ICU Decoded › Library › ICU Decoded chapters › Shock & ResuscitationShock & Resuscitation
Six critical-care chapters, free in full — recognition and first moves, then each shock state in turn. Every chapter is cited to a current guideline.
Shock: Recognition & First Moves Shock means the circulation fails to deliver enough oxygen; sort it at the bedside into cold & wet (cardiogenic), cold & dry (hypovolemic), warm &… Bleeding & Volume Loss: Hypovolemic Shock With hemorrhage, controlled or uncontrolled, stop the bleeding FIRST (pressure, tourniquet, surgery, IR); fluids only buy time. Septic Shock: Source, Cultures, Pressors Sepsis-3 pairs infection with SOFA ≥2; septic shock adds vasopressor need for MAP ≥65 plus lactate >2 despite fluids. When the Pump Fails: Cardiogenic Shock Defined by SBP <90 for ≥30 min with low cardiac output, elevated filling pressures, and hypoperfused organs (cool, mottled, oliguric). Anaphylaxis in the ICU Give adrenaline 0.5 mg IM into the anterolateral thigh IMMEDIATELY and repeat q5 min; true anaphylaxis has no contraindication. Obstructive Shock: Tamponade, Tension PTX, Massive PE Obstructive shock arises from tamponade (pericardiocentesis), tension pneumothorax (needle/finger decompression), massive PE (thrombolysis), or… Respiratory Failure: First Assessment Type I (hypoxemic): weigh V/Q mismatch against shunt, hypoventilation, and diffusion; check the A-a gradient. Setting Up the Ventilator Start with A/C volume control, VT 6–8 mL/kg PBW, RR 12–16, PEEP 5, FiO₂ 100%, then wean to SpO₂ 92–96%. Blocked Airway: Upper Obstruction Assume stridor means partial obstruction until proven otherwise; look for angioedema, foreign body, infection (epiglottitis, Ludwig… ARDS: Lung-Protective Strategy Berlin definition: non-cardiogenic bilateral infiltrates appearing ≤1 wk after the insult, with PaO₂/FiO₂ ≤300 while on PEEP ≥5 — mild 200–300… Crash Asthma in the ICU Run back-to-back salbutamol nebs with ipratropium and give systemic steroids early; onset takes hours, so give NOW. COPD Flare on the Vent Reach for NIV first when pH <7.35 with hypercapnia; it cuts intubation and mortality. Recheck the ABG at 1 h. Sleep Apnea & the ICU Patient Fragmented ICU sleep worsens delirium and slows weaning; OSA patients desaturate post-op and with opioids. Effusion, Pneumothorax & Pleural Disease Light's criteria distinguish exudate from transudate; a parapneumonic effusion with pH <7.2 → drain it. Liberating from the Ventilator Pair daily SAT + SBT once FiO₂ ≤40%, PEEP ≤8, minimal sedation, pressors low or off. NIV: BiPAP, CPAP & HFNO Best indications: acute cardiogenic pulmonary edema, COPD exacerbation with acidosis, plus post-extubation support in high-risk patients. STEMI & NSTEMI in the ICU STEMI: reperfuse without delay — PCI <90 min; lytics when PCI is >120 min away; give DAPT (aspirin + ticagrelor) + anticoagulation. Arrhythmias & Conduction Blocks Any unstable tachyarrhythmia needs synchronized cardioversion immediately (sedate when time allows). Aortic Dissection: Impulse Control Tearing pain with a pulse deficit or wide mediastinum → CTA; FIRST β-block (esmolol/labetalol, HR <60) and only then vasodilate to SBP 100–120. Acute Heart Failure & Pulmonary Edema Wet & cold (congestion + hypoperfusion) → inotrope ± pressor — ICU; wet & warm (congested, perfused) → IV furosemide ± vasodilators. Hypertensive Crisis Organ damage (encephalopathy, APE, ACS, AKI, retinopathy) = emergency; no damage = "severe hypertension" (formerly urgency) → oral agents; no… RV Failure & Pulmonary Hypertension A decompensated RV produces jugular distention, edema, and hypotension with clear lungs; echo reveals a dilated hypokinetic RV with septal flattening. The Comatose Patient Document GCS, pupils, brainstem reflexes, and motor pattern before any sedative; check glucose NOW. Status Epilepticus: Stop the Seizure Seizing for 5 min = status: give lorazepam 0.1 mg/kg (max 4 mg ×2) or midazolam 10 mg IM; move to second-line at 20 min. Ischemic Stroke: Reperfusion Window For disabling deficits (not NIHSS alone) give alteplase 0.9 mg/kg or tenecteplase 0.25 mg/kg (max 25 mg, co-equal Class 1, AHA/ASA 2026) within 4.5… Subarachnoid Hemorrhage Thunderclap headache: non-contrast CT (97% sensitive <6 h), LP if negative; CTA/DSA finds the aneurysm. Intracerebral Hemorrhage Immediately reverse anticoagulation: PCC + vitamin K for warfarin, idarucizumab for dabigatran, andexanet or PCC for Xa inhibitors. TBI & ICP Management Treat ICP above 22 mm Hg; escalate care stepwise: head-up 30° and normocapnia (35–38) plus sedation → hypertonic saline/mannitol → EVD → paralysis →… Cord Compression & Cauda Equina Weakness with a sensory level and sphincter loss means cord compression: get an emergent MRI, give dexamethasone 16 mg only for neurological symptoms… Weakness in the ICU: GBS & MG Myasthenic crisis: intubate when FVC <15 mL/kg or NIF >−20; treat with IVIG or PLEX; on the ventilator hold pyridostigmine; steer clear of crisis… Sedation, Pain & Delirium Lead with analgesia (fentanyl), then target the lightest sedation (RASS 0 to −1); propofol or dexmedetomidine beat benzodiazepines. Neuro Complications of CNS Infection Fever + headache + altered mental status: only focal signs, seizures, immunocompromise, or papilledema require CT before LP. Meningitis & Encephalitis When meningitis is suspected → blood cultures + ceftriaxone 2 g q12h + vancomycin NOW; never let LP delay antibiotics. Brain Death Testing Prerequisites: known irreversible cause with confounders excluded (sedatives, hypothermia >36 °C, metabolic, paralytics). Severe Community Pneumonia Severe CAP means 1 major criterion (pressors/intubation) or ≥3 minor (CURB/SMART-COP): ICU admission plus β-lactam plus macrolide or respiratory… Hospital & Ventilator Pneumonia VAP prevention bundle: head-up 30–45°, daily SAT/SBT, subglottic secretion drainage (when available), oral care, DVT prophylaxis. Skin & Soft Tissue Sepsis Necrotizing fasciitis: pain out of proportion with bullae/crepitus/systemic toxicity means SURGERY NOW; antibiotics alone fail. Bacteremia & Line Infections CRBSI workup uses paired peripheral plus catheter cultures; pull the line for septic shock, S. aureus, Pseudomonas, fungi, or tunnel infection. Invasive Fungal Disease Candidemia: echinocandin first (caspofungin 70/50), remove lines, dilated ophthalmologic examination in symptomatic patients or when clinically… The Immunocompromised Host When ANC <0.5 and T ≥38.3 (or ≥38.0 ×1 h): cultures, then antipseudomonal β-lactam inside 1 h. Infection Prevention Bundles CLABSI prevention: hand hygiene, maximal barrier for line placement, chlorhexidine prep, subclavian preference, and daily line-necessity review. C. diff & ICU Diarrhea CDI is suspected after antibiotic exposure with ≥3/24 h liquid stools; only test unformed stool (NAAT ± toxin). Pulmonary Embolism: Risk-Stratify & Treat Risk tiers drive therapy: massive PE (shock/PEA) → thrombolyse; submassive (RV strain + troponin) → anticoagulate ± intervention; low-risk patients →… Low Platelets: HIT, TTP, DIC Think dilution, sepsis/DIC, drugs (HIT!), TTP/HUS, immune (ITP), marrow, and liver disease. Coagulopathy & the Bleeding Patient Coagulopathy patterns: low fibrinogen (early in DIC), low platelets (ooze), high aPTT (factor deficiency), high INR (liver/warfarin). Transfusion: When & How Much Stay restrictive: transfuse at Hb 70 g/L (80 cardiac/ACS); platelets <10 for prophylaxis, <50 when bleeding; plasma treats bleeding/procedures, never… The Clotting Patient Know the patterns: HIT, TTP, DIC, catastrophic APS, warfarin-induced skin necrosis, and heparin resistance. Rheumatologic Crises Lupus flare or sepsis? High CRP favors infection; low complement + high dsDNA favors flare; screen ferritin/HLH. The Transplant Patient Transplant sepsis follows a timeline: <1 mo nosocomial/donor, 1–6 mo opportunistic (CMV, PCP, fungi), >6 mo community. AKI: Workup & Management Stage with KDIGO (creatinine/urine output); causes split into pre-renal, post-renal (bladder scan + ultrasound), and intrinsic (ATN, AIN, GN… Dialysis & CRRT Choose continuous (CRRT) for hemodynamically unstable patients or cerebral edema, intermittent HD for stable patients, SLED as a hybrid. Sodium, Potassium, Calcium & Magnesium Hyponatremia: urgency is driven by symptoms; severe symptoms get 3% saline 100–150 mL boluses, and cap correction at 8–10 mmol/L/24 h. Metabolic Acidosis & Alkalosis The GOLD MARK mnemonic covers high anion gap acidosis: glycols, oxoproline, L/D-lactate, methanol, aspirin, renal failure, ketoacidosis. Respiratory Acid–Base Disorders With acute respiratory acidosis, pH falls 0.08 for every 10 mmHg rise in PaCO₂ (chronic: 0.03). Upper GI Bleed Resuscitate first: 2 large-bore IVs, type & cross; transfuse restrictively (Hb 70 g/L threshold). Lower GI Bleed Most are diverticular; 75% stop spontaneously; resuscitate + CT angiography if ongoing brisk bleed. Acute Pancreatitis Diagnose: 2 of 3 (pain, enzymes ≥3×, imaging); cause: gallstones, alcohol, TG, drugs, hyperCa. Acute Abdomen in the ICU ICU peritonitis is blunted; watch for fever, rising pressor needs, feeding intolerance, and lactate. Acute Liver Failure ALF = INR ≥1.5 plus encephalopathy in acute injury; give IV N-acetylcysteine for acetaminophen ALF and consider it in early non-acetaminophen ALF… Jaundice in the ICU Fractionate first: unconjugated (hemolysis, Gilbert, drugs) versus conjugated (sepsis-associated cholestasis, obstruction, TPN, hepatitis). Cirrhosis Complications Variceal bleed: octreotide + ceftriaxone + band ligation within 12 h; consider rescue/early TIPS for uncontrolled or recurrent bleeding. DKA & Hyperosmolar State DKA: start fluids (15–20 mL/kg/h), add insulin 0.1 U/kg/h once K⁺ ≥3.5, add dextrose when glucose hits 14 mmol/L, and treat until BOHB <0.6 with… Insulin & Glycemic Targets Target 140–180 mg/dL (7.8–10 mmol/L); tight control (80–110) increases hypoglycemia and mortality. Thyroid Storm & Myxedema Thyroid storm (Burch-Wartofsky) is treated with PTU 500–1000 mg load, then 200–250 mg q4h, iodine 1 h afterwards, propranolol, and hydrocortisone —… Adrenal Crisis in Critical Illness Adrenal crisis means immediate hydrocortisone: 100 mg IV bolus, then 200 mg/24 h in D5NS — never delay for a cosyntropin test. Cancer Emergencies: TLS, SVC, Hypercalcemia TLS: high-risk patients get fluids plus rasburicase (check G6PD!); manage hyperkalemia; refractory K⁺/PO₄/overload triggers dialysis. Too Cold, Too Hot: Temperature Emergencies Hypothermia: handle gently and rewarm passively plus actively; keep CPR going ('not dead until warm and dead'); withhold epi until >30 °C and double… Overdose & Poisoning Every poisoning gets ABCs + glucose + ECG (QRS/QT); call the poison center early. Trauma: Primary Survey (xABCDE) Run the primary survey xABDCE per ATLS 11th, controlling catastrophic bleeding first while resuscitating simultaneously; activate massive transfusion… The Pregnant ICU Patient Pregnancy physiology: ↓SVR so BP falls, ↑plasma volume causing dilutional anemia, compensated respiratory alkalosis, and aortocaval compression after… Preeclampsia & Eclampsia Load MgSO₄ 4–6 g then run 1–2 g/h for seizure prophylaxis and treatment; repeat a 2–4 g bolus for recurrent seizures. Organ Donor Management In the brain-dead donor, provide hormonal resuscitation (T3, methylpred, DDAVP/insulin per center) alongside hemodynamic targets. Arterial Line Placement For vasoactive infusions, ABG needs, tight BP control; radial is preferred (modified Allen test, ultrasound). Central Line Placement For pressors, TPN, caustic drugs, or access; subclavian has the lowest infection rate, IJ/femoral per context. Intubation: Preparation & Technique Prepare with SOAP-ME (suction, O₂, airway gear, pharm, monitoring equipment) and preoxygenate 3–5 min. Tracheostomy Timing is after day 7 when prolonged ventilation is expected; sooner for poor GCS or failed weans. Chest Drain Placement For pneumothorax (tension/large), hemothorax, empyema, or malignant effusion; stay in the triangle of safety. Paracentesis Tap ALL new ascites and any admitted ascites diagnostically, screening for SBP with PMN ≥250. Lumbar Puncture Weigh indication against contraindication, doing CT first with focal signs, seizures, papilledema, immunocompromise, or GCS drop. Thoracentesis Always ultrasound-guided; run Light's criteria on fluid: protein, LDH + pH, glucose, Gram/culture, cytology, ADA. Swan-Ganz Catheter Reserve the PA catheter for mixed shock, uncertain volume status, PH/RV failure, or high-risk surgery. Hemodynamic Monitors Compared Pulse-contour systems (PiCCO/Vigileo), echo, and bioreactance estimate CO and SVR from the arterial waveform. Fluid Responsiveness Testing The most reliable bedside test of fluid responsiveness is a passive leg raise with a cardiac output change ≥10%. Pericardiocentesis Diagnose tamponade clinically and on echo: RA/RV diastolic collapse, plethoric IVC, and pulsus paradoxus. ECMO & ECLS Refractory cardiogenic shock or arrest (E-CPR) with a reversible cause → VA-ECMO; severe ARDS failing conventional care → VV-ECMO. Point-of-Care Ultrasound The RUSH exam looks at pump (LV/RV/tamponade), tank (IVC, FAST), and pipes (DVT/aorta) to classify shock at the bedside. Feeding the ICU Patient When the gut works, start enteral feeding early (24–48 h): gastric route first, trophic 10–20 mL/h, then advance. Family Communication at End of Life Communicate prognosis early and honestly, holding family meetings within 72 h of ICU admission for the critically ill. ICU Equations Cheat Sheet Must-know calculations: A-a gradient, PaO₂/FiO₂ ratio, anion gap with delta ratio, osmolal gap, corrected calcium, MELD/MELD-Na. Key Drug Interactions Anchor on CYP450: rifampicin induces and kills warfarin, OCP, and DOAC efficacy, while azoles, macrolides, and amiodarone inhibit. ICU Drug Dosing Reference Sedatives: propofol risks PRIS/TG, dexmedetomidine bradycardia, midazolam tachyphylaxis; analgesia first.
All 91 chapters: ICU Decoded contents · open the interactive version .