Diagnostic and Therapeutic Techniques In Critical Care

Module details

Title

Diagnostic and Therapeutic Techniques In Critical Care

Type

Specialist

Module code

SPS125

Credits

5

Requirement

Compulsory

Aim of this module

This module provides trainees with the knowledge that underpins the third year specialist module in Critical Care Science and gives trainees the tools to undertake learning in the workplace. This module will introduce the trainee to a range of diagnostic and therapeutic techniques used in the care of critically ill patients, including electrocardiography, chest X-ray, emergency cardiac pacing and extracorporeal therapies. Trainees will be expected to build and extend their professional practice.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1, 2, 3	Competency Perform all tasks in accordance with relevant procedures/protocols/legislation, including infection control, health and safety, and critical incident reporting, ensuring appropriate patient identity checks are performed and the patient is fully identified on each type of recording.	Action View
# 2	Learning outcome 1, 2, 3	Competency Respect the dignity, rights, privacy and confidentiality of patients at all times, taking appropriate action to respond to the specific needs of the patients.	Action View
# 3	Learning outcome 1, 2, 3	Competency Explain the procedure to the patient, if they are fully cognitive, or the relative if present, address any procedure-related questions and gain appropriate consent.	Action View
# 4	Learning outcome 1	Competency Perform electrocardiogram (ECG) recording in a range of patients, ensuring that an accurate, artefact-free tracing is obtained, modifying the procedure (in accordance with national guidance) if a suitable recording cannot be made. Re-record if necessary.	Action View
# 5	Learning outcome 1	Competency Identify life-threatening and common ECG abnormalities.	Action View
# 6	Learning outcome 2	Competency Describe the application of temporary/permanent cardiac pacing.	Action View
# 7	Learning outcome 2	Competency Assist in performing emergency external cardiac pacing in the critical care environment.	Action View
# 8	Learning outcome 3	Competency Set up extracorporeal therapies related to mechanical ventilation (CO2 removal).	Action View
# 9	Learning outcome 3	Competency Manage extracorporeal therapies related to mechanical ventilation (CO2 removal).	Action View
# 10	Learning outcome 4	Competency Use a systematic approach to identify the features of a normal chest X-ray and identify some common abnormalities seen in critically ill patients.	Action View

Assessments

You must complete:

• 1 case-based discussion(s)
• 1 of the following DOPS/ OCEs:

Set up and program a haemofilter in order to treat a patient.	DOPS
Set the mode and settings on an external cardiac pacemaker.	DOPS
Assist the clinician in setting up for Extra corporeal CO2 removal.	OCE
Perform a 12 Lead ECG and interpret the trace.	OCE
Participate in a medical round and discuss radiological findings.	OCE
Participate in a discussion with nurses medical staff relating to the programming of a haemofilter therapy for a specific patient.	OCE

Learning outcomes

1. Perform electrocardiography in a range of patients and interpret the results.
2. Assist in performing emergency external cardiac pacing in the critical care environment.
3. Set up and manage extracorporeal therapies related to mechanical ventilation (CO2 removal).
4. Identify the normal features of a chest X-ray and some common abnormalities seen in critically ill patients.

Learning outcomes

1. Justify the indications and contraindications that influence the selection of suitable methods of investigation, including the sensitivity and specificity of the investigation as related to a range of diseases commonly leading to admission to critical care.
2. Explain the basis of effective clinical decision making, including history taking and clinical examination, accurate differential diagnosis supported by critical thinking and reflection.
3. Discuss and justify the indications, limitations and basic interpretation of laboratory investigations of blood and other body fluids.
4. Describe the principles of blood and blood component therapy.
5. Discuss the management of severe acute haemorrhage and blood transfusion, measurement of clotting times and factors and correction of coagulation disorders.
6. Describe the physical principles of medical ultrasound, the indications, limitations and basic interpretation of cardiac ultrasound and wider use of ultrasound in critical care, including ultrasound techniques for vascular localisation.
7. Explain the principles and application of electroencephalogram (EEG) recordings, including the origin of the electroencephalogram related to brain structure and functions.
8. Recognise the characteristics of the normal waveforms, phenomena and normal variants in the awake and sleep EEG.
9. Describe the principles, indications, contraindications and limitations of basic radiological methods, angiography, CT and MRI scanning, cardiac nuclide imaging.
10. Explain how emergency external cardiac pacing is used in the critical care environment.
11. Explain the principles and the application of extracorporeal therapies related to mechanical ventilation (ECMO, CO2 removal), recognising the risks associated with anticoagulation used with extracorporeal therapies.
12. Describe the principles and application of renal replacement therapy and the underpinning evidence base.
13. Explain fluid balance and treatment prescription in relation to the clinical condition of the patient.
14. Explain the principles of pharmacology, pharmacokinetics and therapeutics, and describe the mode of action of a range of drugs used in the critical care setting.
15. Critically analyse and validate all these critical care technologies, their interaction and effects on each other and the physiology and clinical condition of the patient.

Indicative content

Indications and diagnostic investigation selection

• Accuracy
• Convenience
• Reliability
• Safety
• Cost
• Relevance to the patient's condition

Laboratory investigations of blood and other body fluids

• Urine, cerebrospinal fluid, pleural and ascitic fluids
  • Haematology
  • Immunology
  • Cytology
  • Blood grouping and cross-matching
  • Urea, creatinine, glucose, electrolytes and lactate
  • Liver function tests
  • Drug levels in blood or plasma
  • Tests of endocrine function (diabetes, thyroid disorders, adrenal failure)
  • Microbiological surveillance and clinical sampling

Ultrasound physics

• Basic principles and physics of ultrasound, spectral Doppler and colour flow Doppler
• Instrumentation associated with 2D, 3D, spectral Doppler, colour flow Doppler
• Near and far fields; amplitude, intensity; power and
• Velocity, elasticity and density; acoustic
• Attenuation in tissue with reference to reflection, refraction, scattering and absorption.
• Dynamic range concept
• Specular reflection, curved and irregular surfaces
• Focusing using lenses
• Speed of sound in soft tissue; 1540 ms^^-1  and its significance
• Range determination
• Recording methods: choices, advantages and disadvantages

Storage and display of images

• Basic concept of digital acquisition and system systems
• Scan converters and digital memories
• Display devices and controls and recording techniques 

Transducers

• Piezo-electric effect
• Concepts of 2D and 3D transducer construction
• Characteristics of the ultrasound beam
• Beam steering methods
• Focusing methods and the use of dual focus
• The role of intracardiac echocardiography 

Image optimisation

• Use of gel to include infection risk from transducer and operator
• Positioning of the patient
• Standard views
• Use of non-standard views
• Adapting procedure where necessary

Use of ultrasound in critical care

• Ultrasound techniques for vascular localisation, including the underlying anatomy
• Principles, routes and techniques of peripheral and central venous cannulation
• At-risk patient groups potentially needing chest drain placement under ultrasound or CT guidance
• Cardiac ultrasound
• Ventricular function
• Filling status
• Valve abnormalities
• Heart size
• Pericardial effusion with or without evidence of tamponade 

Therapeutics

• Clinical conditions and ECG indicators where temporary and permanent pacing may be indicated

Pharmacology and prescribing

• Basic principles of pharmacology, pharmacokinetics and therapeutics
• Major classes of cardiac drugs, mechanisms of action, uses and significant side effects in critically ill patients
  • Anti-arrhythmic
    • Class I – sodium channel blockers (a, b, c)
    • Class II – beta blockers
    • Class III – potassium channel blockers
    • Class IV – calcium channel blockers
  • Cardio-inhibitory
  • Cardiostimulatory
  • Diuretics
  • Use and function of:
    • Thrombolytics
    • Vasodilators
    • Vasoconstrictors
• Drugs used to manage hypertension and hypotension
• The clotting cascade
• Coagulopathies
  • Measuring clotting times/factors
  • Prothrombin time (PT)
  • Activated partial thromboplastin time (APTT)
  • Fibrinogen (FIB)
  • Activated clotting time (ACT)
• Thromboelastogram

Principles and application of renal replacement therapy

• Renal pathology, pathophysiology
• Continuous veno-venous haemofiltration (CVVH)
• Continuous arteriovenous haemofiltration (CAVH)
• Continuous veno-venous haemodialysis (CVVHD)
• Continuous veno-venous haemodiafiltration (CVVHDF)
• Intermittent peritoneal dialysis (IPD)
• Fluid balance and treatment prescription in relation to the clinical condition of the patient
• Fluid and electrolyte management

 

Activities

• Observe cardiac ultrasound and Doppler scanning and describe the features of a normal cardiac ultrasound scan, relating these to the normal anatomy of the heart and vascular system.
• Shadow a pharmacist working in the critical care environment and discuss the mode of action, indications and contraindications for the treatment regimens in a range of patients.
• Observe the management of severe acute haemorrhage and blood transfusion, the measurement of clotting times and factors and discuss how acute haemorrhage and coagulation disorders are managed in a critical care environment.
• Observe and assist healthcare scientists recording electroencephalograms (EEGs), recognise the characteristics of the normal waveforms, phenomena and normal variants in the awake and sleep EEG, and discuss common abnormalities of patients requiring critical care with the neurophysiology healthcare scientist.
• Observe a series of ultrasounds of the abdomen (liver, spleen, large abdominal vessels, kidney, urinary bladder) and explain the role of abdominal ultrasound in the care of critically ill patients.
• Observe a series of computerised tomography (CT) or magnetic resonance imaging (MRI) scans of the head demonstrating fractures and/or haemorrhage and explain the role of CT and MRI in the care of critically ill patients.
• Observe the use of renal replacement therapy in critical care and in a renal dialysis unit, and describe the principles and application of renal replacement therapy in critically ill patients and those requiring chronic therapy and the impact of renal dialysis on quality of life of patients with chronic renal disease.
• Contribute to a meeting at which the outcome of a clinical audit, research, innovation, or service development is presented and discuss with your training supervisor how evidence-based practice is implemented with respect to critical care.