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Intensive Care Guidelines

SCORE TEST RESPONSE


EYE
4 Spontaneous Open eyes without outside stimuli
3 To Speech Opens eyes on verbal stimuli
2 To Pain Opens eyes after painful stimuli
Glasgow 1 Nil Doesn't open eyes after any stimuli
VERBAL
Coma 5 Orientated Is orientated, aware in answering questions
Scale 4 Confused Appears confused but can produce meaningful
sentences
3 Inappropriate Answers with inappropriate words often obscenities
2 Incomprehens Groans, moans or mumblings, no intelligible words
ible
1 Nil No verbal responses to any stimuli
MOTORIK
6 Obeys Accurately responds to commands of physical actions
Commands
5 Localized Moves a hand or arm towards a painful stimuli to
Pain remove it
4 Withdraws Withdraws a body part from source of painful stimuli
from Pain
3 Decorticate Abnormal flexing of joints in response to painful
Reaction stimuli
2 Decerebrate Abnormal extension of joints in response to painful
Reaction stimuli
1 Nil No motor response to any stimuli
The Seven Components

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nalgesia

edation

hromboembolic
prevention

ead of the Bed elevated

lcer Stress Prophylaxis


lucose Control
Scoring of APACHE II

A. TOTAL ACUTE PHYSIOLOGY SCORE (Cum of 12 above points)


B. AGE POINTS : < 44 = 0; 45 to 54 = 2; 55 to 64 = 3; 65 to 74 = 5; . > = 6
C. CHRONIC HEALTH POINTS:
If the patient has a history of severe organ system insufficiency or
is immunocompromised, assign points as follows:
: for nonoperative or emergency postoperative patients
: for elective postoperative patients

TOTAL APACHE II SCORE


(Add Together the Points from A+B+C)

0 to 4 4 % death rate
5 to 9 8 % death rate
10 to 14 15 % death rate
15 to 19 25% death rate
20 to 24 40 % death rate
25 to 29 55 % death rate
30 to 34 75 % death rate
Over 34 85 % death rate
The HEART

The Pressure
and Oxygen
Saturation
measurements
In the various
chambers of
The Heart
Diagnostic Criteria for ALI and ARDS
1. Acute Onset
2. Presence of a predisposing condition.
3. Bilateral infiltrates on frontal chest x-ray,
consistent with pulmonary edema.
4. PaO2 / FiO2 < 200 mm Hg for ARDS,
PaO2 / FiO2 < 300 mm Hg for ALI,
regardless of the level of PEEP.
5. Pulmonary artery occlusion pressure =18 mm Hg or
no clinical evidence of left atrial hypertension.

Bernard GR, Artigas A, Brigham KL, The AmericanEuropean Consensus Conference on ARDS:
Definitions, Mechanisms, Relevant Outcomes, And Clinical Trial Coordination.
Am Rev Respir Crit Care Med 1994;149:818824.
Present Score
Lower limb trauma or surgery or immobilisation
+1
in a plaster cast
Bedridden for more than three days or surgery
+1
within the last four week
Tenderness along line of femoral or popliteal veins
+1
(NOT just calf tenderness)
Entire limb swollen +1
Calf more than 3cm bigger circumference,10cm
+1
below tibial tuberosity
Pitting oedema +1

Dilated collateral superficial veins (non-varicose) +1

Past Hx of confirmed DVT +1


Malignancy (including treatment up to six months
+1
previously)
Intravenous drug use +3
Alternative diagnosis as more likely than DVT -2
Pre-test Clinical probability of a DVT with score:
DVT "Likely" if Well's > 1
DVT "Unlikely" if Wells< 2
Severe Septic
Infection SIRS Sepsis
Sepsis Shock

Microorganism (Criteria: 2 meets SIRS with a Sepsis with organ Refractory


invading SIRS definition) : presumed failure/Dysfunction hypotension
sterile tissue Temp >38C or confirmed Hypotension (w/adequate fluid
infectious Hypoperfusion (Lactic resuscitation)
(100.4F) or < 36C MODS Criteria
process Acidosis, oligouria,)
(96.8F)? (Blood Evidence of 2
Heart Rate > 90? Vascular collapse
Culture or Organs Failing
Resp Rate > 20 or Procalcitonin
PaCO2 < 32 mm Hg proven)
WBC>12,000/mm3 Steroids
< 4,000/mm>3, or
> 10% bands? Drotrecogin Alpha
Early Goal Directed Therapy
Antibiotics and Source Control
Insulin and Tight Glucose Control
Sumber : Critical Care And Cardiac Medicine_Current Medical Strategies; Matthew Brenner, MD, p-67; 2006
SEPSIS GUIDELINES 2008

DVT Prophylaxis Antibiotics within 1 hr EGDT and Protocolized Antibiotics within 1


H2 Blocker PUD for Septic Shock Resuscitation hr in No septic
Prophylaxis Glycemic Control Fluid Challenge Shock Patients
No Routine Use of Crystalloid = Colloid BC prior to Abx 7-10 day Antibiotic
SGC Duration
PPI PUD Prophylaxis Source Control
No Renal Dose
Low VT for ALI Dopamine or Consider Limiting
Dopamine
HOB >45 Norepinephrine Support
No High Dose
Limited Transfusion Limit P plateau <30 cm
Steroids
H2O
No Antithrombin II
No Erythropoietin PEEP
De-escalation Antibiotic
Sedation
Weaning Protocol/SBT Conservative Fluid in
ALI with no Shock
Avoid NMB

APC in high risk and non- PRBCs or Dobutamine Wean Steroids


surgical
Low dose steroids for
Hemodialysis: CVVH septic shock
NIV for ALI/ARDS B/S < 150
hypoxemia
Prone Position in ARDS
PEEP 5 5 8 8 10 10
FiO2 0,3 0,4 0,4 0,5 0,5 0,6
PEEP 10 12 14 14 14 16
FiO2 0,7 0,7 0,7 0,8 0,9 0,9
Grade Tetanus Ringan : <9
Sedang : 9 16
Berat : > 16

MASA INKUBASI IMUNISASI

5 < 48 JAM 10 TIDAK ADA


4 2 5 HARI 8 MUNGKIN ADA / IBU MENDAPAT
3 6 10 HARI 4 > 10 TAHUN YANG LALU
2 11 14 HARI 2 < 10 TAHUN
1 > 14 HARI 0 PROTEKSI LENGKAP

LOKALISASI NYERI / FAKTOR YANG MEMBERATKAN


PORT DENTRI
10 PENYAKIT / TRAUMA YANG
5 INTERNAL / UMBILIKAL MEMBAHAYAKAN JIWA
4 LEHER, KEPALA, 8 KEADAAN YANG TIDAK LANGSUNG
DINDING TUBUH MEMBAHAYAKAN JIWA
3 EKSTREMITAS PROKSIMAL 4 KEADAAN YANG TIDAK
2 EKSTREMITAS DISTAL MEMBAHAYAKAN JIWA
1 TIDAK DIKETAHUI 2 TRAUMA / PENYAKIT RINGAN
1 DERAJAT STATUS FISIK/
ASA PENDERITA
CHAIN OF SURVIVAL (AHA GUIDELINE 2010)

TAHAPAN RJP SESUAI GUIDELINE 2010

ABC (AHA 2005) -> CAB (AHA 2010)


Highlight AHA 2010