Critical Care Curriculum

Critical Care Lecture Series Curriculum

Schedule

Monthly; 18 lecture series; curriculum course covers 1.5 academic years

Goal

to provide critical care topics with a focus on current literature, institutional protocols,
and intensive care unit best practices

Literature

Each topic the residents will be provided with two current review articles and a Shands Hospital protocol (if applicable). All of these will be located on the One Note system located on each computer under “critical care lecture series”

Each lecture will be given using the Critical Care Case Presentation PowerPoint format which consists of (total 45 minutes):

5 minutes: a short introduction on topic and learning objectives
20 minutes: case presentation with emphasis on learning objective critical thinking
5 minutes: summary discussion with presentation of Shands protocol if applicable
10 minutes: question/answer time from residents/faculty
5 minutes: CC-ED resident to present one interesting case they had during the month they want to share with group (no powerpoint component)

Topics

1. Hazards of Mechanical Ventilation: insight into ‘alarm’ management

‘Alarm’ management including high and low pressures, hypercarbia, and hypoxia management from
the ventilator standpoint; also best use practices (decreasing FiO2 earlier, types used in our
institution).

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Integrate a plan to analyze high pressure alarm on a mechanical ventilator
b. Integrate a plan to analyze low pressure alarm on a mechanical ventilator
c. Explain possible causes of hypoxia alarm on a mechanical ventilator

2. Emergent management steps in septic shock

Can discuss current sepsis protocol we have established in ED, indications for invasive monitoring (CVP, arterial line), and current strategies to improve hemodynamics in these patients.

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Define steps in early goal directed therapy in septic shock
b. Describe endpoints in resuscitation in septic shock
c. Demonstrate indications for use of steroid in septic shock

3. Hypertensive emergencies

In specific, CHF exacerbation, Stroke patients, and Aortic dissection; with focus on what medications to use in different processes and why they are preferred (calcium channel blockers for head bleeds, labetalol for aortic dissection, nitroglycerin for MI etc…)

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Differentiate hypertensive emergency from hypertensive urgency
b. Distinguish between causes of hypertensive emergencies and preferred blood pressure reducing medications
c. Specify a plan for hypertensive emergency in aortic dissection

4. Massive GI bleed

Upper and lower GI basics, airway concerns, resuscitations methods, access issues

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Define massive gastrointestinal bleeding
b. Construct a plan for management of airway protection in massive gastrointestinal bleeding
c. Describe use of adjunctive devices and medications to decrease gastrointestinal bleeding

5. Current therapies to reduce Increased Intracranial Pressure

ICP guidelines for traumatic brain injury have been implemented in surgical and neurosurgical ICU’s and these will be reviewed (also includes ICP increase in stroke and other encephalopathies). Recent literature on ways to decrease ICP, including how to use mechanical ventilation, temperature control, medications, decompressive craniectomy.

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Identify etiologies of increased intracranial pressure
b. Create a plan for airway protection (including medication use) in patients suspected of increased intracranial pressure
c. Name five methods to decrease intracranial pressure

6. The crashing pulmonary embolism patient: Massive pulmonary embolism

Massive PE protocol will be reviewed as well as important findings to consider in massive PE patients including but not limited to hemodynamic fragility with positive pressure ventilation, thrombolytic administration guidelines, and hypoxemia correction strategies

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Classify patients who have submassive or massive pulmonary embolism
b. Construct a management plan for a patient with submassive/massive pulmonary embolism
c. Determine indications for using thrombolytic therapy in submassive/massive pulmonary embolism

7. Life-Threatening Bleeding

Anticoagulant reversal, TEG use, how to use Level 1, Massive Transfusion Protocol – Discuss the current protocols that we have established already in the SICU, which includes TEG directed as well as factor replacement options, and Tranexamic Acid. Anticoagulant Reversal – specifically on life threatening bleeding with focus on current hospital recommendations of specific drugs (warfarin, pradaxa, heparin, etc)

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Categorize methods of anticoagulant reversal using guidelines developed at Shands
b. Demonstrate when and how to initiate massive transfusion protocol
c. Operate the Level 1 transfusion equipment in trauma bay

8. Non-invasive ventilation strategies

Status asthmaticus, COPD, and CHF: separate from mechanical ventilation emergencies, this focus is on use in specific situations, CHF, COPD, Asthma, Pneumonia and consideration of weaning process in ED, weaning protocol set up by Elie, and general information on use.

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Distinguish between continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP)
b. Recognize various clinical conditions that non-invasive ventilation can be used
c. Summarize weaning strategies in patients improving on positive pressure ventilation

9. Beyond ACLS: Critical thinking in the cardiac rhythm and conduction disturbance emergencies

Acute arrythmias, bradycardia requiring pacemaker, tachycardias requiring cardioversion (how to set up devices), STEMI – specifically discuss our STEMI alert system, what our role is, and discuss management strategies for STEMI including thrombolytic therapy for areas where we do not have cath labs

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Demonstrate procedure of placing a transvenous pacemaker
b. Specify a decision plan to evaluate causes of pulseless electrical activity
c. Determine toxicologic causes of cardiac arrest and treatment plans

10. Hypothermia post ROSC protocol

Discussion focused on initiation of hypothermia protocol in the ED. We have agreed to Arctic sun in the MICU and can discuss what factors
include and exclude patients from Hypothermia protocol, and what our role is in establishing central access, immediate cooling, start of Arctic Sun, seizure and shivering management

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Identify appropriate candidates for hypothermia protocol post return of spontaneous circulation
b. Initiate treatment plan to cool patient determined to be appropriate for hypothermia protocol
c. Review and prevent complications that can occur during the cooling process

11. Emergencies at End of life: Palliative care in ED and Ethics

Treat process as a procedure with review of terminology used, what is required at Shands to make patients DNR, withdrawal of care (comfort care), and what to do with medications, extubation, etc. Again Shands specific guidelines should be presented, End of life decision making and care

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Explain to family members end of life decision making options
b. Describe steps to initiate DNR and Withdrawal of Care (Comfort Care) on a patient
c. Indicate why and when to initiate palliative care consult

12. Respiratory Distress in the Pregnant patient

Specific causes to discuss are: Mag toxicity, CHF, aspiration, amniotic fluid embolism, and the difficulty of obtain airway due to edema, placement in left lateral decubitus.

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Name causes of respiratory distress in the pregnant patient
b. Explain why pregnancy causes difficulty in obtaining an airway
c. Discuss safe medications to use in the critically ill pregnant patient

13. Ultrasound use in the Hypotensive or Hypoxic patient: Protocols

Specifically for hypotension the RUSH protocol, hypoxia the BLUE protocol, and algorithms for use in cardiac arrest. Other protocols exist and can be briefly discussed. Emphasis will be on why the algorithm approach can be useful and current evidence base/research on particular topics. Particular sonogram findings will only briefly be shown since other ultrasound lectures are available in the curriculum to focus on those.

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Integrate an algorithm for use of ultrasound in a shock patient
b. Integrate an algorithm for use of ultrasound in a respiratory failure patient
c. Integrate an algorithm for use of ultrasound in the cardiac arrest patient

14. Status Epilepticus: Brain Tissue Dying

Not the regular seizure patient, what meds preferred, what etiologies should be thought of, and Shand’s protocols

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Define status epilepticus
b. Construct a stepwise approach to the treatment plan for status epilepticus
c. List causes of treatable status epilepticus

15. Vasoactive and Inotropic therapy: Why we use what pressor and when

Use in settings of different types of shocks and specifically at Shands what we currently use in the ICU and rationales. Cardiogenic shock – causes, procedures we can do, preferred medications and workup

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Discuss anticipated side effects of common vasopressor and inotropic agents
b. Summarize preferred pressors used in different types of shock
c. Classify mechanism of action of common vasopressors and inotropes utilized

16. ABG interpretation Made Easy

Discussion of how to interpret the ABG in the Emergency room to make medical management changes; discussion of US method (Henderson-Hasselback) and Europe method (Stewart Approach). This should not be a complex mathematical lecture, instead simplified to be able to use to understand acid-base better to make management decisions.

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Use Stewart Approach to analyze acid base disorders
b. Compare Stewart approach to Henderson-Hasselbach approach
c. Demonstrate a method to interpret ABG’s at the bedside to aid in clinical management of acid base disorders

17. Smoke inhalation and Airway burn injuries

Crashing Burn Injury patient: focus on inhalation injury evaluation, airway stabilization, cyanide, fluids, shock resuscitation

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Describe importance of inhalation injury in prognosis of burn injury
b. Specify a plan for airway stabilization in the airway edema/burn patient (including endotracheal tube stabilization)
c. List causes of persistent shock states in severely burned patients

18. Severe Electrolyte disorders with focus on hyponatremia, hypernatremia and
hyperkalemia

3% use and when for hyponatremia and correction rate, Emergent hemodialysis requiring renal toxicity: focus on placement of dialysis catheters, location, type in our institution, what common pathologies may require this

Learning Objectives: At the conclusion of this activity, participants should be able to:
a. Formulate treatment plan for severe hyperkalemia with ECG changes
b. Explain sodium replacement strategies in the severe hyponatremic patient
c. Explain possible causes of severe hypernatremia and initial treatment plan