furosemide, Mannitol, Bumex, Diamox

m. Sodium bicarbonate

n. Calcium

o. Amiodarone

p. Labetalol

16. Estimate volume requirements in acute trauma, burns, and hemorrhage; and institute replacement therapy.

17. Control external blood loss.

18. Perform pulmonary artery catheterization, including determining catheter position by pressure wave recording and electrocardiogram (EKG).

19. Manage cardiogenic and septic shock.

20. Use pneumatic antishock garments.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

Complete the coursework and testing to obtain Basic and Advanced Cardiac Life Support (BCLS and ACLS) and Fundamental Critical Care Support (FCCS) and Advanced Trauma Life Support (ATLS) certification.

Section One: Administration

1. Define and describe the role of the surgeon in the critical care setting to include these aspects:

a. Unit administration/management (surgeon as unit director)

(1) Triage of patients

(2) Economic concerns

(3) Data collection and computer usage

(4) Infection control and total quality management (TQM) issues

(5) Ethical concerns (consent, durable power of attorney, living wills)

(6) Local laws for referral to Medical Examiner

b. Management/consultation for specific surgical conditions

c. Coordination of multidisciplinary consultants relating and interpreting information between non-surgical consultants

2. Identify and outline criteria for admitting patients to the intensive care unit (ICU) to include:

a. Medical indications (related to specific diseases, e.g., pulmonary, cardiac, renal)

b. Surgical indications directly related to specific surgical illness

3. Identify and outline criteria for discharging patients from the ICU, to include:

a. Medical indications

b. Surgical indications

c. Patients unacceptable for ICU (e.g., futile care, do not resuscitate [DNR] orders)

4. Identify and explain the considerations surgeons must make when working with consultants in managing critical care situations.

5. Identify potential Organ, Tissue Donor candidates, as well as the hospital specific procedure for contacting families for potential donation.

Section Two: General Pathophysiology--Body as a Whole

1. Describe the normal physiologic response to a variety of insults such as sepsis, trauma, or surgery by associating the adaptation of the following systems from their pre-stress to post-stress states:

a. Respiratory d. Metabolic

b. Hemodynamic e. Endocrine

c. Renal

2. Describe the concept of the Systemic Inflammatory Response Syndrome (SIRS).

3. Describe prophylactic measures routinely used in critical care such as:

a. Gastrointestinal (GI) bleeding prophylaxis, including neutralizing, inhibitory compounds, and surface agents

b. Prophylactic antibiotics (demonstrate differences between true prophylaxis, empiric and therapeutic uses)

c. Pulmonary morbidity prophylaxis (incentive spirometry)

d. Prophylaxis against venous thromboembolic events

e. Aseptic technique

f. Universal precautions

g. Skin care protocols

h. Guidewire catheter changes for work-up of fever or change in clinical status

4. Discuss the pharmacotherapeutics of drugs used for support and treatment of the critically ill patient with emphasis on 1) mode of action, 2) physiologic effects, 3) spectrum of effects, 4) duration of action, 5) appropriate doses, 6) means of metabolism or excretion, 7) complications, and 8) cost:

a. Vasopressors

b. Vasodilators

c. Inotropic agents

d. Bronchodilators

e. Diuretics

f. Antibiotics/antifungal agents

(1) Distinguish between empiric, therapeutic, and prophylactic

(2) Demonstrate knowledge of classes of anti-infectives

g. Antidysrhythmics

h. Antihypertensives

Predict applicability of different classes in a particular situation:

(1) Use of beta blockers in hypertensive tachycardic patient

(2) Use of ace inhibitors in hypertensive patient with congestive heart failure

(3) Use of calcium channel blockers in hypertensive patient with angina

5. Outline the indications and methods for providing nutritional support by completing the following activities:

a. Discuss indications, selection of formulations, cost, route of administration of parenteral versus enteral forms of nutrition

b. Explain complications of parenteral and enteral routes of feeding as well as select methods to avoid the complications

c. Interpret findings associated with abnormalities in levels of glucose, chloride, sodium, phosphate, magnesium, trace metals/elements, and vitamins in the critically-ill patient receiving enteral or parenteral feedings; prepare recommendations for elderly patients under these same conditions

d. Estimate protein calorie requirements for patients of varying degrees of illness, and be able to analyze adequacy of nutritional support using commonly obtainable laboratory values

6. Outline the principles of postoperative fever with respect to causes, empiric diagnostic modalities, and specific therapy. How useful are these principles when considering the elderly patient?

7. Describe, apply, and revise appropriate treatment interventions based upon analysis of changes in the patient's clinical and laboratory parameters:

a. Adjustment of intravenous fluids with respect to expected stress response, including metabolic, hormonal, cardiovascular, and renal responses to replacement of fluid losses (Describe association between high levels of stress hormones and alterations of glucose metabolism remembering: do not volume resuscitate patients with excessive amounts of glucose.)

b. Efficacy of prophylactic measures for PE, stress ulceration and infection

c. Adequacy of nutritional support in a patient with multiple sites of protein losses (e.g., fistulas, drain sites, or metabolic stressors [infection, acute lung injury {ALI}, hyperthermia, respiratory failure])

d. Analysis and treatment of postoperative fever and methods of treatment

e. Events leading to and responsible for initiation of ventilatory support

f. Differentiate low cardiac output, hypotensive/hypertensive states in terms of preload, pump, or afterload

g. Analysis and treatment of seizures or acute change in mental status, including the role of:

(1) ABC's (airway, breathing, circulation); draw electrolytes/blood-urea-nitrogen (BUN)/ creatinine/glucose/calcium, magnesium

(2) Glucose/thiamine intravenously

(3) Evaluate medication record for new drugs or interactions (Ativan, Versed, phenobarbital, Dilantin [ not applicable in the acute event])

h. Analysis and treatment of acute respiratory failure from changes in the airway, pump, or lung

8. Review the management and diagram a plan for the care of the critically ill surgical patient with multiple medical problems such as:

a. Cardiac dysrhythmias

b. Pulmonary insufficiency from airway, bellows (pump), or parenchymal problems

c. Acute/chronic renal failure with hemodynamic instability or need of specific fluid therapy (TPN), renal replacement therapy, high output GI fistulas

d. Diabetes mellitus and its special problems in the realm of nutritional support

e. Hemodynamic instability in the face of acute/chronic renal or pulmonary insufficiency

Section Three: Airway-Respiration

1. Describe the commonly used indications for initiation of ventilation support, including:

a. Indications and commonly acceptable values for initiation of mechanical ventilation

b. Evaluation of airway

c. Evaluation of adequacy of thoracic pump (muscle strength)

d. Evaluation of lung parenchymal characteristics (arterial blood gases and chest x-ray)

e. Analysis of commonly used pulmonary values (e.g., tidal volume [Vt], maximum ventilatory volume [MVV], compliance static and dynamic, functional residual capacity [FRC], PEEP, auto PEEP, airway pressures)

f. Indications and commonly acceptable values for weaning from mechanical ventilation

2. Review respiratory physiology, and describe the specific pathology involved in ventilation and perfusion deficits.

3. Discuss the association of airway obstruction with age, giving consideration to each of the following:

a. Repeated disruption of the balance of inflammatory mediators and humoral protection (elastase and antielastase, oxidant and antioxidant)

b. Neutrophil recruitment

c. Tissue repair culminating in flammatory lung destruction

d. Accumulated environmental oxidant injuries

4. Analyze and compare the principles of ventilator mechanics, including modes of ventilation, triggering mechanisms, and possible uses.

5. Describe the pathophysiology of acute lung injury (ALI, with spectrum from mild to severe ALI, also known as ARDS) and the management of the long-term ventilator-dependent patient to include:

a. Pneumonias (aspiration or nosocomial)

b. Acute renal failure

c. Cardiac failure

d. Prevention of malnutrition or restitution of body stores

e. Systemic Inflammatory Response syndrome (SIRS, MODS- Multiple Organ Dysfunction Syndrome the most severe form known as MSOF- Multi-System Organ Failure)

f. Sepsis

g. Skin care problems

h. Physical therapy (maintenance of muscle mass and function, prevention of contractions)

i. Psychological support for both patient and family

6. Review management of the following complex respiratory problems:

Mechanically ventilated patient with:

(1) Areas of differing compliance

(2) Bronchopleural or bronchoesophageal fistula

(3) Borderline cardiac reserve (non-compliant left ventricle, recent myocardial infarction, valvular dysfunction)

7. Explain why otherwise healthy elders may be more vulnerable to poor outcomes from diseases affecting diffusion (producing lower oxygen levels, e.g., pneumonia, COPD). Consider these factors in your explanation:

a. Heart rate

b. Ventilatory response to hypoxia

c. Ventilatory response to hypercapnia

8. Analyze the pros and cons of the use of the following drugs to improve respiratory function:

a. Bronchodilators (aerosols vs. parenteral medications)

b. Membrane stabilizing agents (cromolyn sodium, steroids)

c. Diuretics

d. Venodilators

e. Analgesics and sedatives

f. Mucolytics

Section Four: Circulation

1. Describe and compare the following cardiac function parameters:

a. Preload b. Afterload c. Myocardial contractility

2. Define the information obtained from the use of the following invasive/non-invasive monitoring devices. Specify: 1) which information is directly/indirectly measured or calculated, 2) the accuracy and 3) cost of obtaining the information, and 4) review the hemodynamic principles associated with the use of each device:

a. Arterial catheters

b. Central venous catheters

c. Swan-Ganz catheters

d. Intracranial pressure monitors

e. End tidal carbon dioxide monitors

f. Pulse oximetry

g. Peripheral nerve stimulators (for testing adequacy of neuromuscular blockade)

h. Foley catheters

i. Intestinal pH monitors

j. Bioelectric impedance

3. Outline the protocols for definition of patterns and management of hemodynamically unstable patients, and analyze the selection of appropriate therapy by completing these activities:

a. Predict improvements in hemodynamic status with manipulation of definable variables, including fluid and drug therapies.

b. Detect and revise therapies based on the use of invasive/non-invasive monitoring devices.

4. Review cardiac function and hemodynamic monitoring from the following standpoints. Interpret changes in accuracy of values obtained from hemodynamic monitoring devices in:

a. Patients with severe pulmonary insufficiency who have low compliances or high PEEP

b. Patients with severe valvular insufficiency/stenosis

c. Various shock states (hypovolemic, septic, spinal, or cardiogenic)

d. High dose vasopressors

5. Summarize the effects of appropriate volume and drug therapies to manipulate the cardiovascular system in the following patients:

a. Hypovolemic hypotensive patient

b. Hypotensive euvolemic patient

c. Hypotensive hypervolemic patient

d. Hypotensive oliguric patient

e. Hypotensive, hypervolemic oliguric patient

f. Hypovolemic oliguric patient

g. Hypotensive, oliguric hypoxic patient

6. Discuss the significant patient characteristics in a geriatric population associated with increased risk of thromboembolic disease, including:

a. Underlying congestive heart failure

b. Prolonged immobility before surgery

c. Paralysis

d. Previous DVT

e. Hypercoagulable states (due to malignancy or coagulation factor deficiency)

Section Five: Renal

1. Review acid-base and electrolyte abnormalities common in critically-ill patients.

2. Identify, define, and classify the major categories of acid-base disturbance (metabolic acidosis and/or alkalosis, respiratory acidosis and/or alkalosis) in the context of the patient's altered physiology. Cite common clinical scenarios for their appearance:

a. Metabolic acidosis (hypovolemic shock, chloride excess resuscitation, occult ischemia)

b. Metabolic alkalosis (contraction alkalosis excessive diuretic use)

c. Respiratory acidosis

d. Respiratory alkalosis (early sign of sepsis vs. ventilator complication)

3. Discuss the identification and correction of complex acid-base problems such as choice of intravenous fluids for electrolyte replacement in the:

a. Hyperchloremic, metabolically-acidotic patient

b. Hypochloremic, metabolically-alkalotic patient

c. Stuporous, dehydrated, hyponatremic patient

d. Stuporous dehydrated hypernatremic patient

e. Patient with central diabetes insipidus

f. Hyponatremic, volume overloaded patient with carbon dioxide retention

Section Six: Neurologic

Describe the initial evaluation, ongoing, acute monitoring and long-term management of possible neurologic or behavioral abnormalities occurring in the ICU setting:

a. Seizures

b. Coma

c. Stroke

d. Multifactorial effects of “postoperative confusion”

e. Delirium

f. Brain death

Section Seven: Gastrointestinal/Hepatic

Discuss specific fluid compositions and the effect of the losses of such fluids as gastric, pancreatic, biliary, and succus entericus from intestinal fistulas of various levels. (Fluid should be described in terms of volume, electrolyte composition, and replacement fluid of choice.)

Senior Level:

Section Eight: Administration

1. Describe the criteria for predicting preoperatively the patient's need for critical care, including:

a. Pre-existing disease states (cardiac, pulmonary, or renal)

b. Operation-specific requirements for postoperative intensive care management

2. Review and interpret the relationships of physicians, nurses, and administrators in managing patients assigned to the ICU.

3. Discuss the value of an interdisciplinary approach to health care for the critically ill, elderly surgical patient. Include consideration of these groups/disciplines, working together:

a. Surgery f. Pharmacy

b. Nursing staff g. Religion

c. Family-friends as caregivers h. Social work

d. Physical therapy i. Hospital administration

e. Medical consultants

4. Identify new modes of intensive care therapeutics by completing the following activities:

a. Predict and analyze the need for a new technology.

b. Formulate a plan for the institution of new technologies or therapeutics.

c. Critique and revise applicability of new technologies or therapeutics on a cost: benefit ratio.

5. Summarize the following moral and ethical problems encountered in the ICU:

a. The need for organ donation and the identification of potential donors

b. Decisions about whom to resuscitate and to what degree

c. Care for the mentally incapacitated or incompetent patient

d. Dealing with a difficult family and futility of care

e. Identifying and interacting with alternate religious/cultural beliefs

Section Nine: General Pathophysiology--Body as a Whole

1. Discuss the use of sepsis severity scores.

2. Distinguish between the major characteristics of septic shock and hypovolemic shock:

a. Summarize initial evaluation and presentation

b. Analyze therapeutic options

c. Revise therapeutic options based on clinical parameters obtained from monitoring devices

3. Explain the concepts of tissue oxygen supply and demand. Demonstrate the contributions from the following components:

a. Calculate oxygen delivery

b. Calculate oxygen consumption

c. Analyze the effect of cardiac output and varying preload, pump, and afterload to oxygen delivery

d. Analyze the contributions of hemoglobin and percent of saturation on oxygen delivery