in ICU, we have fewer cases to handle, but we offer maximal care that one could offer to those who are in need. still there are cases which we are not able to salvage, for example those who are in really bad with impending mortality, and those which curative management was not available at the time of diagnosis, due to whatever reason.
please never forget about the man who had anti-NMDA encephalitis, who presented with subacute onset of confusion, with florid frontal lobe symptoms, followed with increased in stupor, respiratory distress, and most importantly, excessive orofacial movement and dyskinetic movement of limbs – seizure mimics. the prognosis could be poor, as there is no specific therapy that could be directed to the condition. intravenous immunoglobulin may not be suitable in case of high fever. and even with plasmapheresis, many of them still remains in that poor condition. those who have an identified source of neoplasm/ malignancy might or might not be benefited from resection. young women with benign teratoma, classically.
never forget about the case with open pulmonary TB being undiagnosed for years, with poor respiratory reserve and emphysematous lungs. in case of respiratory distress, please actively look for any pneumothorax. also to have a look on the blood gas to seek out which type of respiratory failure it is. be it type I, or type II. if you miss a pneumothroax and connect the patient back to a ventilator, you are creating a positive pressure ventilation which definitely worsens the chest condition and leads to lethal tension pneumothorax. in case of hypotension and shock, always classify it into which type of shock it could be – cardiogenic, or non-cardiogenic (which can be distributive, hypovolaemic, or obstructive), pneumothorax and tamponade should be recognisable. always think about the 5Hs 5Ts which have been taught in ACLS.
ACLS is useful. follow the secondary survey, ABCDs.
drowning lady. only fifty odds. failure to achieve adequate oxygenation despite high PEEP and high FiO2. bronchoscopy might only be helpful in those with obstructive lesions, and had limited role in aspiration, but risking the patient to de-recruitment. check the airway with DL, or FOB.
ischemic bowel por-por. i felt really helpless to her condition, despite what i could offer, including inotropic support, fluid resuscitation, taking over her airway and breathing by IPPV. if the surgeon is not doing the things, what could i do? i mean, how should i have done to strongly influence and persuade the parent team?
last long night, in BPT. then, to koh tao!