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Critical Care - C5VL011
Title: Neodkladné stavy v resuscitační péči
Guaranteed by: Department of Anaesthesia and Intensive Care Medicine 3FM CU and UHKV (12-ARO)
Faculty: Third Faculty of Medicine
Actual: from 2021
Semester: both
Points: 1
E-Credits: 1
Examination process:
Hours per week, examination: 0/12, C+Ex [HS]
Capacity: winter:unknown / unknown (unknown)
summer:unknown / unknown (unknown)
Min. number of students: unlimited
4EU+: no
Virtual mobility / capacity: no
Key competences:  
State of the course: taught
Language: Czech
Teaching methods: full-time
Teaching methods: full-time
Level:  
Note: you can enroll for the course in winter and in summer semester
Guarantor: prof. MUDr. František Duška, Ph.D.
MUDr. Anne Le Roy
Examination dates   Schedule   
Annotation -
Last update: prof. MUDr. František Duška, Ph.D. (30.09.2021)
"OMG! Doc! Come here quick!" As a doctor the day will come when you here this. Critical care aims to prepare you for such a situation, i.e. to tech you a structured ABCDE approach to rapidly deteriorating patients, the necessary minimum of manual skills, such as airway maneuvers and, last but not least, necessary non-technical skills such as how not to loose your nerves and lead a team in a crisis. We also aim to teach you how to recognise and treat sepsis and how ICU works and what to expect from it.
Aim of the course -
Last update: prof. MUDr. František Duška, Ph.D. (30.09.2021)

Goals:

1. Act before they arrest: Recognise acutely sick patient. Do simple things fast and withou panic - learn ABCDE approach to an acutely deteriorating patient. Understand team dynamics in a crisis and how to deal with it. 

2. Sepsis kills.  Learn how to recognise and treat it. 

3. Visit ICU. Learn that intensive care is mighty but it can be burdensome. When to offer it to your patients?  
Literature -
Last update: prof. MUDr. František Duška, Ph.D. (30.09.2021)

 

Very practical little book is the Oxford classic (http://www.amazon.co.uk/Oxford-Handbook-Critical-Care-Handbooks/dp/019263190X). This can be supplemented by pathophysiology chapters from any reference textbook of your choice (i.e. Waldmann et al. Oxford Desk Reference - Critical Care, Oxford University Press, new ed. 2019) or check Guytons Physiology (It's all there!) 

 

There is also plenty of free educational resources on the Internet based on FOAM platform (FOAM – Free Open Access Meducation)  Check this one first https://lifeinthefastlane.com/collections/

Still not happy? Then try: 

European Resuscitation Council Guidelines 2015: www.erc.edu

www.acidbase.org

Basic life support: http://www.lf3.cuni.cz/en/departments/anesteziologie/vyuka/studijni-materialy/resuscitation/

Advanced life support: http://www.lf3.cuni.cz/en/departments/anesteziologie/vyuka/studijni-materialy/advanced-resuscitation/index.html

www.academy.esicm.org 

There is much more... 
Teaching methods -
Last update: prof. MUDr. František Duška, Ph.D. (30.09.2021)

Organisation:

Block of 5 days

Students are divided into 4 groups  (A-D), and rotate through hands-on workshops, simulations and interactive workshop as follows: 

IL = interactive lectures

W = workshops

SIM = simulations

GP = group project

Den 1 - ALS, ABCDE
Group A Group B Group C Group D
8:00 – 8:45 ABCDE, NTS, demonstrace ABCDE (IL)
8:45 – 9:30 NTS Bingo (W) NTS Bingo (W)
9:30 – 9:45
9:45 – 10:30 Srdeční zástava (IL + S) Peri-arrest (W)
10:30 – 11:15 Peri-arrest (W) Srdeční zástava (IL + S)
11:15 – 11:30
11:30 – 12:15 Simulace I Simulace II ICU
12:15 – 13:00
Zasedací místnost KAR Místnost 218 Místnost 220

Den 2 - Respirační selhání
Group A Group B Group C Group D
8:00 – 8:45 Těžká pneumonie (CBL) CHOPN (CBL)
8:45 – 9:30 CHOPN (CBL) Těžká pneumonie (CBL)
9:30 – 9:45
9:45 – 10:30 Airway (W) x Simulace II
10:30 – 11:15 x Airway (W)
11:15 – 11:30
11:30 – 12:15 PV workshop Simulace II ICU
12:15 – 13:00

Den 3 - Limitace intenzivní péče
Group A Group B Group C Group D
8:00 – 8:45 Komplikace intenzivní péče, koho (ne)přijmout (IL)
8:45 – 9:30
9:30 – 9:45
9:45 – 10:30 Skupinový projekt (GP) Skupinový projekt (GP) Simulace I Simulace III
10:30 – 11:15
11:15 – 11:30
11:30 – 12:15 Skupinový projekt Simulace I
12:15 – 13:00 PV workshop

Den 4 - Šok, ABR
Group A Group B Group C Group D
8:00 – 8:45 Šok (CBL) Šok (CBL)
8:45 – 9:30 ABR (IL)
9:30 – 9:45
9:45 – 10:30 ABR (W) Simulace III Airway (W)
10:30 – 11:15 Airway (W)
11:15 – 11:30
11:30 – 12:15 Simulace II ICU Acid Base (W)
12:15 – 13:00 PV workshop

Den 5 - Sepse
Group A Group B Group C Group D
8:00 – 8:45 Sepse (CBL) Sepse (CBL)
8:45 – 9:30
9:30 – 9:45
9:45 – 10:30 Simulace III Simulace I Skupinový projekt (GP) Skupinový projekt (GP)
10:30 – 11:15
11:15 – 11:30
11:30 – 12:15 ICU Simulace III Skupinový projekt
12:15 – 13:00 PV workshop
Requirements to the exam -
Last update: prof. MUDr. František Duška, Ph.D. (30.09.2021)

Credit: Minimum of 4 topics must be attended to get a credit (80%)

Examis in OSCE format (Objective Structured Clinical Examination). Consists of 4 stations – two theoretical stations focused on physiology and the diagnosis and management of the critically ill, one minicase and one simulation scenario. Rather than on details of multiorgan support, we put emphasis on testing candidates' understanding of mechanisms of critical illnesses and their initial management.

 Pass mark is set a priori by modified Angoff method (Angoff WH. Scales, norms, and equivalent scores. In: Thorndike RL, editor. Educational Measurement.2nd. Washington, DC: American Council on Education; 1971. pp. 508–600). Terms are set a priori with 160% seats (relative to the number of students) and cannot be expanded due to demanding logistics of the exam. Thank you for your understanding. With any questions, please contact Dr Anne Le Roy. 

 

* The practical skills marked with an asterisk can be required during the examination. 

1) PROCEDURES

Airway management

  • Manual airway manoeuvres *
  • Endotracheal intubation – indication, technique
  • Laryngeal masks – indication, technique *
  • Bag mask ventilation, Guedel airway *
  • Tracheostomy – indication, advantages in long-term ventilation, complications
  • Respiratory distress in a tracheostomy patients
  • Oxygen therapy – low flow, high flow (HFNO)

Invasive procedures

  • Arterial catheter – indications, uses, complications
  • Venous access – techniques, choice of technique
  • Central venous catheter – indications, technique, complications, drugs given through CVC
  • Management of the patient with pneumothorax – emergency chest decompression, chest drainage - technique
  • Intraosseous access – indications, localisation, technique, complications
  • Nasogastric tube, gastric lavage

Ultrasound techniques in emergency and critical care

  • FAST - focused assessment with sonography in trauma – uses, projections
  • Focussed echocardiography in emergency medicine, RUSH – (Rapid Ultrasound for Shock and Hypotension), ultrasound in the diagnostics of reversible causes of cardiac arrest
  • Ultrasonography of the lungs and pleura
  • Uses of ultrasonography in invasive procedures – cannulation, chest drainage, peripheral nerve blocks 

2) PHARMACOLOGY

Drugs used in critical care incl. Dosages

Adrenaline, amiodarone, morphine, alteplase, heparin, flumazenil, naloxone, phenytoin, tranexamic acid, atropine

Antibiotics

  • General principles of antibiotic therapy in sepsis
  • PK/PD approach to antibiotics, practical consequences
  • Overview of antibiotics used in critical care + dosages in the following antibiotics: vancomycin, ampicilin, ceftriaxone, meropenem, gentamicin
  • Antibiotic prophylaxis in surgery
  • Surveillance of antimicrobial use

Vasoactive drugs

Adrenalin, noradrenalin, vasopressin, dobutamine, ephedrine

Others

  • Acute pain therapy, analgesics, multimodal analgesia, opiates, patient-controlled analgesia
  • Sedatives used in critical care, sedation holiday
  • Fluid therapy – crystalloids, colloids – advantages, disadvantages 

3) CARDIOLPUMONARY RESUSCITATION

  • Cardiopulmonary resuscitation
    • Advanced cardiopulmonary resuscitation with drugs and equipment in the hospital and outside (Advanced life support)
    • Management of haemodynamically significant bradycardia
    • Management of haemodynamically significant tachycardia
    • Reversible causes of cardiac arrest - 4H, 4T
  • Recognising the sick patient, prevention of in-hospital cardiac arrest
    • Structured assessment of the acutely ill – structured approach ABCDE, recognising the cause and immediate management *
    • Approach to the unconscious patient *
    • EWS - early warning scoring systems
  • Principles of initiating and terminating cardiopulmonary resuscitation
  • Postresuscitation care

 4) NON-TECHNICAL SKILLS AND CRM (CRISIS RESOURCE MANAGEMENT) IN CRITICAL AND EMERGENCY 

  • Early call for help, safe communication, SBAR/RSVP *
  • Leadership and followership –roles assigned in the team, principles of effective communication between team members, (sharing the mental model, closed loop communication, speaking up, graded assertiveness) *
  • Fixation error – prioritization, delegating, step back method *

 5) CRITICAL CARE – SPECIAL PART

RESPIRATORY FAILURE AND MECHANICAL VENTILATION

 

  • Pathophysiology:
    • Lung volumes
    • Compliance, resistance, time constant
    • Dynamic hyperinflation
    • Pressure-volume diagram, hysteresis, pathophysiology of recruitment manoeuvre
    • Ventilation vs perfusion, West zones, alveolocapillary reflex, VQ ratio and VQ mismatch
    • Respiratory failure, types (partial vs. global), causes
    • ARDS - definition, Berlin criteria, phases of ARDS, differential
  • Mechanical ventilation
    • ARDS - principles of ventilator settings, protective ventilation, prone position
    • Mechanical ventilation - characteristics of the respiratory cycle in pressure and volume controlled ventilation, PEEP, assisted ventilation
    • Non-invasive ventilation: indications, contraindications, hemodynamic effect of CPAP in pulmonary oedema
    • Ventilator associated pneumonia (VAP) - prevention, diagnostic criteria, therapy (choice of antibiotics, length of therapy)
  • Management of the most common causes of respiratory failure: COPD exacerbation, status asthmaticus, pneumonia

 

CARDIOVASCULAR PATHOLOGY AND EMERGENCIES IN CARDIOLOGY

 

  • Pathophysiology
    • Determinants of oxygen delivery
    • Relationship between global oxygen consumption and delivery, central venous oxygen saturation (ScvO2) as a hemodynamic parameter
    • Determinants of stroke volume - preload and Frank-Starling law, afterload, contractility
    • Dissociation curve of haemoglobin, Bohr´s effect
  • Effect of mechanical ventilation on intrathoracic pressure and hemodynamic parameters (cardiopulmonary interactions during mechanical ventilation)
  • Shock  - definition, types of shock (cardiogenic, obstructive, hypovolaemic, distributive), compensatory mechanisms, stages of shock
  • Clinical signs of shock and organ hypoperfusion
  • Invasive measurement of arterial blood pressure, arterial waveform - shape and description of the normal waveform
  • Fluid responsiveness prediction - dynamic measurement of preload (pulse-pressure variation, passive leg-raise test), ultrasonographic methods, fluid challenge
  • Initial management of emergencies in cardiology
    • Acute myocardial infarction
    • Hemodynamically significant bradycardia and tachycardia
    • Aortic dissection
    • Hypertension crisis
    • Pulmonary embolism
    • Cardiac failure and pulmonary oedema

 

HAEMOSTASIS AND THROMBOSIS

  • Effect of drugs on haemostasis - anticoagulants, antiplatelet drugs, fibrinolytics, antifibrinolytics - mechanism of action, indications, laboratory evaluation of effect, antidotes
  • Coagulation tests - INR, aPTT, fibrinogen, antithrombin, D-dimers, anti-Xa, TEG/ROTEM
  • Blood products - indications of administration
  • Massive transfusion protocol
  • Bleeding in patients using warfarin, NOAC, anticoagulants
  • Pulmonary embolism - diagnostics, therapy, pathophysiology, effect on hemodynamic

SEPSIS

  • Definition, SEPSIS-3
  • Septic shock – definition
  • Infection vs. colonisation vs. contamination
  • Basic pathophysiology of sepsis and MODS (activation of endothelium, cytopathic hypoxia, myocardial dysfunction, immunoparalysis)
  • Clinical identification of sepsis, early diagnosis – qSOFA
  • Initial therapy of sepsis – the three pillars of therapy
  • The role of lactate in the therapy of sepsis
  • Antibiotics in sepsis – initial choice and de-escalation
  • Antibiotics choice in community acquired infection vs. early and late-onset nosocomial infection, ventilator associated pneumonia

NEUROINTENSIVE CARE

  • Pathophysiology
    • Auto regulation of cerebral blood flow
    • Monro-Kellie doctrine and intracranial pressure
    • Examination of brainstem reflexes
    • Intracranial pressure (ICP) and cerebral perfusion pressure (CPP)
  • Unconsciousness – Glasgow Coma Scale, differential diagnosis
  • Intracranial hypertension – therapy, neuroprotective regimen
  • Initial management of emergencies in neurology
    • Stroke, indications for thrombolytic therapy
    • Subarachnoid haemorrhage
    • Subdural and epidural haemorrhage
    • Purulent meningitis
    • Convulsive states, status epilepticus
    • Management of blood pressure in neurological emergencies
    • Traumatic brain injury

METABOLIC DISORDERS

  • Acid-base balance
    • Anion gap – calculation, normal values, importance in the interpretation of arterial blood gas
    • Buffer mechanisms, Henderson-Hasselbach equation for the bicarbonate buffer system
    • Potassium and ABG
    • Interpretation of ABG *
    • Metabolic acidosis – types, causes, indications for administration of bicarbonate
    • Metabolic alkalosis
    • Acid-base balance in respiratory disorders
  • Regulation of osmolarity and extracellular volume – ADH, RAAS, natriuretic peptides
  • Hyperkalemia and hypokalemia - therapy
  • Emergencies in diabetes – diabetic ketoacidosis, hypoglycaemia, hyperosmolar hyperglycaemic state
  • Lactate and lactic acidosis – causes, types of lactic acidosis, its role as a severity marker and goal values
  • Effect of infusion therapy on acid-base balance

ACUTE RENAL FAILURE

  • Renal perfusion, renal perfusion pressure, renal auto regulation
  • Acute renal failure - KDIGO classification, causes (prerenal, renal, postrenal), consequences (effect on extracellular volume, minerals, acid base balance)
  • Drug nephrotoxiciy – NSAID, ACEI, aminoglycosides, iodinated contrast, colloid fluids (mechanisms of nephrotoxicity, prevention)

LIVER FAILURE

  • Acute liver failure – causes, symptoms, laboratory findings
  • Portal hypertension and bleeding from oesophageal varices – stabilizing the patient, therapy

METABOLIC CHANGES AND NUTRITION OF CRITICALLY ILL

  • Physiology of simple starvation
  • Pathophysiology of stress starvation and the classic phases of critical illness – hypometabolic phase, hypermetabolic phase, prolonged phase
  • Enteral feeding – advantages compared to parenteral feeding, routes of administration
    • Nasogastric tube – insertion, contraindications, complications
    • PEG tube
    • Nasojejunal tube
  • Parenteral feeding – indications, routes of administration
  • Glycemic control in the critically ill
  • Intra-abdominal hypertension and abdominal compartment syndrome
  • ICU acquired weakness – risk factors, prevention

TRAUMATOLOGY

  • Approach to the polytrauma patient *
  • Consumption coagulopathy (vs. disseminated intravascular coagulopathy)

EXTERNAL FACTORS

  • Hypothermia – consequences, therapy
  • Burns – initial management
  • Intoxications: Benzodiazepines, opiates, tricyclic antidepressants, alcohol, sympathomimetics (amphetamines, cocaine), paracetamol  
  • Anaphylaxis and anaphylactic shock

OTHERS

  • Delirium – causes, risks, management on the standard ward and in the ICU
  • ECMO – principle, indications
  • Transport of the unstable patient

DYING IN THE ICU AND ORGAN DONATION

  • Brain death – diagnostics, caring for the deceased organ donor
  • Organ donation after brain death and after cardiac death (DCD)
  • Difference between withdrawal of treatment and euthanasia

 
Syllabus -
Last update: prof. MUDr. František Duška, Ph.D. (30.09.2021)

See Methods
 
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