CCC Update 011

Updates to the LITFL Critical Care Compendium are coming thick and fast at the moment. Here’s a quick summary as these entries don’t appear in the LITFL blog feed

Here’s what is new in the CCC since CCC Update 010:

Cerebral venous thrombosis

This condition reared its head in the last round of FCICM exam vivas I believe — and it wouldn’t surprise me if it turned up in the written exam in the (very) near future. The presentation is variable (headache +/- anything else) and diagnosis can be tricky.  Diagnosing CVT requires a high index of suspicion — ensure your antennae are especially pricked up in those with risk factors (such as thrombophilia, oestrogen excess or local factors predisposing to thrombosis like head and neck infections). Remember that the presence of haemorrhages (which are common) are not a contra-indication to therapeutic anticoagulation.

Coroner’s clot
A CCC Update without a new airway entry just doesn’t cut the mustard, so here you go… The feared ‘coroner’s clot’ was the cause of one death in the famous NAP4 study: “In one case, an inhaled blood clot after tonsillectomy produced total tracheal obstruction which was initially attributed to asthma and led to fatal cardiac arrest.” Know about it then face your fears.

The Elderly and Critical Care
This page centers on defining the physiological and pathological changes seen in the elderly that are of relevance to the critical care physician. I expect it will continue to evolve as this is a really important topic IMO. The benefits and harms of ICU admission for the elderly is a complex topic, and an increasingly important one. I’ve taken frailty out and given it its own page.

Extremity injuries
Extremity injuries are sometimes under appreciated when faced with the maelstrom of the critically ill multi-trauma patient. However, there are a host of life and limb threats to be found when extremities are traumatised. This page gives you an approach and includes life-threatening haemorrhage, crush, compartment syndromes, neurological injuries, degloving and open fractures. Extremity arterial injury is dealt with in more detail on it’s own page.

Extremity arterial injury
Direct pressure goes along way, but there is more to it than that. An approach is provided covering the hard and soft signs of arterial injury, including the role of the arterial pressure index (API) and CT angiography. Management goes beyond direct pressure, and includes resuscitation, tourniquet use and both surgical and IR interventions.

Fluid balance
Having added a critical appraisal of fluid bolus therapy and exciting topic of de-resuscitation and positive fluid balance and last time round, it seemed necessary to have a page on the humble concept of fluid balance, with a focus on the pros and cons of the equally humble fluid balance chart. You can’t join the intensivist club unless you develop a nagging urge to eradicate positive fluid balances from your ICU… just remember that the fluid balance chart usually lies.

Frailty syndrome
“Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability that predisposes to the accumulation of deficits as well as adverse outcomes from acute stressors”. Assessment of frailty and poor physiological reserve is becoming increasingly important for intensivists because it portends poor outcomes despite the mobilsation of an armada of intensive care therapies, equipment and interventions — which come with a hefty price tag. Frailty accounts for much of the badness associated with the critical care of the elderly — yet though they are associated, not all elderly are frail, and not all frail are elderly.

ICU-acquired weakness
This is a potentially crippling sequela of critical illness / critical care that can really undo a lot of good critical care leave the patient with persistent disability. ICUAW is a common issue that probably doesn’t get the respect it deserves. Part of the answer to the problem may (or may not) be early mobilisation (see below).

Mobilisation in ICU
This page considers the physiological benefits of patient positioning and mobilisation in the ICU, as well as the pros and cons of mobilisation and the barriers to performing it. Early mobilisation in particular is a hot topic, with the results of the TEAM study pilot trial hopefully being released soon…. Early mobilisation may help attenuate the impact of ICU acquired weakness on the longterm outcomes of critically ill patients. The evidence to date is reviewed, but the story is far from over.

Multi-Organ Dysfunction Syndrome (MODS)
We all know it when we see it, as it is the sine qua non of full-blooded critical illness. Yet, it remains unclear what triggers MODS, or why it only seems to occur in certain patients or whether it could even be an adaptive process.


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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