Intensive Care Guidelines

SCORE TEST RESPONSE

EYE
4 Spontaneous Open eyes without outside stimuli
3 To Speech Opens eyes on verbal stimuli
2 To Pain Opens eyes after painful stimuli
Glasgow 1 Nil Doesn't open eyes after any stimuli
VERBAL
Coma 5 Orientated Is orientated, aware in answering questions
Scale 4 Confused Appears confused but can produce meaningful
sentences
3 Inappropriate Answers with inappropriate words often obscenities
2 Incomprehens Groans, moans or mumblings, no intelligible words
ible
1 Nil No verbal responses to any stimuli
MOTORIK
6 Obeys Accurately responds to commands of physical actions
Commands
5 Localized Moves a hand or arm towards a painful stimuli to
Pain remove it
4 Withdraws Withdraws a body part from source of painful stimuli
from Pain
3 Decorticate Abnormal flexing of joints in response to painful
Reaction stimuli
2 Decerebrate Abnormal extension of joints in response to painful
Reaction stimuli
1 Nil No motor response to any stimuli
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 Scoring of APACHE II

A. TOTAL ACUTE PHYSIOLOGY SCORE (Cum of 12 above points)

B. AGE POINTS : < 44 = 0; 45 to 54 = 2; 55 to 64 = 3; 65 to 74 = 5; . > = 6
C. CHRONIC HEALTH POINTS:
If the patient has a history of severe organ system insufficiency or
is immunocompromised, assign points as follows:
: for nonoperative or emergency postoperative patients
: for elective postoperative patients

TOTAL APACHE II SCORE

(Add Together the Points from A+B+C)

0 to 4 4 % death rate
5 to 9 8 % death rate
10 to 14 15 % death rate
15 to 19 25% death rate
20 to 24 40 % death rate
25 to 29 55 % death rate
30 to 34 75 % death rate
Over 34 85 % death rate
 The HEART

The Pressure
and Oxygen
Saturation
measurements
In the various
chambers of
The Heart
Diagnostic Criteria for ALI and ARDS
1. Acute Onset
2. Presence of a predisposing condition.
3. Bilateral infiltrates on frontal chest x-ray,
consistent with pulmonary edema.
4. PaO2 / FiO2 < 200 mm Hg for ARDS,
PaO2 / FiO2 < 300 mm Hg for ALI,
regardless of the level of PEEP.
5. Pulmonary artery occlusion pressure =18 mm Hg or
no clinical evidence of left atrial hypertension.

Bernard GR, Artigas A, Brigham KL, The AmericanEuropean Consensus Conference on ARDS:
Definitions, Mechanisms, Relevant Outcomes, And Clinical Trial Coordination.
Am Rev Respir Crit Care Med 1994;149:818824.
 Present Score
Lower limb trauma or surgery or immobilisation
+1
in a plaster cast
Bedridden for more than three days or surgery
+1
within the last four week
Tenderness along line of femoral or popliteal veins
+1
(NOT just calf tenderness)
Entire limb swollen +1
Calf more than 3cm bigger circumference,10cm
+1
below tibial tuberosity
Pitting oedema +1

Dilated collateral superficial veins (non-varicose) +1

Past Hx of confirmed DVT +1

Malignancy (including treatment up to six months
+1
previously)
Intravenous drug use +3
Alternative diagnosis as more likely than DVT -2
Pre-test Clinical probability of a DVT with score:
DVT "Likely" if Well's > 1
DVT "Unlikely" if Wells< 2
 Severe Septic
Infection SIRS Sepsis
Sepsis Shock

Microorganism (Criteria: 2 meets SIRS with a Sepsis with organ Refractory

invading SIRS definition) : presumed failure/Dysfunction hypotension
sterile tissue Temp >38C or confirmed Hypotension (w/adequate fluid
infectious Hypoperfusion (Lactic resuscitation)
(100.4F) or < 36C MODS Criteria
process Acidosis, oligouria,)
(96.8F)? (Blood Evidence of 2
Heart Rate > 90? Vascular collapse
Culture or Organs Failing
Resp Rate > 20 or Procalcitonin
PaCO2 < 32 mm Hg proven)
WBC>12,000/mm3 Steroids
< 4,000/mm>3, or
> 10% bands? Drotrecogin Alpha
Early Goal Directed Therapy
Antibiotics and Source Control
Insulin and Tight Glucose Control
Sumber : Critical Care And Cardiac Medicine_Current Medical Strategies; Matthew Brenner, MD, p-67; 2006
 SEPSIS GUIDELINES 2008

DVT Prophylaxis Antibiotics within 1 hr EGDT and Protocolized Antibiotics within 1

H2 Blocker PUD for Septic Shock Resuscitation hr in No septic
Prophylaxis Glycemic Control Fluid Challenge Shock Patients
No Routine Use of Crystalloid = Colloid BC prior to Abx 7-10 day Antibiotic
SGC Duration
PPI PUD Prophylaxis Source Control
No Renal Dose
Low VT for ALI Dopamine or Consider Limiting
Dopamine
HOB >45 Norepinephrine Support
No High Dose
Limited Transfusion Limit P plateau <30 cm
Steroids
H2O
No Antithrombin II
No Erythropoietin PEEP
De-escalation Antibiotic
Sedation
Weaning Protocol/SBT Conservative Fluid in
ALI with no Shock
Avoid NMB

APC in high risk and non- PRBCs or Dobutamine Wean Steroids

surgical
Low dose steroids for
Hemodialysis: CVVH septic shock
NIV for ALI/ARDS B/S < 150
hypoxemia
Prone Position in ARDS
PEEP 5 5 8 8 10 10
FiO2 0,3 0,4 0,4 0,5 0,5 0,6
PEEP 10 12 14 14 14 16
FiO2 0,7 0,7 0,7 0,8 0,9 0,9
 Grade Tetanus Ringan :
MASA INKUBASI
5 < 48 JAM
4 2 5 HARI
3 6 10 HARI
2 11 14 HARI
1 > 14 HARI
LOKALISASI NYERI /
PORT DENTRI
5 INTERNAL / UMBILIKAL
4 LEHER, KEPALA,
DINDING TUBUH
3 EKSTREMITAS PROKSIMAL
2 EKSTREMITAS DISTAL
1 TIDAK DIKETAHUI
<9
Sedang : 9 16
Berat : > 16
IMUNISASI
10 TIDAK ADA
8 MUNGKIN ADA / IBU MENDAPAT
4 > 10 TAHUN YANG LALU
2 < 10 TAHUN
0 PROTEKSI LENGKAP
FAKTOR YANG MEMBERATKAN
10 PENYAKIT / TRAUMA YANG
MEMBAHAYAKAN JIWA
8 KEADAAN YANG TIDAK LANGSUNG
MEMBAHAYAKAN JIWA
4 KEADAAN YANG TIDAK
MEMBAHAYAKAN JIWA
2 TRAUMA / PENYAKIT RINGAN
1 DERAJAT STATUS FISIK/
ASA PENDERITA
CHAIN OF SURVIVAL (AHA GUIDELINE 2010)

TAHAPAN RJP SESUAI GUIDELINE 2010

ABC (AHA 2005) -> CAB (AHA 2010)

Highlight AHA 2010