VE & I D

E
IV

DI
CRITICAL CARE IN EMERGENCY

TR

&
I
IK

TR

I
IT PREPARED BY:

SM
DR.NAITIK D. TRIVEDI,

A
NA
M. PHARM, PH. D.,

HA
AM
LECTURER (GOVERNMENT AIDED)
A. R. COLLEGE OF PHARMACY & G. H. PATEL INSTITUTE OF PHARMACY
UP
.

VALLABH VIDYANAGAR

S.
DR

MOBILE: +91 – 9924567864

E-MAIL: mastermindnaitik@gmail.com
.

N
WEB SITE: https://sites.google.com/site/drnaitiktrivedi/
DR

RI
AF

1
 CONTENTS

VE & I D
E
 Introduction to critical condition and emergency

IV

DI
 Organisation of Critical Care

TR

&
 Critical CareTeam
 Level of ICU Care

I
IK
 Challenges in Critical Care condition

TR

I
 Admission Criteria for ICU
IT

SM
 Drug administration in ICU

A
NA

HA
 Monitoring in ICU
 Disorders Treated in ICU AM
UP
.

S.
 Name of critical conditions
DR

 Detailing about some critical conditions

.

N
 Pharmacologic Agents Commonly Used
DR

RI

in the ICU
 SpecialTechniques
AF

2
 INTRODUCTION

VE & I D
 Critical condition[1] –

E
 Vital signs are unstable and not within normal limits. Patient may be unconscious.

IV

DI
Indicators are unfavorable and high risk of death within 24hr of patient known as

TR

&
critical condition.
 Critical care[2] –

I
IK
 The specialized care of patients whose conditions are life-threatening and who

TR
require comprehensive care and constant monitoring, usually in intensive care

I
IT
units with other parts of hospitals.

SM
A
NA
 Intensive care[3] –

HA
AM
 Extensive and continuous care and treatment provided for an acutely ill patient,
usually in a specially designated section (intensive care unit) of a hospital
UP
.

S.
DR

 Medical emergency[4] –
 A medical emergency is an injury or illness that is acute and poses an immediate
.

N
risk to a person's life or long term health.
DR

RI
AF

3
  Emergency medicines[5] –

VE & I
 Emergency medicine is the medical specialty dedicated to the diagnosis and

D
treatment of unforeseen illness or injury. It encompasses a unique body of

E
IV
knowledge as set forth in the "Model of the Clinical Practice of Emergency

DI
Medicine.”

TR

&
 Critically ill patient differs from that required in less severely ill patients, with
immediate resuscitation and stabilisation of the patient’s condition taking

I
IK
precedence.[8]

TR

I
 High-dependency care provides an intermediate level between intensive care and
IT

SM
general ward care; it is appropriate for patients who have had major surgery and

A
NA
for those with single-organ failure. [8]

HA
AM
UP
.

S.
DR

N
DR

RI
AF

4
5
DR
.
DR NA
. IT
AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
 Organisation of Critical Care

VE & I D
E
 Critical care includes intensive care and high dependency care.

IV
 Intensive care unit (ICU) are for the care of very ill patients with potential or

DI
established organ failure.

TR

&
 High dependency care unit (HDU) provides an intermediate level of care between
intensive care and general ward cure.

I
IK

TR
 It is appropriate for both patients who had major surgery and for those who had

I
single organ failure.
IT

SM
 Critical care units include

A
NA

HA
AM
 Medical Intensive Care Unit (MICU)
 Surgical Intensive Care Unit (SICU)
UP
.

S.
 Paediatric Intensive Care Unit (PICU)
DR

 Neonatal Intensive Care Unit (NICU)

.

 Coronary care unit and burn unit.

N
DR

RI
AF

6
 Critical Care Team

VE & I D
E
• Critical care specialist or physician in a medical

IV
speciality like surgery, internal medicine paediatrics

DI
Intestivists or anaesthesiology.

TR

&
• Medical practitioner who received special education,
training for critically illness.

I
IK

TR

I
Critical Care IT

SM
• Provide high level of skilled nursing care.
Nurses

A
NA

HA
AM
UP
.

S.
DR

Pharmacist /
• To recognize the needs & problems of critical care
Clinical
.

patients.
N
Pharmacologist
DR

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AF

7
 VE & I
Registered • Asses food & fluid needs of patients

D
Dietician / • Improve nutritional health & promotes recovery of critically

E
Nutritient ill or injured patients.

IV

DI
TR

&
Respiratory

I
IK
Therapist /

TR
• Maintain & improve respiration of patient using respirators.

I
ICU
IT

SM
Technician

A
NA

HA
AM
UP
.

Physiothera
S.
DR

pist & • Help maintain flexibility & muscle strength to prevent

Occupation disability & speed up recovery
.

N
al Therapist
DR

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AF

8
 Levels of ICU care

VE & I D
E
IV
1. Level I

DI
High dependency – short term ventilation [<24hr]

TR


&
2. Level II

I
Prolong Ventilation – done in any general hospital

IK


TR
3. Level III

I
IT

SM
 Tertiary Hospital –

A
NA
 All aspects of ICU required.

HA

AM
All complex procedure has been done.
UP
.

S.
DR

N
DR

RI
AF

9
Challenges in Critical Care Treatment/Condition

VE & I D
E
IV

DI
 Population

TR

&
 Aged population – increase number of chronic illness
 Increased number of patient’s population

I
IK
 Economic Condition

TR

I
 Hospital budgets
IT

SM
 Cost of condition maintenance

A
NA

HA
 Competition
AM
 Competition between hospitals [Nationally & Internationally]
UP
.

S.
DR

N
DR

RI
AF

10
 Admission Criteria for ICU

VE & I D
E
IV
 To check some parameter likes,

DI
 If patient come with chronic impairment of one or more organ system. [COPD,

TR

&
Heart failure]
 If patient require endothracheal intubation and invasive mechanical ventillatory

I
IK
support.

TR

I
 If patient require support of two or more organ system.
IT

SM
A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

11
 Drug Administration in ICU

VE & I D
E
IV
 The route of drug administration depends upon condition of Patients, urgency of

DI
treatment, available dosage forms, duration of therapy.

TR

&
 All routes of drug administration including Intravenous(IV), Intraarterial,
Intramuscular(IM), Epidural, Intraventicular, Intrathecal, Subcutaneous(SC),

I
IK
Inhalation,Topical, Oral, Sublingual, Rectal used in ICU.

TR

I
 Intravascular
IT

SM
 Mostly IV solutions gives via peripheral veins.

A
NA
 In some conditions pharmacologic agents or electrolytes may be damaging to

HA
AM
peripheral vein at that time central venous administration is preferred (e.g.
norepinephrine, dopamine)
UP
.

S.
DR

 IV route also preferred for supplement of nutrition, blood products, fluids

and electrolytes.
.

N
DR

RI
AF

12
 VE & I
 Epidural

D
 Epidural administration of narcotics, morphines, fentanyl, sufentanil, local

E
anaesthetics – for relief of pain.

IV

DI
 Epidural analgesia is generally contraindicated in patients who have systemic

TR

&
infections, or receiving anticoagulant therapy.
 Other routes

I
IK
 In that IM route is mostly preferably.

TR
 Patient with thrombocytopenia, a coagulopathy, who receiving anticoagulant

I
IT
medicines = high risk of bleeding and hematoma formation due to IM

SM
injection.

A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

13
 Monitoring in ICU

VE & I D
E
 Regular check for physical signs such as respiratory rate, appearance of patient,

IV
restlessness, conscious level, poor peripheral perfusions.

DI
 Many monitors have alarms which will activate if certain maximum and minimum

TR

&
values are displayed.
 Alarm may help to identify that a patient has become disconnected from ventilator.

I
IK

TR
 Monitors,

I
 Electrocardiogram
IT

SM
 More sophisticated machines can print out rhythm strips and monitor ST

A
NA

HA
AM
segment shift, which may be useful in patients with ischemic heart disease.
 Blood Pressure
UP
.

S.
 Measure using automated sphygmomanometer but in critically ill patient
DR

continous intra-arterial monitoring using line the radial artery is preferable.

.

N
DR

RI
AF

14
 VE & I
 Cardiac Output

D
 Measured by using thermodilution techniques using PA catheter.

E
IV
 A bolus of cold 5% dextrose is rapidly injected into the right atrium via CVP

DI
line (Central Venous Pressure) and mixes with the total venous return in the

TR

&
ventricle.
 Cardiac output is derived from the volume and temprature of the injectate

I
IK
and the resulting change in temprature measured in the pulmonary artery.

TR
 Urine Output

I
IT

SM
 It is sensitive measures of renal perfusion, which provides kidney functioning.

A
NA
 It is normally measured hourly and the lower limit of normal is 0.5

HA
ml/hr/kg body wt.
AM
UP
.

S.
DR

N
DR

RI
AF

15
 Disorders Treats in ICU

VE & I D
E
 Cardio vascular system

IV
 Myocardial Infraction

DI
TR
 Cardiogenic Shock

&
 Arrhythmias

I
 Congestive cardiac failure

IK

TR
 Hypertensive Emergency

I
IT

SM
 Pulmonary system

A
NA
 Respiratory Failure

HA
 Pneumonia
AM
UP
 Pulmonary Embolism
.

S.
DR

 COPD & Asthma

 Kidney, GIT, Liver
.

N
DR

 Acute Renal Failure

RI
AF

16
 VE & I
 Liver Dysfunction

E D
 Bleeding Ulcers

IV
 Nervous system

DI
 Stroke

TR

&
 sepsis
 Otehrs

I
IK

TR
 Multiorgan dysfunction

I
 Poisnoning IT

SM
A
 Trauma
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

17
 VE & I
LIST OF SOME CRITICAL CONDITIONS

E D
IV
 Circulatory failure – shock[6]

DI
TR

&
 Respiratory failure[6]
 Renal failure[6]

I
IK

TR
 Neurological failure[6]

I
IT

SM
 Burns[7]

A
NA
 Heart attack[7]

HA
 Anaphylaxis[7] AM
UP
.

S.
DR

 Brain Death[7]
.

N
DR

RI
AF

18
 CIRCULATORY FAILURE: ‘SHOCK’

VE & I D
E
 Circulatory failure or ‘shock’ exists when the oxygen delivery fails to meet the

IV
metabolic requirements of the tissues.[7]

DI
TR
 Circulatory failure also characterized any condition in which the arterial blood

&
pressure and consequently, the capillary stream are reduced to such a extent that if it
prolong the functions of the normal organs are impaired and those of previously

I
IK
deranged organs are prevented from regaining of normal activity.[10]

TR

I
 Cause[7] :-
IT

SM
 Hypovolaemic

A
NA

HA
AM
 Reduction in blood volume, e.g. haemorrhage, severe burns, dehydration.
 Cardiogenic
UP
.

 Any form of severe heart failure, e.g. myocardial infarction, acute mitral

S.
DR

regurgitation.
.

 Obstructive
N
DR

 Obstruction to blood flow around the circulation, e.g. Major pulmonary

RI

embolism
AF

19
  Neurogenic

VE & I
 Brain or spinal injury producing disruption of brain-stem and neurogenic

D
vasomotor control; may be associated with neurogenic pulmonary

E
oedema.

IV

DI
 Anaphylactic

TR

&
 Inappropriate vasodilatation triggered by an allergen. e.g. bee sting.
 Septic/SIRS

I
IK
 Infection or other causes of a systemic inflammatory response syndrome

TR
(SIRS) that produce widespread endothelial damage with vasodilatation,

I
IT

SM
arteriovenous shunting, microvascular occlusion and tissue oedema,

A
resulting in organ failure.
NA

HA
 Signs of shock[7] :-
AM
UP
 Hypotension (systolic BP <100 mmHg)
.

S.
DR

 Drowsiness, confusion, irritability

.

N
DR

RI
AF

20
  Tachycardia (>100/min)

VE & I D
 Oliguria (urine output <30 ml/hr)

E
 Cold, clammy skin

IV
 Rapid, shallow respiration

DI
TR
 Multi-organ failure

&
I
IK

TR

I
IT

SM
A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

21
 RESPIRATORY FAILURE[9]

VE & I D
E
IV
 Acute respiratory failure is the inability to maintain adequate blood oxygenation

DI
and/or alveolar ventilation in the absence of an intracardiac shunt.

TR

&
 Increase in PaCO2 >50 mmHg with arterial acidemia and/or a PaO2 <55 mmHg
while breathing room air.

I
IK

TR
 Types[9] :-

I
IT
 Hypoxemic Respiratory Failure

SM
 patients exhibit a rapid shallow breathing pattern and a low or normal PaCO2.

A
NA

HA
AM
This form of respiratory failure is commonly the result of a diffuse acute lung
injury with high-permeability pulmonary edema (ARDS), severe pneumonic
UP
.

infiltrates, or cardiogenic pulmonary edema.

S.
DR

 Hypercapnic Respiratory Failure (Pump Failure)

.

 hypercapnia is the result of abnormalities in one or more of the determinants

N
DR

of the PaCO2 PaCO2= kVCO2/VE(1 −VD/VT)

RI
AF

22
  Cause[10] :-

VE & I
 muscular dystrophy

E D
 spinal cord injuries

IV
 Drug (narcotics, sedatives, anesthetics)or alcohol overdose

DI
 Lung diseases and conditions

TR

&
 Signs[11] :-
 inability to breathe

I
IK

TR
 bluish coloration in skin, fingertips, or lips

I
IT

SM
 Treatment[12] :-

A
NA
 Medications

HA
AM
 Pain medications may be prescribed.
 Surgeries
UP
.

S.
DR

 For severe cases, a tracheostomy (artificial airway in the windpipe) may be

performed.
.

N
DR

RI
AF

23
24
DR
.
DR NA
. IT
AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
 Renal Failure[6]

VE & I D
E
 Renal failure (RF) is defined as a relatively sudden (over hours to days) decrease in

IV

DI
renal function leading to serious derangements of body fluid homeostasis. [6]

TR

&
 Types of renal failure conditions[8] :
 Prerenal

I
IK
 Cause –

TR
 Absolute ECF volume depletion

I
IT

SM
o Extrarenal volume losses

A
NA
o GI losses

HA
o Third-space losses
AM
UP
.

o Inadequate fluid intake

S.
DR

o Hemorrhage
.

o Renal volume losses (diuretics)

N
DR

 Relative ECF volume depletion

RI

o Congestive heart failure

AF

25
 o Decreased peripheral vascular resistance

VE & I
 Changes in renal vascular tone

E D
o Nonsteroidal anti-inflammatory drugs

IV
o Angiotensin-converting enzyme inhibitors

DI
o Hepatorenal syndrome

TR

&
 Diagnosis[6,8] –
 Intake/Output Of Water And Urine.

I
IK

TR
 Urinalysis

I
 Treatment[6] –
IT

SM
A
 The cause of fluid losses should be identified and treated if possible.
NA

HA
AM
 Left ventricular function should be maximized if congestive heart
failure (CHF) is playing a role.
UP
.

S.
 Drugs should be discontinued.
DR

 Hepatic transplantation may restore renal function to normal.

.

 volume expansion with appropriate intravenous fluids.

N
DR

RI
AF

26
  Postrenal

VE & I
 Cause –

E D
 Urethral obstruction

IV
o Urethral valves

DI
o Prostatic hypertrophy

TR

&
 Bladder obstruction
o Neurogenic bladder

I
IK

TR
o Bladder tumors

I
o Cystitis IT

SM
A
Ureteral obstruction
NA


HA
 Intrinsic
o Ureteral stones AM
UP
.

S.
o Papillary necrosis
DR

 Extrinsic
.

N
o Tumors
DR

RI

o Retroperitoneal fibrosis
AF

27
 o Aortic aneurysm

VE & I
o Pregnancy

D
 Diagnosis –

E
IV
Suspected on history and physical examination.

DI
o Alternating polyuria and oligoanuria

TR

&
o Urinary obstruction
 Laboratory tests

I
IK

TR
o Hematuria

I
o Pyuria
IT

SM
o crystalluria.

A
NA

HA
AM
 Treatment –
 percutaneous nephrostomy
UP
.

S.
 urethral or suprapubic catheterization.
DR

 Intrinsic renal disorder

.

 Cause –
N
DR

RI

 Glomerular diseases
o Acute glomerulonephritis
AF

28
 o Rapidly progressive glomerulonephritis

VE & I
 Tubulointerstitial diseases

D
o Acute tubular necrosis

E
IV
o Drug-induced

DI
o Ischemic

TR

&
 Acute interstitial nephritis
o Allergic/drug-induced

I
IK
o Idiopathic

TR

I

IT
Vascular diseases

SM
o Renal artery

A
NA

HA
AM
• Thrombosis/embolus
• Dissection
UP
.

S.
• Trauma
DR

o Renal microcirculation
.

• Vasculitis
N
DR

RI

• Malignant hypertension
AF

29
 VE & I
• Disseminated intravascular coagulation (DIC)

D
• Thrombotic thrombocytopenic purpura (UP)

E
• Cholesterol atheroemboli

IV

DI
o Renal vein thrombosis

TR

&
 Diagnosis –
 urine sediment rate

I
IK
 FENa is typically >3% in intrinsic ARF

TR

I
 invasive studies e.g., angiography, renal biopsy
IT

SM
 Treatment –

A
NA

HA
 Drugs withdrawn
AM
 Control of fluid and electrolyte balance
UP
.

 Modification of drug dosages

S.
DR

 Dialysis should be entertained

.

 Use Calcium-channel blockers

N
DR

RI
AF

30
 Neurological failure (Coma)

VE & I D
E
 Coma is a term denoting neurologic unresponsiveness.[8]

IV

DI
 It represents part of a continuum from normal functioning to the absence of

TR
neurologic functioning with intermediate states of drowsiness and stupor. [9]

&
 Part of Consciousness:[9]

I
 Level of Arousal

IK

TR
 Level of arousal depends upon the interaction between the reticular activating

I
IT
system of the brain stem and the cerebral hemispheres bilaterally.

SM
A
 Content of Consciousness
NA

HA
AM
 Ability to communicate directly with the environment is absent
 Cause – [8,9]
UP
.

S.
DR

 Cerebrovascular accidents
 Central nervous system (CNS) trauma
.

N
DR

 CNS infections
RI

 Drug intoxication
AF

31
  Metabolic

VE & I D
 Metastatic or primary CNS neoplasia

E
 Systemic infection (sepsis)

IV
 Unknown

DI
TR

&
 Diagnosis –
 Careful History and Physical Examination

I
IK
 Head trauma (e.g., hemotympanum)

TR
 Cerebrospinal fluid (CSF) rhinorrhea

I
IT

SM
 Contusions

A
NA
 Lacerations

HA
 Toxic-Metabolic Phenomena
AM
UP
 Hypo- or hyperglycemia
.

S.
DR

 Hypo- or hypernatremia
 Renal failure
.

N
DR

 Liver dysfunction
RI
AF

32
 VE & I
 Computed Tomography (CT) Scan of the Head

D
 Mass lesions

E
IV
 supratentorial

DI
 posterior fossa

TR

&
 Lumbar Puncture
 Treatment –

I
IK

TR
 Drug - Naloxone, a narcotic antagonist (2–8 mg IV), and dextrose (50 g IV

I
push).
IT

SM
 Nonspecific Management

A
NA

HA
AM
 Stress ulcer prophylaxis
 H2-blockers, sucralfate, proton-pump inhibitors, etc.
UP
.

S.
 Skin care
DR

 Passive range of motion of upper and lower extremities.

.

N
DR

RI
AF

33
 Burns

VE & I D
 Any injury caused by exposure to Heat, Friction, Flame, Chemicals, Electricity,

E
Radiation is called Burns. [9]

IV

DI
 Most of these burns are minor, approximately 3–5% of burn injuries are life

TR

&
threatening.[8]
 Pathophysiology[8] –

I
IK
 Partial-thickness burns involve heat damage to the epidermis or a portion of the

TR
dermis.

I
IT

SM
 Full-thickness burns involve injury to tissue deep to the sweat glands and hair

A
NA
follicles.

HA
AM
 Shock may develop due to transudation and sequestration of fluid in the burned
areas and elsewhere in the body.
UP
.

S.
DR

 Cardiac output may drop in major burns, due to myocardial dysfunction.

 Classification of burn[9]
.

N
DR

 Major burns
RI

 Partial-thickness burns >20% BSA in children or the elderly or 25% BSA in

adults
AF

34
  Full thickness burns >10% BSA

VE & I
 Burns involving the face, hands, feet, or perineum that may produce functional

E D
or cosmetic impairment

IV
 Moderate burns

DI
 Partial-thickness burns of 10–20% BSA in children or elderly or 15–25% BSA

TR

&
in adults
 Full-thickness burns <10% BSA

I
IK
 Cause [8,9]

TR
 Expousre to flame

I
IT

SM
 Excessive Heat

A
 Corrosive chemicals
NA

HA
AM
 High voltage elctricity
 Clinical Presentation [9]
UP
.

 Partial-Thickness Burns

S.
DR

 First-degree burn :
.

 Only upto the epidermis.

N
DR

Blanching erythema but no bullae formation.

RI


AF

35
  Second-degree burn

VE & I D
Upto the dermis


E
 Produces edema and fluid exudation.

IV

DI
 Bullae formation is characteristic. Develop quickly after burn injury.

TR

&
Consider infection if bullae appear 18 h or later after a burn occurs.
 Full-Thickness Burns

I
IK
 Third-Degree Burn

TR
 Surface is dry and inelastic.

I
IT

SM
 Skin surface may become white or gray.

A
NA
 This burn will not regenerate from unburned edges.

HA
 Fourth-Degree Burn:
AM
UP
 Extends beyond the depth of the skin.
.

S.
DR

 Involve underlying muscle, tendons, vascular structures, periosteum, or

bone.
.

N
DR

 Survival depends on the extent and depth of the burn, the age of the patient, and
RI

associated injuries.
AF

36
  Vascular effects in burned skin are immediate vasoconstriction followed by

VE & I D
increased capillary permeability and plasma extra vasation.

E
 Burned skin also permits increased insensible water loss.

IV

DI
 Complications [8,9]

TR

&
 Coagulation necrosis at the burn site produces an advantageous setting for
bacterial growth. Infection is one of the most important causes of death in severe
burn injury.

I
IK

TR
 Gastric dilatation and a dynamic ileus occur in major burns.

I
IT
 Acute hemolysis may occur due to heat damage of red blood cells.

SM
A
 Acute renal failure may occur as a result of shock.
NA

HA
AM
 Hypertension may be present in burn victims, especially children.
 Multi organ failure is the leading cause of death in patients with burns.
UP
.

S.
DR

 Manipulation of burn wounds has been shown to result in bacteremia in 20% of

cases.
.

N
DR

RI
AF

37
38
DR
.
DR NA
. IT
AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
  Treatment [9]

VE & I D
E
IV

DI
Evaluate airway (smoke inhalation) and perform endotracheal intubation.

TR

&
I
IK
Establish intravenous access.

TR

I
IT

SM
A
NA

HA
AM
Evaluate burned areas under sterile technique.
UP
.

S.
DR

Assess for presence of other injuries, especially with burns associated with
.

explosions.
N
DR

RI
AF

39
 Insert nasogastric tube (to treat ileus) and urinary catheter to monitor urin output.

VE & I D
Obtain baseline laboratory values:

E
IV
• complete blood count (CBC), electrolytes, serum urea nitrogen (BUN), creatinine,

DI
glucose, arterial blood gases, and carboxyhemoglobin level.

TR

&
Estimate extent of burned area.

I
IK

TR

I
Classify severity of burn.
IT

SM
A
NA

HA
AM
Fluid resuscitation.
• Within the first 24 h, administer isotonic balanced crystalloid solution.
UP
.

S.
• May administer colloid-containing solution as needed after 24 h, at least
DR

• 12.5 g of albumin for every liter of crystalloid administered.

.

• Monitor urine output. The patient should have at least 50 mL/h in the adult
N
DR

• (or 1 mL/kg ideal body weight) and 1 mL/kg/h in the child.

RI

• Inhalation injury may significantly increase fluid requirements.

AF

40
 VE & I
Topical care

D
• Initially, cover burned areas with dry sterile sheets.

E
• Clean burned areas with water and mild soap and remove particulate matter

IV
from burn.

DI
• Debride any overtly necrotic skin.

TR

&
• Apply topical agents, such as silver sulfadiazine or mafenide acetate.
• Apply biologic dressings and synthetic skin substitutes to achieve temporary

I
IK
wound closure.

TR

I
IT

SM
Nutrition

A
NA
• High-protein diets appear preferable to conventional diets.

HA
AM
UP
.

Escharotomy

S.
DR

• Chest: diminished respiratory excursion, hypoxemia, diminished tidal

.

volume.
N
DR

• Extremities: diminished pulse and deterioration of circulation distal to the

RI

burn.
AF

41
 Heart Attack[7]

VE & I D
E
 A heart attack or myocardial infraction is permenant damage to the heart muscle.[14]

IV
 Heart muscle requires a constant supply of oxygen rich blood to nourish it. [14]

DI
TR
 Risk Factors [11] –

&
 Aging

I
 Male gender

IK

TR
 Family history

I
IT

SM
 Smoking history

A
NA
 Hypertension

HA
 Diabetes mellitus
 Dyslipidemia
AM
UP
.

S.
DR

 Cause –
 Plaque formation or blood clot in coronary artery or blood vessel. [14]
.

N
DR

 Any coronary artery disease. [14]

RI

 Hypertension. [14]
AF

42
  Diagnosis [11,14] –

VE & I
 ECG

D
 Chest X-ray

E
 Stress test

IV

DI
 Tilt table test

TR

&
 Electrophysiology
 CT heart scan

I
IK
 Myocardial biopsy

TR

I
 Heart MRI
IT

SM
 Pericardiotesis

A
NA

HA
 Treatment[9] –
 Therapeutic AM
pericardiocentesis should be performed immediately in
UP
.

hemodynamically compromised patients.

S.
DR

 Two-dimensional echocardiography-guided pericardiocentesis is successful in

.

95% of cases with no major complications.

N
DR

 Reaccumulation of fluid is likely to occur in malignant effusions but can be

RI

prevented with chemical sclerosis (i.e., tetracycline), radiation therapy, or

AF

surgery (i.e., pleuropericardial window or pericardiectomy).

43
 BRAIN DEATH[7]

VE & I D
E
 Brain death, defined as the permanent cessation of all brain function. [8]

IV
 The patient who is brain dead is DEAD. The physician does not require any permission

DI
of the family or other individuals to remove a dead patient from mechanical ventilation

TR

&
or other life support systems. [9]
 Symptoms [8,9] –

I
IK

TR
 Coma of established cause

I
 Temperature ≥32◦C
IT

SM
 Absence of significant central nervous system depressants or significant

A
NA

HA
AM
metabolic disturbances
 Patient not in shock
UP
.

 Absence of spontaneous movements, decerebrate or decorticate posturing

S.
DR

 Absence of brain stem responses

.

 Pupils fixed
N
DR

RI

 Corneal reflex absent

AF

44
 VE & I
 Unresponsiveness to pain in the distribution of the cranial nerves (i.e.,

D
supraorbital pressure)

E
 Absence of cough or gag reflex

IV

DI
 Absence of “doll’s eyes”

TR

&
 No eye movement with cold water (caloric test) bilaterally
 Absence of respiratory activity for at least 3 min

I
IK
 Diagnosis [9] –

TR

I
 Apnea test
IT

SM
 Cold Water Caloric Test

A
NA
 Ancillary Tests for Brain Death

HA
 Electroencephalogram (EEG) AM
UP
.

 Cerebral Angiography

S.
DR

 Cerebral Radionuclide Studies

.

N
DR

RI
AF

45
 Anaphylaxis[7]

VE & I D
 Anaphylaxis is an immediate, generalized, life-threatening reaction resulting from

E
IV
the release of bioactive substances from mast cells and basophils. [9]

DI
 It can occur in up to 20% of anaphylactic reactions and typically occurs within 8 h

TR

&
after resolution of the initial symptoms. Recurrences up to 72 h later can occur. [9]
 Causes[9] –

I
IK
 Drugs

TR

I
 Antibiotics (i.e., penicillins, cephalosporins, sulfonamides, vancomycin)
IT

SM
 Local anesthetics (i.e., lidocaine, procaine)

A
NA

HA
 Muscle relaxants
AM
 Others (i.e., insulin, protamine)
UP
.

 Foods

S.
DR

 Nuts and seeds

.

 Fish, shellfish
N
DR

RI

 Milk, eggs
AF

46
  Food additives

VE & I D
 Aspartame

E
 Monosodium glutamate

IV
 Diagnostics

DI
TR
 Iodinated radiographic materials

&
 Insect and snakes (stings and bites)

I
 Exercise

IK

TR
 Other

I
IT

SM
 Latex gloves

A
NA
 Heterologous serum (i.e., tetanus antitoxin)

HA
 Symptoms [9] –
AM
UP
 Early signs
.

S.
DR

 Agitation
 Dizziness
.

N
DR

 Headache
RI

 Nausea, vomiting
AF

47
  Cutaneous involvement

VE & I D
 Generalized pruritus

E
 Flushing

IV

DI
 Urticaria

TR

&
 Upper airway obstruction
 Respiratory failure

I
IK
 Cardiovascular collapse

TR

I
 Laboratory Finding [9] –
IT

SM
 Do not wait for laboratory data to institute therapy!

A
NA
 Patients with anaphylaxis may present with leukocytosis or leukopenia.

HA
AM
 Thrombocytopenia may appear in severe cases.
UP
.

 Immunoglobulin E (IgE) measurements may not be helpful, because many

S.
DR

 patients may manifest non-IgE-mediated anaphylaxis.

.

 Treatment [9] –
N
DR

 Epinephrine = 0.3–0.5 mL of 1:1000 dilution (0.3–0.5 mg) subcutaneously

RI

every 10–20 min or intravenously.

AF

48
  Endotracheal administration can be attempted when no other route is available.

VE & I D
 Antihistamines

E
 Diphenhydramine (Benadryl) 25–50 mg intramuscularly (IM), intravenously

IV
(IV), or PO q6–8 h.

DI
 H1blockers alone; i.e., cimetidine (Tagamet) 300 mg IV or PO q6 h.

TR

&
 Preventive Measures [9] –

I
 Avoid exposure

IK

TR
 Slow administration of suspected agents under medical supervision in adequate

I
facility (i.e., ICU) IT

SM
A
 Optimal management of underlying disorders
NA

HA
AM
 Short- and long-term desensitization (i.e., penicillin, aspirin)
UP
.

S.
DR

N
DR

RI
AF

49
Pharmacologic Agents Commonly Used in the ICU[9]

VE & I D
E
IV
Acetaminophen (Tylenol):

DI
TR
Route: PO, PR

&
Dosage: 325–650 mg q4–6 h (adults), 60 mg/kg/24 h in divided doses q4–6 h(children)

I
IK
Acetazolamide (Diamox):

TR
Route: PO, IV

I
IT

SM
Dosage: Metabolic alkalosis, 250 mg q6–12 h

A
NA
Altitude sickness, 250 mg q6–24 h

HA
Acetylcysteine (Mucomyst): AM
UP
.

Route: PO, IV, nebulized

S.
DR

Dosage: For acetaminophen toxicity

.

PO: Dilute to 5% with cola or other soft drink. Initial dose 140 mg/kg, then 70 mg/kg for
N
DR

RI

17 doses (do not give activated charcoal).

AF

50
 IV: Load with 150 mg/kg in 200 mL D5W over 15 min, then 50 mg/kg in 500 mL D5W

VE & I
over 4 h, followed by 100 mg/kg in 100 mL D5W over 16 h.

D
Dosage: For contrast-induced nephropathy

E
IV
600 mg PO, NG q12 h for 4 doses

DI
Activated Charcoal (Charcoaid):

TR

&
Route: PO
Dosage: For poisoning

I
IK

TR
Initial: 30–100 g (1 g/kg) in 250 mL water

I
IT
Maintenance: 20–40 g q6 h until drug removed from body

SM
A
NA
Adenosine (Adenocard):

HA
Route: IV
AM
UP
.

Dosage: 3, 6, 9, 12 mg (fast IV injection)

S.
DR

Alteplase (Activase):
.

Route: IV
N
DR

Dosage:Acute pulmonary embolism: 100 mg over 2 h.Acute ischemic stroke 0.9 mg/kg.
RI
AF

51
 Amphotericin B (Amphotec):

VE & I
Route: IV

E D
Dosage: 3–4 mg/kg/day

IV
Ammonium Chloride (generic):

DI
Route: PO, IV

TR

&
Dosage: Urine acidification, 4–12 g/d PO in divided doses q4–6 h
Amiodarone (Cordarone, Pacerone)

I
Route: PO, IV

IK

TR
Dosage: Pulseless VF/VT 300 mg. If VF/VT recurs a supplemental dose 250 mg followed

I
IT
by infusion of 1 mg/min for 6 h, then 0.5 mg/min.

SM
Amrinone (Inocor):

A
NA

HA
Route: IV
AM
Dosage: Bolus, 0.75–3 mg/kg over 2–3 min, followed by infusion of 5–20 μg/kg/min
UP
.

Atropine (generic):

S.
DR

Route: PO, IV
Dosage: Bronchospasm, 1.5–2.0 mg by nebulizer q6 h
.

N
Bradycardia, 0.5–1 mg IV push, repeat q5 min to max. 2 mg.
DR

RI

Prophylaxis for bradycardia pre-endoscopy 0.6 mg I.M.

AF

52
 VE & I
Bivalirudin (Angiomax):

D
Route: IV

E
Dosage:Acute coronary syndromes undergoing PTCA/PCI 0.1 mg/kg followed by 0.25 mg/kg/h.

IV
Bretylium (Bretylol):

DI
Route: IV, IM

TR

&
Dosage: Bolus, 5–10 mg/kg over 10–20 min IV, followed by a continuous infusion of 1–5
mg/min

I
IK
Carbicarb (Carbicarb):

TR
Route: IV

I
IT

SM
Dosage: Severe acidosis, initial dose 1 mEq/kg, followed by 0.5 mEq/kg (adjust dose as indicated

A
by clinical condition and blood pH)
NA

HA
AM
Chlordiazepoxide (Librium):
Route: PO, IV, IM
UP
.

Dosage: 15–100 mg/d in 3–4 divided doses

S.
DR

Chlorpromazine (Thorazine):
.

Route: PO, PR, IM

N
DR

Dosage: Severe psychosis with agitation, 25–100 mg IM q1–4 h until control is achieved
RI
AF

53
 Cisatracurium (Nimbex):

VE & I
Route: IV

D
Dosage: Bolus: 0.1 mg /kg Infusion: 1–3 mcg/kg/min

E
Clevidipine (Cleviprex):

IV

DI
Route: IV

TR
Dosage: Hypertensive crisis, postoperative hypertension when the oral route is not feasible 1–2

&
mg/h as start dose and double every 3 min to a maximum of 32 mg/h.
Clonidine (Catapres):

I
IK
Route: PO, transdermal (in some countries IM and PR used)

TR

I
Dosage: Hypertensive emergencies and urgencies, 0.2 mg PO, then 0.1 mg/q20 min to 0.8 mg or
IT

SM
until BP is controlled

A
NA
Dalteparin (Fragmin):

HA
Route: Subcutaneous
AM
Dosage: DVT prophylaxis: 2,500–5,000 Units subcutaneous once a day. DVT
UP
.

S.
treatment: 200 Units/kg
DR

Dantrolene (Dantrium):
.

Route: PO, IV
N
DR

Dosage: Malignant hyperthermia, initial dose 1–2 mg/kg IV via rapid infusion; may repeat to
RI

total 10 mg/kg, if needed

AF

54
 Daptomycin (Cubicin):

VE & I
Route: IV

D
Dosage: 4–6 mg/ kg once a day.

E
IV
dDAVP (generic):

DI
Route: Intranasal, IV, SC

TR

&
Dosage: Hemostasis, 0.3 μg/kg in NS over 15–30 min
Diabetes insipidus, 0.5–1 mL IV/SC bid
Diazepam (Valium):

I
IK

TR
Route: PO, IV, IM

I
IT
Dosage: Status epilepticus, 5–10 mg IV (1–2 mg/min)

SM
Diazoxide (Hyperstat):

A
NA
Route: PO, IV

HA
AM
Dosage: Hypertensive crisis, 1–3 mg/kg IV (max 150 mg) q5–15 min until BP is controlled
UP
Digoxin (Lanoxin):
.

S.
DR

Route: PO, IV, IM

Dosage: Digitalization, 0.4–0.6 mg IV (may require up to 1.25 mg total); maintenance, 0.125–
.

0.25 mg/d PO or IV
N
DR

RI
AF

55
 Dobutamine (Dobutrex):

VE & I D
Route: IV

E
Dosage: 2.5–15 μg/kg/min most commonly used

IV
Dopamine (Inotropin):

DI
Route: IV

TR

&
Dosage: Dopaminergic stimulation, 0.5–2.0 μg/kg/min
Alpha-, beta-dopaminergic effects, >10 μg/kg/min

I
IK
Drotrecogin alfa-activated protein C (Xigris):

TR
Route: IV

I
IT
Dosage: 24 mcg/kg/h for a total of 96 h.

SM
Enoxaparin (Lovenox):

A
NA

HA
AM
Route: Subcutaneous, IV.
Dosing: DVT prophylaxis 40 mg daily, DVT treatment acute 1 mg/kg/q12 h or 1.5
UP
.

mg/kg/daily.

S.
DR

Epinephrine (Epinephrine Injection):

Route: IV, SC
.

N
DR

Dosage: Beta1-, beta2-effect, 1–4 μg/min

RI

Alpha-effect, 4 μg/min
AF

56
 Epoprostenol (Flolan)

VE & I
Route: IV, can be inhaled.

E D
Dosage: 1–2 ng/kg/min

IV
Ertapenem (Invanz):

DI
Route: IV, IM

TR

&
Dosage: 1 g daily
Esmolol (Brevibloc):

I
Route: IV

IK

TR
Dosage: Bolus 0.5–1.0 mg/kg, followed by infusion at 50 μg/kg/min; maintenance 50–200

I
μg/kg/min
IT

SM
Etomidate (Amidate):

A
NA

HA
Route: IV
Dosage: Intubation: 0.2–0.6 mg/kg AM
UP
.

Fenoldopam (Corlopam):

S.
DR

Route: IV
Dosage: 0.1–1.0 μg/kg/min, titrate to achieve desired blood pressure
.

N
Fentanyl (Sublimaze):
DR

RI

Route: IV, IM
Dosage: Sedation/analgesia, 1 μg/kg IV/IM
AF

57
 Flumazenil (Romazicon):
Route: IV

VE & I D
Dosage: 0.3 mg IV

E
Furosemide (Lasix):

IV
Route: PO, IV, IM

DI
Dosage: 10–120 mg IV/IM, adjusted as necessary until desired response obtained.

TR

&
May use continuous infusions.
Fosphenytoin (Cerebyx):

I
IK
Route: IV, IM

TR
Dosage: Status epilepticus 15–20 mg/kg (loading dose)

I
IT

SM
Glucagon (generic):

A
Route: SC, IM, IV
NA

HA
AM
Dosage: Hypoglycemia, 0.5–1.0 mg SC/IM/IV, may repeat in 15 min
Bradycardia, 1–20 mg/h
UP
.

Haloperidol (Haldol):

S.
DR

Route: PO, IM, IV (not FDA approved)

Dosage:Acute psychosis, 2–5 mg IM q1–2 h until symptoms are controlled
.

N
DR

Heparin (Liquaemin):
RI

Route: IV, SC
Dosage: DVT prophylaxis, 5,000 U SC q8–12 h
AF

58
 DVT/Pulmonary emboli therapy, bolus with 100 U/kg followed by a continuous
infusion of 800–1,200 U/h, titrated to maintain aPTT 11/2–2 times control

VE & I D
Hydralazine (Apresoline):

E
Route: PO, IV

IV
Dosage: 5 mg IV bolus; 5–10 mg IV q6 h maintenance

DI
Hydromorphone (Dilaudid)

TR

&
Route: IV, PO, IM, SC
Dosage: 0.7–2 mg every 1–2 h as needed for pain

I
IK
Imipenem and Cilastatin (Primaxin):

TR
Route: IV, IM

I
IT

SM
Dosage: 500–1,000 mg every 6 h.

A
Isoproterenol (Isuprel):
NA

HA
AM
Route: IV, SC, PO, inhaled
Dosage: Infusion 1–10 μg/min
UP
.

KetorolacTromethamine (Toradol):

S.
DR

Route: PO, IM
Dosage: Initial dose 30–60 mg IM, then 15–30 mg q6 h
.

N
DR

Labetalol (Normodyne):
RI

Route: PO, IV
AF

59
 Dosage: Rapid BP control, IV bolus 5–20 mg (slowly); repeat after 5 min if needed. Continuous

VE & I
infusion of 1 mg/mL started at 1–2 mg/min and titrated to effect.

D
Lepirudin (Refludan):

E
Route: IV

IV

DI
Dosage: Bolus 0.4 mg/kg followed by continuous infusion at 0.15 mg/kg/h with a maximum

TR
dose of 44 mg as a bolus and 16.5 mg/h as infusion

&
Lidocaine (Xylocaine):
Route: IV, IM, SC

I
IK
Dosage: Bolus 1.0–1.5 mg/kg followed by 1–4 mg/min

TR

I
Linezolid (Zyvox):
IT

SM
Route: PO, IV

A
NA
Dosage: 600mg every 12 h.

HA
Lorazepam (Ativan):
Route: PO, IV, IM AM
UP
.

S.
Dosage: 2–10 mg/d in divided doses PO/IV/IM (some patients may require continuous
DR

infusions).
.

Mannitol (Osmitrol):
N
DR

Route: IV
RI

Dosage: For cerebral edema, IV infusion 0.15–2.0 g/kg as 15–25% solution over 30–60 min;
AF

max dose is up to 6 g/kg/24 h.

60
 Meperidine (Demerol):

VE & I
Route: PO, IM, IV, SC

D
Dosage: 50–150 mg q3–4 h

E
Meropenem (Merrem):

IV

DI
Route: IV

TR

&
Dosage: 1–2 g every 8 h.
Midazolam (Versed):
Route: IV, IM

I
IK

TR
Dosage: 1–4 mg q2–6 h

I
Morphine (Duramorph):
IT

SM
Route: IM, IV, PO, PR

A
NA
Dosage: 5–10 mg q4–6 h (some patients may require continuous infusions).

HA
Naloxone (Narcan): Route: IV, IM, SC
AM
UP
Dosage: 0.4–2.0 mg IV; may repeat up to 10 mg. Continuous IV infusion at 4–5 μg/kg/min.
.

S.
DR

Nicardipine (Cardene):
Route: IV, PO
.

Dosage: Hypertensive emergencies 5 mg/h/IV increase by 2.5 mg/h every 5–15 min to
N
DR

achieve desired blood pressure.

RI
AF

61
 Nitroglycerin (Nitroglycerin):
Route: PO, IV, SL, topical

VE & I D
Dosage: 10–400 μg/min IV

E
Norepinephrine (Levophed):

IV
Route: IV

DI
Dosage: 4–10 μg/min

TR

&
Octreotide (Sandostatin):
Route: IV, SC

I
IK
Dosage: Hypoglycemia in sulfonylurea poisoning: 50–100 μg SC every 6 h as needed.

TR
Esophageal varices: 25–50 μg IV bolus, followed by IV infusion of 25–50 μg per hour.

I
IT

SM
Ondansetron (Zofran):

A
Route: PO, IV
NA

HA
AM
Dosage: 4–8 mg every 6–8 h as needed.
Pantoprazole (Protonix):
UP
.

Route: PO, IV

S.
DR

Dosage: 40–80 mg IV daily or a continuous infusion of 8 mg/h.

Phenobarbital (Barbita):
.

N
DR

Route: PO, PR, IM, IV

RI

Dosage: Status epilepticus, 10 mg/kg IV at 50 mg/min; up to 20 mg/kg total (adults)

AF

62
 Phentolamine (Regitine):

VE & I
Route: IV, IM

D
Dosage: 5 mg IV/IM pm, taper to effect (adult); 0.1 mg/kg IV prn (pediatric).

E
Phenylephrine (Neo-Synephrine):

IV

DI
Route: IV
Dosage: 15 mg dissolved in 250 mL D5W (60 μg/mL); start at 20–30 μg/min, titrate to

TR

&
desired BP
Piperacillin and Tazobactam (Zosyn):

I
IK
Route: IV

TR

I
Dosage: 2.25–4.5 g IV every 6–8 h.
IT

SM
Procainamide (Procainamide):

A
NA
Route: PO, IV

HA
AM
Dosage: 100 mg/min IV to effect or to a total dose of 1,000 mg, followed by infusion 2–6
mg/min
UP
.

S.
Prochlorperazine (Compazine):
DR

Route: PO, IM, IV, PR

.

Dosage: 5–10 mg PO tid/qid; 5–10 mg IV q3–4 h; 25 mg PR bid

N
DR

Propofol (Diprivan):
RI

Route: IV
AF

63
 Dosage: 2–15 cc/h by continuous infusion to achieve the desired level of sedation

VE & I
Propranolol (Inderal):

E D
Route: PO, IV

IV
Dosage:Titrate 0.5–1.0 mg IV q5 min to effect.

DI
Protamine (Protamine sulfate):

TR

&
Route: IV
Dosage: 1 mg for each 90 U of lung heparin or 1 mg for each 115 U of intestinal heparin, by slow

I
injection over 1–3 min; max dose 50 mg in 10 min.

IK

TR
Rocuronium (Zemuron):

I
Route: IV
IT

SM
Dosage: Intubation 0.6 mg/kg.

A
NA

HA
Sodium Bicarbonate (Sodium Bicarbonate Injection):
Route: IV, PO AM
UP
.

Dosage: Severe acidosis, initial dose 1 mEq/kg, followed by 0.5 mEq/kg; adjust dosage as indicated

S.
DR

by clinical condition and blood pH.

Sodium Nitroprusside (Nipride):
.

N
Route: IV
DR

RI

Dosage: Mix 50 mg in 250 mL D5W. Start at 0.5 μg/kg/min and titrate to effect.
AF

64
 Sodium Polystyrene Sulfonate (Kayexalate):
Route: PO, PR

VE & I D
Dosage: 15 g, PO q6–24 h

E
Succinylcholine (Anectine):

IV
Route: IV, IM

DI
Dosage: 1–1.5 mg/kg IV; 2–4 mg/kg IM (pediatric use only)

TR

&
Thiopental (Pentothal sodium):
Route: IV, PR

I
IK
Dosage: General anesthetic, 2–3 mL 2.5% solution (50–75 mg) IV q20–40 s until desired

TR
effect reached Seizures, 75–125 mg IV

I
IT

SM
Tigecycline (Tygacil):
Route: IV

A
NA

HA
AM
Dosage: initial dose 100 mg, then 50 mg every 12 h.
Trimethaphan (Arfonad):
UP
.

Route: IV

S.
DR

Dosage: Start at 0.3 mg/min and titrate to effect.

Valproic Acid (Depakote):
.

N
DR

Route: PO, IV
RI

Dosage: Status epilepticus 15–45 mg/kg (loading dose), infusion 1–4 mg/kg/h.
AF

65
 Vancomycin (Vancocin):

VE & I D
Route: PO, IV

E
Dosage: 500–1,000 mg per day in divided doses PO. 2–3 g per day in divided doses IV.

IV
Vasopressin (Pitressin):

DI
Route: IM, IV, SC, IO

TR

&
Dosage: Pulseless cardiac arrest: 40 Units IV/ IO. Vasodilatory or septic shock 1–6 Units/h.

I
IK

TR

I
IT

SM
A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

66
 Special Techniques

VE & I D
 AIRWAY MANAGEMENT

E
IV

DI
Endotracheal intubation.

TR

&
I
IK

TR

I
IT

SM
A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

67
 VASCULAR ACCESS

VE & I D
Modified Seldinger technique for vascular access.

E
IV

DI
TR

&
I
IK

TR

I
IT

SM
A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

68
69
DR
.
DR NA
Central venous cannulation

. IT
AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
70
DR
.
DR NA
.
Radial arterial cannulation

IT
AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
 Pulmonary artery catheterization and waveforms

VE & I D
E
IV

DI
TR

&
I
IK

TR

I
IT

SM
A
NA

HA
AM
UP
.

S.
DR

N
DR

RI
AF

71
72
DR
Tube thoracostomy

.
DR NA
. IT
AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
73
DR
.
DR NA
. IT
Intra-aortic balloon pump.

AF UP IK
RI AM
N A TR
IV
S. TR E
HA I VE & I D
SM DI
I &
74
DR
.
DR NA
. IT
AF UP IK
RI AM
N A TR
IV
THERAPEUTIC HYPOTHERMIA (TH)

S. TR E
HA I VE & I D
SM DI
I &
 References

VE & I D
1. https://en.wikipedia.org/wiki/Medical_state

E
IV
2. http://www.medicinenet.com/script/main/art.asp?articlekey=24812

DI
3. http://www.thefreedictionary.com/intensive+care

TR

&
4. https://en.wikipedia.org/wiki/Medical_emergency
5. http://www.acep.org/Clinical---Practice-Management/Definition-of-Emergency-Medicine/

I
IK
6. http://www.who.int/surgery/publications/imeesc/en/

TR
7. http://www.accessible-insurance.com/Archive/Articles/CriticalIllness/CriticalIllnessList.htm

I
IT

SM
8. Critical Care And Emergency Medicine; Chapter – 3; Page No. – 19-31.

A
9. Joseph Voren, Pilar Acosta; Handbook of Critical And Intensive Care Medicine; Springer; Usa; 2nd
NA

HA
Edition;
10.
AM
Carl J. Wiggers; Circulatory Failure; The Journal of the American Medical Association; Vol-17; No.-8;
UP
23rd February; 1918.
.

S.
DR

11. http://www.nhlbi.nih.gov/health/health-topics/topics/rf/atrisk
12. http://www.healthline.com/health/acute-respiratory-failure#Symptoms5
.

N
http://www.healthline.com/health/acute-respiratory-failure#Treatment7
DR

13.
RI

14. http://www.m.webmd.com/heart-disease/guide/heart-disease-heart-attacks
AF

75