Summary FCCS

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Summary - FCCS

  • 1 Recognition and Assesment of the Seriously Ill Patient

  • How long does physiological deterioration preceed cardiopulmonary arrest?
    Several hours
  • What is the direct methodology?
    Detection, intervention, reassessment, effective communication and teamwork
  • 1.1 Recognizing the Patient at Risk

  • Immune compromised patients may not show a vigorous and obvious inflammatory response
  • 1.1.1 Assessing Severity

  • Acute illness typically causes predictable physiological changes, it is important to recognize these, initiate monitoring and take appropriate action.
  • Cognitive signs of deterioration
    Confusion, irritability, impaired consciousness or sense of impending doom.
  • Signs of deterioration during inspection (4)
    Shortness of breath
    Sympathetic response: pallor, sweating, cool extremities.
  • Six most relevant vital signs
    Pulse rate, blood pressure, respiratory rate, oxygenation, temperature and urine output
  • The main goal of the early stage of assessment (primary survey)
    1. Recognize existing problems
    2. Maintaining physiological stability
    3. Pursuing the cause
    4. Initiation treatment
  • Even normal vital signs may be early indicators of impending deterioration if they differ from prior measurements.
  • Tachycardia in response to physiological abnormalities (ie, fever, low CO) may be increased with pain and anxiety
    OR suppressed in patients who have conduction abnormalities or receiving B-blockade.
  • 1.1.2 Making a Diagnosis

  • Important question: "What physiological problem needs to be corrected NOW to prevent further deterioration of the patients conditions?"
    Life-threatening physiological abnormalities take priority over make an accurate diagnosis.
  • 1.2 Initial Assessment of the Critically Ill Patient

  • A primary and secondary survey approach is recommended in the assessment of a seriously ill patient.
  • What is the goal of the primary survey? (Initial Contact - First minutes)
    Finding the main physiological problem
  • What is the goal of the secondary survey?
    Finding the underlying problem
  • What do you need to know from the history in the primary survey?
    Main features of circumstances and environment
    • Witnesses, personnel, relatives
    • Main symptoms: pain, dyspnea, altered mental status, weakness
    • Trauma or no trauma
    • Operative or nonoperative
    • Medications and/or toxins
    • What treatment has been given so far?
    • Delay in treatment?
  • What do you need to know from the examination in the primary survey?
    Look, listen, feel -> ABCD (D: level of consciousness)
  • What do you need to know from monitoring in the primary survey?
    Essential physiology, vital signs
    • Heart rate, rhythm
    • Blood pressure
    • Respiratory rate and pulse oximetryLevel of consciousness
  • What do you need to know from the investigations in the primary survey?
    • ABG
    • Glucose
  • What are the first steps in treatment during the primary survey?
    • Adequate airway and oxygen
    • IV access (and fluids)
    • HELP
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Priorities in adrenal insufficiency (3)

- volume
- IV cortico
- vasoactive med if needed
Priorities in anaphylactic shock (2-3)

- volume
- subcutaneous epi

very low BP: IV epi
Priorities in septic shock (5-6)

- volume (sec. vasopressor (nor > epi)
- AB
- control infection (catheter removal, surgery, drainage etc)
- lactate
- cortico's (200 mg/24u)


in case of myocardial dysfunction: dobutamine
What is the effect of milrinone on HR & BP?

HR: +++
BP: +++ (beta 2) / beta2 = dilatation > don't kill hypovolemic patients

> CO > stroke volume
What is the effect of dobutamine on HR & BP?

HR: +++ / ++++++ (a.k.a. Tachycardia in hypovolemic)
BP: ++ (beta2) / --- in hypovolemic

Inotrope > increase CO/stroke volume
What is the effect of vasopressin on HR & BP?

HR: /
BP: potent (V1 receptor)

Indication: refractory hypotensive shock
What is the dose range and eenheid of fenylepifrine?
25-300 ug/min
What is the effect of fenylepifrine on HR & BP?

HR: /
BP +++ (alfa)


pure alfa > arterial dilation without cardiac depression > e.g. Neurogenic shock or hypotension by epidural anesthetic
Side effects of epi? (2)

Increase myocardial oxygen consumption
Aerobic lactate producation (instead of hypoperfusion-induced)
What is the effect of epi on HR & BP?

HR: ++++
BP: +++ (beta2) > vasoconstrictor at higher doses