Critical Care

PLABABLE
CRITICAL CARE
Tricyclic Antidepressant
Overdose
Presentation
● Dilated pupils
● Dry mouth and skin
● Hypotension
● Urinary retention
● Tachycardia
Investigation
● ECG: Widened QRS and broad complex
tachycardia
● ABG: Metabolic acidosis
Management
● IV Sodium bicarbonate (50 ml of 8.4%)
● IV fluids (NS)
● ECG monitoring
Paracetamol Overdose
Presentation
● Right upper quadrant pain
● Nausea and vomiting
● Liver failure (NAPQI toxicity)
○ Jaundice
○ Encephalopathy
○ Lactic acidosis
Investigation
● Paracetamol (4 hrs post intake)
● ↑ ALT
● ↑ PT/INR
● Hypoglycemia
Management
● Activated charcoal if presented <1 hr after
intake
● IV N-acetylcysteine if at 4th hr after intake,
paracetamol value is above the treatment line
● IV N-acetylcysteine if staggered dosing or
ingestion of unknown amount irrespective of
paracetamol value
● Liver transplantation in case of liver failure
Refeeding Syndrome
Metabolic disturbances occurring after reinstitution of

carbohydrate to starved patients
Presentation
● Hypophosphatemia
● Hypomagnesaemia
● Hypocalcaemia
Management
● Correction of electrolyte imbalance
● IV fluids
● Prevention: Feeds should be given slowly with
electrolyte supplementation
Refeeding Syndrome
Brain trainer:
A 21 year old woman with a BMI of 12 was

admitted to the medical ward for feeding
through a nasogastric tube. What is electrolyte
abnormality should be expected?
➔ Hypophosphataemia
Subarachnoid Haemorrhage
MC cause: Bleeding from a berry aneurysm
Presentation
● Sudden and severe headache (worst headache
of life or thunderclap headache)
● Neck stiffness or pain
Risk factors
● Hypertension
● Smoking
● Polycystic kidney disease (↑ Berry aneurysm)
Investigation
● CT head (first line) - hyperdense appearance of
blood in the basal cisterns
● Cerebral angiography (gold standard)
● If CT is normal but there is still a clinical
suspicion: lumbar puncture after 12 hrs -
xanthochromia
Treatment
● Nimodipine to prevent cerebral vasospasm
● Platinum coiling to stop bleeding
Brain trainer:
A 35 year old man attends the ED with a severe

headache and vomiting for a day. He has neck
stiffness and photophobia. Head CT is shown
below.
What is the most appropriate management?
➔ Nimodipine
Brain trainer:
A 32 year old man presents with “the worst

headache of his life”. He has photophobia, neck
stiffness and has vomited multiple times. CT scan
shows no evidence of an intracranial bleed.
What is the most appropriate next step?
➔ Lumbar puncture
Extradural (Epidural) Haematoma
Collection of blood between the dura and the skull

Presentation
● Skull fracture → Middle meningeal artery
rupture
● Loss of consciousness immediately → Lucid
interval → Deterioration of condition
● Blown pupil or pupillary asymmetry due to ↑ ICP
Investigation
● CT head: Bi-convex or lentiform shaped
haematoma
Management
● Craniotomy or burr hole (big haematoma)
● Conservative (small haematoma)
Subdural Haematoma
Collection of blood between dura and arachnoid mater

Presentation
● Associated with blunt head injury
● Chronic SDH is seen in elderly
○ Gradually evolving focal neurological deficits
○ Speech difficulties and
○ Drowsiness
○ H/O Anticoagulation
● ↑ ICP
Investigation
● CT head: crescent-shaped haematoma
Management
● Craniotomy or burr hole (big haematoma)
● Conservative (small haematoma)
Acute Chest Syndrome
Vaso-occlusive crisis due to sickle-cell disease

Presentation
● Chest pain
● Shortness of breath
● Cough
● Triggered by infection (Pneumonia)
● H/o sickle-cell disease
Investigation
● Chest X-ray
● Monitoring oxygen saturation
Management
● Oxygen supplementation
● Analgesia
● IV fluids
● Antibiotics to treat pneumonia
Massive Pulmonary Embolism
Presentation
● Breathlessness
● Haemodynamic instability
● Leg swelling (DVT)
Investigation
● CT pulmonary angiography (CTPA)
Management
● Thrombolysis
● Surgical embolectomy
Blunt Abdominal Trauma
Diaphragm rupture
● RTA
● Chest and abdominal pain
● Diminished breath sounds on the affected side
● X-ray: Gas bubbles in the pleural cavity
Splenic rupture
● RTA
● Abdominal pain
● Tenderness in the epigastrium and left flank
● Hypotension
● FAST scan abdomen
● Splenectomy (severe injury)
Diaphragm Rupture
Brain trainer:
What is the most accurate method for checking

the correct placement of a nasogastric tube?
➔ Chest X-ray
Splenic Rupture
Brain trainer:
What is the most commonly injured organ ?
➔ The spleen
Splenic Rupture
Brain trainer:
What is the imaging modality of choice with a

patient suspected of splenic rupture?
➔ FAST (sonography - when clinically

unstable)
➔ CT (when clinically stable)

Renal Trauma
Brain trainer:
A man falls from a ladder and receives a bump

on his flank. He has haematuria and is
hypotensive. What is the most appropriate
management?
1. IV. fluids until stable
2. Urgent CT abdomen
(FAST if CT not an option)
Status Asthmaticus
Presentation
● Acute breathlessness
● H/o asthma
● ↓ SpO2
● Poor respiratory effort
Management
Salbutamol nebulisation + oxygen
Ipratropium bromide nebulisation
Intravenous hydrocortisone
Intravenous salbutamol and

aminophylline
Intravenous magnesium sulphate
Intubation and ventilation

Status Asthmaticus
Brain trainer:
A 6 year old child with breathlessness for the

past 12 hours presents to the ED. He is drowsy
with poor respiratory effort and has a silent
chest. He is started on oxygen.
What is the most appropriate management?
➔ Intubation and ventilation

Image Attributions
https://commons.wikimedia.org/wiki/File:CT_of_subarachnoid_hemorrhage.png
Shazia Mirza and Sankalp Gokhale CC BY-SA 4.0
http://creativecommons.org/licenses/by-sa/3.0/)
https://commons.wikimedia.org/wiki/File:Subarachnoid_haemorrhage.jpg
Lipothymia CC BY-SA 3.0
https://en.wikipedia.org/wiki/File:EpiduralHematoma.jpg
James Heilman, MD CC BY-SA 4.0
https://commons.wikimedia.org/wiki/File:Ct-scan_of_the_brain_with_an_subdural_hemato
ma.jpg
Lucien Monfils CC BY-SA 3.0
https://commons.wikimedia.org/wiki/File:Sickle_Cell_Anemia.png
Bruce blaus CC BY-SA 4.0

Critical Care

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Critical Care

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PLABABLE

Metabolic disturbances occurring after reinstitution of

A 21 year old woman with a BMI of 12 was

MC cause: Bleeding from a berry aneurysm

A 35 year old man attends the ED with a severe

What is the most appropriate management?

A 32 year old man presents with “the worst

Collection of blood between the dura and the skull

Collection of blood between dura and arachnoid mater

Vaso-occlusive crisis due to sickle-cell disease

What is the most accurate method for checking

What is the most commonly injured organ ?

What is the imaging modality of choice with a

➔ FAST (sonography - when clinically

➔ CT (when clinically stable)

A man falls from a ladder and receives a bump

1. IV. fluids until stable

Ipratropium bromide nebulisation

Intravenous salbutamol and

Intravenous magnesium sulphate

Intubation and ventilation

A 6 year old child with breathlessness for the

➔ Intubation and ventilation

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