Mohammed H. Eid - The Intensivist-Middle East & ElMarwa For Publishing & Distribution, GN (2019)

THE
INTENSIVIST
ICU BASIC PRACTICAL NOTES
MOHAMED H. EID
‫ﺇﺫﺍ ﺍﻧﺗﻔﻌﺕ ﺑﻬﺫﺍ ﺍﻟﻛﺗﺎﺏ ﻟﻁﻔﺎ ﺍﺩﻋﻡ ﺗﻁﻭﻳﺭﻩ ﺑﺷﺭﺍء ﻧﺳﺧﺗﻙ ﺍﻟﺧﺎﺻﺔ‬
The
INTENSIVIST
ICU Basic Practical Notes
Demonstrator
Mohamed Hesham Eid
Critical Care and Emergency Nursing Department
Faculty of Nursing - Mansoura University

The intensivist: h.iigil flj.till i~JiKg

MIDDLE EAST LIBRARIES
—in—
Elmflrujfl
ICU Basic Practical Notes
publishing and distribution
Tenth Edition
by
Mohammed H. Eid
Faculty of Nursing
Mansoura University
Egypt
Copyright © 2019 Middle East &El Marwa for Publishing &Distribution.

All rights reserved.
ISBN: 978-977- 6551- 46-6
7491/2019 :^VI £;
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materials mentioned in this book. This book does not indicate whether a particular
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Index
Chapter 1 : Parenteral Solutions
Introduction
Ringer's Solutions
Saline Solutions
Glucose Solutions
Voluven
Mannitol
PK merze
Kidmin
Aminoleban
Amiparen
Panamin G
Dipeptiven
Smoflipid
Fresubin
IV Administration Set
Peripheral Venous Cannula
Infusion / Syringe Pump
IV Fluid Flow Rate Calculation
Chapter 2 : ICU Drugs

• Refrigerator Drugs 36
• Antibiotics in ICU 53
1 Emergency Drugs 63
1 Narcotics 72
1 Drugs Preparation 73
1 Patient's 10 Rights 75
1 Routes of Drug Administration 76
1 Notes on Insulin Injection 87
1 Lidocaine in ICU 90
1 Mixing Drugs 92
• Drugs Abbreviations 94
Chapter 3 : ECG Interpretation
History of ECG
ECG Procedure
Conductive System of the Heart
Basic Principles of ECG Interpretation
Heart Rhythm
Heart Rate
Cardiac Voltage
Position of the Heart
Cardiac Axis
PWave
P-R Interval
QRS Complex
ST Segment
TWave
QT Interval
Professional Notes on ECG
Chapter 4 : Arterial Blood Gases

• ABG Procedure 139
• Basic Concepts of ABG 141
• Elements of ABG 145
• ABG Interpretation 146
1 Anion Gab 158
« GAB GAB 161

• Base Excess 162
• Delta Ratio 162
Chapter 5 : Mechanical Ventilation

• Mechanical Ventilator Basic Concepts 163
• Indications of Mechanical Ventilation 166
• Types of Mechanical Ventilation 167
• Humidification System 169
Modes of Mechanical Ventilations
Care of Ventilator Dependent Patient
Ventilator Alarms
Failure to Tolerate the Ventilator
Weaning of Mechanical Ventilation
Chapter 6 : Lab Investigations

CBC
Liver Function Test
Renal Function Test
Thyroid Function Test
Cardiac Enzymes
Lipid Profile
Coagulation Profile
Arterial Blood Gases
Common Tumor Markers
Electrolytes
Body Mass Index (BMI)
Miscellaneous
Test Precautions
Others
Sampling
Chapter 7 : ICU Procedures
• Oropharyngeal Airways 216

1 Nasopharyngeal Airways 219
1 Endotracheal Intubation 221
1 Tracheal Suctioning 225
1 Oxygen Therapy 230
1 Nebulization 233
• Incentive Spirometry 235
1 Arterial Puncture 238
• Arterial Catheter Insertion 241

CVP Measurement
Cardiac Monitor
Pulse Oximeter
Capnograph
Bispectral Index
Electrocardiogram
Cardiopulmonary Resuscitation
Pericardial Shock
Blood Transfusion
NGT Insertion
Enteral Feeding
TPN
Enema
Urinary Catheter Insertion

Hot and Cold Application
Chapter 8 : Miscellaneous
Glasgow Coma Scale 291
• Pain Scale 293
« Revised Trauma Scale 295
• Bundles 296
• Maximum Duration 297
« Crash Cart 298
• Bed Sores 300
• Patient's Position in the bed 306
• Chest Physiotherapy 311
• Diagnosis of Death 315
• Units and Conversions 316
• ICU Abbreviations 317

‫‪r— Chapter 1‬‬
‫‪Parenteral‬‬
‫‪Solutions‬‬
‫‪innc —I‬‬
‫‪Solutions‬‬
" In clinical matters, ignorance canbe dangerous
butignorance of ignorance can be fatal"
•P.L.M-
I Parenteral solutions
-L_L
Introduction
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intracellular l£UJt Jib £jyh ^j 6Lul'
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intravascular ( plasma ) (LjMJI ^) hy>A\ -L&jVl Jib
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( Permeability )ÛUI ,> ^> ,> ^Lu L^îiui âi JJi^Ji ^s ( Thomas graham ) (JUl
: O^jJ J! (intracellular) Lpiill J) (intravascular) ^j-jII ^jVl o'j^ J*^ t>
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UjjJas>ia U_pbll î i*iL (jju Crystalloid -II Jîj "^-Ulj jajjII ^jLpiill £jUJ.--.'*, _,i
W <u! ,>u ( Colloid ) l«-J Û^lill &Jill

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ICU -Si c^ îj^J j^> c^' J#î ÎjJl <_£ (> fJiiJA Ua.1 bChapter -JI ^
Page 1
1 Parenteral solutions 1
Ringer's solutions
ICU -SI ^ IfrWrnm ^l JJL^JI j&i (> Ringer -SI
(Sydney Ringer) ujh^\ J^] J\ V^ ^rV^ ^^! J* W

1885 ^-^Jû1*'
Ringer -H d*^ 6* £1*' 3Ujj& *ua
Ringer's Injection Ringer Lactate Ringer Acetate
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Page 2
Parenteral solutions
(1) Ringer's Injection
ciiLisI ij\ jj^j Ringer " plain " Jjl=^ ^ jjk-i'^11
(Na+ : 147.5 mEq/L) ?&y-° i> '°J^ 6j

( CI": 156 mEq/L ) x-jljjlS
( k+ : 4 mEq/L)
( Ca^ : 4.5 mEq/L )
jjaiu fiLa ^ v-lljj oJ iajlill J£j
312mOsm/LWÔsmolarity 4^jj
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. <fil jjsl Death !•£ -i«j j^j Coma v&j Shock t^ d*^ oô^'j Circulatory Collapse
Js. Jialaj (jUc Burn -IIj Sever Diarrhea -II ^Vla-j Sever Vomiting -Jl ^jVU ^ •u^vmi; -2
Uiii j^j^l Jll c5Ub/l i>j^j (.Jl ^ ljUjjVi jj£j2 j ûaJI ^ Electrolyte Balance -Jl
JULVI £li i_iliaJI JJU-o (_jj jjUui ^ (^jla-u <gV Dehydration -Jl CjVLs. ^ <usimii -3
Septic Arthritis -II ^VU ^J Arthroscopic Lavage jj.^1 £><^ -u-iiiui -4
For Laboratory Experiments f*?JI £j^ V^Vlj *L«acVl Jiia. ^ LaJ âu<^ -5
W^ Cephalosporin -Jl 4c_j-»->^ <jU±LuL Lj^c Antibiotics -Jl' '«j^*J ^ J*i*J l£« W-k -6
.J£llj <ljjll Jib s^jiu <uV Ceftriaxone -Jl <^Li.j
Ijjj^j lW c^ 'j^1^ ^ ,JJ Ringer -Jl £- Ceftriaxone tj=*i t3U Ui« £ji»*
Fatal »-ta ljjj o^1 U-jjS Crystals »j_y-a ^ i_iuijiu bj (CaCL) fjj-^l -^jj^
. New Born Infants -JJ <^L Lajjuaij
Page 3
1 Parenteral solutions
I
(2) Ringer Lactate (Hartmann's solution)
1
(Alexis Hartmann) ^ d* »j^» ^

(Na+: 130 mEq/L)
(CI": 108.7 mEq/L)
( k+ : 4 mEq/L ) ipUll ringer -Jl
( Ca++ : 2.7 mEq/L )
ljjj£V j.jjjj<-all Na Lactate -Jl ^.j-u" -ULal Cj^jj
>L *U ^ ljIJj »j ioJiJl JSj (28 mEq/L )
l,ia, sjJiHo AJiA« Acidosis -J' ^^ J .•vi^lj

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? Lactate 4^_><i?-« ^jUI j?jjU uiUal jA
Metabolism UJ"t>jj Liver -Jl J& £jjk »^ lsj cju£5UI
(Mild Acidosis ) <^=y^\ ^JUi JtiLj Bicarbonate J! Jj^j >^JJ
? ojjjS' JaUU <La tliJfrJa i_iui>U (jSJj
tj^jj* jl£ Ul JUJUj Bicarbonate -J 6j*zh ±£1\ ^jjl ?ji UljS U^j Lactate -Jl *cj*v»; Vji
, aj^j w. yi ^1jjjjj Metabolism ^>l ^'^jj lA* "^^ ^
ooiLu jl£Ul jluJI o<aj>« (jJIjJIjj (Hyperglycemia J**jj ) j^JI £*j£ Lactate -Jl jl <-«jj»-« : yj^
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cyJL-iLactate (^—J=»j ji«ii_u JL-ilUj Lactate—Jl ojLhj j-* ^—*J l$n ... <*_jajAa. îj
OJjji <UU]I JjJJ (JjW (jUc
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. Burn -11j Poly Trauma -Jl ^VUj Severe Diarrhea -Jl
Parkland ^^ Ringer Lactate -Jl J-»j->j JjJU^j Burn -II o^j* o^j*^ J
In first 24 hour : the total amount of fluid is
* 4 ml Ringer Lactate x wt in kg x percent of TBSA burned
• Half of the amount given in the first 8 hour and
• The remaining half given overthe next 16 hour
Inthe next 24hour 2 ml Ringer Lactate x wt in kg x percent of TBSA
Page 4
(3) Ringer Acetate
tP&VI c> Ringer -SI £ljji Jî j*

~j«i_ (Na+: 130.6 mEq/L)
CjUjlLo (jjiii (jA -UUjia
(CI": 109.3 mEq/L)
( k+ : 4 mEq/L) î*]! ringer -Jl
( Ca++ : 2.7 mEq/L)
LjUuai jijjjjiâli >ja+ Acetate -Jl **-y>** 4iUai cj*jj
~ K . APR. 22
jJak *U J Ui oJ JsylaJl Jaj ( 28 UlEq/L )
Jj=4»* Acetate -Jl ^=jj Lactate-Jl»j& u-^ i** ^j^

Acidosis -Jl ^JUiBicarbonate -1 ^ l ^
^jJ^w tj) J-P^ j1^ Liver -Jl ^ Metabolism U^j ?jj -ul Lactate -Jl *&*« ^-"^ lw
t^jlc ^ Acetate -Jl Ui] o.iiU <ji*iiw ^£11 u^jj^ JIjJWj
All tissue and organs has the enzyme that converts acetate to bicarbonate especially
liver, muscles, myocardiumand renal cortex.
Bicarbonate -J <!j=»ja JAI organ J\ jV aK£* J^L* ».iii ±£ o^j* jJ ^ J^j

. Acidosis -Jl ^JUj <-^j
£+Ji ^jJj t_^. <llaJl jjjjj uV cjjj£V Uja (_rl«j (jixiiw US ^Jll Lactic Acidosis -Jl ^V^
. (j^jjaJI >^>j U jjc (j«j Acidosis -Jl jJUiA -(-jajjj Acetate Uixi jSUJI ^
(Hyperglycemia J«#) jS-JI LSi1^ ^j^ ^} j^-Jl t-r"3^0 t* C-J^^J' V£Ju cAS.
. ^JS-U (jijiw fjA*. ooiU (jaA« Diabetic Patient -Jl J*» Jk&ij !•£ J***> uU Acetate -Jl H
4^ j* j*^ £>»i Bicarbonate -1 Acetate -Jl Jjj^ <A*c jl Ijjilj

jMLVl jjJc. jajjllÎjjl Jjaii Ringer Acetate -Jl J^ 'Jj Bicarbonate -J Lactate -Jl Ju=^
Bind to Calcium Ions fj^-MI ÛjjI î ii«jj -ul âj Acl„

ûtaJI (j* ^j;uJl£ll ^jji JSI jUcAcetate -Jl ?m*A j£^ IjSjj IjS Ja*jj jiu» Lactate -Jl u^ J^
. Reduction of Calcium Excretion
Page 5
Warning for all Ringer's Solutions
^jjii g-i. ' Ceftriaxone • '£> -1
CaCl 2 ?-»- Jl£,

jjjl£ jj £jj j ajjll u aJSj a.jxll ajj JIS11 x «J—tliliA A iV bj
. New Born Infants -JJ V*^ Ua>^j Fatal »jU ^jj jî LjjI Crystals »jj^> ^ v^Jyj
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Potassium (K+) Sparing Diuretics as ( Triamterene - Spironolactone - Amiloride )
»j_s& j»jj_u:U_jJI <u_uij »i_jj (j__a Uiji Renal Patient —Jl £—•«j-1—^ ^J«»'' »"' UjuL ^jV -4
. <"iil j^J Cardiac Arrest j Dysrhythmia ^1*4 j^> i^JJIj
sjja.jJI ( Citrate ) Jakjll <UjU1I sjUII jV Blood Transfusion -Jl <&& *tia <u£jj ^ji« -5
. Particles jj^j j?jjll ^ ij*.j*\\ Ca"1^ -Jl cy d^ c£" j*^1 o*£ c^
Page 6
1
Saline Solutions
ICU -Jl (^ (_W L/""1 ^y^ I"» >"•' (_<J <LuLLliUJ (jS-a-a Jj^-9 JJÎ J* ^tLali Jjla-a IxiL
^LJI JjJLxa (>fjjji 3 UJuC- Aj2
Hypotonic Saline Isotonic Saline Hypertonic Saline
... SOD1 M ( 111 OR ur 3%W/VSOI>UM(HL.tmil.r

nniuii bw t v n -«>•• n*. m u
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^ji-ajll Ttiall Jjla-a (î*Jl) yjujUl jUl Jjk- (tripple) J-^l jJ-ll Jj^
(0.45 %) (0.9%) (3%)
Page 7
i
(1) Isotonic Saline (Normal)
Nonnal Saline -Jl ji %0.9 ^ Jjl=- y> jJLill <uJ UJa
Paul Marino p^j <-SJ ^^1 ^ ^.jiw ji& jJj jl £*

JIS <Ub <u}& (^jsjjI -Ue jJSjj Ul
However, it is called Normal saline, This Solution is
NOT nonnal neither Chemically nor Physiologically.
:i
(Na+: 150 mEq/L) pij?- 9 ij'- Liyî JJJJI

(CI": 150 mEq/L)
?? a l*VI
Jai<jall (jistijj jUit Normal Saline -Jl â Ul LL <UU Jjl£ iai^l JajjA ljVU^ UiL -U.U Jji
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Electrolyte Disturbance - Sever Vomiting and Diarrhea
(jjjâJlj ^jjaJI 4jjJuixj (jSUo aioo JjU jA
130 -120 ^> <Jaj-y <jîj JJa (»jjj_Î csji" jJ Mild Hyponatremia -Jl ^>VU J jUS -da*!^
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-Lyi ?1ja UjSjuaj jjSjkJI £* Jjaai îl UjcU Stability -Jl
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Page 8
1
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Triple Saline -Jl jl J££& jJ-»Jl Jjla-« ja ^jLill -u^l UJa
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(CI": 513 mEq/L)
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. (j^j^Jl ^ u^j^l j^ ( Hypertonic Saline " Triple " ) -Jl
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. Brain Edema <&** : JjVl -U.U1I
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acU pjjj^lj Hyponatremia »^ u^j-, lilUS j ^ ^ ;U*nil jp. J££b\ ^Lll j- jjU _U
Ito. JaJj_& 4fitij JjxJl jj j- Lub ilL ^lliJ£&\ jUU <<JajxiA j 120 j- L$
Uit tliaj jlj SjJuia (^j <Ualill l_iu,bUj (CPM) -Jl ^J^- M1^ j1-^^^ / J- 30 C5^ ^
Aggressive Conection ofHyponatremia -Jl j* WjM jfrî j! i^^1*
More Scientific CPM Occur if Serum Sodium Increases more than 12 mEq over 24 hr.
Page 9
1 Parenteral solutions 1
(3) Hypotonic Saline (Half)
Half Saline -Jl jl u*""''^ fcUl Jjla-a ja ajUJI -Uuj) UiL
•
j<« Jal <US ajJjjjâll Ajjjij ?dU J_jU-a (j\ jA -Uj Jj).<-|ilfl'lj
WM^h -:--
^îW^^.
•"-"-
%0.45 >-iJI Ûl ja aJ gjisll ^\j 0.9 NaCl -Jl
tM,w«»*
gtfSL -ujU cjl jj£jj -U-a -us
issSsr: >^ î U^ jiUll ja %0.45 -Jl lw %0.2 j % 0.33 -Jl i*J

'"" 7L J 6 LA
^^•lM DEC-I7
-15"" NOV-2Z
"SB"'p,i7!
-
(Na+:75 mEq/L j»lj^4.5 Jc (^jiaJJ jjIII
(CI" :75 mEq/L; AjIjjIS. aJJ.i^J-0
?? ^1^1,71
îxill -Uuij jj jj U jjc. (j« (_jj -U-JI i_yajxAA -uV Half Saline -J' J •-°.'a i_w Nj* -^j ^^> '-^ l^j-0
Intracellular Dehydration f^l LiÛl Ljlia. um jaUa <u^j* <UU î

Hypernatremia - DKA - Hyperosmolar Hyperglycemic State -Jl <jj
JiLuu jSUo b jV LiverDisease- Burn -Jl ^VU â J^jLaUia dil (_>«j <u« tdlU jjJk
I-UcjVI Jib sjja.jxll <lJ1 JILa -uj ^gjxM Depletion ofIntravascular Fluid Volume
Ascites ji£i J -icUai IjLj l£UJI jjjlja. UjjJjj
fA-^jJ IV r*Ja*j (ji*iiu Jjp%0.2 or 0.33 j£j Hopotonic Saline â jJ

150 t>o <Jal Osmolarity J&u JÎxa uil Ua sjcUIIj
^ j jL j>u> ^ l^bJj ji« icu Community -* Ul h^L hjSi U& *ua

Amiodarone Nor adrenaline (levophed) Valium
Amphotericin B Oxaliplatin Sodium Nitroprusside
\+icth stability Jl ^3 J3S3K 3\ iSib & J3K0 ^ J^ Igokao <U9 is> ^1

%5 J3S3K Jc Jjlob LJajj |j£ 0Lc 3JJI (jo Jâji ^ jjSjWI go
Page 10
1
Warning for All Saline Solutions
Hyperchloremic Metabolic Acidosis -Jl ^VU J jAii jiaj UL*

(.j-j -UUJI jjjjj jjl^JI -ijjj* •*-< j? (^-iU Saline ts-J^J j*ij* (j-" JI^Wj jjJ^JI *jWj j* U-b-ia. i—u-j jV
1-Renal Diseases as (Renal Artery Stenosis - Nephrosclerosis).
2- Liver Disease (liver cirrhosis) "to avoid edema and ascites".
3- Cardiopulmonary Disease (Congestive Heart Failure - Pulmonary Edema).
4- Patient Receive Salt Retaining Steroids/Corticosteroids.
5- Hypernatremia, Cerebral Edema or Preeclampsia.
6- Primary- SecondaryHyperaldosteronism, Hypertension.
jV bj Saline J>* Glucose J& UJac) Sodium Bicarbonate J**i* jJ
Sodium Bicarbonate + Normal Saline = Hypertonic Saline
Page 11
Parenteral solutions j
Glucose Solutions
J) jj£>l£]! ) i—ijjxJI jc -UiiJI JJUxJI (j-a U\Ja

jjSjlaJl JJUa (> £|j3i 3 U^p <bfi
Glucose 5 % Glucose 10 % Glucose 25 %
•.rWÛVimHM
FE 16 LA -
S«.5l* 8A10LA m
TED -ID "
JAN -2 3 ""
—P= M4 •JAN • 1Q ™
= ?EE • • r>.:r: 2 1 -
PTU2S
rU* 25 ^ 500 ml -Jl <>j ! ?lj* 50 ?& 500 ml Jl ^ ?\j± 125 ^ 500 ml -II J*i
tf j JA*1* i> ^*k J* ICU Community -* Ul h^h hj*\ Uifc <ua
J3S9KJI (jo J-osI 3I0 J3KX) jJb f^Jijj

Page 12
1
,lu.i
wucose solutions
Hypoglycemia jÛll o-3^ <^VU ^ aj£1 ^MS <UUa_« Û UJa

!"??? i^ljl UUo J«UiiA Hypoglycemia ^JU d^c _J uJa
J—100 ^^ c^-1"^ % 25 jj-SjJ> <&-te j-JsGlucose ?!>-* 25 c^-^ I—3»J J—Û

cjVUia.Vl a*jI bj Glucose 5% VI jUL. >! îL J* 250 <•" <j-1»ja Glucose 10% ^^ >J ^>
Syringe s-1 ^gj J-""j par> "''» J-^> 40 Jjl j] al—clj* £__« (Îj—?. 25) <-U£ J_j_la_o ijljl ^ 1-n ia
Severity -Jl v^^ ^ ^j^ j^Jj ^ ^ u*- JjJ fb* 25 -Jl L*J=j One Shot (Bolus) '-^
.Û Patient -Jl s^ J*-j iP Hypoglycemia -Jl ^
Glucose UsV NPO LictL oû^l j) ^JU J Nutrients -* ^.lîmvi UJa

Ulill Uaifjoui yJJI yUall jA ^Jll ATP ^J tjj^
.Glucose -ftj ''-âjj -uajxL Jav^J bUal -UjJi Jsj^jk-oj Appendicitis jb& uîc jl
paJ'^j.'ÎJ Hepatic Coma -Jl l^j*

Secondary Hyper Aldosteronism with Salt and Water Retention
.(Salt Retention =^) 5UJ ?*!ji° ^ c^1 u5^ Dextrose -II J^j JjJU* IjoiU _J JUUj
CNN -II ^ t^JI %5 j£jh- Je. Ukjlub J-îj jiS -UjJ <ba
(Cordarone, Nitroglycerine, Norepinephrine " Levophed")
#cUl (> <>i jjSjkll yi-UtU Stability -Jl jSf bj
.Normal Saline -Jl j- Jî Glucose 5% ^ UU J^j U-Jixo JuWvi -UjJ
?? <ul !_jla Û jJj-jji cjlja.j 5 oUaj jjajU Jz*±i ?d\ J JU fji-JjjJI ^ Hyperkalemia -Jl ^VU>. J
Jaxii îl ^ JU fjiJSji <£&£• _>! IjS (jLic.j fjj-»U_jj »U« JiAu UMill jjSjUJiJ# j*j j^j-"^' u^
fj yi Jsj JUlUj UiUJI Jib j.jiu.U_<JI »U. Jixjj jjSjkll JiJj jJj^Vl jUc jJj-ulJ jAsV
^jÛjj ljVjw'I Ja*jA jl Hypokalemia -Jl ^VU ÎUIa jl -tLiill u-iil JUlUj
Glucose lAj o^ j^=h Ringer ji saline J& WM
Blood Hemolysis M**^ <& -uliL^j fil ^ jjSjkJI *Ua&J 'UU3 ^
Page 13
Warning for All Glucose Solutions
1- Anasarca
2- Severe Dehydration
3- Diabetic Patient
4- Hyponatremia
5- Hypokalemia
•Û Stability -II jV Normal Saline ^ c*% ^^ jJ<-J^ Penicillins -Jl

Glucose -II j* Jâai jUIt*
Management of Hyperkalemia ?
I St
1 step in management of hyper K
IV Ca gluconate "IfECG changes - K+ more than 6.5 mEq/L "
Most effective way to remove k+ from the body

Hemodialysis
Most rapid way to lower serum k+
Insulin + Glucose
Salbutamol Nebulizer
Na Sodium Bicarbonate
Page 14 —
Parenteral solutions 1
Voluven (Ji>i«£5l - CfijiM)
-v-/ % 6 Hydroxyethyl starch 130/0.4in

sodium chloride injection %0.9
•% his tia/t.4
^yA -UUjSLa
Osmolarity
154 mEq sodium
308 Mosm/L
154 mEq chloride
Plasma Volume Expander V) ja U jiljill
W(,1^1-VI
Prophylaxis and Treatment ofHypovolemia j* <J V^b j^Vlj JjVl ^hVu.iVl

jUJlJaiâ ^jjj j$i IjS J«j Ul JulUj Intravascular »j^ sjja Jâki ^ju Colloid <& b_j
JpJ jjju VUlL <U£1j jjiajjjl 4X.U -bj^sJI tj j j Jl J ijJA liiiic ijjj <UU ,J -ulc JaJUjjj
Jalaall JJjC Vj *l>oJI (.Jl OUjSl
Pulmonary Edema -Jl U*a! jjj£ JSUU J**j jLm <u* Over Dose -Jl j) j- lwU1U Ja
jjojjjjL: 25 j* J5I «jlj^ ^J-1 -^ -Uvbll yi Jaiaj Ujb

-U1U1I ojljaJl CjUjJ (jc siulj Jjjjill J ^.tUj Vj
: lsj ^ Precautions "bj^ ^
.Sever Sepsis -Jl ^VU î Voluven -Jl JUUJ ^
UUiUj Blood Coagulability -Jl J& Jh *$ *^^ *#M J$l\ Cy

. (jiljill (jc .iulJalaJI J JSLU oAJC QîJA J.iJC jla
(jiljill dlkcl ^Lu Intracranial Hemorrhage »-^ ^-bj o<ajjJI jJ
Sever Liver Patients -Jl £» <UU*iJ jî

NOT related to Hypovolaemia jJ ^>Li Renal Failure -Jl ^VUj
Page 15
Mannitol (Ji^l)
% 25 -^ % 5 Jjl j* iS^î <iiii-o ijIjj£jl j_>?.j-o JjiiiUll
%20-Jlj % 10 J ja W jKSllj
.... M \NM|OI
Osmotic Diuretic if-»jb6- VI ja U JjiuUll

ha. <blU Osmolarity <J j£J_s (Diuretic) JjJJ j^> J*i
Osmolarity 44"^ »•> Mannitol 10% jJ 11>4
549 mosm/L Uui
7 LO SLA
DCC • I 7
NOV•ZO
t' t 1 9 0 0
(5^ -blUll Osmolarity -Jlj J\y&\ ^_y m^j
Hematoma ti'l ji Edema ij m3-^ ^! sjÎ ^ ^^
" Cone. Above 10 % " JjJ> «J ^ j skull Jl J^ a**
Intracranial Pressure -Jl lU% Jblbj Diuretic bijS U^j -uV
Reduction of Intracranial Pressure and Cerebral Edema jJl ^-^ J%> M* Jjl
Urinary Excretion ofToxic Materials and Poisoning J«j JjJJ j-^Diuretic j* M=j
jj«J1 Jai<ja JjIHI in Reduction of Intraocular Pressure -JÛj jUS
Ua.iUl <UU jjla î J.ijc îiix jl RoadTraffic Accidents -Jl ^-VU J
\£. jbk.j Electrolyte Imbalance <-j^ ^!l^ V*"' Side Effects <J UJa
Monitoring of Sodium and Potassium J**j UUUl jja.Ua-
-uJac <M Juaa. jli Jjjc Urine Output -Jl Jjj^ Diuretic ^! 0*5j^& 'Jj* ^ isj
Accumulation ofmannitol -II ^-i^^J jV tp -Uaiulb i_uJall <jljj cjjjb JJa <J JjJI jl cJaa-Vj
^Jc-bj o-ajjJl JiAjj Overexpansion of Extracellular Fluid <JJ«j d£*«
jjjS <UU JSUUj Congestive Heart Failure J
(_jj <UuJI i iVi-%nj <U jjjij Jjjj Ja33 J« 100 Ujii -U-i ^J-n'nj AjJui J.iaj Jau <d\axluuj Ul
Physician Order-II s-1-^ J^ J- 100 jc ^jjj j^«j l^j-JI jjj M**3- J^-
Brain Edema j* Ja*^ IjS j« jsSi jV -uiL 20- 30 JÛ Jm s4«ja jJ

tdcU (j^jjJI jl <UU ^ J<nunj V
( Hypotension < 110/ 70 , CVP < 8 CmH20 , Oliguric )
Triple Saline J«j-ua i^jjJJI Brain Edema <&&. jJcP<1U1I ^j
Contraindicated in Sever Renal Impairment
Page 16
1
Pk merz (jj^> ^)
Amantadine Sulphate
II Mil
nCMl-li. Infusion
<-- 200 Je. isj±* JjkJl j- J- 500 -II
Amantadine Sulphate -Jl j*
?? al^lx-VI
'uomjutn'mVU
j-ll UiUl iuix« Brain Stimulant»jjj*jj jjjSo.U
Ul JJE. jVI (jji UljJ*- JJC. OJJjU jSlj
Promote Functional Recovery AfterTrauma
U> (jjiu -uki jjUj ii* <UU Coma J J^ Û o^^l jl <UU ^ <U«1uli
dLicUaJl (_i»<-ai j* s.ia.1j ^j Akinitc Crisis -Jl £Û J jU£ <d«iuu
Muscle Control -Jl j-^ <iV Parkinsonism -Jl o-^j-J J~«Uj J\\
Parkinson -Jl i>=ljci J£ jJUu j Stiffness -Jl JSjj jU£j
Influenza Type A -Jl <r^*J Antiviral effect <J
Ischemic Stroke -Jl ^VUJ ^JjVI ljUUJI JiU ojUatl JjJaiu ul cJli siua. cjUIjj -ua
Promot Restoration of Consciousness <&
Neurological Deficit -Jl J%j jUSj
W -^ o^j^ "SA=*J J^bj Sodium Chloride J& tsyâ ^jUuJI ^ -uV t*!L ^
Sever Hypernatremia -Jl ^VU J
:lU^ lS-^j Contraindications <i^ <J
1- Sever Decompensated Heart Failure.

2- Cardiomyopathy or Myocarditis.
3- 2nd or 3rd Degree Heart Block; HR <55 bpm.
4- Pregnancy and Breast Feeding.
Page 17
I
Parenteral solutions I
Kidmin (&**& )
7.2 % Amino Acid Injection

ZafM .„ "SS
For Renal Failure

'" ^^Tp
8 1 57L3 *~
=1» AUG• -.<!

5(-:p -18™
—
p T5 *0 0
Essential Amino Acids (EAA) J* uy±i J>^> j*
To improve survival and enhance recovery
Branched Chain Amino Acids (BCAA) J*- lsi^> Jj1^ j*

to improve N Balance and mucle synthesis
J <dUuJ Ji effective uVîUaVU

Intradialytic Parenteral Nutrition (IDPN)
to increase plasma total protein and albumin
Available in two forms: 250 - 500 ml
-Uu^J a£ju!I oU^jj lj*^ ,_jjU Central Vein J Peripheral Vein (JjjJ= Cp ^Jm
<UU -l<Uaj Malnutrition -IIj Hypo Proteinemia -Jl ^VU ^ jUS -Ob
Page 18
L 3ns
Parenteral solutions I
Aminoleban ( dk^ Jî )
8 % Amino Acid Injection for

:«. ~— ••"' "-
Hepatic Encephalopathy
•,;;•••'.
1
... ..
*^-•;
<fO
• "
W ^liiiuiVI
ssssa "
* F1 UA
— -, =
5 HM : 1 s
- =
Has high efficiacy in conscious level of
hepatic encephalopathy patients
<Uli£ll -bjJjiJI OîJî (jCjJI (JjJuu (jit JUa jjjU <d
Effective in correcting disturbed free amino acidpattern in the blood and the brain
. £jlj (»JI J AjJxoVI (jiaUa-VI £JJjJ lAc-\ Jc Jakj
Improve ammonia metabolism and hyperammonemia in hepatic patients
Ujx jnK'llj -•"^ " J oJjljll Uj^^SU Ûbl JjIojII -UUc j1"^,','
±&\\ Jc JxaaJill jjAJ ^Jall ^^JajA <b.isull *jjjiCjVU jji.i-%*i
-Ui-aJI 'aSj^\ Ljbxoji uuaj tjlc Central Vein J Peripheral Vein J -^-ji
£.ia.l_dl <a.Ujl! (JlAcUi 4 jl-i-« Jc UsjJ jJJaU.j J^xaj jijJ
Page 19
Amiparen (cyjWÎ )
10 % Amino Acid Injection
AMMREN KT- W, Mutton
Wj-.llsau.VI
:r;
Branched Chain Amino Acids (BCAA) -Jb jc Jjk* ja
I" "«•" Which increases the synthesis of plasma totalprotein

•35.1m: FED '28
('19700
Leucine -Jb J&. J_>k* ja
• «* The most potent BCAA Jâ J&j
Arginine and Glutamic Acid -Jl J& ijyî JjJ^ j*
Precursor of Glutamine Ua ^Jllj
1,1a. -LabjJI 4j<jUVI 4jJx«VI jiUa.71 j« j£JJ Jc\ Jc LjJJaJ
. -UjaJI CjVUIIj ((jjjjaJI ifljjVI 4-U.ljaJI itjj.iljaJI j^j-ajJ
Available in two forms : 250 - 500 ml
-Ui^jJl <l£jJil1 cjU^.jj vTji.iaj îc Central Vein ji Peripheral Vein J Ja-jJ
,£.la.1_jjl -*-a.Ujll CjUU 5 jli« /jJc- U1^ jfUUj J-i*-"J AiU
Page 20
1
Panamin G (£ Oiî )
27 gm / L Amino Acid Injection

•*, ^
Mi ?? ^lîluiVI
Elevatethe immunity in case of proteinmalnutrition

•—>-
BftwiHllW»
„ a-. 1 2LA _
jJJjjjll j*aSu illVU J -Iclisll o«.US Sibj (_Jc J«j
"rHg i t- ''30 ~
Arginine -Jb ^Jt JjU* ja
50 g/L Sorbitol Jc î^ jUSj

^_
(^jSJl (.Jsllj CjjaJI (.UjJV :UljaJI CjVU ^ 1.1a. ^ bj
Indicated in pre andpostoperative nutrition support
,<Ua.ljaJI CjbLutJI .lauj JjS<b.ijui1 j« p_jj£ Uj^c iîluu
539mosm/L Ui«ja Osmolarity ^b^'J.1
Available in one form : 500 ml
-UiâJI A£jill oUuajj Liuaj Îc Central Vein J Peripheral Vein J '^ji
.is.la.ljll -U.Ujll i. iirtij <cU jlio Jc Uajj ClUUj Ui>b J.1xaj jijj
Page 21
Dipeptiven (C&ki tf,J )
; dbjS-JI
1-Glutamin
1-Alanine
gjpeptiven ?? fl.iilu.VI
w
te for solution W It**
BL-tfutamfne). water**
"»L*U«ninel.v.awB-'.'-
l&»molartty : 921""jV
5.4. m ^
j£U« c?JJI Parenteral Nutrition-Jl j« *j> j*
•JJJjJI (JJjJa jc- (j<aJjJl ljSjn,»'i
Mainly Imune Nutrition j* jU*uib
AcUuj JUlUj-UuiUVI -Uii«VI (_paUa.VI j-uâ jo -iaJj Uj JLoUjia. Jc (^jJaJJ jA

. (JjJ^lj TJJ^JI ?^J) J^ •ic-Uuj (jiuVI AjIoC. -.jhilj jjjjjjll «j'ii<-i'i -Ulac. ^^Jc.
(.Jl (^ja-o JiJjUi) j.iajj jUbjiSbll JUbj <jU«Vl jl-ia. liLUj Jc JcUtu <Ul jA <US <UU îj
.Septicemia -Jl j» lsa±# Ij&j
^jjIJlSI JjIojII -bloc. Acjxji j\ .vl^JI <U Jul ^ JaUlo o-lic. (jiajj-i jl jUS <UUU
(Hypercatabolic andHypermetabolic states)
GVU. J <UUduj jlu
Sever Liver Impairment ^^Jl a4JI J^!
Sever Renal Impairment ^-^1J&\ S^c\
Page 22
I
Smoflipid20% (±&*^>)
Soya oil-Medium Chain Triglycerides-Olive Oil-
Fish Oil- Omega 3
_ <Uinlu.ll <Ua*ujlo <Uj>U!l jjAJl - UjjkJI Cjjj
3 Uaajl —jjJJjll dijj —ijb.iill tluj
?? j»tJiiu.VI
<UUJI jjju jUSj BreastCancer -II isj jLLjJl g-ljji <_â*j ±±J\j jit <U *|jc. Lsi ja
JSVI (jJt 3jJJI JLu V(jiajj-a (_$! ji 4jJu jUa-oj ]\fPO iJcU jUbl jl Ajjjll (JjjJa jc -ula*jjj
I^J^-J 6 U^jVI j 3 Uj-«jVIj JaJI Cjjj ^Jt <Uljja.V -Uj -Uâjxjja <ulidl <bJullj
^JiaU ojU tjij EDTA <ua jLic -ullja. UJjj CiUuUiill •. ^<:
iSA\\A'\\i\Vi (_pajjJI jjiajaja CjliioUjJ] •[.. 11-.I •.<. .li ig\ aIAc (uj
(j-ojjjj IjS 0«j <cU 24 (jlaJjJ U Jxj Iajii Ujll
Central Line J <^> <£& Uib JjaL

^•bj Infusion Rate -Jl (O'Wj
50ml/hr. cS^V
Fat Embolism s^^tû
More Scientific, Rate = 0.1 gm/Kg/hr
( ^-b./ Jx 33 Jlja. ) <UU / pa. 7 .liUA (.Ija. jLS 7Q -Ujj J±}J* jl (îu
Page 23
Fresubin (c^J^J^' )
A Flavored Liquid Consisting ofProtein

(Milk &Soya), Vegetable Oils (Sunflower Oils)
Vitamins, Minerals.
( bj^ - jJ ) (jJljJ* dfjji 4JJjl^ J*

( (jMAniil jLc. CUj ) ^bj Uyj sUjij
jlivJIj CjbLwbbill (jiasu (ji) AiUbVb
?? fiikiu.vi
(><ajjjl <cU -U^Jull U.Il-i <Luu
Jjjjll J J* Jjljll Jc lUjjjj .J ^lllllllllllb (_Jli ^
Jjl jlU JiâjJJJj TPN (J** "-1
Diazone W-JU Jîî Fresubin -Jl J^ Diabetic ^bj j^jjJI jl WJU
Jjljib jbojJJJ 4-âjJj jabill ^âj^ [_yn K.lhlU <Jj
(12 am - 6am ) j*J-^l ^biU. jjSj Jâjj i-jUU 6ALaLj -icU 18 jl^> Jc ia.jj
Page 24
IV Administration Set
IV Infusion Set -Jl j* p_jj t> j&l Uiie <ua

(1) Polyfusion Set
2 types *i- J ^ b fcjjUj

I.V. Infusion Set with Air vent I.V. Infusion Set without Air vent
Si. -Jj Air vent iSj-

dJi. Jj air Vent C (J J.
il>U Jj La 4 aU.j j «Ja*j uu <uk« Jjia-« <L>U.j £* A,Uh1,,,ij jlijA <jiL«

i f^ ^J'^fJf^183^1, ^J b*j> jJ^j'^j perfalgan Jl c*j
elj-fjjl Jja.iJ A-o-udA llSjj aU .nil will ijjl jJk
2-^Jj uj-JjII j<<_ij ^_ij Jj_laJI Jjj_jj frl>"J1 J-^ C^ ^^ ^>^ 0-"
<b uJb J î bI—juLj I JJJJajJI Jj-âJ Wj^ Jji-J L^JW L^" 'JJ Jji*JI JJjjj
Patient's Safety -IIj Infection Control -JJ | .o^hj^ iPjjj ^Jjj Jjla-JJ
Approximately 20 drop = 1 ml
JjIsmJI j* Jb 1 (JjLjO Aio ajJaS 20 -Jl
Page 25
(2) Microfusion Set

1
jc ajbc jUajib IJ
I.V. Infusion Set with Micro Drip
Pediatrics -Si ^ sî ^ -ubaiaL. uJa
Jjia-JI qa Jb 1 (_5jUoJ -UU sjlaij 60 -Jl
(3) Polytrol Set
jc sjbc jU<aja.b b
I.V. Infusion Set with Flow Regulator

4+^h j^jii ji b Regulator -Ji &£& bJa bibJj
-ub-ajjj ail j Separate J^ jj»j* Dialflow -Jl
. lilcbj FlOW -Jl }"!•'-'J) lilfrbb jpuL
^j-K jb-<ucl Dial flow —Jl (j-^ -^-^ u^-j oh

Cannula —Si isj <jji >h* J-«Ij*j jMh ^-ft
j...j <<> i w.l <. J-A j 4_jl Jl ig ...!«« bgJc JbâjJiA (_SJJI
u_ajjcj Vein —si j—iaaj Jj u«,i p_j—jj VVj

aJc j-uxjj ji. ICU community•* uî Ij£ jbic
Jjla-JI QA jb 1 (JjUuJ -UU ajiaa 20 -SI
Page 26
I
(4) Novofusion Set
jc Sjb& jLaoiL IJ
I.V. Infusion Set with / without Airvent

"Y" Injection Port ±j*j ja 
Multiple Injections <J^ <> J**i «&l ^^
J JjkJI (> jb 1 (^jbui <uu sjLa 20 -SI
(5) Oncofusion Set
(jc sjb'1 jU«aia.b IJ
I.V. Infusion Set with 0.2 Micron Filter
Particles ^ p*a l$^ J& Vj j* l. b jJili

Entrapped Air, Bacteria or Fungi *i>-
Venous System -U d»ja Up) i>
JjK<mI (jx Jb "\ (_5jUiJ 4-U ajJaa 20 -SI
Page 27
J Parenteral solutions 1
(6) Polytrol - Micro Set
(jc sjbc jl' •Vi'tb IJ
I.V. Infusion Set with Micro Drip & Flow

Regulator
dial flow <£ uisjli ^ jj Micro Drip J* ^j^
Pediatrics -Si J uj&h <su*ij <u^jjj
JjUoll (> Jb 1 (JjUij -Uo 6jJa2 60 -SJ
(7) photo fusion Set
(JC sjbc jU*aIa.b lj
1V Infusion Set for Photosensitive drugs
1 jjiajAJ V(_,bSl -bjJvl! (jî.-T^-a jA -Uajjl (j-o lj pjjll
11 photosensitive drugs *j^ss

ojU (j^ Acju^<a Aicbb Tube -Si j^
1 ^jui jbJbj Resistant to UV Light
•f Laj.-aa.j ^j i^j&i Decomposition -Si ^c
0
(_5jl j .'"<*< * (ji<j <uJ Ij p jJJlj (»IjjjI ^j-^l
JjKrt'l j-a Jb 1 (^jUij Al« ojJaS 20 -Si
Page 28
1
(8) Blood Transfusion set
1
(jc ajbc jbâiib IJ
I.V. Infusion Set for Blood Transfusion

tfjl ill IV Set Jl jJ JJ 4 JJJ (JJ—ill f-i—II J—iJ jl ja.
200 Micron Filter Jc <sy*k •ub Champer -li j! >&
fjJI J.U-S (j-3 BlOOd ClOt &>-Jc 4_j3 jj -LJl ^—A A lijhj
. Patient -lij j£U Uljij ^ ja Particles c?i ji
Jjk-JI (j-j Jb 1 (_5jUiJ <UU Ulljiaij 10 -SI
(9) Burette Set / soluset
Jc ojbt jbuabib IJ
I.V. Infusion Set
Burette Set ^>i <uJ
Soluset sj-^jj bbJj
Volumetric set ^l^^bbbJ
tlkijjlllUu sbuAui (jJJjjua«aS Liajj
lU 150 - J* 100 b>s^ <" ^

r-100-50inline -li J>
jA l»;J-
Injection Port for Intermittent Medication
(j-abUl sjbâ. -J jjSj ->ljJ J£ jj UJa Jb-aiij
^SS^Sj Micro Drip Jc ^j^ j*

Jjia-all j-J Jb 1 (_£jUii <UU 'ijJaa 60 -SI
Page 29
(10) Elastomeric Infusion Pump ( PCA pump)

4 a '.-.".11.. "lUa. /*|C- D lUc iUâJLa.lj IJ
For continuous Infusion

Route lsU ji Epidural ji Intravenous «bjji Uj J-j j^>
ijl«ju ^j^ Continuous Infusion J-«j jb-i& û
sJUJIî
Chemotherapy , Pain Management,
Chelation Therapy
i_ili=M. bÛi aâJi Balloon J^ csi^ ^
J-300 J! 100 t>^
Manually sjj—* Filling W^ ^

iâ jja.j- Valve -S^ a* Syringe fbii-^
cs^ Balloon -H Recoil y-c. jbâ-. ^jIjj IjS j*j

Lai jja.jJi ^ûis Pushing lS^*> WS^- (>j
Tube-Si J!
<CaJ aUuâ fjj Tube -11 J <U3 lj£ J*J
•S •. ^> J
aJaiu jll ja -uJ j- bj Flow Restrictor -Si
jus (ijiajjj (5 ml/hr) î. J.j**j Flow Rate -li
Bolus 5 ml 4?^ ^ c^± J Button J*
Manufacturer-Si m^ Jc ^^ i£**j
Continuous Sedation jy c£** W^j WJ>>

jiiSlji 4cUi 24 o^ AjUco ^jUc J*J (jiaJjxil
Page 30
1
Peripheral Venous Cannula
Peripheral Cannula -IS Size <> jî ^c ^

bj-ifSjJ <!lJjia jc -iK'ilA (jlo
Because i am sure that you already mastered it at the bedside my friend

^ja sJ^Jj JS jjj (jjjill Ua j£JJA (jSlj
Color Size Catheter Length (mm) Flow Rate (ml/min)
Orange 14 G 45 mm 305 ml / min

Grey 16 G 45 mm 220 ml/min
Green 45/32 mm
Pink 20 G 32 mm 65 ml/min
Blue 22 G 25 mm 36 ml/min
Yellow 24 G 19 mm 23 ml/min
Violet 26 G 19 mm 17 ml/min
A_C11 aUjVI LJj jjj ji_^l VJJjball L. cLS J_jjyj b$cU. j^LJull alU jl (> Alb ^la.
<-iUJI î (jUj -Ui^l fcâi .j^biU LAHii Catheter Length Jlj Flow Rate -Jl
<jjliL<i j jSii L^JS
Page 31
ns I
acU72 L$l£-« J l^bj Max Duration -Jl u! o^jjÎ

UplL. ,J buj- Signs of Thrombophlebitis J -S*^ jiu Uul f JjL jilj
Paul Marino J^lsj
Every 72 hour is recommended but if there is no evidence of localized

phlebitis you can leave it in place.
?Thrombophlebitis ^J*i^J*
Inflammation ofSuperficial Veins &• lJ-f- J^^ l^
?Ubcbb symptoms -Si «* ^! ^
- Redness.
- Hotness.
- Swelling.
- Mild edema.
- Palpation and tenderness over the affected vein.
?b>bbb grades -Si^-S.'.j
Grade 1 : only pain and no reaction around it.
Grade 2 : pain and redness.
Grade 3 : pain, redness, edema and painful streak over the vein.
Grade 4 : pus, edema, redness and painful streak over the vein.
bull* j- UjU Grade 1 J J* Thrombophlebitis ^ ji uJ^v J Jblbj
Page 32
1
Infusion/Syringe Pump
jb» jc- sjbc- jA
used to deliver fluids into a patient's body in

a controlled manner
4lJaci J Jjx-aJ pljjll Jasu liljcUaj 4jj jA Ajju*

JjaUuiJb -ubi but jjij jLa-. manually
i^ljhTj Aj\ jila (_jj
0.1 mL of drug per hour

(too small for a drip) V^ W= <j^j
oJjLabj LJjl jja-o Claj ^J 5jj*-« Jjia-o 4-Lafi. 0^*"' tiki ojJS '^J^'j; Ij^Jj
^J-url liljj .Û ^...^ jUS
injections with repeated boluses requested by the patient,

up to maximum number per hour (e.g. in patient-controlled analgesia)
-Ul jjibj lj Int.hlbj lilcli Line -SI J J^C laiuJa jljjj <U) b jb>=JI oj&
.JjlauJI jia. Jj*^> ^ aiai
jl (jÛiVI £* Syringe Pump -SI .kbjalb -uj

JjkJI jj^b Jb-ajjjj Infusion Pump -SI
Syringe Jc J^jjI Syringe Pump -SI u^l
. ab-s'iinj/l (JJiiij SjSill (juij (JjU
Page 33
1
IV Fluid Flow Rate Calculation
(jj ALUall iJaiaJA
acU. 12jI-j-« tr-Jc- c?jL& ±-ijj j-& j»l.jij-^b RingerLactate j^J 1.5 ls-J^' jbi*-.jJ JUlbj
drop/min ^ J--*-»j t^bj JjUJI (_j.Ua IjS Ul ^
1500 (ml) x 20 (drop / ml)

Fluid (drop / min):
12 x 60 (minutes)
30000
= 41 drop/min (gtts / min)
720
41 drop/min jj£j £y=H <Ûj Jj^-JI JajliA IjS Ul Ju
Page 34
J Parenteral solutions |
tplc jjjj jUa. JwiulA cjjIj <\iij 40 jIjxJc 300 ml ampicillin 500 mg mj^ ^ ^
(20-gtt/ml)
300 (ml) x 20 (drop / ml)

Fluid (drop / min) =
40 (minutes)
6000
150 drop/min (gtts / min)
40
Jjj jUa.Jot'iu'ia ljjIj CjUU 4 jIj« Jc two 250 ml Packed RBCs J=<*-> <&* ±>J^* Û i_Ja
(lOgtt/ml)^
500 (ml)x 10 (drop/ml)

Fluid (drop / min) =
4 x 60 (minutes)
5000
= 21 drop/min (gtts / min)
240
Page 35
‫‪r Chapter 2‬‬
‫‪ICU Drugs‬‬
‫‪Drugs‬‬
11 Poisons and medicine are oftentimes the same substance
givenwith different intents"
- Peter Latham -
1865
‫‪Refrigerator Drugs‬‬
‫‪»SL4l4-tt4‬‬
Refrigerator drugs
AijjuJi! AjjJJ
(1) Anticoagulant Drugs
iliUalaJI CJjJaJ -UiajC jjS.^1 (âla.uiMl UjbIgjl-n'i.ij CjUalaJI jJj£i £J»JJ ^JJÎ iS-'J •
as a Prophylaxis UU*.«i.i J6 J**! v^l t^j-j J«lj*Jl ijj
aAsIAaj jjjUjJI Jftuu.i (_$Jj •
; bb'j>" •
• Fast Onset and Longer Duration

»jJl jJlja. ja <lkc:>U jUU jUaaij Subcutaneous iajJ-"'j
Heparin Examples:
Cal Heparin
Heparin Sodium
Heparin Lithium
Heparin Derivatives Examples

Clexan 20,40,60,80
(Enoxaparine)
l!*iiH,frM^
Arixtra2.5-7.5
(Foundaparinux
Innohip 4500,10000,14000,18000
! nn
(Tinazaparine)
Fraxiparine0.3-0.6MI
(Nadroparine)
Page 36
Refrigerator drugs
(2) Thrombolytic Drugs
( J«ilU <bj£j* 4Jbla. i-Jj-iJJ ) diUalaJI vJj-JJJ 'bj.jl t£JJ •

Jl (j j dVUll (jiaxj ^ l{<a,lVin.i •
• Pulmonary Embolism
• Myocardial Infarction
• Ischemic Stroke
• Deep Venous Thrombosis ( DVT)
jjjlUi jJJjU J SJja.j«j Aijj ^j *"*''.' (Jjj
Streptokinase Examples
Streptase
Sedonase
(750,000-1,500,000)
Alteplase
TPA
(Alteplase Activase)
jbjll JajiiA diil IjS jV ( bj-a.jii) Shaking Jb*j ^JJj pjU^ (_jj ^j^Vl Jbbj ojIj UjL
jSaJJ (jî><-i-s<ill oUJI 1J-mm Ujj) j£Jj AlteplaSe -J' U<ajâa. 1.1a, AjlLft Ajjjl (^Jj
Shaking <_U*^ U« jj-^ ÎjJb JLill jlâ. Jc <Jjjjjj IaU* ^b> ^JSI
Page 37
Refrigerator drugs I
Insulin
pijjl 5 <J* <J3 jjUuij'tfl
Rapid Acting Insulin

> Onset: 10-30 Min
> Duration : 30-90 Min
Examples:
glulisine as Apidra ( Pen )
Lispro as Humalog ( Pen )
Short Acting Insulin
> Onset: 30-60 Min

> Duration : 2-5 Hours &
Examples:
Actrapid, Humulin R (Vial)
Novorapid (Pen )
Intermediate Acting Insulin

> Onset: 1,5-4 Hours
InsuiatareCHM
> Duration : 12 Hours
Examples: in
Humulin N(Vial) tautotMPHMftnfi*
Willi!
Insulatard (Vial-Pen
Long Acting Insulin
> Onset: 1-5 Hours
> Duration : 24 Hours
Examples:
Glargine as Lantus ( Pen)
Detemir as Levemir (Vial - Pen
Mixed Insulins
Mix of Short and Intermediate Acting
Examples:
Novomix 30-70 ( Pen )
•Js
ifcM urn
Humalog Mix 25-75 (Pen)

Mixtard 30-100 IU/MI (Vial)
LJ
Page 38
Refrigerator drugs
Drugs for Treatment of Anemia
(1) Erythropoietin
itA^ j*3* J* J^ÛUj % 20 <J""J ^Jl iyj % 80 <^JJ (J^JI j* jjU JJ-JA jc Sjbc si
( Bone Marrow ) j»Ua*jl ^-Uj j, „lj-aJI <.J CjIj£
jUS ->b»i.,.u.ij <Uxua. ^ jjiijj jU jj-j-jJl jV Renal Failure lSjJ^J' J-iili j^j^J <jJ=«jj Ua.1 JUlUj
SAiiill UujVl v-jVU j
'.lj,'nil J«ljl *, '.ui bejj-uil CjIô CjvUI %ja ja jlaJI .".^' I'i.l". jsa. jc ojbc jAj
Erythropoietin Examples
Eprex
( 2000 - 20000) IU
'«
EPOFORM
StenteV*
Erythropoietin
I
Epoetin 4000IU/tml
ftrtV.*.3.C.m(K«« 7.
2000, 4000 )IU
Jjjj l^.ll-IT j.l (_jjj
Recormon
5jj5.uu.i- i
(2000- 20000 )IU
Erythropoietin Derivatives Examples
(Darbepoetin)
Aranesp
15,20,30,40,60 meg
r S
Aranesd'
•4
>^
Page 39
Refrigerator drugs
(2) Iron
Iron Deficiency Anemia -Jl oVU J bl«iî UjL
: jfUU>. 1(j'iKi"iUI J iiiaJJ jSUo)

(<UÛ1IC jUjI
Cosmofer
U.X1I J hi-."; jS-")

(<U!5Ull EjU. jl
(3) N-Plate
Thrombocytopenia -b^l jULUJ! j^L* cjVU â b^-ja^
-bj*l juUua ^'i.nj -Lil ^^lc lUasJl pUj jiai LgJV alj
Page 40
Refrigerator drugs
(IiUj^jfll
(1) Progesterone Hormone jjj^jjJ! ujp>>
-Liâll J-iaJI jl jjSlo jiUa.) l(jl.<->-.n ^1 CjljiuJl jj^Ji 3 Jji J Uajâa. (J-aaJI CjjjjjI .^"...<
b^-J J&* 0*J *i" "4*
- Injection j^l
MOROICa
Gestone GESTONE" 10Omg/frt
50,100 mg/ml
IPOM I
Prontogest'
Prontogest 100 mg / ml
P1
•Vaginal Ovules /Pessaries J&*^ lhjjUI
Endometrin 100 mg Prontogest 200, 400 mg Cyclogest 200,400 mg
'actaWs
Cyclogest*
(Progesterone)
I5peisariw
Page 41
Refrigerator drugs
(2) Fertility Hormones -bj-âJI cAjj-ja

pjjjl 3 J) f"iVn.i <_SJJ
A- Human Chorionic Gonadotropin
Estrogen -Jlj JUjll lie Testosterone -Jl jlja] Jc itU LH -Jl jj*j* uj oyj* »Jj
(tbu'lll IJC
B- Human Menopausal Gonadotropin (Menotropin)

Gonads (Sperms, Ovules) -Jl jbjl Jc icUu LH -Jlj FSH -Jl j* -^ ^j
Merional 75 IU ( Vial Menopur (Vial Menogon75IU(Vial
Merional' «g> ?••§ PlENOGoHl
C- Follitropin Alpha and beta

(jJaJjJjll Jc IcbuJJ FSH -Jl i_jj olj
Epigonal 75 IU ( Vial) Fostimon 75,150 IU ( Vial Puregon50,150IU(Vial
3^
I'uiceon if:
•
lsSS>.-:Sg..
Page 42
Refrigerator drugs
(3) Testosterone
aUa*jl SUUiA CjVU Jj JUjll <bj.<T=»ll SlUjl 4bin.,in SjjSill j j<jA jA 1-;^ oJj
Testolic 100 mg Nebido
TESTOLIC*
fcHaMcont propionate 100mg
NEBIDO
i ri i
i
2 • •
(4) Growth Hormones ( Somatropin ) j*jJI jyj*
jaill ^ ja.U aAJjft J\\ JUlabU <Ua*jUj jajII jj*jA llj
Page 43
Refrigerator drugs
Drugs for Treatment of Joints Diseases
(1) Osteo Arthritis
«;•-"' jc -,..^11 i_i3jj J\ (JljJJ olj 4£jaJI -USj j j jll Sibjj jjJI i_JJ<^ djlaJJ jUaUall J AllUa j^lj
uiyjUaiJI ( Cartilage )-Jl J JSU Uiiajj cijll âj J^>Uall J ija.jJ JjUI synovial Fluid -Jl
1.1a Sja.Ua <Ua.j^ (Jlj Ifl.ni'i al hr11 Ajlir,<ill
sod hyaluronate intra articular injection -Jl ji^jjj2j£ jl ^*" u^ j* a^c-
Sod Hyaluronate Intra Articular Injection
Duration -Jl J V-axj jc aliai SjiS pjjil -u* -ui
,*JjUl 5"3 '•J-'J UcjJxul iij* ^-.ITi.i jsa.
Curavisc20mg/2 ml Orthovisc30mg/2ml Hyalgan20mg/2ml
m ,m
QSaSKle Hyalgan
I
4JUaJI i.imt JjjJjj 6-3 S^J Jg-"1 J^ °J"" 1^-Ujj jia.
Page 44
Refrigerator drugs
(2) Rheumatoid Arthritis
<Uaja cjUUill ljj<jjj jUalull j»aUj -ul ^1% lilcU ^x-UJl jbaJlj Autoimmune disease °ij
.AcUaJI jb-a, Jajjj Ajjll jl Cjbjjjjjja Ul Ua.vlc
Ijjl -bjjMl JUaj
Enbrel Humira
(Entanarcept) adalimumab)
Page 45
Refrigerator drugs
AjjjjiiLSil AjjJJ
(1) Cholecalciferol
0 JLaUa I^jS -Ujll jc ajbc !_jl
aUaxll îjljj -UiLuA TriUl J-J-â ol^l Uajj SlaJj oja 1-ylTi.i JlilaÛ ailb -J3^ j1- °jbc l5^J
Alfacareno drops Alfacalcidol drops One Alpha drops
One-
AJfacak.dcl
(2) Calcitonin
Ûa*ll <djjajj Îja.) JJajj JSVI ja ^jjjJISJI (joUaiaj jjiajl Thyroid Gland -Jl j* jjiyj jyj>> »ij
Miacalcic50,100,150IU Miacalcic 200 IU
(oral drops) (nasal spray)
Essf-SaKC
Page 46
Refrigerator drugs
Anti - Cancer Drugs
Drugs used for Treatment of Cancer

(jUaj<aill £• iU J a.lJ.In'i -bjji
Avastin 100,400 Bleocin Decapeptyl0.1-CR

(bevacizumab) (bleomycin) (triptorelin)
For: brain , colon , rectal cancer For bladder cancer For Breast cancer
•I 1
•
^Hficwj
jftacm
41
Gemzar200mg-lg Mabthera 100-500

Mitomycin 5,20,40
(gemcitabine) (rituximab)
For solid tumours
For solid tumours For non- hodgkin's lymphoma
MabThera 10Omq Mab -"-- a 500 mg

=£"'°'fff "" ""*•*"
"rtTliCT.i 500*
Leukeran
Carboplatin
(chlorambucil) Cisplatin 10,50,100
For: ovarian , cervix
For hodgkin's and non hodgkin's For: gonads cancer
carcinoma
lymphoma and leukemia
CiSplatin
Injection
il'MIMM.™
<,ma/mlJ^ SB CiSplatin 5sMl

Fo* inimwiMM Um Only • IK'EWI-M*! ES^H
[SSSRtTE ' -••'
OkUiWt dwttuo *ow*

4 ^S— r-v^SS^M
SBlM/larr
Page 47
Refrigerator drugs
Paclitaxel Viscum Fraxini
Oxalipiatin 50,100 30,100,150, 300 (mistletoe)

For: colorectal cancer For: ovarian and breast Used for variable number of
cancer neoplastic diseases
Viscum Fraxn 4 <'
Navelbine 20, 30,50 Zoladex 3.6,10.8

For: testicular carcinoma - Hodgkin's (goserlin)
and non Hodgkin's lymphoma For breast cancer
fjNAVELBINE
Zoladex' lOSmg
jUajJI <bjlV AjfibaJI jJalj&Vl £vUl alai-ii Ajjli
For treatment of neutropenia Neupogen Filgrastim
Aclasta Zometa 40 mg
For Treatment of
Hypercalcemia and 4
ZOMETA 4 mg
I t; ;:<i:-
\
Aclasta Zoledwnsjure
Osteoporosis Aclasta .
:.- in;i :
Page 48
Refrigerator drugs
Eye drops
Lubricant ur*JI s^j^ UjIjLs

Blephamide
Cornetears drops Hypotears gel Genteal gel
gel
Antibiotics ^jp> Uibbjax,

Orchadexoline drops Okacin drops Isoptofenicol drops Ocuphenicol drops
Okacin'
<2>
SfMTMd*.'
Spersadex Comp Drops
Glaucoma -M ^^ &\Js&
Xalatan Travatan drops Xalacom drops
1>;alatan"
unnoprott
UpHtnHnC | Viacom
0.035;;
* felocom
Page 49
Refrigerator drugs
Antibiotics
Ivanz Tienam Tygacil

(ertapenem) (imipenem) (tigecycline)
Erttpmn
Tycf^ndl
(tigacycHne)
II
Targocid Vancomycin Zyvox

(tiecoplanin) (MRSA antibiotic) linezolid)
Cancidas
(caspofungin)
'&mm*j)jg« OncMas
IOBMbV lOHBMl
LB3
""••••(' m
Mrkn
3ldM
Omso
• 9
•Til
Page 50
Refrigerator drugs
miscellaneous
Diprivan - propofol Dopamine Dobutamine

(IV anesthetic) (inotrope) (inotrope)
t
• »
IsS
Methergine
Flumazenil
(ergometrine) Syntocinon 5,10 IU
(antidote for
Labor induction through (oxytocin)
benzodiazepines)
contraction of uterus muscles
i
'••Mm "••
Clopixol Atracurium Esmeron

Antipsychotic injection Muscle relaxant Muscle relaxant
_ MntoMaaM
"11 1n—giOV*l
Tridil
Levophed
(nitroglycerine ) Voluven
noradrenaline)
TTT of hypertensive crises
fc#
I ..rfOflTIH
*3SJg';
Page 51
Refrigerator drugs
All Vaccines Albumin Daktacort cream
HUMAN ALBUMIN
250 g/l BAXTER
H\ Soluliontot Inlutlm
Synacthen Depot
(tetracosactide)
Jl (jojauoij J l<jl<n1ui.i
adrenal gland insufficiency
LjLajjJÎ 4.nilin oljul dijl£ jl
IjJjA jjjJJJj^JI (Jj t<jjcljj
Jk <ua jl bajl <lLai 30 J^
lla jc jljiyi jaijjA bâ
Page 52
" The danger with germ killing drugs is that, they may
kill the patient as well as the germ "
• J.B.S. haldan •
Antibiotics in ICU
Anti-Microbials
JlikjJ Y-Set Incompatibility

<ba.H-a
^jai t>- lUj eLtx l^Lu jiatiiiu 4jjll
.Ijlll
jU jjMll o^J
J-100 Lasix, Heparin,

ojlja. <U.jJ
mn <~4.5 %5 JjSjJ^ aLSi 30 Propofol, Controloc,
ajj 1 SijjJI
plA (JjK^ jl Zithromax, Insulin
Augmentin / 600-
Lb 100 Acyclovir,
Magnabiotic 1200 Jiij30
JaSS ?tb Jjla_a Jbbl Tetracycline
jjljUaji
Lb 50
0.75- ojlja. 4a.jl
% 5jjSjl*- ALL 30 Aminoglycosides,
/unictam/ ^1.5 4ijjJI
Ttia (Jjia-« jl Amidarone,
sulbin/ dilcLoi 4
Amphotericin B,
t> 100
ultracillin
<Uj|j 30 ciprofloxacin
i-3 % 5jAjJ* fb;I 3
?tla (Jjli-« jl
Page 53
Antibiotics in ICU
(2) 3 generation cephalosporins (mainly against gve j

(Strong anti- staph effect- strong anti-pseudomonas esp: ceftazidime)
Y-Set
slkjj
<ba.Xî Incompatibility
jjSjffl Jc lWj J* olju la.ll: jixiiLa Ajjll
jlâ
jJÛIj^j^
Lb 50
30
%5 jj^jk Amphotericin,
f*l
(Ceftriaxone) <Uj3J Zithromax,
?tla (Jjla-A jl ojlja. <ba.jl
by*"jj Dobutamine,
Jl iita. J, 1.1a JUi " Diflucan,
J-100
l*ojx»ij gastroenteritis 30
Tienam,
" typhoid -II £VU f*2 %5 jj£jk
<Ug1 Magnesium.
ftlo Jjiaâ jl
Cordarone,
Amphotericin,
Fortum / kefadim Zithromax,
Lb 50
30 ojlja. Aa.jl Dobutamine,
(Ceftazidime)
f*l %5 jjSjk Dormicun,
(ujjS fJJ 1 AijiJI
Tela (Jjla-a jl Controloc,
"Strong anti-pseudomonas"
Phenytoin,
Diflucan,
Vancomycin.
Zithromax,
J-50 ojlja. 4a.jl
(Cefotaxime) 30 Diflucan,
f*2 %5 jj£jk Aijill
<jijj&s Controloc,
<bii
Ttlo (Jji^-a jl 4cU 12 Dormicum,
Vancomycin.
Page 54
Antibiotics in ICU
(3) Macroli
Y-Set Incompatibility
Jc djlll <ba.M-a olx-a .JÛj jjxAiLa 4jjl1
j£UI o&J
Atazanavir,
ojlja. 4a.jl
verapamil,
60 4ijill
amolidipine,
<Uj31
?Jil
J JaiaJ V ergotamine,
<U5131I
insulin
Amikin, Claforan,
Ceftriaxone,
ojlja. 4a.jl
4ijiJ1 Ciprofloxacin,
60 Dalacin, Fentanyle,
f_W 1
<Ui31 Lasix, Gentamycin,
4ajbll
Tienam ,Tavanic,
fM7
Morphine, Tazocin,
Potassium Chloride
4) Tetracycline
Cordarone,
ojlja. 4a.jJ
30
Amphoteracin,
4ajill Ceftriaxone,
4US1
?Ji 1 Nexium, Risek,

Dobutamine.
We don't give tetracycline with pencillins because tetracyclines are bacteriostatic and
inhibit the growth of bacteria and penicillin worksonlyon actively dividing organisms
Page 55
Antibiotics in ICU
(5) FlurO-QuinOlOneS (effective against G+ve&G-ve)

gastroenteritis & UTI Jl "Via. J l.pUhiI-1 jfii
Aa.jJ
j^l J*- cKj <jlj.j!l 4ja.!iL« obu .la.Lu jcJtiiia 4jjjl
J^Jc
Lb 100 Amphotericin, Unasyn,

200 ojlja. 4a.jl
%5jjSjk aLL60 Zithromax, Maxipime,
4ijill
Dexamethasone, Lasix,
?jil4
Lb 250 Solucortif, Solumedrol,
uj-jjij" 400
%5jj^jk 4iii 60 jc llJxJ iaiaj Vancomycin Controloc,
TtLa (Jjla-a jl ftji rill Phenytoin, Propofol
J-100
500
%5jj£jk 4iii60 Lasix, Heparin,
(*-
ojlja. 4a.jl
Levofloxacin TtLa (Jjia-a jl Propofol, Controloc
4ijill
J* 150 ,Zithromax, Insulin,
750
%5jjajk 4ijai 90 ^3
magnesium, calcium
Ttla (Jjla-a jl
(6) Aminoglycosides (mainly against G-ve

: Ijs&S* nephrotoxic &ototoxic l*JW i+c-Uj side effect JW >j
Lb 150
500 Amphotericin,
%5jj£jk 4ijjai60
Ttlo (JjiÔ Jl ojlja. 4a.jl
Zithromax,
Amikin Lb 250 4ijill
f* 1 %5jjajk 4Lai 60
Controloc, Propofol
(most ototoxic)
cb5p0 4cLui 24
120 , Lasix, Heparin
^1.5 %5j/jk
4uai
^la (Jjla-a jl
LblOO jb*J ajV Amphotericin,

20-
%5 jjSjk 4SJ3J 60 VjjJlUl Flush Zithromax,Lasix,
40
Gentamycin 7UA (Jjii-a jl Jli*j
Infusion Propofol, Heparin,

(most nephrotoxic) j fih i La
J-200 Controloc, Tazocin,
120 ^la JjK <i.l
i^80 %5 jjSjk
<U.H1
%5 jjSjk jl Phenytoin
TLi-O UJ rt jl
Page 56
Antibiotics in ICU
^•Ji Y-Set Incompatibility

4ja.>L<a
Jc lKj Jc ol*-a laAjJ j?.»i'"« 4jjll
«.ljlll
J
±A jj^JI jA*J
Lb 100
30 Cordarone, amphotericin,
%5 jjSjk 4a. jl
4ii31
7tl« (JJ'^--" jl "ojlja.
Zithromax, diflucan , sodium
J* 200 4ijiJI
60 OlcLui 4 bicarbonate
%5 jjSjla. A 'a .a \
7UA (Jji^-* j'
^JJ
Lb 100 Amphotericin, flagyl, calcium
30 ojlja.
%5 jjajk gluconate, potassium
4iiL 4ijill
7UA (Jjl^-a jl chloride, Zofran, Zovirax
L_ib.Lui 4
cb 100 30 L^JW
Jaaa 7tb J jla-a 4lil Jbbl
•]*I^]ill[*l4
Lb 10 J <Jk
i qq-îj (j^> c-l-4 60 Albumin, amphotericin,
Lbl50c<>
4uai
%5 jjSjk 4a. jl ciprofloxacin, unasyn,
Vancomycin
?tlo |Jji^-C Jl 'ojlja.
maxipime, claforan,
jjLUUAjSjli cb 10 t-i ljIij 4ijill
i—kiajj jia. <>La 90 ?Jil ceftriaxone, heparin,
1000
^250^ controloc, propofol, TPN
4ii31
%5 jjijk
^LLO (Jjl^-0 Jl
cb 3 J i_j|jj
200- jaall >La 30 L^^jy
400 Jc L-kiaj »j
4ii31 JbJ
Lb 50
tlLo (Jjia-o
fusion of concentrated vancomycin solution cause RED MAN syn
Page 57
Antibiotics in ICU
I
(9) miscellaneous
j£jSll iA <J=^ <> »ljil
15 ajlja.
<CjaJ| Solucortef
^L Jjla-o Ja 50 ALL
%5 jj^jV jl ^7
Sjlj* Amphotericin,
500 (jlaij jAla. (Jjli_o 30
cU 100 AJLaj ceftriaxone,

ft* (*-«l
meronam, controloc
iîsii
5ajJ
J-50
600 30 Sjlja.
Alfaclindamycin -
fjJ 16
Amphoteracin,
Zyvox/ linezolid jjiaJJ jfcl^ Jjla-o JUJ! Neuril ,
Phenytoin,
Ceftriaxone.
Page 58
Antibiotics in ICU
Anti-Viral
Y-Set
L5^ **5i Incompatibility

J*- Lî *\y&\ kia.yâ
oL J« 10 Jc- i]î Maxipime,

Dopamine,
4LL6O
^L Jjk^ J- 100 Dobutamine,
AijiJI
%5 jA?k j1 SttLu, 12 Tavanic ,Zofran
*UJ« 10 J& (JÛ Controloc,
,^3 hit j V Tazocin,
Aiij 60
jL J_jk^ J* 300 Gentamycin,
%5 j^> j1 Granitryle.
L>* ^V AijjJI
500
*L J- 10 Jc JaJ
2x.L« 12 Maxipime,
Zofran,
^L (Jjk* J* 100 Flush J«j ?ji
Tazocin
%5 jj*> j' Jxjj (_JjS tlLs
AjUaol
n's Rapid Infusion Can Cause Increased Toxicity and Excessive Plasma Level
Ij£ otic Ia* jiijji* UjiUi yi <Uiuuj Toxicity <J**j £*>" J"5*-^ Cymevene -*' £yla&l ^
Page 59
Antibiotics in ICU
Anti-fungal
TTTÎ I Pw'iTf' gent Effective Against Fungi

Y-Set
^JJ Incompatibility
dljlll <ba.X-a
jl^t> oLl»-»j b jiall fLa 30
cefotaxime,
Lb 100^ 44J&1
v
Dobutamine,
Ttla (Jjia-o ojl ja. 4a.jl
Dormicem,
LblOtsrJccUj abl 7 <Ujill
Morphine, Zofran,
. i°-\; £ jiiail cLo 60
Insulin,
^200^ 4L1S1
Tela Jjl-\.fl amphotericin B
tbig^jlc Jau
Quinidine,
aJ jiail jfcla. oLa
200 Carbamazepine,
Lb 100 Jc L-iiaj 4iij3Q JlaJlîia.jj
(voriconazole) jl TLLa (Jjia-a Rifampicine,
%5 jjSjk
"ijlja. 4-^jJ
jblC^lc Lbj CJJ 1 4S>H Tygacil
aj jiall j&la. «.La
120
50 «jxlJl j<=J*J V Corticosteroids,
Lb 100 Jc L-iiaJ
(bad 4ii31
%5 jjSjk Flush lU»j fjVj
nephrotoxic Digitalis
U'aa
%5 jjSjlaj
effect)
4jLkcj Jxjj JjS
Page 60
Antibiotics in ICU
Notes on Antibiotics
Anaphylaxis-N l?* Sls^ L-jb^^l £* Ijliii Aiaii jj£I UuL
(ilfrbu ^jj^JI ibôJI t5<k«j l» Ji Sensitivity Test J**^ ,0^ iP ^11 "r^ u^-j
Intradermal ^J^j ^ U^ ^^ ^M1 l> tU 0.01 - 0.1 '.'•>•»*.' ^1 Aj^ l^-
jjl ajjjl 4_ajjjulJ
Sjjjyall (â J\ i$j bleb <^" UJ&*
jilL 5 i*j bj>bjj jiijjj mark bjLuu*
a |.,)1...-. .jij.lja.0, lilc-Lll (jiaJ ixll UJ 4_ala. ^jViIkTXi j]
(_gllc- (j;jjaJl ibja-aJI la.b jS-a-aj
itching J^- J J Red or hot <-*i Up) Jj-^ jJ Uj]

<bxuiLuiaJI ' """ (jJjJaJI il.'— «.1 oUac] J-LoJ (_jl 4lLaJI ^
? /el jl LJjjutajjA Si...l ...^ 4jb<aa.j l£J^ ^' -"^ ijîj^ djJac.1 liljl Jj-aa. j] <—lla
4j!-it1.i (^111 <jlj.l]l LJajik 4ja.La. Jjl -
Airway, Breathing, Circulation -Jl t> &] -

as^l %100 Jc J*i^ lU»jja -
Plain Saline J=*lj-
Order-51 ^ fgjk'"»j ( Dexamethasone - Avil -Adrenaline )-II j*^ buLj -
Page 61
Antibiotics in ICU
Anaphylactic reaction?
Airway, Breathing, Circulation, Disability, Exposure
Diagnosis-look for:
• Acute onset of illness
• Life-threatening Airway and/or Breathing
and/or Circulation problems1
• And usually skin changes
V J
• Call for help
• Lie patent flat
• Raise patient's legs
Adrenaline2
When skills and equipment available:

Establish airway
High flow oxygen Monitor:
IV fluid challenge3 • Pulse oximetry
Chlorphenamine4 • ECG
Hydrocortisone Blood pressure
Page 62
Emergency drugs
Emergency Drugs
ajtjlall AjjJ)
j_j£j |CU -II <ji JiSJS jLic ajllllV <Ucj]| ^ Ûln^ *lji 50 î Jji
L?'j! J*"i'\.'.' j»*ja la.lj JS (Jji tâJjS j»Alij liLuJ ,Jj ajjJaaLa.
Stimulate All Alpha&

Mainly Cardiac Beta Receptors
Arrest Arrest Jl ^VU. J *j^j

chrome
Epineph .ilia Jijj jU»JI jl Jai Jc JteW><Js
- sever
Adrenaline Ventricular J -jab.
(Adrenaline) anaphylactic Fibrillation
eral Vein
jLbt.
shock Jl jAja ja ejajj ^ JJI
i Necrosis
Shockable Rhythm oi'iJ^'J
- sever asthma
jajjs DC Shock J«J3 1 ' Arrest
Jl CjVU. J -
Bradycardia
Ijja J£ i+\*. Jji rdia UjJc
Ja*^ tlli) Jjklc juajd <ubxjj J4
Anticholinergic
Atropine ! Antagonize A.CH on enlarged prostate Jl
Jl oVU J -
i.n. .1j (JSa* <uv
Organophosphate M Receptors)
urine retention
/Carbamate
Toxicity icoma u4!j*< J«>j V
Antidote Jl y. jV
Stimulate Alpha and

Beta 1 Receptors
AclL CVP Jl ji^Jo J«j
Sever Jl Alpha 1 Jl Jc Jiiiu
Blood Jl J sjja.>«
Hypotension
Tachycardia ^JJc jJ -
Uj*«jj Vessels
4Jal» j] uJlijJVI j j -
Noradrenaline jS-a* c.ljj <J*âal jjb J*«js Stimulation
Îoj» Ul UjjVJi- j.jV
(Levophed) Vasoconstriction
^. . '-.11 ij|l»a .j Tissue Necrosis
h't , ,'iU a3 u3
cDiWi jc Beta 1 Jc Jiiluj Jul JUc Cul jl ULal .

<Uijjj lifcUj Rate JL
Jl jjjjj <_Jill Ji
U.:.5j.-...i ».j.
COP Jj Contractility
...u.j >Ja]l xi u3
methylene blue ^Vjî
Page 63
Emergency drugs
In Low Dose 3-5 Meg

Jl LlVla. J - Dl Jl Jc Jiii*
4jJ=*1j Anuria Jjjjj V.D J»«j» Receptor • ntnifKr-iwi
Renal Blood Flow Jl

Low Dose J i^jVIJl" J 4Ja*j J
Urine Output Jl Jjjja
Renal Dose b~J
Dose '"ijIt.i jl j"il. 1*11;n j1 -*
3-5Mcg/Kg/Min
5 -10 Mcg/Kg/Min
Tissue Necrosis
Beta 1 Jl J1 <jL£ Jii%»
Jl tilkijja COP J' Jjjjs
Dopamine Jl LlÛ J - Systolic Blood Pressure
Hypotension Diastolic J1 jf-1> lW
JaTi>i1l lilkjjjA Dose i-jj1>cI jl
rdia »•*<«
10-20 Mcg/Kg/Min
J! Jc jUS Jin.Mfl.
JI^Mt- .ilUua Alpha 1
Congestive Heart tSlUiJi Vasoconstriction
Failure
Systolic & jm—JI
Diastolic
Stimulate Beta 1
Receptor
Congestive Heart Tachycardia
Stimulation l$la*jUli
Failure
Contractility-li JjJtt*
Jc oJiL j HeartJl ^ JuLi Cu\ J
Dobutamine ,,ature
Ij^Jpo^ Heart Rate Jl
Dobutamine
Ventricular
(Dobutrex) jja (JjaSl jA IjS (jUaCj
CHFJlj^ Jdw-MI jntraction (PVCs)
Jj JjA <UV j Contractility Jl Vtach *&
Renal Blood Jl JjJyLa
Jt'i.'ji Jui *Si Flow
Alpha lJl Je-
Decongestant and Stimulate All Alpha
Bronchodilator and Beta Receptors
lH jJill &M«V.i | Hypertension
Temporary Relief Bronchi JJ i^L JlilU,
of Bronchial J«j» Tachycardia
Broncho Dilatation
Ephedrine Ephedrine Asthma
cljjd.1 tij?-" (J^JiJ
Hypotension of LJSjil (jjj J j
IjUmjjjII
Ujs Jl ljIjljsVIJJL*
any cause except Enlarged Prostate
hypovolemia peripheral VC lUaj
Page 64
Emergency drugs
Active Mechanism Of
Drug Uses Precautions
Ingredient Action
jb*JI ^Jc doiUll Cm

Bronchial
Anticholinergic Drug (JjOU liBb Jij (juJJ
Ipratroium Asthma
dbjija J SjLj '.'.'"') Vj JJC J (Ji.Jj jli_ill
Atrovent J^juj-uV
Promide JiSl (Jai jA iJJjlj ...mi Juuj 4lV (jiajjaJI
Broncho
jJJjlill (> Blurred Vision
Dilatation
<uv <a.Mi Jk
Inhibit The Production of »jiiail sensitive
Bronchial
Pulmicort Budesonide Inflammatory Mediators JJ'<t»'H Ji jjjjjj
Asthma
Ljjja. Cjljx JJC Jl'aj.. JlllLl a i> J5' ifiji J*iJJ*J
asthma Jl *-jjia j^ j 4£.Lui xjj
Selective B2 Agonist
and also Inhibit The A-a *Lal *V.,,il ajc J• '-q'
Albuterol +
Bronchial Release of Inflammatory Jwjj <UV .Jiill (îaja
Farcolin Ammonium
Asthma Mediators or Broncho uJall Ljbjii J SjIjj
Chloride
Constricting Substances JiJl (jia*j Jjc <Lic jj
From Mast Cells
<ulazj ^jVJil 4jl-n"A jj

Increase C-AMP By
4SjSJ 20 J±>Jc- Jail
Inhibition of Its
4cJx<J <CLjacl jj <UV
Moderate To Degeneration By
Dysrhythmia J-=^j
Sever Phosphodiesterase
Cardiac Arrest J^"j
Aminophylline Aminophylline Enzyme
Bronchial Narrow <J J ullbJij
Relaxation of J«j »jj
Asthma Safety Margin
Bronchial Muscle
J.nr. (jTit q'n aj JJJj AjiaAJj
JuuS
cb*j (j£>M 4lV
Broncho Dilatation
Scar Tissue
1~* •~H Jc dlilC
4iV Heart Rate Jb
Sedation- Hypotension & lU«jj
Hypnotic Bradycardia
Jc Jt'ImMI
Agent cUuj <uV iMi Ji
jL-ajjA J Inhibitory GABAJi Apnea
propofol Diprivan
Ciia Jc jUjJI J<IT.U IjSlj UjjjiJj cj^ Jjj cM1"^ jl
JuuA jl Hypnosis J*j discard 4La*j
procedure <Giaia. j] J^. Cjtclui 5
jjjij r-Liâj <LOBJI J
âjV .JljJj Jjjlj Ji .. n. .• n
jjSjjjj ûi 3 Jc <l .11 irl
Page 65
Emergency drugs
Active Mechanism Of
Ingredient Action
Reduce Gastric Histaminic2 Receptor

Zantac/ Ranitidine
Acidity -
Hydrochloride Antagonist
Peptrelif cJa^JI a. >rij<o. Jlajj
Proton Pump Inhibitor

Peptic Ulcer as It Bind To The H/K
ATpaseThus Decrease
Controloc Pantoprazole All Gastric Secretions
-
Gastro esophageal
jS-CvO *_=.L^ JâSl jA .JJJj
Reflux
Reduce Gastric Plavix J' ^ 4i*! JMj

Nexium Esomeprazole Acidity Proton Pump Inhibitor
PlavixJI JcJh^
Antagonize Dopamine
Receptors in The
Anti - Emetic
Chemoreceptor Trigger
Primperan Metoclopramide Vomiting Zone -
UJ J.n-ijft (jla JLlXlj

(Preventions TTT)
J-^ja Jai stimulation
vomiting
. ^'"~ tjcllj (jjaJj^JIjl
Centrally Acting Jjj QT Prolongation
Anti - Emetic Antagonize Serotonin IjSdiV AoUj J5U
Zofran Ondansetron
Vomiting 5-HT3 Receptors i_y ^ l)^' Ji-jj oô
4—1 Vtac Jl i>
(Preventions TTT)
Tasade De Point
,Ja Jj£l <La|jiluil X1A1
Ketorolac To Treat Pain & Inhibit Synthesis of tdLuu jl" 4JV f.LI 5
Ketolac Inflammation Prostaglandins jLaSj Sjx^JI J 4=.j3
Tromethamine
jsji jc ji*
jiJ (JjJaC- <uLwj <jTi»Vn<a
Anti - muscarinic
(RelaxesSmooth
Hyoscine Acute Spasms of u^ Anti Coagulant
Buscopan Muscles of All (J.n-ij jlaa
Butylbromide viscera
Abdominal and Pelvic
Intramuscular
Organs) Hematoma
Diclofenac To Treat Pain & Inhibit Synthesis of <J jLaSj

Voltaren (NSAID) Inflammation Prostaglandins
nephrotoxic effect
Fever °jj=- o-^j^ j*
ajV jbb3jJ <tJaxjAj
Analgesic- jjj <Cijljj* 4j>jJ Uj^l
Inhibit The Synthesis of
Perfelgan Paracetamol Antipyretic fjV 4j>jJ 38 i> J5I
Prostaglandins
ojljjJl j-âîj jS. 111 Jva 4iV JjVI CjblaS
4j>jJ ji jjjII aJJujA
l'jS(>JclSjljJl
Page 66
Emergency drugs
Mechanism
Action
- In low dose
Jl JjjJiJ XJoJJ
Jl Prothrombin Heparin Induced
lU*jj4jV Thrombin Thrombocytopenia
inactivation of (HIT Syndrome)
factor Xa Jl jj jjj£ £1Jl 4ii JSOt,

Heparin Anti-Coagulant
- In high dose Cat Heparin - Heparin
Jl JjjVi Jl jaj.l Sodium
lju! jJjUiijJI fly*,ill
inactivate factor 4jl Jl Jc jjU Jw <UV £J
IX,X,XI and XII
Low Molecular
Enoxaparin Weight Heparin
(Heparin Anti-Coagulant
Inhibit Factor Xa ST Segment elevation
Derivative)
Clotting Factor myocardial infarction)
JjUjJ -tia i mg
Protamine 100 Unit of Heparin Hypotension
Antidote of Heparin
Sulfate
Maximum Dose:
50 mg
increase Oigoxin Level

Class IV
hiiall Jc .iljjc <uiauj <iilj
Antiarrhythmic Drug Hypotension li^-a 4JV
.Hr l"j. *J k!| BJ <] I««".,.". ...all.
Digoxin Jl (> Jîl ajjc
Isoptin Verapamil Ca Channel Blocker Sick Sinus Rhythm (SSS)
^JjVLll 4jl <Uaij J
or AV Block
(ECG Jl _«Li J ff»j- »Jj)
Controlling
beta jy> cijh«J.i J"
Ventricular Rate (jJWl u. ^-n blockr
bradycardia & J''
Na,Ca,K Channel
Cardiac Dysrhythmia
Blocker ledical Cardioversion
As:
Jl oj^ JJajJ IjS(jUic
Hypotension
Amiodarone Atrial Fibrillation Action Potential
<ijte
Ventricular
Repolarization 2 (jc SjLcLoading Dose
AV Jl JISjj Maintenance Dose j Jjj-I
Tachycardia JU jajj 4JUJI j.JaJJjxal 4
Conduction
Page 67
Emergency drugs
"echanism
vm
Ingredient Action
Calcium Jl Aiî jjjjj

-CHF
Ljllll L5Li Jib »Jja.j<J1
Lanoxin Digoxin Jl Jj Jj JULj 60 (jc ji Aii!
•Angina i_uU11 ijijj
Contractility
Sxa.
Systemic Vasodilatation
- Angina
Leading To Decrease
Nitroglycerin Hypertensive
Blood pressure,
Crisis
Preload and Afterload
Relax Vascular Smooth

Hypertensive
.illajuIjSJj Muscle
Crisis ta j JJk-i JihTilM
Sodium Jl J%s Vaso Dilatation
VJSJIj jjSJI Jijjo
Nitroprusside Preload and Afterload
-Acute CHF «ajfc <bl jjjJlaJ! Ja
Dilatation of J«jj jLaSj
ide kjj»J
Coronary Arteries
-Acute Renal
Failure Diuretic JjJl j±»
- Pulmonary Edema (Inhibit Na & CL Reabsorption
Furosemide
-CHF In Distal Tubule and
-Hyperkalemia Ascending LoopofHenle)
-Hypertensive Crisis
Block Betal&Beta2
- Hypertension Receptor
Heart Rate-11 JliyiJ^j
Inderal Propranolol - Prophylaxis b£jj Contractility Jlj
against Migraine (JISja <UI 4JLiyU Yn. fill JIsja
jLic Oxygen Demand Jlj
Angina J' J^m'.nj IjS
-Acute Renal
Corticosteroid
Insufficiency
JljSJj
Solucortef Hydrocortisone - Status
Onset of Duration
Asthmaticus
Lu£jJI qa c jjj <cLjj
-Septic Shock
J jA -J âVI fljiluVI
Ji dyw
Multiple Sclerosis Corticosteroid
(J.ni jj 4 inl->
and
J'f-J
Solumedrol Methylprednisolone
Acute Exacerbation prolonged use
Jl CjVUj Anti-Inflammatory
difficultyof J*
Acute Spinal Cord breath"
Injury
Page 68
Emergency drugs
Active Mechanism Of
Ingredient Action
Mainly In Allergic Glucocorticoid -

Decadron Dexamethasone
Anti-Inflammatory
-
Condition
Avil Pheniramine Allergic Reaction Anti-Histamine Enlarged Prostate
Jc ij jjajj jA
Hemostatic
Phytomenadione •Jj Vitamin Kl
Konakion (To Control
(Vitamin Kl) Jl aj'hfi'i J JcLuJJ -
Hemorrhage) Clotting Factors

Vasoconstriction lU*jj
Platelet jUSJ^j
Hemostatic
Dicynone Etamsylate '-isjj* Aggregation
(To Control
^jjjjl -
Hemorrhage)
AJJ—aJ J OJjjJ <iLja^Lj
Clotting Factors Jl
J=xja*l
Cyclokapron Inhibit Fibrinolysis CLlVbi J <uJ<nnml xial
Kapron Anti-Hemorrhagic
(Tranexamic Acid) ijj U-liJl tLulSj "Mil
Subarachnoid Jl
Hemorrhage
Muscle Relaxant Cholinergic Receptor CJS j] VI Jaxi V

Antagonist
^_jSjjA j] AImUajuA Jc jL-ajjjA (jiajjA\
J Relaxation J«jj
Endotracheal Tube Skeletal and Jl JS ^ l Jj Ventilator
Tracurium Atracurium
Smooth Muscles
or Mechanical
Respiratory Jl bj Lu -J JU. Jjialc iljjl b
Ventilation J" jL*Jl J*j Muscles ^liAMBU

<L-aaJ Jib jjb JjjA
Ali JjAij Jslu Jaxj

Sedation Enhance Inhibitory lillaju (jSJl-a
Dormicum Midazolam
Respiratory
Seizure Abortion Effect of GABA
Depression
JjSlI (jiujj Ja*J V
Benzodiazepine ^Lj Receptors Jl Jiiy <U7 <Oa l*11U Jli

Antidote Benzodiazepines Jl .-Mb*J Jâ
Anexate Flumazenil
( Dormicum GABA Jl ^ Jblbj Respiratory
Antidote) Depression
Page 69
Emergency drugs
Active Mechanism Of
Ingredient Action
Contraindicated in
Essential in Physiologic Renal Failure
Potassium Potassium Hypokalemia
Processes 4_Ja*J J^L <LuaJUA jJ -
Peripheral Vein J
Increase Serum Calcium

Hypocalcaemia and Stabilize Cardiac
Calcium
Calcium muscles Leading To
Dysrhythmia
Gluconate Hyperkalemia Increase Cardiac
Contractility
j -«q'.^ *Ala M^l Jli -
Afi Peripheral aAoi
Jl Jliai 3 ojjSj (_w Gluconate Jl o^ Phlebitis î«j l£"
Calcium JJalc
Calcium
Chloride Arrest J~=»=>j l£" Shot <bJ=>ci jlj Gluconate
^ 'J** Jaal fji -
A\cjxjil Ajjlacl jJ (Ji
Arrest lL^j*
f»l jV Torsade's- Blocks Peripheral

jj-cai: aA LiJUj-kii
Magnesium a T11 " ,f"-LaJI Neuromuscular Anticonvulsant of
Magnesium -Anticonvulsant
Sulfate Transmission, Produces Choice in eclampsia
Sulfate - Eclampsia
Jl jILuj <UV Anticonvulsant Effects
Seizures
- Metabolic Increase Serum

Sodium
Sodium Acidosis Bicarbonate (Increase -
Bicarbonate Bicarbonate - Hyperkalemia

- TCAD Toxicity Buffer Stores)
Succinyl Depolarizing Skeletal Jasuj <U7 <b* Mi Jli

Succinyl - muscle relaxant
Succinyl Apnea
Choline Choline -Anesthesia Drug Muscle Relaxant
ICP Jl Jjjwj
Juuj 4JV 4iaMl Jli

Seizure Abortion Enhance Inhibitory
Hypotension and
Valium
Diazepam Muscle Spasm
Effect of GABA Respiratory
Agitation
Depression
Page 70
Emergency drugs
Jl unSJj 4iV --1.H . .A..

-Mucolytic
Acetaminophen Sjjj>jJI Bisulfide Bond
Acetylcysteine Overdose
Secretions Ji J
- Nitroglycerine
Tolerance «JJ ULk;j JJI j
loading dose -J Jjjj
10-15 mg/kg
Anti convulsant
^\c (Jwuj IjS J*Jj
Lgj3 Ja'...4jj^ Jji jphelepitis
maintenance dose 3tb^ Jlj*
Phenytoin •VI J t -. I
100mg/8hr .USh J*lj **al*

Status
J=ii jda Jjb-a Jc Jujj <Ulau la J*j jj\ (j<ujS
epilepticus VJaj JJJlaj u*Zuuj
%5 jJjb Jc J^ Vj
'min ^^«jj
-kjjjj airbubbles JjSjj <iV
More selective j*
antidote of
- Bleeding GIT Jljt
sulfonylurea
dostatin Octreotide esophageal vasoconstriction lU^h
(as amaryl)
varices ^jjj JLULj vessels Jl
£iUl ^VuiM «. ijj bj
Jljjll <UU. J LJjjjll
type 2 D.M
methanol Jl Jjj*j £j«jj

Methanol or
fomepizole lsjj formaldehyde Jl
ethanol toxicity
Ts-ail 0j.>i<ill *LabJI ajLJI Â
Page 71
‫‪" Pain is perfect misery, the worst of evils‬‬
‫• ‪- John Milton‬‬
Narcotics
Narcotics
Pain control
Opioid receptor agonist
Jl v-jVU J l^î. causing
Morphine myocardial Inhibition of ascending
infarction nd hypotension
pain pathway
cancer J' ^jVU. jUSj fJVI JlSl jiuj JUUj
Analgesic
Bind to
JcbiJJj (5J3 J. i a synthetic material of
(_sl !> L)<ll>*lll J^ Opioid receptor morphine
tramadol abjjl J Jjj. i'n (jo 4i*.7n At '• ini sJla j*
il*jA\ Causing inhibition of
(jjjj><jl
ilLLV Ja.'.Mj.l liLpJj ascending pain pathways jjaJI Jji (>• 1/10 Jxaj
i_l1 inV.VI Sjj3
Bind to
Opioid receptor
Meperidine Acute pain JjjUljoll /JA j jii (JjSjjaII
Causing inhibition of
Jl Ijl qa1/8 Jiu <UjSj
ascending pain pathways
Opioid agonist
Pain control and substance B Jl JIsjj jbSj
Fentanyl Jl JC <ljluuJl SjUll ^Jj
sedation
pain transmission
jJVI iliajj IjSjj
Kappaopioid Jl Jc
analgesic j* Ij%j receptor
Jl (jaVU Jmjj J
Partial agonist
Nalufin nalbuphine HCI mu opiade receptors
Pain control
antagonist of morphine «aiJJj jij>Ji jjiu Jliu, juiibj
J»j jjSjib Jaju ULi lala Pjlia
jJÎ Jjji* US liUV ojijjoll
Page 72
‫‪rugs‬‬ ‫‪• n‬‬ ‫‪r*r\.n‬‬
‫*‬ ‫‪:jff‬‬ ‫^‪r‬‬

Drugs preparation
Drugs Preparation
Drug Concentration Preparation method Recommended dose

fljjJI jjirtVill 4Jbja 4\iM<Ml4SjaJl
Dopa dose:
1-3 mcg/kg/min
200 Mg in 50 ml NS
Beta dose:
Dopamine 200 mg / 5 ml
(^b 50 Jc JjJ) 4-10 mcg/kg/min
Alpha dose:
>10 mcg/kg/min
250 mg in 50 ml NS 2-20 meg/kg/minute
Dobutamine 250 mg / 20 ml " 20 meg / kg / min is the maximum
(^b 50 Jc «JjJ ) dose recommendedby ACC / AHA
and SCCM"
4 mg in 50 ml glucose 5%
Nor Adrenaline ( ls^c jj£J)
4 mg / 2 ml
(Levophed) 8 mg in 50 ml glucose 5% 0.01-3 meg/kg/minute
( LJcbja* JdSjJ )
5 mg in 50 ml NS 0.04 - 1 meg/kg/minute
Adrenaline 1 mg /1 ml (^b 50 Jc (j>i 5 ) " veryhigh dosesfor refractory
100 meg J1 csjJ»*(JU1 Jt CiAAw hypotension "
Loading dose: 300 mg over 1 hr then

Amiodarone 300 mg in 50 ml 10-50mg/hrover24hrs.
(Cordarone) glucose 5% over 1 hr
150 mg / 3 ml Followed by
In atrial Maintenance dose:
fibrillation 450 mg in 50 ml
100-200 mg/day as
glucose 5% maintenance
30 mmol in 50 ml NS
KCL 10 mmoI/5ml
(^b 50 Jc Jjj-i 3 ) -
0.4 mg in 50 ml NS
IsoPrenaline 0.2 mg / 5ml (j£j3D 5 /1)
2.0 mg in 50 ml NS
-
( lS^& jj£J )
Usually thick but when diluted

Nitroglycerine 50 mg / 5ml 5-200 meg/minute
lOmgin 40 ml glucose5%
Page 73
Drugs preparation
Drug Concentration Preparation method Recommended dose
fljUl
Sodium
50 mg / 2 ml 50 mg in 250 ml glucose 5% 0.2-10meg/kg/minute
Nitroprusside
3 amp in 350 ml NS
5mg/kg
Aminophylline 125 mg / 5 ml over 30 minutes
then 0.5 mg /kg/hr
then 1 ampin 125mlNs
Bolus of 0.4 -0.5 mg/kg,
Usually not diluted but when
Atracurium 50 mg / 5 ml followed by
dilute it use glucose 5%
0.24-1.2mg/kg/hour
Loading: loading
Amp in 50 ml -> 17 ml 1 meg/kg over 10 minutes
Dexmedetomidine
200 meg / 2 mL over 10 minutes
(precedx) Maintenance:
Maintenance:
0.2 to 1.4mcg/kg/hour
3.5 -25 ml/hr
Administer undiluted by Loading dose:

Diazepam 5 to 10 mg
5 mg / ml slow IV push as Rapid
In status
amp is 2 ml injection may cause respiratory May repeat every 5
epilepticus depression or hypotension minutes
Loading:
loading:
4 - 5.5 amp in 200ml NS
Phenytoin 250 mg 15-20mg/kg
over 35 min Then
then 100/6-8hr
100 mg/6-8 hr. over3 min.
1.5 million unit in STEMI
50 ml NS overl hr 1.5 million unit over 1 hr
PE
Streptokinase 1.5 million
1.5 million unit in
units
250,000 U over 30min
50 ml and give 8 ml
then 100,000 U/hr
over 30 min then
for 24 -72 hrs
3.3 ml/hr for 24-72 hrs
Page 74
‫‪Patient's 10 Rights‬‬
‫‪tj-JhJt .A‬‬
Patient's 10 rights
Patient's 10 Rights
Patient's 10 Rights
iviaj vail ajjjl iya .jSIjJi

Right Patient's Name
<jlj.jl! Jkull (JA jSlllI

Right Medication Name
(eg : epinephrine - ephedrine ...)
 -^^'
Right Route
(eg:SC-IM-IV-...)
Right Time (iljJI pLkcl L-lij JA jSlllI
oikbA ^giil oljil o^Jli AJjjus ^ o^J^' (J9ak

Right Patient Education
(eg : action - side effects )
Right to Refuse t.\j-jll JjLjj <Jfrj aJlC. ^ ^vajJAjl (jj^ f'j^'
xilol jl o.li.1 jiajjxll J* J^-^J flj-jll UJ? '""' °JJJJ"'a

Right Documentation (remember that no documentation
means not done)
Right Assessment t\jAjI fLkrl 1- lj J l" j"-*'j«U <UI-J »'•>-. ^.'1 xIjSjjI
Right Evaluation (^VOjJîl <ULa. (_5JD oljill JJjb aJJlli
Page 75
Routes of drug administration
Routes of Drug Administration
Classification
Systemic
Local
Enteral Parenteral
Oral / Ryle Intradermal Skin topical
Sublingual Subcutaneous Intranasal
Rectal Intravenous Ocular drops
Intramuscular Mucosal, Throat,
Intra-articular
Vaginal, Mouth, Ear
Intra-thecal Inhalational
Intra-osseous
Page 76
l> ^jL Û jb-aiLb (â ^Jll Dermis -II aLL Jib ViVn Injection l> '"J^- (J*
Just Below The Epidermis -M
among all types of injection oÛûyi ^ £jj UJ ^
Jl îiVbJ Sensitivity Test lU& J Jaaa <L«iu<j Ul b ^jill
TB, Drug allergy (Antibiotics), Tetanus Test,
LjUaJaill (jjaxj oUacjj Local Anesthesia Administration
Inner Surface of the Forearm -II > *Ua&û^ J-îj
Lesions, Rashes or Scars Wa u^ ^^ J^ ^Mj
jbjiVI Aajlij Aijx^ libit i it,r\ ^Jui Jia jLuif.
(jjja.la. Jaa.vbA (jJJaJJJ lLuIj pJIIV
Dermis Jl '^> J <Jjl JJj u jiai l_uIj Resistance ^ u! M^ <Jj'

Subcutaneous Tissue Jl J Jaj jjiajij dijlj (jjSJjj Bleb jj^j j* ajjUII «U>UJI
Epidermis
Dermis
degrees
Muscle
Subcutaneous
Page 77
Intradermal Injection Performance Checklist
1. Wash hands and wear your gloves.
2. Withdraw 0.01 - 0.1 ml of medication into insulin syringe.
3. Identify the patient and explain the procedure.
4. Select injection site : (the best site is the inner surface ofthe forearm)
Avoid bruises, scars, edematous areas, masses, tenderness and sites of
previous injection.
5. Use antiseptic swab in a circular motion to clean skin at the site ofinjection.
6. With your non dominant hand stretch skin over site with your forefinger
and thumb.
7. Insert the needle slowly at 10 - 15 angle with the bevel up,the needle tip
should be seen through the skin.
8. Slowly inject the medication resistance will be felt.
9. Note a small bleb under the skin surface.
10. Don't massage or rub the site.
11. Mark the site with a pen and wait 5-10 min and reassess the site.
12. Remove your gloves and wash hands.
13. Documentation (date, time, medication given and any reaction signs).
Page 78
Subcutaneous Injection (SC)
jLualib ^ Jl\ Adipose Tissue Jl ^JuL Jib UâJj injection Cf- *J-P J*
Just Below the Epidermis and Dermis -M t> ^ bJU
:J* d&w k* Absorption Rate Jl ^Jj Has a Few Blood Vessels ip "<&*& UJ»
• The outer surface of the upper arm

• The abdomen (from below the costal margin to iliac crest)
within one inch of the belly button
• Anterior aspect of the thigh
• Upper back
• Upper ventral gluteal area
Anticoagulants Jlj ÎjjLi Insulin Jl j* SC UJaxij^Jll jsaJl Îjji j^\ buL
Page 79
Subcutaneous Injection Performance Checklist

1. Wash hands and wear gloves.
2. Withdraw medication into insulin syringe.

4. Select injection site: the best site is around the abdomen and lateral aspect
of upper arm or thigh.
5. Use antiseptic swab in acircular motion to clean skin at the site ofinjection.
6. With your non dominant hand pinch skin over site with forefinger and
thumb.
7. Insert needle slowly at 45 - 90 angle.
8. Quickly inject the medication and release skin.

9. Don't massage or rub the site.

11. Documentation (date, time, medication given, site ofinjection and any complicatins).
I I •t
I I M<
FRONT BACK
Sites of Subcutaneous Injection
Page 80 -
Intramuscular Injection (IM)
Muscle Fascia Jl ^Lk Jib Uiaaaj Injection Cf- h^ l^
Faster J& UJ Absorption Jl JMLj Has a Rich Blood Supply & ^^l M»
SC JU AjjliU
^yA <>UaC.)fl jSUI j<jJii
Upper Outer Quadrant of Buttocks
Deltoid Muscle
Vastus Lateralis of Thigh
Ventrogluteal Site
Dorsogluteal Site
Tt~iig|-| /Vi i t i
The ttudknt part ol trx-

n 2 SSom (13 hnê. t
»** the rnadaaottary Kne.
Hip Buttncks
Page 81
Intra Muscular Injection (IM) Performance Checklist

2. Withdraw medication into syringe and remove all airbubbles.

4. Select injection site: the best site is the upper outer quadrant of buttocks and
vastus lateralis.
5. Use antiseptic swab in acircular motion to clean skin at the site ofinjection.
6. With your non dominant hand pinch skin over site with forefinger and
thumb.
7. Insert needle quickly at90 angle and keep about 0.5 cm ofneedle outside
espcially in pediatrics.
8. Pull the plunger back 0.5 cm ( aspirate) to make sure you are in safe region.
9. Inject the medication slowly.
10. Don't massage or rub the injection site
12. Documentation (date, time, medication given, site ofinjection and any complicatins).
(IMonly) iS^c V) ii.jp V*jji
Alphachemotrypsin
Page 82
Intra Vascular Injection (IV) Performance Checklist
l. Washing hands and wear your gloves.
2. Withdraw medication into syringe and remove all airbubbles.
4. Select injection site.
5. Apply tourniquet 4- 6cm above the selected site and ask patient to open and
close his / her fist several times.
6. Use antiseptic swab in acircular motion to clean skin at the site of injection.
7. Stretch the skin taut and stabilize vein with your non dominant hand.
8. Insert needle slowly at 20 - 30 angle with bevel up.
9. When blood return is obtained decreases the angle ofthe catheter to 10

degrees and advance needle carefully.
10. Release tourniquet and inject the medication slowly.

I. Remove the needle and press with dry sponge on the needle site, But Don't
rub or massage the area.
12. Remove yourgloves and wash hands.
13. Documentation (date, time, medication given, site of injection and any complicatins).
Page 83
Bone marrow-II J^ «J^ Ujiajj injection t> ""J^ l^

to obtain vascular access &>H J£ oLa ajI ai^ 1*11*1*
jbit J& diSj <&jb Vj Vascular Access «=2L.IjS jiy^j lsj! Critical <^ dfe. jl ji
CVC lhVjjjjo: ujajj liljj ^ Trial t> j$ ^
JUJaVl JuJki U-al-iii-il L-llfrlj
Systemic Circulation Jl JibJjU& Ûj Medication Jl J Fluids Jl Ji^ l^^>Hj

^ u^ Intravascular -SI **>* o^Wjj£j Intramuscular Route Jl i> £>J ^J
b* JJS cjSj yi Fluid -SI i> W"»j*£ ^£ .^ Û e^ W IV Route -Jl t> cM
Circulatory Collapse <&s& u! û c^ ^!J ^J l^ ^j
0aiJa\\ jjj ^ pUj lAjUiil fit J\j UicUb Cannula -U ^^ ^^ 3 -4»
3 Needles
P5—«K» 15 mm 3-39 KG
25 mm > 40 kg
45 mm >40KG
Page 84
Checklist 4â Jia Routes ofDrug Administration -SI l> b £jJI

jjjS. 4_£j4A J>a jl <c£j4A ^Jll dljl Jia i_JUll ^ jV
<Ul<$JTJ (jbiic. Jjj^JI (__b»J (_J& (_><1J JLaJ*A (jaJj
But I am sure that you will master it at the bedside my friend
Page 85
Jl jUoji ^ju spinal Canal -SI J*^ sjÛ* UpiiaJj Injection l> »jW& is*
iaaa JJ-jiJI ÛJal Uyjlilmjij 1.4a. Limited UÎ-jiU UJa
Jl bUb fjj -Ljji t5L«j jbk. jjiu UJUuLLil lJUJI ^
methotrexate - cytarabine -
Chemotherapy
hydrocortisone - thiopeta
^L.',.„',, HI Ui Jj.1 -iijjl 4 Jl LaA Uj iSj
chronic spasticity due to intrathecal baclofen
injury, multiple sclerosis and cerebral palsy injection
spinal anesthesia heavy Marcaine
pain management intrathecal morphine
Antibiotic treatment adjuvant to systemic Gentamicin

antibiotic therapy in bacterial meningitis and intrathecal injection
other infections of the CNS
? LlllJU (Jl AJbjlaSU Jl 4jJ.jVl (_<Ja*JJ ^J 4-J=
Blood Brain Barrier -SI J* uî && <MI J*^ J* ^ %>!' o^
. Jl LJÛJI ,J <UjU AJjjjL J (ja JjJaaij £jjj UjiV 5ibjaVb <Uj$joiJ £tJJ Jâj4A JUlUj
Page 86
Insulin injection
Notes on Insulin Injection
1. Sites of injection
1. abdomen (peri-umbilical) (o^^^\ t^ )s>Jl tJ> r15

2. Back of the arm fcj^j ^-^ us '^^
3. outer thigh
4. upper outer quadrant of buttocks
lipodystrophy &bad absorption ^j^ ls^

bja J£ jiiaJI jli* JJ4*J L_iaJ
In abdomen & buttocks
jjcjjJ JS lb*L. bj u jll. â.j4 djjaj rotation lsJ^ J^ j*3-* u^j-Si

In arms & thigh
Ij£Aj ajljaj jaJJai i^JJ ai LJaJl <jjS j- 4J& Jâaj J**l -Sai f^JÂ
2. Routes of injection
1.SC(main route) JaJic^ jiaJi

Jîi jSajj <a.jj 45 ajjI jj »jjyi lK^j pinch ofskin ^^
2. IV or IM û^1 j' L^3*]l li-*1, ^ ^

jbja*j| (^> j* <Jiaj jl« Actrapid -Jlj ( lÎjSi humaline R ) î cJj^]
DKA -SI l5j LsjljlaSI oVU J iijj\ J
Page 87
Insulin injection
3. Insulin Vial
In mixtard &intermediate insulin (e.g, Humalin N) vial

1.44a. gjjjl JalaJ jJjjaiJVI '_".." Jjii jajJI jJJ Aji.la.jll liljS m^
jJjjaiiVI L-la-u: qa ( it in'i <JjA dlftlaa jjSuj V<_sJa. <la.La.jll ?7j pJaa
4. Insulin syringe
There are two types of insulin vials
40 lU/ml ii^j 40 <ui J- 1 JS Jixj
100lU/ml blSLJ 100 ^ J- 1 Ul cyJW
There are 2 types of insulin svrinae
40 units syringe -ULî 40. Ujj
100 units syringe <i=j^ 1oo y>
40 <J?JJJJ (ji Ajia.l 40 jJj^l ijasJl ,^44 bJ

100 ^J" ^ Aiaa.l 100 jJj^Jl ji^b âai UJj
100 <U*JJ" J 40 jJjîl CjS^ dujiajJal J
(dj£j j^^-* t^y °j^ <^J_>" (ji jj**-a jljj)
2.5 J dll.Ja.jll lie <_l j.îlft
100 Aa-i>jJ ^ i_hj 40 jJjJJÎ l> »-J*-J 20 L?J JjL& ; y±A
(AaJjjJl j^jj) SJia.j 50 Jl\ Ju
40 VlJJJ. ^ 100 jJj^jl Jl\ LllJjlajJal jl
(ojij-aj jja-Ua^s iJm ajJ*j-o AaJjJjJ J jjjS JJ^Jj)
2.5 l^ dilaa.JI J^t pmlaA
40 ^jj" c<J lw 100 jJj-»Jl j- s-^j 20 lsî jjic : %A
llll.4a.j 8 Jl\ Jaa
Page 88
Insulin injection
jJjmjVI (J-mii Jjg in'l
îUA sljfrll jia.1 JUII J ojjVI Ji^J btlj -LjlJaJI jJjjjjJYI *u^ J3 ^ pIjA <.i-,mifr,
AaJjjJl j* £jUJI "jljfrll V*^ U^ J-^W jiSj^^l
5. Insulin Storage
JjiLtll jJjjjuVI Jba .1
.Ua-ib-all <iUbjl jjjU (jja. -Jaia. jltJj <UOU]l ^ Jaiaj ji t_Jaj

f-jjLall jjljuaj^l JUa .2
( *ul*ll (jlc JUill £s*i jyjU <jUS. JjJaL ) AaJii iu jjJj a-ltl jilJijbujU Îbâ
jSaJI jba ajjil Aa-iUll -T jLi A£ji Jjaii (joLill uJasOj iUll J AxjJaj L-JaJj
jiiaJI -J4C. Jl '.'.""J.' -jjUSI jjSj^VI j^
<UlbJI ajl jaJI Aa.jJ ji (JjjalJI AjJaJjaJ ji JJJjill J JUill âj f-Jaa ,3
6. Lag time
Lag time is the time between injection of "R" shot &onset of action
l^ . •, A_il:iJj L_ib_ia.jSI J_J3 jOJ' ui* ^j—j]I Jj-JubJI <*JJ—« A_JiaJI jj_) aj—jill
L_$Jfr Jj-JtJjJ (J-ai •- J—^ !(!.' "'M.' î—Sj J—^V U^ "•» U-^ ' '« S*i" ^s—Aj
Aja. all Jl3 A&Lul • '«. "'i /JujJ IJLc. (JjiJ
Page 89
‫‪Lidocaine in ICU‬‬
‫|‪a-^j* jWIkoj 4<a«,‬‬

Lidocaine in ICU
Lidocaine in ICU
Trade name Xylocaine 2% (vial 50 ml)

Onset < 2 minutes
Duration 0.5-1 hour
Maximum dose 5 mg / kg ( not to exceed 300 mg)

Maximum adult volume 15 ml of lidocaine 2%
Adrenalized lidocaine
(i \iin\\ -jbjj) jâJi jjjU ajii eijjl epinephrine ^Jj <-ju^ juSjjJ jc *ajU&
vasoconstriction cause slow absorption &J* l>
jijio jji adrenalized lidocaine -Si l«j-& u^
^j jSU 3 ^ adrenalized lidocaine -!i JUmU £ji~.

Fingers - toes - penis
vasoconstriction Aj^-j end arteries Jc ^^ l$* d£U> *i jV
ischemia &necrosis J! cPJ« u^" ^ o^ i/l
•jjjfîjJ ^ 10 <j\b 63J-XU Jo 1 JS vj\iaj %1 jjfijj 0^.9^

(^J pô 20 =Jo 1)Jo 2Jl LJlc 3a jjJI ^ fcbbJI j^>JI
Jo 15 =îo5> ^jw-tfl li! /^° 300 Ljoliijjujl oôj &j> ^rS\ cJ ^
Example
Child weighting 10 kg. What is the max volume of lidocaine 2%?
Jo 2.5 = p>o 50 =^ I*>a 5 =6>oflJI 4c>sJI
Page 90
Lidocaine in ICU
ICU Jl isi flUiajJ
Local Anesthesia -£ a1«1ou Aa.u Jji buL

u^j-il Painful Procedure j Jâ ji jjVjji- ±&j& J
Conscious j^j^ ABG '<*&• Lâî* t&l aIU ^
jiia.La. jbic jJjuJl AaJjjjj jySjjJ AJajJj 30 eLkcl '.'?'
Lidocaine *$& k+ Painful & sM <ji: Vji
Jii SjjVI jjj bt jja^ t_4a-uj ciua. jli involuntary UuL artery Ji jl : UjU
jaSjiA LiiJaci j] Uji i_ja^j Uij»ja ji* JuiUj constriction J-aaj* artery Ji
j-1-43^4 (JIaaj 11jii .JcUj flow Ji JuiUj constriction JâÂ Jia ji AibJi ^
ajj4a ?j aj^s radial artery Ji
J«iui4 jfb« continuous pain °^c ^Lb ^jJi jl Alia, ^j

analgesia -li l> t-^ lidocaine infusion Ji
^k. ^ ALajû antiarrhythmic drug ja WL

<^j ventricular dysrhythmia Ji
myocardial infarction , cardiac manipulation or digitalis intoxication
PVCS JJ%JJ-»H Jc CLuSj j].JJ.lI Aj>la. £jj
Page 91
‫‪Mixing Drugs‬‬‫‪m‬‬
‫‪^MkJA‬‬
Mixing drugs
Mixing 2 Drugs in One Syringe
6.42Jj AiUJJai J Lgiali. j5b«J ^jjll AjjJÎ J^J-V <Ulai
Zantac + Dexamethasone
Zantac + Primperan
Zantac + Visceralgine ( Buscopan )
Primperan + Dexamethasone
(jbajJAll g*J& ciB CuajjJi (jjiii J UjUaC-l *±aj Ajjî
Drugs Rational
Tetracyclines are bacteriostatic and

inhibit the growth of bacteria and
tetracyclines penicillins
penicillns work only on actively
dividing organisms
= sever chest pain and prolong QT

Azithromycine antihistamines
interval
Ondansetron Ondasterone decrease the analgesic

tramadol
(Zofran) effect of tramadol
Iron Iron need acidic media to be

Anti acid
(in pt with IDA) absorbed
Page 92
Mixing drugs
Drugs Rational
Metronidazole inhibit metabolism of

Metronidazole
Warfarine warfarine that may cause fatal
( Flagyle)
bleeding
Furosemide
Gentamycin May lead to hearing loss
(Lasix)
Non dihydropyridine Both of them cause sever brady

Beta Blocker
(verapamil) cardia and heart block
Both of the cause vasodilatation

Sildenafil Sublingual
leading to sever hypotension and may
(viaagra) Nitriglycerine
be death
Nefipidine
Both of them cause vasodilatation
(any drug with Nitrate
and sever hypotension
"dipine")
Antiplatelets or
Omega 3 Cause bleeding
Anticoagulants
Statin Gemfibrozil Increased risk of myopathy
Warfarine Nsaids Increase risk of GIT bleeding
Page 93
‫‪Abbreviations‬‬
‫‪<*vii‬‬ ‫‪.~*it‬‬
abbreviations
Drugs Abbreviations
Abbreviation Meaning
Amp ampules (Jjftl
Vial vial JLja
inj injection (£»
ID intradermal JaJI^
SC subcutaneous JaJI CjaJ
IV intravenous LS^JJ
IM Intra muscular Jôc

SL sublingual ^jLlJJI iLjiJ
local local (jJâjA
rectal rectal iS^J*

inhale inhalation jl nil'ml
PO Per oral f*J! (JWjl3 jc
supp suppositories o»J
syrup syrup L-lljui
cap capsules Cjijmii,
tab tablets U-aljSl
cream cream H*
Oint ointment ^y
jel iel J-
•^ 11 i\ i\' •y^'-
MO Mouth wash
U'o.'^
dp drops
NS Nasal spray OibU j-Uu
eff effervescent JJ
Powder ijjjj
Pd
sach sach O-bal
od Once a day *jjl ^ "Ua.1 j SJ*
Bis in die
bid fj^SI l^ u^J*
(twice daily)
OD Over dose Jobj Ac ja.
LD Lethal Dose jjjla<bji
Ante meridiem la.Ui.i*i
Am
Post meridiem bLuLQ
pm
PRN Pro re nata ijjUl jjc
Sos Si opus sit
Page 94
‫‪i— Chapter 3‬‬
‫‪ECG‬‬
‫‪Interpretation‬‬
‫‪ECG‬‬
" The golden rule, is that there are no golden rules "
- George Bernard Shaw •
/
/
ECG interpretation
History of ECG
fbjfjSJI <l<ua ij.ii-.,; jjlc. jlSj dbjfSJL Lb«JJ ûi»JI jl jbuJVI t-iuiiSJ
( galvanometer) j4>jjU1?J1 a*J jb^. ^jlkli LjaLsjIj ^j
AJSbS ^jJc oJjji.jJI jJJjVI JUa. ja (_jj *bj<j£ll Sii bajauj Jlga. b
jjjjjl 4_£ja. ab^jl tj^jla j-c (ibjj^l abajj (j-iajxJJ jbaSj jL$aJI
ajj Jlj diLi (}ac b (Ja.ljJl ( vvillem Einthoven ) a*J jJLc <*]]= loS. iu
6uai
j^Lajj b jlwjjULJI jig-?, ^jl ( jjjjSJV! ) jj£LJI l_>U. Ji,Vr»b jA
Left arm Jl Jc j\i\\ ijjm\j Right arm Jl Jc ijj&\ lUj (l)

(lead I) obujij j^jjj jâJi jjj jJij
Left leg Jl Jc ^jUI jjjISJVIj Right arm Jl Jc jjjjSJI J^j (2)

(lead II) obujij ^jjj jjaJi jjj jalij
Left leg Jl ,> Jbll jjjSNIj Left arm Jl ,> JjjjSJI lUj (3)
(lead III) obujij j^jjj j^JI jji joiij
Einthoven triangle
Page 95
ECG interpretation
( Lead 1- lead II - lead III ) b> 3lead Jl jc -^ »jb^ '**» 18 sj-1 ECG Jl cb^j
( 3 Leads -> ^ Uw ECG Jl aa- 18 )
fUaii 3 Uaii (Einthoven )
left arm J'j right arm Jl ox asU*1! jl) iSixAi jOLaVl tsjUi. cJj<JI jl j-ajji] (1)
Uai LuJa bj leftleg Jl leftarm Jl iy asLhII lsj^
<UaSj Ja -j...? Jill j^ Lias. Wa ,JJ <""Sj' J ^Jaiij L> 'jb^ M^' j! L^-A' (2)
<uj JLajill U UjI liver ajj jjaJIaÛ Lka. UjL bj JLuil-1 ^j jjaJIAja.U <jIjj$£jI ^jjjj jl o^jJi) (3)
VuiVI csj jii- eljjil (ji <>Ijj*}£jI JUjjI JUbj stomach / air
^J t-Lki-VI jSJjj ujUS Vj jiaic I960 Aiu t>J ebail jjjkj iU <_>Jjll JS tfi AjjU (jJ olLa-VI jV Ajiajjj
jjjbll b^j da-i Aa.U cJbc jU£ ja ( Wilson )*-*^\ (Jit jlL b£ j*j
jj j^ 4-a.lj lead ls-^Jj^ 3 leads -Jl £-***
AijjLJI j-iij Einthoven jSUI jjij J aLojj »j leadJl mW-j
acUj jjjjSJVI jl Jjj^j Right arm Jl Jc Jl JjjjSJIj Left arm Jl Jc Acli jjjSVl lUj (1)
Right arm Jl J J *bj^H "^ lW%* lW1 J J^ •jjjjsMI ty J-°a*i1kt>« Left arm Jl <>=• i**1'
VR (voltage of right arm )Ji J^=j J^> J^1 Ajj&M d* lw
jx.Lu jjjjSJVI j) ciia.j Left arm Jl Jc jz jjjjsIIj Right arm J1 Jc aÛj jjjjSVI lUj (2)
j Ji\ *bjî «^ lw^ J1^1 <> ^ Jjj^W1 Si) >-> AiLa^ Right arm Ji t> J
VL (voltage ofleft arm )Jl J*&>j >-= J® jV j-j Left arm Jl
<u.Hj jjjjSVI jl duij Left leg J' J J* JjjÎj Left arm J' Jc **& jjjî J^j (3)
sjj?.^ îli objî saJj ooyijA JL—ill J?.jli Jc J^\ jjjjSJVI b] j^ jjiL^^ Left arm Ji Jc J
VF (voltage ofleft leg) Jl J*^j J^ J& & o* Left leg Jl J
Page 96
1 ECG interpretation
aILlAi ^J dbj*^' ^ Jj«jj ljjI^ y&A right arm Jl acLu «.bj$£ll jj ^j aUu«\ aKAa J ljjI£ j£1j
( galvanometer) jL-^?JI >jS> .iij-^jSji-i (_£—> l_$ij a^jJ |j_a. *,<m ,n LjJj-^ Cj_il£a 'ij_s.lj
jÛuij j£ja\\ J\j*i jia iluî (_5J dbjfr^l Augmentation ajLc Jotj (Goldberger) jJ^Jl jibs
avR (augmented voltage / vector of rightarm
avL (augmented voltage / vector of left arm)
^ji jjjjilj jjî ^j chest leads Jl jL^VI ^jjs.1 IjS j*j

( bljjll JS j- L-JJill jjj-ojj ) bja oJjs.j^ ^JII JbajJI J <ibj^£Jl
Right Ventricle Jl Ijjj^=jj Jjj Vi- V2 bait

intra ventricular septum Jl Ijjj^jj Jjj V3 - V4
Left Ventricle Jl Ijjj^ Jjj v5 - V6
V1-V2 J JjiJt uW^ Right Ventricle Jl J ^ ischemia uO ^^"> J^s. J ajI lsixai
V5-V6 J jb> Left ventricle Jl J ^ J o^- J*
jLjsJI jbc 'dJa CibjSI Ijlbj
ij, jc "»Jac Single channel ECG a—I jLjjJI jlS ajIaJI J <•. Jaaa ajjjij jj&i aA LjljjJajll cliij
. J^ Lujij "Jjia iaJjJj J l(ji>i»..i LJJs. bJS leadS Jl axujl Jtt ^ o4s.lj
1»mw.hv ;<,*•«.'. v. i.-.f
I um .ml
!"»«»'
W1 SM
Page 97
ECG interpretation
0j Jlilb af**) i-a^ waves Jl Ij-^jw Ji 3 ajj Jli oJj 3 channel ECG Jl Ijbc IjS 4*j
m
II IT 1!%
. r IP
JX^~Mrrv-Y^'jr-
n. t—f—+—+ _U -0—-_-J_~—-JU^ "4"
iju f^jjj j^jsj AjuIj ojjjj Îc ljIjII Ijauijjj ^ 3 ] jj) 4 <ua 4channel ECG Jl LibiJa IjS o»jj
[ Lead II long strip
i *
i i jj-<^-
i i j j i i
hAL—-,_
ivK i-/vJrH^M^~
ju-j^- 4^l^^4^4--4^4-~
ji (;•>» a-io1t.,1I ij£sll jSlj j<»4.i,.i« yjtull jjJajll a^Jj liije. jâx. ^ Wireless ECG ^jJj <^j
Ajju j-a^/ls.
Page 98
1 ECG interpretation
ECG Procedure
ECG ( Electro Cardio Graph ) J-»j ljjjs. jl AJbii lis ^jj jjjjlc
relaxed ÎA j^jJI J±h Ui : Jjj\ AJaiUi
metal object j J b-uV jewelry j o^k

shaving J«ja Ja lJuj£ j*A jlj bed side rails Jl jAÂ*
chest leads Jl j£L°i : ajuii AiaisJi

r Vi. Fourth intercostal space right to sternum
V2: Fourth intercostal space left to sternum
V3: Between V2 and V4
- V4: Left Fifth intercostal space mid clavicular line

At the same horizontal line
V5: Left Fifth intercostal space in the anterior axillary line
Left to sternum
V6: Left Fifth intercostal space in the mid axillary line
?¥
<Gsj f^Jaîj breast Jl ^jj* Vj breast Jl 6J •jjjjSIVI JbsjA J* female aIU. jl i_Ja
(menopause ) a-LJI jJ CiL^j female Jl »j* t-AulS jli According tothe age : Ajb>Vl
as.U. ^l ^ l£Lu> jjU jAj Ija. ^jlc Aiji jjjj£JVI JasJ jlw, cAuijj Ja b This is not a breast
IjS jj^.1 ( Lactating ) Jbbi £âjA £ijI£ J b^ji-aAj JJ\ jj j;,-;!.^,, ^ caJi c_ul£ jl Lj)
J~j* b Breast Jl ^ ^ya.y J\\ JH\ jV ?? <ul ^ aiUj jjjjSVI J^jjj Breast Jl ^jj <OV
. Low Voltage <4clu ECG Jl J±aj Effusion
Page 99
ECG interpretation
Limb leads Jl jSUl : ttfll-JAMI
<J£ jJUII J AAb (Jl jljlVl ji jj% Aijjju. bJa
Green: left leg
Yellow: left arm

RA
flffl: right arm

Hfffl: right leg
JjâaaA AjsAs, jAiaj AjSjAo jAio i_Jjlc oi ?? J-as.^1 J-4 Jj^VI J.JJJ j^">
i_JjlLa '.'J* lilctu ECG J' IjS J^-aVl £* j*a.Vl JjA 'JJI js<" (J*« L-aJj
Jalcj
!?? jjj tflclA Lead Jl <->->->» Burn °Ac ji jjjjsA* %a j\ ( amputation ) Ji J*U jbJl jl ^Ja
Sjjibo knee Jl 6J <^jv z^ ^ ankle J -^ ^J^] ^-^ &*""*" MjS' Jc .... ^Vtfl
j^^j ajj jLjjJI ^ Jj-ajjj femoral Jl i> jjj&! -^ l?j ^l ^ â, J-^ jA J-b- jl lJ»
J tLjjSto Ij-bbi j^jV bj Bipolar Limb Leads <*^ Lead I- Lead II - Lead III L>Ac
SjsJj Akij J <j-bj<£ll Ijj-^jj j^jV Unipolar Leads pfc^'j JjJ avR - avL-avF bul
Page 100
ECG interpretation
1
Cardiac Conduction System
UjAuLii s.A nodeJl j* ^LbA *bj$^ll ajI^JI J
J *bj*£ll j>^±i IjS ixi ( pacemaker ofthe heart) Jl
J^sjj Bachmann's bundles Jl ijjj* jc Both atria Jl

AVNode
W*"! Jm *bj$£ll aaL (Jlj Atrial contraction
Moderator bind /> Lettbundle branch • ( pwave ) a^jII J j^JiA J\\j Atrial depolarization
Rightbundlebranch
bfrjV a<j_u.jll ^J j-jJaa Jua j^lj Atrial relaxation ( repolarization ) J i<-r>n \iS iû
. QRS complexJb masked jjÂ
. ( PR interval ) ls-^ j/jjj delay ajjA; bâ Jâ^ a.V node Jl £jjj »bj«jJl l-^ i*a
»4s.lj aLÎj UK J4.JI Bundle of His Right and Left Jl J&j *bjj£ll IjS j*j
J! *Lij«^l jJ^j Anterior and Posterior fascicles J jâa Left Jl bul

„bjj£Jl aaA j£Jj Ventricular Contraction J^^ jJaJI Jia. J JZZj Purkinje Fibers Jl
. ( QRS complex )Jl ljiac UJj-jj J& Ventricular Depolarization b^J
isoelectric period Ujûuj Electrical Activity J bja JJa Sjlj j.^n iji j«j
. ( ST segment) Jl ts*c bii«A ^1
LjAul *bj$£]l aaL j£1j Ventricular Relaxation J'^n JjAJc Uj*j
. (T wave ) Jl n&c bJA>A ji\j ventricular repolarization
Page 101
I ECG interpretation
Pwave represents atrial depolarization
PR interval brief delay of AV node
QRS complex represents ventricular depolarization
ST segment isoelectric period (electrical in activity)
T wave represents ventricular repolarization
represent time from beginning of depolarization

QT interval
to the end of repolarization
U wave commonly seen in hypokalemia but its cause is unknown
Page 102
(duration ) JlJj*jj bj liai jûA ECG Jl Aijj &*& LJ

(amplitude) «-bj$£]l so.! ^jjc JIuj bj 'bJj j-ojAj
%
j it .n LJUjja IaIjs. ojjjS lAIxjja 4<unVijJI

cJjj Ja 0.5 = 5 x 0.1AijS jjj£1I jjjJI Ûlbj
jV b JUJb positive wave J**} AAsb a^jIj «.bjg£JI ^1 olsJVI bub

j JLilb negative wave Jâaajc 4*jA ^Jll oLsjVIj
Y
JLnjyall Ajslj Ajils. J jj jijjitJI jj (_5Aiaj JLnJJI Ajsli (_5-^bi (Jaai '."'"" Ajjj(j£ oLsjI
Negative Wave c<J»j avR - Vx Jl lsj lW ^jsI. ^l Jblbj Positive Wave Ja*i&
^jxjjiall b Negative AAiil jl avR Jl p 'Jac a^.U. Jjl ECG Jc o-îx ^ J—as. J&
laic Jjxjui .ilclA ECG J' Ja Positive AAal jl i_Ja ( AaLsjI (jiiSc ) Aic 4*jA dsj^l\ jV
( AjjJi Jja UjSiiA ,^111 ClVlsJI (ji»j dljAAab )
Page 103
ECG interpretation
1
• |j i_iujjJ| (jaili I^jajjJa ECG Jl ^JJ &A*A loj"
(1) Rhythm
(2) Heart rate
(3) Voltage
(4) Position of the heart
(5) Axis
(6) P wave
(7) PR interval
(8) QRS complex
(9) ST segment
(10) T wave
(11) QT interval
Page 104
ECG interpretation
Heart Rhythm
(regular) AaLaa ijjâi ajJsL. i_Ji,l cLjja J* LJjJii ^1 am jj,^,"^ Rhythm Jl

(regular) A<Jaiu ijjâi 0ji <ul bJa ^jujAJIj (irregular) aJaaa jjcSjj^ Vj
lw lead c«i LijJi 4js.j* Ja jlj lead II long strip Jc jâ Îa^ Rhythm Jl >,>»•** jLic
Rhythm Jl Jc ^ jii; jbk. objâ 3 j* j£\ aJc jjSj
tt Rhythm Jl ^ tflj] ^
cjlaLJl ljjsJ jl (ji«jija. ( r wave) jjAI jjj (ljUjjJ jjc) ljUUJI j«iA &\ jjjL jc
irregular rhythm (JLy ajjLa> Ja J, ujL regular rhythm b Jjjj ajjLa,
ajUJI jyn, j*xi Ljis. ( r Wave ) jjAI jjj cjIjUJI jî bus. jl ^j Sjj^l ^ Dii.
jLS ljUjj.. 4 AAlillj AAbll wave Jl jjj ajUJIj jUS ljLuj. 4 ^jLA waVe Jlj Jji jjj
WâxJj Waves J' j" AjjbA, CiliboJ bj bSftj SjjjS Cjbjjc 4 ^j AjuIjIIj AjIUII jjj AJLJIj
regular rhythm ajI oj rhythm Jl Jc JjA Jblbj
jb^ ja*aja) ajjLjAL. bâxjj waves -11 oh ^bLoull jV regular rhythm jb«S ^4Sjj^JI
( JâgJAj
Page 105
ECG interpretation
: jjAj jAjU. J irregular jJ^ l£" regular jjx *JcLA ECG Jl j! cr*^1
I
Atrial Fibrillation : JjVl aJUJI
Premature contraction : âÎ ^jAsJI
Atrial Fibrillation
5j- 200 j^- mj-^ Atria JlJX* *bj*^ lj*byj ^ Atria J' J >*y>y> Foci j- j"^ *J o\ ^
Fibrillatory Waves Uj-—-w3—^j u—a^** J—^j ;l-u* PWave ^^ '.4_^.lj ^j lw—»-j
irregular Jm IjS jbic Ventricle Jl AAljJic ^ sjaJj ^j »j JS1 delay lUj AV node Jl ?J&
?? Jj\ bij»A
<bjUL. jjc ^ bjaMlA l^-ajuj waves Jl Cm •^L^ o*& ^! briJ^ j6 -
Fibrillatory waves LJIjj J^j* l£1j Pwave J'^ J* -
jj Ja Ajlbllj AAbll Wave Jl cm AiLuJl ^j jA. Wave A Jji jjj AiLJl ^j Sjjj-JI J %a
Fibrillatory Waves ajj j£1j pWave Jâ jUSj AjjUA. ji. l^JS olaU-Jl IjSaj a*jIj!Ij AjJbll
Atrial Fibrillation 'Ajj*- a,^.** Jjialc b
; 1 1 I j ' Fibrillatory waves

"ii.ii'i m
Li mf
Fibrillatory waves <J> j£Jj pwave lA^j ^jLai* jjc l$K lAbl-Jl ?y£l\ jij ^4Sjjâll
Atrial Fibrillation : Jj^lc j^mi'II
Page 106
ECG interpretation
Premature contraction
Ventricle Jl J j Atria Jl J H Foci ajj jj b^j UjU^ Ji ciLas. Wave &* b-H j*
UtAxA Jjj Wave CjL<as.j jjli frbj&S Cjxlla

^^^^^^^^^^^^.••••••••••••••••••••^.••••••••••••••••••liiiiiiiiiiMHiiiiiiiiiiM^^^^HHIH
; jjcjj IfjAo Ajj
(1) Premature Atrial Contraction (PAC) (2) Premature Ventricular Contraction (PVCs)
?? J jl bij*A
UjI** Ji wave ^ »Wi jSlj ajjULoj <yujAi ajJsL. bâxjj waves Jl On •A.laiuJl l^^ja
(PAC) lsi Jii narrow QRS Ljisl jl ^4 wave Jl Jc .Jac io. ^La rhythm Jl â.jj
. (PVCs) ls^ Jaa IjS wide QRS bJJil j! ^J=
sUi j£ij Axihtu Sjj.-aj <bJiLj Ajjboio 4 waves Jji jjj AiLubJi J&a (ji ijj^\ J yii
JjLlc ^4 (jjijj narrow QRS b-Aal b^ t^ l*JJaa- î** Ji Wave Âs. ajuIJI Wave Jl ^j
Premature Atrial Contraction (PAC)
4*J oUi jSJj 3 WaVeS Jj' JJJ AjjIALo AjJajj Ljlilui^JI ô\Si\ jij jyi& l$jj UJj jl (_J4 ojjâll
JjJalc (_j4 ^yjijj wide QRS bAil bJc Lsiic Cuias. U4U« Ji wave ^ ajUSII wave J'
" jj^« bJÂ, ^jj" Premature Ventricular Contraction (PVC)
Page 107
ECG interpretation
Conclusion
Rhythm Jl ^ ECG Jl J b#- o~w M* Jj1 •

(regular) AaLuA> »jjj-<aj AjjiU iAac L-Jjill AibjiJa Ja ajj 4j.^<i1Ij •
(irregular) a^Jaaa jjc Sjj^jj Vj
very minimal irregularity <* JLu ALiJI J Jlj regular jji ^ cr^1 •
respiratory sinus rhythm W*^j respiration Jl aj>jA
??? ^1ji j,...^-v
Regular rhythm j*a li] ajjIal. jl Vûj waves Jl Cm AiliUJI jji j) ^jJa jc
!! jAj) j- Alls. J jjSjjo4j irregular rhythm Jaa ajjIal. jjc. Jj
atrial fibrillation : J^l ^bJl
jyn Ja jL£j AjjbuAi jjc bJS bâxjj waves Ji Cm aajLoJI ^^ ^,1 ^jA, jc bij*j (jij
fibrillatory waves bJbj J^n jilj p wave
premature contractions : aaUII aIIsJI

rhythm J' '"'^j,1 bjb-o Ji wave lAs. olâ j£lj <ulvii<i »jjk^»j ajJjU cilibjuJI ^vLi* (_j4j
aKAAi jALi ^jLc bAAlaj JLaa (jij PAC lsj ^ narrow Lpi! jl lsj waveJl ^ â^
Ventricular Fibrillation lU; jL« bJV Ij* jlaA ^jj PVC <Jbj Wide QRS UA*1 J sJa
Page 108
ECG interpretation
Heart Rate
irregular Vj regular ^-cbj rhythm -II lU jjJj JjVI *ji heart rate -II -AXJ L')U-Jx.
ur* L«lc- l>^ M* Jji *jY 1-^ jLAic heart rate Jl s-L-a. (JaÎa <LjL <d, ^ 4s.ij J£ jV
Rhythm Jl
: (^VlS heart rate Jl >.in«j» regular ^1A rhythm Jl J

(1) 300 / number ofbig squares between 2 adjacent R-R interval
(J-a*J S-ua. R jiAl jjj SjjjSII OUjj<JI 44c /300
(2) 1500 / number ofsmall squares between 2adjacent R-R interval

lh3*^ S"^ R jjjjI Cm ojjA^JI AjUjjJI jjc /1500
waves Jl jjj ajjLal. AilaUJ jycm, rhythm Jl ^ bJc jî aÛ Jji ill, ^4 Sjj^l J
?W heart rate Jl v^> ÎJ ^ regular rhythm ^ li] ( jb* AjUjj. 4 )y^n,
75 beat / min = 4 / 300 J*** jî ljjs. qrs jjSI jjj Sjj£1I ljUjjJ 44c / 300 *>&
j&i accurate Jaa jbla AAb aLjjA,
75 beat/ min = 20 /1500 J**a jû uiA> qrs jjAI jjj ij» all CjUjjJI 44c /1500
7"
QRS
1 1 1 1 1 I. 1 t 1 1 1 r , .111111
_JU it Jl-
1 1 1 1 1 1 1 1 1 1 1 1 I I I- 1 I I I I I I I I I I I I I
: JbLj regular ^ lil (ijJJ*—a ÎAjuja 3 JJ1)5 jjUjja 4) AjjLALo AilJbuJI SjSill juij (^4 Sjjjâil
Heart rate = 300/4.5= 66
Heart rate = 1500/23 = 66
sjj»1<-i'l lAbjjiJb 1—uaa.1 jbjijalb rate J' ' .'•••*"' jjlc jl
Page 109
ECG interpretation
hja j* jjai bJj ajjjjsj Uja ^ ?? ^1j] bj-jaJA irregular 'JtLA Rhythm Jl j] a!U ^ ^jA,
4j9j
mA 300 jjaj j*jj-^ JÛ jj fÂI p- 30 J (îjâij jbS iAiUjja 10 (^3 JOja.ja\\ QRS Jl J^c 4xj ji** -
S_ASj1I ,jj iij j.LS i.i•.li j<jy .<jAj!I
<LjjIj 0.2 Ajoj jjjSII j-jjAI j) Aua.j 10 ^ j^jjUAj jjj£ £1ja30 J SjjajJI QRS Jl ^ •*" l£« -
<Lilj 60 IjJAuj JjJ {-jj- 300 A' IJl
(<tiuS4)
15 ^ f$J>Aj £J* 20 J AljajJI QRS Jl ^ 4*4 cJaa -
W¥ tiljj rate Jl '•:""'»» '-J* irregular l^ k) SjjL^" of- Allium AaAa. Jjl ^ ^j \\JyA\
30 ^ 4J>Aj 4 waves <*&!= ^^ jL£ AjUjj* 10 ^ ^
120 = 30 x 4 lsj1^ ts^ rate Jl !•£ ^
0 0
-J Jul JlmS—*mJ\\r~J
1 , 1
5qrs jx^js jjSLUja ^j* 20 J*J j^" rate Jl ^âj bus. jl Irregular rhythm ijaiil j-ij (ji sjjâll
75 = 15 x 5 lsjL^j t^LA rate Jl !•£ Jbj 15 J ^j^j
Page 110
ECG interpretation
Regular tachycardia
Sinus tachycardia Supra ventricular Ventricular

Atrial flutter
tachycardia (SVT) tachycardia (VTAC)
Ija. <jjA waves Jl Jî* ajJIA p wave Jl li* jc Sjbc (_;4
P wave WA5 QRS JSj lis. jlAA <u£Aj
Jl jjc Foci j* wide bizarre QRS
SA node jo AjuUa f.ujqS. bjfwij Saw teeth
S.Anode -II j) **#3 4jj^
Ajjjj; 0JjUj (L) U^ «1W*. > jjlu l8KA lj£ jbic ventricle Jl ^ foci appearance
120 beat/min U>lj 4j (Lib. ' " \C- LJj JXA b Kni UuAj
^LÂjL^-rJ
Regular Bradycardia
Idioventricular Sick sinus

Sinus Bradycardia A.V nodal rhythm
rhythm (IVR) syndrome (SSS)
S.A node Jl jl lUs. Jll '-JabA.V node Jl JjI»a

jji, ^jjit waves J' J^j&
jo FOCi LojJAj jLoS ^
P wave b^ QRS JSj -JLI J\ â.V node Ji ^Jjj Jll .jA jakJI jlja. jjSoj <_j]£II Ua
IjS jlAc- '"'^".j jjil frbjfjiJI QRS Wide JIjIIjj ^ ^
jl <bjliu p wave Ji jm» SjJ^j! l_JJ*i»JJ jjjVI J^l&J aJX sUvij Tachy Jl*A
j* J*' ujÂ
jo JjJUa (\lJ$£l\ jV AjjU jU aJj^ J I 1 uJaJJ MjAjil a
60 beat/min Brady ^la
normal bAiUQRS Jlj âl p-p interval different from
R-R interval
•^ ^t 4a. -W--R-R interval II j|/jU

I—;—tm
Page 111
ECG interpretation
Conclusion
Rhythm Jl v**^ JjVl »Ji heart rate Jl h^ jbic •

?? J J. rate Jl LJâA* Regular ^bj Rhythm Jl jl •
: CrnkJ**^
2adjacent QRS Cm b^1 ^joll •"» I 300 (1)

j4i Jin (jij... 2adjacent QRS Cm 'J^1 cjUjjJ 44c /1500 (2)
WL?lj] rate Jl '^^'^ irregular ^cî Rhythm Jl jl •

I 2jjj]a j^ jj£| Ajj
30 J aillc LJJâJj QRS >\Z aÂi lJ>jJAj SJJJS Cjbuj. 10 4«j (l)
10 J abllc SJJ-<aJj QRS a\£ a<J lAjJAj jjj£ jjjo 30 4*J (2)
15 J fA44C LJjjJaJj QRS al* ^ LijJAj jJJs JJJ- 20 ^ (3)
20 J îc mj^jj QRS J* *u& 'JjJAj jus jjj- 15 J*J (4)
accurate l£°^J"* ^Lu rate Jl Jm irregular <JclA rhythm Jl jl •
V? jjjo 300 J*a ^J*-4"! s-"3 •
<Ab 0.2 lSjâ ECG Jl ^ Aioj juSJI jjjJI ji iluaj ALaJI J aIi ?l£ jiu lJSjI L-Luiaj bi jV
( Aiiaj ) AAb 60 = 300x0.2 lSjL^ ffr"j JjJ &j* 300 Jl li]
Ventricle Jlj Jj**j JUA, Atria Jl jl J%& atrial Flutter Jl ^ ^j CiVlaJl jû J •
R-R Jl jij AiUjjJI j«ja Ventricular rate Jl <•.•>"'•>' jjLe aaI jli j^JU. ^pb J4*-j JUA;
P-P Jl jjj ajjiii.-ill ljUjj<JI 4AiA Atrial rate Jl '.'"'*>' j/c jl bul
Page 112
ECG interpretation
Cardiac voltage
dol43 (Jli Waves Jl £tu Amplitude Jl ja Ljjj 4j^L1I Voltage Jl

Lung sjBII Jja sJa ; SjAU sr-fili J^ sjja.jo Chest Leads Jl jl »JiU Amplitude «-Jl
, <^ Jai W& Subcutaneous Tissue ajj Lung Jl Jji ^.Ja , ajjA Voltage Jl J& (.ji"
. jjaibJliSkinJlba^j
Limb Leads Jl J jj£ jjj- j- Jai Ja jji qrs Jl &La Amplitude Jl j] tbajjUl
Chest Leads Jl J JJ jj*jj« jo Jai Jaj
Low Voltage ^La ECG Jl ^fâi IjS ?? Ja J ljL
: Low Voltage ECG J*>u cJaa Jll cAs.bJI -ul i_Ja
Pericardial effusion
Pericarditis
Emphysema
Thick chest wall (sever obesity)
Sever pneumothorax
jjjS jjja jo j£| <uaitJA qrs Jl £lA Amplitude Jl Jc \h^ J bli, |ead 2j- iPSjj-JI
Ls-^LiA Voltage Jlli]
•m
juujo jo JSij limb leads Jl ,J jj£ jjjojo Ja QRS Jl £bj Amplitude Jl JX* Xa ^ ijj^l\
ljjuJI aj] LJjAA Ji (jUiij low voltage »j li] chest leads Jl J jb*
: ,«VS
-'r-J-Hc——«
-r-"—r1—
Page 113
ECG interpretation
1
Position of the Heart
Horizontal Vj vertical ^Ll lJUI jl£ li] lAjcI jl ja Ujj jj-£JI

W ECG Jl L>**JC\ jaxo 14 jAj
MW Jj\ i_Ja I] »i ; AjUÎ
left ventricle Jl j* apex of the heart Jl jjm J& j\ Cm^ ^
avF Jl *«*lj" J 1^ apex Jl jj^ vertical lsjj^ j^ ^^ ^ j&

avL Jl **>!>• J 1-^ apex Jl jj^ horizontal j^ <-M Jj
HH^HE'
(qR )ijiAA Jiii ajcLA wave Jl J^ j] J**i Characteristic Pattern a! Left Ventricle Jl
Vertical J®>\ li] <k>y J apex Jl jl »b« bJLj avF Jl <J "Jjaj- bAsl jl qR Jl Jt Âc-
Horizontal v^ll li] %'r <J> apex Jl j] »Li~ ,,4 .Jjj avL Jl ^ qR Jl Auil J c-Ja
qR Jl jj (J^LiA ^4Sjj^l J lA>*aJ j
Horizontal bA ujEII li] avL Jl J Hj^ja Vertical bA .Jill ii] avF Jl J ^ja-j o
- 1—
-y«
T
^
^
'
\l
1
VJvPJ V V V V 1 V,
T /\ /1
u VI
i \ I'F
/ /V ^z-^-
jiVF |
Page 114
ECG interpretation
Cardiac Axis
^ ?? Cardiac Axis ajI juu

. lW A.V node Jl »U>5l J Ja 0UAI lis J <jUj«S jLUa *Lj«a jLUa UJ s.A node Jl >-^',-
J.U 4s.lj 0Ujj ^ jkA »buj lis ^ jLbA b> jLkL, cbj^SJl Ul jUS ^ A.V node Jl Jlisj
. »L*jJ lis J <ujajj ventricle Jl lU>Jj
^ &J J& J&\ Sj*ll »bA] J jjSA lubj ji U^bAl Jul, bJS ^4 (jjl\ <LLsa^ \a\jxa Ji Axis Jl
( &bj$s lgl..<alj <likAi jjSI (jjU Ja-u ) jjjS «Uj$S
??? ^1jj UvJ-aA CjJa
Lead III j Lead I Auâ jbbuAb Ua.)
-.gjir. (JoAj (Jau CjsJ
Leadl A, Jli 0j JiLjL (jiau ^ j jji] âU^) jAjVI Ua jÂil jl
Lead III jV, Normal Axis <*-! b
Lead 1 y" LSj lâ J<a*J IjjaJJ ) 14 jlaialb jixjl jjj-ab j^' L4* -(jV'l J
( jJaJI J aLJI m jjjjlaAoll
Lead I I j\ Right Axis Deviation a*j b jbj
Leadi A (j<a»J jjiiUa jAo ) lj jAuolb Jâxi jc Ij4*jjj jAjVI Ua **}Ai>J jl

( JUuAll J AL4II ,.jjjjsAjl (_jj I4S
Lead III "\T"
Left Axis Deviation a^J b J11
b jJaiolb t"it'll jJi-ab jAuVI Ua jiÂil jl

Lead 1 \J
NOMANS Land : a^J U Jui
Lead III "V""
Extreme axis deviation : »jaujjjI
Page 115
‫‪ECG interpretation‬‬
‫‪1‬‬
‫‪EXAMPLES‬‬
‫‪Page 116‬‬
ECG interpretation
J
Causes of LAD Causes of RAD
Left ventricular hypertrophy(LVH) Right ventricular hypertrophy(RVH)
AsjIj Jll *bj$SJI JUlAj JUA1I <bs.U .J..U* <uj Aajlj Jll *bj$Sll JUlbj L>°J' ^JaAi ,-*• •'"*' Aji
JUJj UaIsj] (_Sjiill a\ .« jj£| JjSjA JUAJI AjsL jiAi LjAIsj] (Jjll\ Abos-ai jjSI jjSjA jJoJI Ajab
LAD^lb*ji RAD'Jbaja
Pulmonary embolism
Ascites Jjtt j1^ Paul Marino j] l> <^Jb
strain J**jjj diaphragm Jl jijjj ajV when you suspect PE it usually doesn't
the silent killer b, UJa,
LAD Ja*a JUlbj left sideJljc
pattern bJJiij ECG Jl J jUL Uba.1 Ujl V]
RAD lU«A jUSj S1Q3T3 aa*o
Chronic lung diseases

Hyperkalemia jaoJI AjsAj (Ja 1—-jlLsJi J -J-.'-* J«JJ IjiV
RAD Jâ*4
Left Posterior Hemi Block (LPHB)

Left Anterior Hemi Block (LAHB) jjSI jJyyll AjsAj Ajlajj ebj*âJI "laJl j>\\- 11 J -'» 1.
RAD Jo*jj
Page 117
ECG interpretation
PWave
jA-^> jjjo 2.5 x 2.5 WclA cs*^1
cbjaSlI jV ajjIA. UjiiUk AVR Jl o^ J*- 'M-' V*1- <Uj«all jV Lead II Jc j^) j^j5 b^ jjl* j1
ljUU. 7 Jc liliic
(1) Existence
LjVUJI O*"-) J .. V Vj aJjajo Â Ja (^jjloj
ljVU. ^j »4ja.jo jjSA Jio p Wave Jl
v—J 'w**V»^-^L^-v^J U«**Jl/-W*-^ Ljlljj 4ja.jo jjSjjj atrial fibrillation J'
Fibrillatory waves
(2) Duration
Left Atrial Hypertrophy (LAH) Jl ^VU
.... "fr P- Mitrale P-mitrale W*J broad bifid wave Jo*A
ajjIj 0.12 jo JSi jjSA UAilA duration Jl
r i\ {jâ jjjo 2.5)
îitppi
eÎSî. 'Si
cJjUicj J Jaa. 1<jjSji jl
Mitral stenosis JijAJl fUxJI cjâ
Mitral regurg fUâll J ^lajj]
(3) Amplitude
P-Pulmonale
Right Atrial Hypertrophy (RAH) Jl ^VU J
I
• P-Pulmonale:
jo jjSibclA Amplitude Jl PWaveJl Jâ
P-Pulmonale W^j j^3 &J* 2.5
liljLucj J laa. bAji jl
Tricuspid stenosis
Tricuspid regurg
(4) Number
j. jisi JXa atrial flutterJi AjVU j
~r Ujo-uj qrs JS3 p wave
A L/ 6 ^ j.
Saw Teeth Appearance
J UJj Jjjaijjj
Lead II-Lead III-AVF
Page 118
ECG interpretation
i (5) dropped beat

QRS UU-o (jioj Ujs,J ijja. p wave UUt.«
i/yii I-jISj jl |VR JilA Ul U14s. Jai. (_j4j
^jojj Complete Heart Block
(6) direction
I ULs.1 jSlj upward UJj jjs" Ijj] tâJaW
AV Nodal rhythm Jl ^VU. ^j <bJU UJlUu
t1 | ° ♦
T
jjjl CjjA ja AaJUa jjSA <jLj<jaJI iH
(7) shape in the same lead
I i\ J \j.hr; jc 4ilAvo p W3Ve J' J-^J* UUa.1

Jl CiiCa, j UijjAu t<;4j leadJl c>Aj J JSAJI
J XJ KJ Multi focal Atrial Tachycardia (MAT)
COPD Jl <-jVU J UijAbj
Note
!?? <ul J*!* Mitrale - pulmonale j* J* uiAc Jll pwave Jl Jc *$*! jii Ja caI J
b JSAJb Biphasic ajj pwave Jl JX* VI Jc cjJa

right atrium Jl JUjj b j j Jll *jaJl
left atrium Jl Jjojj lAsJ Jll #jaJlj
•JuyVI jjiVI IjS 4*Jj JjVl J^JiAj JAjVI jjiVI jV
P-Pulmonale J*j RAH b Juj lAsJ Jll jo jjSi jj Jll ejaJi ail jlijiaj J ^1 jijjLJI
P-Mitrale J*j LAH b li] jj J1I jo jjSi Jll jA OsJ Jll sj=JI oil J joSxllj
Ifyou found pulmonale in some leads and mitrale in other lead it is called
Bilateral Hypertrophy
Page 119
ECG interpretation
I
PR- interval
delay hj> bj J. <->*>,!.* AV node Jl £jj4 SA node Jl l> ^ *bj^SH ji IjS Ji Uaâj U^j
PR interval Jl is^ jjSjj Jll »j jAj
ajUjjj Heart Block Jl b> <-ij*j JUlbj Atrioventricular Conduction Time Jl l&oj ^ b]
ijiiâ al*jj« 5 - 3 ja Ux-IA Normal Jl j] o^jJ^
aVU. J U>jbA jaj Delta Wave V"! Ma. <J1«j "-jjA^ aUjjo 3jo Jai ^1 UJJa J
(WPWS) Ji
Wolf Parkinson white syndrome (WPWS)
jJAA I4S axij AV node Jl cjJj SA node Jl jo jLbj „bj^l j! LJJ U <jj iSxiAx\\
Accessory Pathway Ai jl WPWS Jl ^la J Jâjj Jll . (1) *lj Sjj-ll uj Ventricle Jl
ajU. Jll *bj*all Jja JjVI Ventricle Jl *bj*all J^jx J^j ^ J^ *bj«all ts^- jja 4jjs. jU*o
jo <jUj«S1I (^sjj IjS j*j (2) jij Sjj-all lsj Delta wave Jl jjx J1 b j»j AV node Jl l>
QRS Complex Jl ubSjj AV node Jl
The Delta Wave Normal Conduction I
\
v rJ
Page 120
ECG interpretation
Different degrees ofheart block Jl <Jij*jj l-i oUjjo 5 ja jsi pr interval Jl JJ= jlS J bjj
• St
1 Degree Heart Block
AjUujo 9 Jij^) ojjA^. alxijA 5 (ja jASi LjiliA pr interval Jl a*j LAja. J ^4 Sj^l ^ lîo
lJ^jAS bjAj long fixed PR interval ls^c bii lij waves Jl J-* ^-a Aib Ujsjj (Sja-â
first degree heart block Jl
! ' f ....—i
,nd
2 Degree Heart Block
JJCjj Igia 4jj
Type lfmobtiztype 1 block;

Type 2 ( mobtiz type 2 block |
(Wenchback phenomenon )
•iijic jyit, gradual prolongation Jl <J-jjc JAo
Gradual prolongation of PR interval tSbic JUja j
LSÂJ^ ^jit 'Jja Occasional non- conducted p wave
Dropped Beat U4»j Jaj jUjio J jji jo IjS Uj^jI AjU (dropped beat)
Narrow QRS UUo jUSj Narrow QRS jUS UUoj jUSj
Mobitz Ior Wenckebach
Page 121
ECG interpretation
3,rd Degree Heart Block
Atrioventricular Dissociation Uja-oi
<bJj j^, JUai atria JlJ^ <J->! cJ*-^ u^ yiiji QRS j,j Ula-J û Pwave Jl J&&
Wide QRS L4U* sJÎ Jj ^ f ^liji ventricle Jlj
Ventricle Jl J^l »Li5l »4aj1 JUA, Ventricle Jlj »^jl JUJi atria Jl UJS jo j juA Ji ^j Sjj-all
( buried pwave )Uj-^ qrs Jl J ajJjo pwave >J-o»j aJaJII j^ ^ jUS ja jîli] atria Jl
buried pwave Jl aA J^>aj jSoo Jll jjajl ^ Jl bj
Conclusion
Ai>U iUjj *Uj«a!l jV Lead II J ^b PR interval Jl Jc u^?

Sjuu-a ljUjjo 5-3 jJ2 Uil normal Jl
WPWS Jl J j^ Ja ""j?â ljUjjo 3 jo Jai j!
Heart Block ujj Jjj 5 j* Jsi jl
1st degree l«J ty long fixed PR ljjIS jl -
2nd degree lsj Jjj Narrow <Aila lil qrs Jl Jc Mc ijÂ cM. Jj -
3rd degree Ja wide QRS ^ lil Uj) -
Page 122
ECG interpretation
QRS Complex
Q wave : is the first negative wave after p wave
R wave : first positive wave after Q wave
Swave : is the first negative deflection following a positive one ( Rwave)
Capital (Q-R-S) Jjjaj oisaa juS b^LA Amplitude Jl J & waves Jl

small (q-r-s) <-s,jja_i ojSaa Oj*^ Amplitude Jl J Uuj
Ventricular Depolarization Jl JjUA <jA
; alJ-s. 3 jc Igji -KTm.
(1) Amplitude
(2) Duration
(3) Q wave
Amplitude
It usually increase gradually from VI to V6
u! cJ~4 prominently negative jjajj ^Jll VI l> c^jJ hJa QRS Jl £iA Amplitude Jl Ub
J**t prominently positive jj-Sjj bJcbu: V6 Lb-ajj bo jJ jjjjj ajc j*jA *bj$Sll Ji negative m^-
AAs.b Ji bJS «.bjj£ll jV positive aJav« jl
Transitional zone- Prominent

Prominently
positive
4- -K X
negative
"Y "Y ~V
V1 V2 V3 V4 V5 V6
Page 123
ECG interpretation
Left Ventricular Hypertrophy ( LVH )Jl ^VU J

clxijA 44c CixAa. Jj jj Positive jjm V6 JX&j tiji negative jjm VI JÛa
V6 J Jll positive R Jl ^ abujJI jjc jo vi J Jll negative S Jl
(jjAô jjjo 35) SjuS aUjjo 7 < jjSja
Luxe. jJj jbiS ab*jj« 3l^Ûa VI J ^j-a.jJI negative S Jl b>^ jJ lsj »jj^JI ^-*
jJSabuj« 7jjbill jj-Sja ^Jixa^j jJSaLujo 4b^jaî* V6 J "»iy*y& positive RJl
Left Ventricular Hypertrophy (LVH) ui <Ul &)
Right Ventricular Hypertrophy (RVH) Jl <*Û î

prominently negative jjm V6 Jlj prominently positive jjx VI Jîa j*oj LVH Jl o^c
fiCjA+A jjSja Negative S of V6 Jl j- positive Rof VI Jl ^Wj- ^ lAws. jlj
(jjA^j jjj. 35) SjjjS abuj. 7i>j^l
ja jSi a^cjAÂ JiHi* Negative S in V6 Jlj positive Rin VI Jl b*â J (ji Sjj^JI !AL»
ECG Jl J positive U^j VI Jc 01.^ J Oil X^>ij RVH ^ ^4 bj jJS aUujo 7
RVH Jl ^ bJ JAa Aj>b, Jji
! i j
1 1
<j
Page 124
ECG interpretation
Duration
( lX»*-» AjUjjo 3 ) AAb 0.12 lsâl VajI oâjJJi QRS Jl £Ja Duration Jl
Wide QRS Jo*a Bundle Branch Block Jl AjVU J
Right Bundle Branch Block
idiopathic vî J : ^bJ
WECGJI J JjlAijÂ
rSR jjj" JSA, a1 Jiii V2 jl VI Jc JAc
</v*
*_^-™*—«-
t
~%^—-
x
^r-
i|i-^C-
c
ii
V2 vs
/
1(JUl
iA •A 1
Jul 1 Ift Jh1 ' '• 1 1
JM |_
1 ^~ $
~
R R*
Left Bundle Branch Block (LBBB)
A \m ECG Jl J J J AijxA
RSR' jo*-JSA, a1 Jbu V5 jl V6 Je <JAe
V1-V2 J Wshape pattern jjbuj V5- V6 J ( Mshape pattern ) Jm
v "N^- /W v6_ 'M'

f "nr
Page 125
ECG interpretation
Qwave
pathological Q jj^ Jul j* UJ j^JI
jAuî jjjo jc jlj LjjcUj duration Jl J -1

uxu jiiRjiy, jo jsibjcbj Amplitude J jlSjl -2
PQT jc Sjbc Complex Jl J*ao»? Q ojIS jl -3
Lead 1--avL-- V6 L5j 'M oJja-jo Ja Ljji jijjLJl lead J i*- j$^ J -4
ULuua (Jl ItfJjSjA jl
Old Myocardial Infarction
4-i- •
-j +-tr
; i
i PQT complex (only Q ]

1 ffc- H-
11 lil
1 /!l
1 l
• \ i 1
i
r v Q 1
*
. [XL
i V
Normal Pathologic 1
Q wave Q wave
Old anterior infarction UUu. Juj VI - V2 J °aj*>ja UAal J
Old Septal infarction b,U*o Jjj V3 - V4 tj *»Jj>j--Lpil J
Old Lateral infarction Ls>iuu. JAj V5 - V6 J '»iy>j* b^ J
Old inferior infarction b-Uu. Jii Lead I- Lead II - Lead III - avF J '*ij*j* b^ J
Page 126
ECG interpretation
ST Segment
isoelectric period Uja^ st segment Jl jj US Ji blj U jj
UJ (siji^ AiUu J\ (JuLo
PR interval Jl iaa. jjij Jc baseline Jl Jc JUA bjl (J=j>JI
ST segment elevation aaJ b 'bj &4 JUkll ja Jci Ljiil Jjj Jâs. J
S ST Segment depression AoJ b *b] »j JaaJI OaJ olji bAjal Jj] Jâ. Jj
SWave J' J AiaiJ jAl jbÂAb ^ j J point Jl b-»J Ajaij 44aJ ?jV JajjlAo U44sj jUic
PR Segment ST Elevation
ST Depression
IBaseline
necrosis Jâxa aJ ^ sever ischemia °b*^ 04 st elevation Jl ijt-j j] Jij«jajV JjVl

pathological Q cs-1^ jjaA* necrosis <aLc jl upV
jJSA, a! Jbj jSô ST segment elevation Jl

(1) Convex Upward
JVla. J bijAA lS4j JcVaj4s^ JuA bjj Jxai Convex Upward bJSA, Elevated ST jjvu *i
Trans mural injury Jl
i
n 1 i
fl
l^x
11
ST
I 1 Segment
1 ^r1-
t ias
! /• ~> f lT^--i J
Poi n t 5 i
Page 127
ECG interpretation
Transmural injury aIU. Oils îj ST elevation convex upward ls^ °jj-»ll uj
(2) Concave Upward
bijjijj u*j JcV UaUA] JUu Ujl Jxai Concave Upward bJSAj Elevated ST jjm °i
pericarditis Jl AjVU. J
FT i
1/
JA
\
J Point
Page 128
ECG interpretation
ST segment Depression
Baseline Jl <AjsJ st segment Jl JÛa Jj] ^ UlAto bsâj U^j
ischemia »b*-« ST segment depression Jl a-^jj
Subendocardial injury Jl uj AjVUJI ji*j J bijAjj
Subendocardial injury aIU. ojIS ^jj st depression bJS ^4 $j_^Jl

m *
ItAl L
^fjt^fH -
ft jiMfig
.
HI V r
.^:.<.J444^
Trans mural injury Jlj Subendocardial injury Jl jjj JJll j^.jA ^4 Sjj^JI
ST segment Jl Jc ^Jtj
Subendocardial injury: Transmural (epicardial) injury:

STdepression ST elevation
Page 129
ECG interpretation
Uî VU UIoxjjj ST segment Jl Jc jjjb a! JUu Digitalis Jc Û JclA j^jjJI J

sagging or scooping
Digitalis Effect
——1
l_—
i ..—
Ul AlbJI jl Lijlc jjSj JJalc Ija. jjJalj aJ SCOOping Jl jl J^» Uui L&4 J ,j;4 ijjâW UJa
. »4 Scooping Jl Mf" l?J' j*j Digitalis Jc ajAU
-1-
. I r, I __ — L
•^-i, ^jî——
KT
*V4N/'V—»-4 w—*-«•-
Notes on ST segment
avR; avL, avF Jl J normally elevated lmm Jm ST segment Jl

V1-V2 J normally elevated 2mm Javj
Page 130
ECG interpretation
Ventricular Repolarization Jl JjoA t wave Jl
Chest Leads Jl J J4 j*o*j Limb Leads Jl J jtJ jjjo(jîi VLjcLa Amplitude Jl
VI Jlj avR Jl <AuAj_, Leads Jl l£ J Positive bJibA Jjl lj*ai qrs Jl »bul ^ ,JAu UaUaI ,
? QRS Jl »UJ] o»»J t^ l»* ^ ^

J*^ OJ »>> j* Lbaajj Depolarization Jl Jj-asaj Ul jL-ajAb
From endocardium to pericardium
(_5jJLoj 0jrJajj (j* jbaajj Repolarization Jl J-aajj Ulj
From pericardium to endocardium
QRS Jl »bAj jjij J Lb t Wave Jl j] mjJI b j»_,
bûAjlâ. Jb. TwaveJI ^Lu amplitude Jl Jaa hyperkalemia Jl c^la.
Tall Peaked T wave
Page 131
ECG interpretation
Tall Peaked Twave-51 ^j^W^cy^1-* bECG-5lM>

.m VI »<
1/
•^ _J .x '\A\ L
I y 'i
1/ 1 1/
\ 1 <
,
'"
,Vb
K jfcf 1 jK;I
1
,,
!'*'! !""i lAy'-b-..y -j: :'»'"• -r'jy'^ î-nîiTpl-
lSJT wave inversion J-wi *jjIj ^VL*. 4jj
Ventricular ischemia - digitalis effect - pericarditis - vent strain as ( P.HTN - PE)
- Page 132
ECG interpretation
(*(p ihjl jjjjlfr iaH 3 ^
( blood Supply-51 o^ <J*i) Ischemia 5aL5*« i$j Inverted Twave-51
( C-J-W î s^VI) ECG -111> J^ u^" tPj
Necrosis J^ W ^jJ lM^1j-^ lw sever ischemia sUmls-j raised ST segment -51
ECG -51 O* J^j ^5duii 4 - 6 '°îij*.j* Jiiij cfi** ij^j
Death ofcells J-^ J*j Necrosis IaU*- Jl ^j pathological Q-51
CjjajL JaJ ECG -51 l> (^"iVift U Uj*e Lâ^Li. (_JJj
Page 133
ECG interpretation
QT interval
Aj-abvll Repolarization Jl •bbJ Depolarization Jl M^ l> «J^ JjJ QT interval Jl
(TJIajUAqJIajI-jj jo ) Ventricle Jb
Normal ECG Long-QT
prolonged QT interval J**i l£" ^b>U. ajj
(1) anti arrhythmic drugs especially class 1

as quinidine - procainamide
(2) Brain injury as : Subarachnoid Hemorrhage
(3) cardiac disease as ischemia - myocarditis
(4) drugs as tri cyclic antidepressants (TCAD)
(5) electrolyte imbalance as hypocalcaemia - hypomagnesaemia
*-"J Ventricular Tachycardia (Vtach )Jl j*£J s-^j 1^ j"- W U> ljIaj
Tarsade de pointes
i^^ww
Page 134
ECG interpretation
Tarsade de pointes
j Courtesy ofJasn E. Roeitgo, CCT, CRAT
^y^-H--4^l
Short QTinterval J«* c£** ^ AjUUaJ
hypercalcaemia - hypermagnesaemia Jl uj
Page 135
ECG interpretation
Professional Notes on ECG
iî-a* hyperkalemia Jl Jj^bs.
all peaked t wave
Low p wave
Wide QRS complex
i^Loaj hypokalemia Jl ^VU
Prominent U wave after T wave
>^L«j hypercalcaemia Jl ^Vl*.
Short QT interval
âxI hypocalcaemia Jl ^^-
Long QT interval
ij1Ut"i (jfLo-o bjV lAs. jJaa. Jlj
Torsade de pointes
Page 136
ECG interpretation
I
ST elevation Jb*j jAoo ljUU. 3 Ujjc ajj
Pericarditis-angina-Ml
f J j] *va (jjj*
leads Jl JS J ST elevation <bU bi^n pericarditis Jl
some leads J ST elevation lUja angina - Ml Jl Lai
?? jOjj jji) Jjl L_Ja
Ml Jl iaVU. J aJU jjSA cardiac enzymes Jl -1

Ml aIU. ^j jl ST elevated j* Uuj AiitiA AcU j-a j*j ECG Jl Ajjc jl timing Jl -2
ECG Jl J bjAU £jjjj jû aLSj 20 ^»-" angina J Lul
Cardiac massage Jb Jajj angina Jl Jl -3
^jU Axa JoUa JUjjj jJJa aAsI ECG bbc angina ajI OiSJij jJliu jUc JU. JSjIj Ul i_Ja
Exercise Treadmill Test ( Stress ECG ) L$*J As.U. J«j IjS j*j jbjl Jaj ljaJJIj
ST elevation Jl >Jac jUa angina j* J ij&â J& *>*j Abclj S4oj rjji U4kj UJa b
: positive Jb> AVR Jl Jaj jS*o Jll cjVUII -uj
Page 137
ECG interpretation
; AjI JLuuA COPD Jl AjVU
Right atriumJl ai^sai AaAi p Pulmonale
(MAT) leads Jl o^ J J ^ PWave Jl Jî

RVH
AjI JLwJA PE Jl CjVU.
sudden pain Jl âJj sinus tachycardia

S1Q3T3 pattern
Qwave - Twave Jl JîAj lsj! 'âac Lead I J JJI Swave Jl J^> <&' J**a
uJ'aIaac Lead III J Jll
; AjI JLxjA CVA Jl AjVU.
Leads J Ja J Deep Twave inversion J1~J
JUui bAUJj %J *Uj*Î ui Axis Jl Jc JU Ja RBBB
LAD JL«j LAHB
RAD Jio*J LPHB
Page 138
‫‪i— Chapter 4‬‬
‫‪Arterial‬‬
‫‪Blood Gases‬‬
‫‪ABG‬‬
" Life is astruggle, not against sin, not against money,
Butagainst Hydrogen ions"
- H.I.mencken
I
ABG Procedure Checklist
ABG AAbjji Ajjc c i-.miA J AJalij IJS jtjjajj jJJjU

: JjVi mat
<a!a Radial Jl j* Sjjai <=Jaij jbb, Jjaii Radial, Brachial or Femoral l«..w, jSô UJ,
. Femoral Jlj Brachial Jl
sja-A UJi (.jv jSlj Radial Jl j* Jac Jll 4^jll jUJI JLu Conscious u-Ai j* ..Îa J
: jAaU. jbic lidocaine spray J J j Locally jJj<Ai a^jjuu jjSJjj XLjJ 30 JaAi
JiA.1j, ^jaÂ ^jxijUic jjSjLj Jhai ?jy± j^jjoll 14s. Ijs. Painful u* ajL-«JI : Vji
JUlbj JLa Radial Artery Jl ^LA Flow Jlj Constriction lUsâ Involuntary M^>i ajI :lAb
±,jaj>> Flow Jl Jblbj jbjJl Dilatation J^sja jjSJjj L_Jaci J jSlj aa, t-^,„j u,jjua Ja
. Jls.1 jj t.li 1nlA IjSjj
; AAbJI AjaiJll
i> Jai JMlA ,J4 AlbJI Jj Cii\ jjj$jA 04jS.jo Ja J jSljAjjjl bjc i^...'.; SjaU. Ajjj^ AjUAjui Aj3
Lithium Heparin Jl j* aL*aa £jj jî aj^,j jjjUJISIIj jvjjJj^ jjjUJI uj juWfrl' l> tJ
fji^j^ jjjWjJI ^ c£c Jc Serum Na+, K+ Jl a_uA Jc JU Ja ajV (^jjAI jjjLuJI)
. Serum K+ Jl ^jJ» jjjbj^JlSll JlJSj <lsjsâ jjcAaAJ Jjla«jj Serum Na Jl ^jjja
; AjUill AjaMl
oyja pulse Jl <joa" ^1 iW bjUc elbow Jljwrist Jl Aj=a Roller Bandage J**"JjI ija, ^
; AjuIJl *Ja*ull
L^jâj Jb4 10 —5 o^J JiilA aaJI t_uÂ U axi Compression JoAi JjI Ijs. Ijs. ^
. anti coagulant Jc Û jiujJI J Jlab10 jo jjSI jl^j Femoral Jj&LA aaJI aalS J
: <Wolvll Aiailll
?Aajja jx, jjSI Ai ?Venous VjArterial JjcLu aaJI Jjl ljjjUa

Venous Sample Jl u^ ij1 Pulsation Aji JÛa Arterial J ?JI £tu Flow Jl ^ Aa.U. Jjl
_AlixW i.runn Jll AAl JjJJMjA
J.JI jj jjiu Venous Blood JlLa] ^li j*J ajJ jjSjj Arterial Blood Jlbub jjl! ^ AaU. ^b
. Arterial Blood Jl J Jja-jJI Oxygenated HbJl ja IjS J l-uJIj ^b.
. tJ=i <ijJl JJSJJJ U Ixi Pa02 J' <JjJa jc j^jjj jjSJ jUS jl«
page 139
I Arterial Puncture Performance Checklist
1
1. Assess factors that influence ABG measurement.
2. Obtain history for any recent surgeries at site ofsampling.
4. Explain the procedure and place a roller bandage.
5. Select the puncture site.
6. Perform Allen's test ormodified Allen's test (unconscious) incase ofradial artery
puncture. ^__
7. Position patient in supine position and position the pucture site:
• Radial, stabilize itover small rolled towel with dorsi-flexion about 30 degree.
• Brachial, hyperextended over rolled towel with wrist outward.
• Femoral, leg slightly owtward with flexed knee.
8. Heparinize syringe and needle.
9. Eject all air bubbles from syringe.
10. Clean the selected site in circular motion with Betadine.
11. Clean the site with alcohol swab and allow drying.
12. Locatepulsating artery.
13. Stabilize artery and bracketing the area ofmaximum pulsation with fingertips of
free hand.
14. Puncture skin slowly, holding syringe like apencil, advance slowly with the
following angel:
• Radial and brachial puncture: 30 - 45 degree
• Femoral: 90 degree angel.
15. Observe syringe for flash back of arterial blood.
16. Ifpuncture is unsuccessful, withdraw needle to skin level. Then advance itagain
17. Obtain 1-2 cc of blood.
18. Withdraw needle while stabilizing barrel of syringe.
19. Apply firm continuous pressure then gauze dressing.
20. Care of the blood sample.
21. Remove gloves and wash hands.
22. Documentation (Date, Time, site ofpuncture, patient's FiQ2 and ABG Results).
page 140 •
1
Basic concepts of ABG
Balance Jl Aja jc 44^ Extracellular Fluids Jl J [ H+ ] jjs.jj4jJI jJ jjSj

. ^4 AjIjAooll ju AlÛJI {ulaji'&c Aj3j HCO3 Jlj PC02 J' jjj Cm
[H+]innEq/L=24x(PC02/HC03)
^4 AUUJI J jjijJLJj HCO3 =24 Jl la^jAJ PC02 =40 J' AluiJo ji ^jjAA
[H+]innEq/L = 24x (40/24)
= 40 nEq/L
ljjLSjjII jjiSc Jc (nEq/L) AjjIAjSj] jjblb *-* JA*A1 bub jja.jj4jJI jjji jjSj ji JMiA cJaaV J
Extracellular Fluid Jl J jja.jj4jJI 0J\ j£j J olAw bj (mEq/L) '^J^jsj] JUb ajc jjAu yi*
AAkjjSjl J1JI jo jjJo jo 4a!j Jl<u LAikijSjl jjbll jV l-jjISJI JjSJ jjjjjJo jo 4s.lj JiLu
[ +H ] J iJbJI Jjjltjlll (â jU^lAb pH Jlj pH unit Jb b jjs.jjJjJI jjj jjSj jc jixh Ubj
pH = negative logarithm of [ H+ ]
Aiuu jl J5Ua 4jju jjs.jj4.JI jjji jjSj UJS ji lJixAi AjUoSc Aijlc â [H+] Jlj pH Jl Cm AaiUllj
Negative logarithm ofH+ Jl â JJ Uuj jV J& pH Jl
Henderson Hassel Equation Jb bÂj PH Jl b> <_uaaJ jL« a1iI*a Ajij
HCO3
pH = pKa + Log
H2CO,
V J
6.1 lsjIî bjojij AAb Aiuii uaj ( dissociation constant) ui"JI AjjU -uJ b PKa Jl ji &axj
20 bjuaj (yuJall jbAVI J AAb Ajjuj (H2C03) JAjJJ^ll jâoa. AiA / ( HCO3 ) '-rjlaJI AfiAj
Jl jl jyii AbUJI Jl jAjAiA
pH = 6.1+log20 = 6.1 + 1.3 =7.4
page 141
1 Arterial Blood Gases
MW AlS b jASII piSJI S4jla <ul <_jL
JjjjA AuJI Lsixi (HCO3) Mjl^jJl jjj 1AJ1 UJS jl J£UA ul A44UJI J AjjjJ. bjSj jl (JJjjj: b L>aj
pH Jl AjjA AJJJA Jblbj 1.3 j* jSi AAuS JJAj 4JJJA JjjU.Jll JJbj 20 L> JAa\ JjUll JUuAj
Alkalosis Jb*j ^jj^JI ^J j J î JJ^ '-^ jbic j Alkalosis lU»jj
ajjJIj jjjja fUJI b] carbonic acid (H2C03) Jl u^c blUu Jllj ciolj pco2 Jl j] ^ J Jj
Jsja PH Jl Jblbj 1.3 j* Jai jjSja ajUAj jUS ja JAa JclA JjjlcJll Jblbj 20 Jl j* Jai jjsja
Acidosis Jb*4 PC02Jl ojbj j] JjiiA IjS jbicj Acidosis JL«jj jb»S <â
Jhi Jll LuljAUoll ajjA Jc JiabJ ?jV aaJ pH Jl Aiuuj homeostasis Jl Jc ^Ls.i jUc Jblbj
J«,j pco2 Jl J âiu bj Respiratory System Jl J J*a, Jj IjS jUa.j ( HC03 - PC02) <J<=-
"jlj! jjj£ JUI jDbA ^ Jaij jlJ] jjju Ulj HC03 Jl J aâjj bj Renal system Ji jb£ J
jA AljUll JtJ-<ajJJ b JjJaJIj *\*t. <-> juSJ!j AjjUj jbic
Acid - Base disor Primary cnar [^3 npensatory cl
Respiratory acidosis t PC02 A ' , .'Q \\ <A 1 >^ n J\^.

tHC03 AjaûI *Ll ai3
Respiratory alkalosis ^PC02 *\ \lnon <4j ai3 JyHC03 <t U >i \1 <d 1 ^ • /\^
Metabolic acidosis 0/HCO3 4,}jJa.jl A-Jajîi. sLPC02 4 ', hqVi 4j ai3
Metabolic alkalosis tHC03 4_bJsul Ajjla t PC02 4 llllill AmUSk *)rt*^
mm 04 compensation Jl J*-aa^ aJj ^lj] jA jijl4 J>Jlj
? J jl Compensation JoAiA Lung Jl <-fJA JL*j Metabolic aISAJI J
(josj aJ juu 4jja Ul J.J Aâjos. jl Jj-aajj Jll metabolic acidosis Jac j] aIU. J <
Receptors acjosJ Stimulation Jâa_u H+ jja-jj-^Jl uJ1 j£J J Sj^jj pH J' J

jUS ojja.j«j Carotid Artery Jl J '"iy>y uij H+ sensitive chemoreceptors L$*J
ventilation J'^jjjjlsj receptors J Stimulation lUsjj Ulj Lower Brain Stem Jl J
respiratory alkalosis JbAii PC02 Jl ^ J^j C02 J! wash Lb-aaj JJbj
Ul o4jS.jJI Aj.r-i<il-sll ijAxi jUic
page 142
1
Silence Jac J^ja U Ju j*S*1I Metabolic alkalosis Jac J
Ventilation Jl J>A Jblbj Stimulation lgl.^-> a Jaj h+ sensitive chemoreceptors J
o-jjajJl aiîosjs ji J4U2J Acidosis aj_J< JLaj jbic pco2 Jl ^ AjJjj
Jjj Compensation lWja Kidney Jl J>jJ>J IJbj Respiratory aISaaII Jj
Jl <ubc 4jj bJ] ajISII Jauj b respiratory acidosis Jac jl

*ji mj^jJI <ôi jjj Jblbj Reabsorption ofHC03 from proximal tubules
. ojja.jJl Aj^«bJl JjU: jbic Metabolic alkalosis
'r-jLaJI (j^âiA] jAau b respiratory alkalosis Jac J <

SHjLajJI ajjA Jai Jblbj inhibit reabsorption ofHC03 from proximal tubules
. ui o4js.joll alkalosis Jl Ji*j jbic acidosis JL«ji
Jl Lbâ-uj 14s. ajuju: jjSa lung Jl ajIsAJ metabolic J aISAJI j] Jib J1a <
•bJ^ j Jh kidney Jl ajUuj respiratory Jac aSjUI J Uaj ac juu compensation
SjjiJjjaii Jblbj reabsorption of HCO3JI ajUc ^4AjUJc AcUi 12-6 J^jj-Uloj
Jl respiratory disorders Jl fJb> !•£ jbk-j ALJa
'.I:?M.":-il^
Acute : ( before kidney compensation begins )
Chronic : ( after kidney compensation fully developed )
buffer system Jl acIa aLUJI jjMs. U1S UJa
C02+H20 <-> H2C03 (carbonic acid ) <->H+ + HC03
page 143
Professional Notes
respiratory alkalosis Jl ^VLa.
(yujall (ja £jJ tjixjiA Ajjiij Ja.bjj g<jjj aJjLIa Jxaa <luaU. Characteristics ^ j^l (J^*
; ^ j Ajjx^ lAi^ba. aa AijAiA
Pain, Pregnancy, Blood anemia ....
respiratory acidosis Jl tuVLa.
; (_jj CjVLs. aa L^jALu
EmpHysema, COPD (esp.tVPe2"biuebioter'j, foreign body respiratory tract, asthma...
metabolic acidosis Jl ^VLa.
; (jj cjjlfbjl jiiu ljVLs. j-0 bJjjAA
Severe diarrhea, chronic renal failure, DKA, heart failure, acute tubular acidosis
metabolic alkalosis Jl ^VU.
page 144
Elements of ABG
I
1
Normal increased
Negative logarithm of Hydrogen 7.35- Alkalemia/ Academia/

ion concentration alkalosis acidosis
7.45
Partial pressure of carbon 35-45 Respiratory Respiratory

dioxide tension in arterial blood mmHg acidosis alkalosis
1
22-26 Metabolic Metabolic
Bicarbonate concentration
mEq/L alkalosis acidosis
Less than 80
Partial pressure of oxygen ->mild

80 -100 hypoxemia
tension in arterial blood AlUll jlbi Less than 70->
"joe old age 02 therapy moderate
ajjl ^3 SJj^jaII jja-LllSVI AjjA
jij^ ji-ojjA La hypoxemia
^bjAll 80 mmHg J Less than 60 ->
sever
hypoxemia
Saturation of hemoglobin with

95 -100 %
oxygen
page 145
i Arterial Blood Gases
ABG interpretation
normal range Jl ^ lW-£-^^ uj£ ?jt ls^ ^ J^
PH: 7.35-7.45 PC02:35-45 HC03:22-26 Pa02: 80 -100
Compensated
11 Compensated <ui J*i
lL-ss. Jllj - - -t
LJJJJUl PH Jl 4-lul jj kidney Jl jSJj jj»- system J ÎSAa (_J4JC Jwas. bl J^
l<j"« ..l-i iA*s.j PH J| A^jjl jâjs. i compensation Jl ^J-t AjUc olaLsAAiI lung Jl jl
? jjl i|iju*
two systems abnormal Jlj pH normal Jl J^*
Example 1: pH : 7.43 PC02: 33 HC03: 20
pH : normal PC02: abnormal (respiratory alkalosis) HC03 .abnormal ( metabolic acidosis)
compensated *&*• u;J SJ^c Ja normal b"Jl pH Jl Jc <Jjjc as.U. JjI
compensation bj^s.j aISjAoII aA jlS Jll j& system csJ' J*^ • ^' ^^ o^j
11 metabolic Jl Vj respiratory Jl Ja
More acidosis More alkalosis

dH
K1'
l
7.35 7.40 7.45
UUo ^jiU Jll system Jl Cm* lj<A alkalosis Jl -bsb JSI aÛ j*j pH : 7.43 Jl J^
Alls. JJalc <_J4 Jbl IjSjj aISAAII Ai jlS Jll b jA Jbjj
ensated Respiratory Alkalosis
page 146
I Arterial Blood Gases
Example 2 pH : 7.37 PC02: 30 HC03 :19
pH : normal PCO 2: abnormal I respiratory alkalosis) HC03: a Dnorme 1( metabolic acic osis)
System irfJ J AAlS *,K,UI Jj b ooj compensated ui JJolc Jai pH normal Jl
acidosis JlajsU jsi Û pH Jl olsjj j J^
Alls, ul JJslc Jll
compensated Metabolic Acidosis
Example 3: pH:7.40 PC02:49 HC03:27

•
pH : normal PC02: abnormal (respiratory acidosis) HC03: abnormal ( metabolic alkalosis)
compensated u± Jy abnormal a&ti two systems Jlj Jb>jj pH Jl Ua
AcidOSiS Jl AJS.U jjSI AjAU ^ Vj JaiJalb j^jll J ^Jxi 7.40 b* pH Jl <Uu3 jSlj
ilia, ui JAj 44sja Jll ja JU1! J\J\ ^4 aJUJI J Alkalosis Jl Vj
Compensated Respiratory Acidosis
page 147
Uncompensated
11 uncompensated "M J*i
jSJj ljjAuI pH Jl AfUij lung Jl cJJj aJ" system J âIa* ls-^ d^3*- ^ J*i
compensation J-*j ta Vj JjjAIo AjJ jbll system Jl
?V j\j\ Ujij*iA
ajSaaJI ujiio. bj abnormal ^.ij J&& two systems Jlj pH abnormal Jl JX&
compensation J**j jLbc JSjsio a^J Jll bj normal Îjj
Example 1: pH : 7.46 PC02: 33 HC03: 24
abnormal ^lj two systems Jlj abnormal bjil pH Jl Jc- &?• ajJs. Jjl
uncompensated Jj=^ cP Jvj normal jLJIj
pH : abnormal (alkalosis) PC02:abnormal (respiratory alkalosis) HC03: normal

aJU. ji JJJc JLu ajSaaJI i-lluj ui jaj pH Jl £a ^jAjU tjbllj normal ^ system l$*c
Uncompensated Respiratory Alkalosis
Example 2 : pH : 7.33 PC02: 42 HC03: 20

normal -Îj two systems Jlj abnormal bjjil pH Jl Jc s&je aj*U. JjI
uncompensated ^ 6J=^c ji Jb. abnormal JILHIj
pH: abnormal ( acidosis) PC02: normal HC03: abnormal ( metabolic acidosis)
aJSAaJI i_uw ui jV pH Jl «LsjI (jai: J (jJiUj abnormal Jbllj normal <*j*J system is^c
Ails. Jl JJalc JlIA
Uncompensated Metabolic Acidosis
page 148
_l_
Example 3 : pH: 7.32 PC02:48 HC03: 24
abnormal -js-Ij two systems Jlj abnormal WAal pH Jl Jc cJjjc asAs. Jji
uncompensated Jj^c- ji JLu normal Jbllj
pH : abnormal ( acidosis) PC02: abnormal (respiratory acidosis) HC03: normal
aIU. ji JJak Juj ajSAaJI l-ujj oi jAj pH Jl ** (J&a (jUllj normal <"Ail system jHc
Uncompensated Respiratory Acidosis
page 149
Partial Compensated
11 PartiallyCompensated ajI j*j
AiaJI juA Jj AjjAuI pH Jl aalAj lung Jl j^Jj j}** system J aISAa ^jjc jâ*. Ui j*j
JijixIa AjJ pH Jl AiA jai compensation Jl J«j \iij mjyijll ljUaa.1 ^bli system Jl
UJc Jji jjsa Vj abnormal aJ ph Jl jV compensated UaI ui ^bJI ^ Jji jjsa Ja LiU
compensation lUj Wj J*Jb ljUaj Jbli system Jl J* uncompensated bj
partially compensated W*^j I4S jbic
? <Jj! bijxJA
jAjI jo As.U. jÂua jyon, jai two systems : abnormal Jlj pH : abnormal Jl J^4
jiaxi xa above normal range b>j b J3*^ t* below normal range H b
Example 1: pH : 7.47 PC02: 33 HC03: 20
jAjVI Uaj abnormal ?eiH two systems Jlj abnormal bAii pH Jl Jc &ic
partially compensated JJJc ^4 jUj^jô below normal range â
pH : abnormal ( alkalosis) PC02: abnormal (respiratory alkalosis)
HC03: abnormal ( metabolicacidosis )
aIU. <_s4 jiAj aISAaII l-iiia 0j ja JUj respiratory Jl LaIm <JiU Jllj pH: alkalosis Jl ^c
Partially Compensated Respiratory Alkalosis
page 150
Example 2: pH:7.32 PC02:48 HC03: 29
jAjVI Uaj abnormal Âj two systems Jlj abnormal UAal pH Jl Jc s*1j>
partially compensated JJJc ^j Jii j±xi xa above normal range aÂii
pH : abnormal ( acidosis ) PC02: abnormal (respiratory acidosis )
HC03: abnormal ( metabolic alkalosis )
aIU. ^j JLuj "JSAaJI Ljjiu 04 ja J11 respiratory Jl UUx Û Jllj pH: acidosis Jl <Jac
Partially Compensated Respiratory Acidosis
Example 3: pH:7.48 PC02:49 HC03:30
abnormal ?&& two systems Jlj abnormal UAil pH Jl Jc ijiLuc
partially compensated JJJc ^4 JU jiaxi x^ above normal fÂ»i jjAVI Ua j
pH : abnormal ( alkalosis) PC02: abnormal (respiratory acidosis )
HC03: abnormal ( metabolic alkalosis )
aIU. ^4 Jujj aISAaJI ljju, 0j ja J11 metabolic Jl bUo Û Jllj pH : alkalosis Jl <JAc
Partially Compensated Metabolic Alkalosis
page 151
ixed / combined
111 mixed ^ J*t
lUSAJ! ^ ^ two systems Jl ^Hc Cii\ Jju
?? Jjl bij*JA
alkalosis *S5C1I L.J b acidosis <M b.1 b UcjA CjljAdo 3 Jl J!>bA
Example 1: pH : 7.33 PC02:47 HC03:19
pH : abnormal ( acidosis) PC02: abnormal (respiratory acidosis)
HCO,: abnormal ( metabolic acidosis )
Mixed / Combined Respiratory and Metabolic Acidosis
Example 2: pH:7.47 PC02:31 HC03:29
pH :abnormal (alkalosis) PC02: abnormal (respiratory alkalosis)
HC03: abnormal ( metabolicalkalosis)
<UU. ui JVb mixed JJ=c ^j JU alkalosis *s&j abnormal f*£ LieJ1 Ajljjiio 3 Jl Ha
Mixed / Combined Respiratory and Metabolic Alkalosis
page 152
Examples
pH PC02 HC03 Pa02 Interpretation
1 7.36 47.8 28 82
2 7.44 46.3 31.8 88
3 7.40 47.1 27.7 72
4 7.50 32.2 25.3 68
5 7.32 44.1 20.3 74
6 7.47 32 24 59
7 7.51 32 20 80
8 7.32 48 28 78
9 7.48 47 27 70
10 7.33 33 21 60
11 7.34 49 20 78
12 7.47 32 28 68
page 153
1
Answers
Interpretation
l Compensated respiratory acidosis without hypoxemia
2 Compensated metabolic alkalosis without hypoxemia
3 Compensated respiratory acidosis with mild hypoxemia
4 Uncompensated respiratory alkalosis with moderate hypoxemia
5 Uncompensated metabolic acidosis with mild hypoxemia
6 Uncompensated respiratory alkalosis with sever hypoxemia
7 Partially compensated respiratory alkalosis without hypoxemia
8 Partially compensated respiratory acidosiswith mild hypoxemia
9 Partially compensated metabolicalkalosis with mild hypoxemia
10 Partially compensated metabolic acidosis with moderate hypoxemia
11 Mixed respiratory and metabolicacidosis with mild hypoxemia
12 Mixed respiratory and metabolic alkalosis with moderate hypoxemia
page 154
1 Arterial Blood Gases
Paul Marino mUS <J sjja.jaj more professional i^ Îj^jj interpretation -U aaI* aAJa aJ
LjjcUi CjVjUioII ^J JUuAj NECLEX jsAAa JUS J-illj AJjxAl UJAiA jllj j>4^j1I £jA jiSI ir^'...;:
j^jlc (JloA 5 rules jc ijic ui aAJAIj
metabolic J-<Jc AlSAoll J jAjcli Jji
jjAVI Ua jxi oUAVI (juii J OS"'-' jAÎ I-4* f*^ jl -1^ PC02 Jlj pH Jl Jc .iUc ; 1,J^L Jji
ljjU 131 jjsJA Jll ji pH Jlj metabolic aJSAAI JJJc JU below normal or above normal Ul L
acidosis or alkalosis
pH:7 .30 PC02 33 HC03: 21
below normal s.^1 (Ji <u=jj pco 2 Jlj below norma 1 UAil pH Jl Jc .-*! ir. »j jUoii j yi*
aIU ^j Jjj acidosis til4ic pH Jlj Metabolic JjJalc AlSAJI lil ,UjVI o A J jAJÎ Ua Jxi
metabolic acidosis
pH : 7.47 PC02: 48 HC03: 29
above normal J& Âj a^jj pco2 Jlj above normal Ua*1 pH Ji Jc &ic »4 JLUll J ill.
aI^s. ,jj JU alkalosis Jac pH Jlj metabolic JJJc <1SAAI lil »UjV1 cJj J jASVI Ua jxi
metabolic alkalosis
jSjlj JljJlj primary metabolic disorder Jl Oiia. o^^- && JjVi sjaill 4*j ; AjjUII sJa*Ji
VVj superimposed respiratory disorder <Ja& <ua (jj bJa
expected PC02 Jl U^! M*. '.' "•>•»» lSj aJAljII Jc i_>jUj jUc
^j aUUAI fV^'miA metabolic acidosis <J-<Jc jl aJU J
Expected PC02 = 1.5 * HC03 + ( 8 ± 2
ja aIjUAI j.jiAnJA metabolic alkalosis J-<jc jl ilia, jj

Expected PC02 = 0.7 * HC03 + ( 21 ± 2 )
page 155
jUjJI jo -UHL Jll measured PC02 Jl £- aIjUAL UU^ Jll expected PC02 Jl ujUja IjS j*j
secondary respiratory acidosis ^lAc *aaI Jjj expected Jl jo Jci measured Jl ^-A*J J
secondary respiratory alkalosis Jjjc Cii\ Jjj expected Jl l> Jai measured Jl AjAI jl Ujj
respiratory îic aISAAI jl jAjcUs aA IjS j*j
j^ji »4a.lj Ua jxi (J&xa oUAj J jjjAU jjAVI Ua jÂil jl PC02 Jlj pH Jl Jc >^jjc : ijaa. Jjl
PC02 Jlj respiratory aISAUII JJJc Jjj below normal aaUIIj above normal
alkalosis Vj acidosis *aj!s IJj jjsja Jll j.
pH : 7.30 PC02: 48 HC03: 21
above normal UjJI PC02 Jlj below normal b^ pH Jl Jc <Jac »j JbJl J ^jo
PC02 Jlj respiratory JJAc aISAJI ii) Ûo sUjj J jSlj eUAVI <jAj J J* om^ L»a ^^jju
respiratory acidosis JJJc aKAAI lil acidosis <Âc
pH : 7.48 PC02: 32 HC03: 24
jAVi Ua jxi below normal U^ PC02 Jlj above normal UAS1 pH Jl Jc ^c t,j JUAl J 5U.
alkalosis ^JJc PC02 Jlj respiratory JJJc jJSaUII lij Ûo »UAJ J jSU oUAVl ^ J Ja
respiratory alkalosis JJJc aISAoII lij
tsj2jl4 JljjJIj primary respiratory disorder Jl ^."s. j^Û Cijl JjVI Jjaill j*j ; AjjUjII sJ^JI
aIU. ua Jaj VVj superimposed metabolic disorder >J^c aA ^ ji AJa
Acute ( Before Renal Compensation )

Or
Chronic (After Renal Fully Compensation )
— page 156 ——
I Arterial Blood Gases
Expected pH Jl U^l aj>U .,,i.»•>;.» ^j AAA1I Jc l-ijUa jUic
Acute respiratory acidosis Expected pH : 7.40 - [ 0.008 x (PC02 - 40 )]

Acute respiratory alkalosis Expected pH : 7.40+ [ 0.008 x (40 - PC02)]
chronic respiratory acidosis Expected pH : 7.40 - [ 0.003 x (PC02 - 40 )]
chronic respiratory alkalosis Expected pH : 7.40+ [ 0.003 x (40 - PC02)]
measured pH Jj expected pH Jl jjUja IjS axi
expected acute and expected chronic Jl Cm ij+y UJj measured pH Jl jl

partially compensated respiratory acidosis or alkalosis aIU. ^4 JA
J^c <ua Jjj expected acute Jl jo Ji measured pH Jl J respiratory acidosis Jl aIU. J

secondary metabolic acidosis
^Sjjc iA jLy Expected Chronic Jl jo JSI JA- measured pH Jl jl Uij

secondary metabolic alkalosis
^4ic <us Jjj expected acute Jl jo JSI measured pH Jl J respiratory alkalosis Jl aJU J
Secondary metabolic alkalosis
tShic <ua Jjj Expected Chronic Jl jo Ji ^Lb measured pH Jl jl Uj

secondary metabolic acidosis
Ui"»JaAll jSlj Abnormal fJ-J pco2 Jlj pH Jl jb a"1*A> Cii\£. IjS JJ Jll LjlJaiJI JS ; s^VI sjajjl
normal jAoAll as.1 Ciisl <M jJU AiLAo
compensated pH aIU UJ u ^j ^j Jjj normal UAJ ph Jl ^lAc jl <JU j

al4ic IjS Cu\ Jii <JU l$i«J J PC02 Jl Jc cSUc SjjvJ <1SAU Ja j/.K.?.,. jiîc <U3j
mixed respiratory acidosis and metabolic alkalosis
.Jjjc oi\ Jii <UJ U>J pco2 Jj normal UJ pH Jl CjAI jlj
mixed respiratory alkalosis and metabolic acidosis
aJU Jjklc ui Jjj Abnormal Jli <> ph Jj normal Jll ^ pco2 Jl cjJI ^1 <!U J v_iL
acidosis or alkalosis cAlSlil jjajj* Jll j, ph Jj metabolic
HiJi \jâjxlii NECLEX jsAA* JU lJJ'j -bia J&a A3j*AI ub joULjSi jai ^j AAJJI jl UJ Ujj
. <ljxâ J JUioj Ijs. AAj^ ulj JjVI AiJJI jA Ajj JiAAj Ua.1 Jll Ul Uio
page 157 —
Anion Gab
11 Anion Gap -4! J*j
Metabolic Acidosis Jl AjVU. J U>isja1j Acid-Base Parameter Jl Cy^> Cy »^'j <Ji

1 LjjJjla AjI i_Ja
H+ ojs.jjÎ jjji JJJ "^kj bjjj- l?j Metabolic Acidosis Jl J* u.jci jj ja

Diarrhea J' ^VU jj mj^JI u^ Wj- Vj Lactic Acidosis Jl AjVU. ^ j
? bjjSi AjI ' 'U
jjSj fjV Extra Cellular Fluid Jl J Electrochemical Balance Jl lj^ d^

Cations ajs.jJI ljUsAJI jjSj ^jUu Anions aJUJI AjUsAJI jjSj
JjjJSllj LJjl^Jlj ?J$lj>*^ LSJ LAujJ fi." "*-'.' Ji' *lj" ^LijjVI JS 04 jjlJll J 'JjbijJj
aJUi jl Ajs.j4 eljjji lAAjj -ifljmVn Jo Jllj
* 1* .i ..^ '.. u\ ll L-lia
Si...,^ ..II jic <bs.joll dbsAjll Al j ajjjju<all uj AJjsAUl Ajs.joll AllK.all
LSjUA
jij.^.II jjc aJUJI AjUsAJI Al j ljjISjJIj JjjJSII uj ajj.h-.q1I ajIUJI CjUsAill
Na + Un Measured Cations = CI + HC03 + Un Measured Anions
Na + UC = CI + HC03 + UA
i_iJa J Ig.i.iiVl JjiA Ja Jllj L-aJa J LjimVi J41J Jll LjbsAiil Jsjj AbUoll J jAuA
UA-UC = Na-(Cl + HC03)
JUlbj Anion Gap Jl^^m Jll b UC Jlj UA Jl Cm JJ1'
Anion Gap = Na- ( CI + HC03 )
—— page 158
1bclA Normal Range Jl ajI uJa
8-16 j-J*j 12 ±4 jo jlS Normal Value Jl
ASTRA JJaA Serum Electrolytes Jl sjUoJ »4j4s. sj^sJ jjaiJ xaj
3-11 l> J*i 7±4 bclA Normal Value Jl iy^

11nterpretation bi«j <Jjj sJ^
High Anion Gap Metabo ic Acidosis ."i.IUj lj" iwa. iM aIU. J
>j£J iijm U Ji H+ u^jj^' jy) jJJ S4bj jA Metabolic Acidosis Jl i 1jiii Jli
Anion Gap Jl 4JJJJ juibJ LJjlSjJI Ajjjii /Jiiu aJ JUbj Carbonic Acic jjSjj l_1jl£jjl XA 4sjA
ljVU, J b>jJA ulj
• Lactic Acidosis
• Ketoacidosis
• End Stage Renal Failure

• Methanol Ingestion
• Salicylate Toxicity
• Ethylene Glycol Ingestion
Normal Anion Gap Metabolic Acidosis <Ai*LWj b-Uo. <M aIL* J

ujLSjJI jjSj jîj ja Metabolic Acidosis Jl m^ u! »L\** ej ju
V? JUjjj AG J' Jj-<ssjj J j! j* Jajlj JljjJIj
Jc Msj jbic jjIjJSH Reabsorption Lb*A j-AlA l-jj^JI LJ kidney Jl j'V AJaUaj ajUVI
cjVU, J U^jjjAj cs4j JUjjj AG Jl Jâ UJc LilJ Jll Electrical Balance Jl
• Diarrhea
• Isotonic Saline Infusion

• Early Renal Insufficiency
• Renal Tubular Acidosis
• Acetazolamide
page 159
?? bj Jji Jll ljUUJI jo \i Anion Gap Jl Ja
Lactic Acidosis AjVU. ^JUi uj* J^ biV csji l$Jc JiÎxia Jll A1U.UJI jo ^4 V
Normal Anion Gap jJIaA'Jli^j
1 Jjl ' ,'1- jJojjJVI jAl! jA 44a.jll UjjjjiHj jlSj

Paul Marino ljUS ja oj Jjj=JI
Un Measured Anions Un Measured Cations
Plasma Protein ( Albumin): (15 Meq/L) Calcium : (5 Meq/L)

Organic Acids: (5 Meq/L) Potassium : ( 4.5 Meq/L)
Phosphates: ( 2 Meq/L) Magnesium : (1.5 Meq/L)
Sulfates : (1 Meq/L)
Total Unmeasured Anions = 23 Meq/L Total Unmeasured Cations = 11 Meq/L
Anion Gap = UA - UC = 12 Meq/L
If The Plasma Proteins Reduced By 50% The Anion Gap Will Decrease 75 %( AG= 4 Meq/L
jjs.jjjj.jll jjji JSJ sjbj ja bjj- Lactic Acidosis Jl uj "VU. jyii uj J& LiUaJ
Normal ^H*« xlL ajIjIA jSlj High ajU-Ua AG Jl l-J-u>- J ^ J=jJJ'j
Component j-Si j* Jj-jsJ' J b> ^j jjojjJVI Ji jjojjJVI j-aaJ ja l-uJI jjSjj ^j aJUJI Jj
UAJIl>
• 1,,,^ J\aa AG Jl Jc j+ojjJVI (_yaal\ LJJlJI jjjUIIj ul AJaiJI Jc IjjliAj jbicj

(Mg/dl) Ajlijjillj (G/dl) j«jj^ jjj J^sJUib Anion Gap Jl
Majority Of The Normal Anion Gap Jl jc jJjj— AjUAijillj jj-jjJVI jV j;UU ojj
AG = (2 x Albumin ) + (0.5 xpo4)
AG =Na - (CI +HC03) bicLA "jjjlajll aIjUJIj ^j aUUoII J cillALkjA Jll jjUII jjLsjj
Jjis. ljUis. »4 (jjll JU jJojjJVl AJjUo jlj jo jjSi Aj4j1sj1I aLLvoII jli J
j^J-^l jjji j£Jl
page 160
Gap - Gap
t fl ft,jjj
JUJI l> Hi lb Anion Gap Metabolic Acidosis Jl ^j J
( Normal AG Metabolic Acidosis ) yii uj Another Metabolic Acid Base Disorder
Metabolic Alkalosis ji
(jjja jc AijAL SJ GAP GAP Jl
( Normal AG Jlj Measured Jl Cm ijjll) AG Excess Jl ajjUU
( Normal HC03 Jlj Measured Jl Cm ijjll) HC03 Deficit Jl3
Normal HC03 =24 Meq/L Jlj Normal AG =12 Meq/L Jl jb Ulc
AG Excess AG -12
HC03 deficit 24-HC03
GAP GAP Jb b4JuAj Ji ui ajuJI
11 Interpretation U1«j Jjl
High Anion Gap Metabolic Acidosis Âc caI jUajAb
'JjcUi GAP GAP Jl ljjjAij
High Anion Gap Metabolic Acidosis >JAc caI JU ja.lj lAjlLL J
Normal Anion Gap Metabolic Acidosis <Jac caI JU jaJj jo Jai CixlL Jj
Mixed Metabolic Acidosis hy'vLSij
Coexistence of Metabolic Alkalosis »Li*« »j JU 4sJj j* jjSI CixlL jl
page 161
Base Excess
The amount of strongacid that must be added to each literof fully oxygenated
blood to return the pH to 7.40 at a temperature of 37°C and a pC02 of 40 mmHg
Measure The Total Body Bases
HC03 (the predominante contribute to Base Excess)

Hb
CL", P0"4, SO"4 HCO" - 24.4 + 14.8 (pH-7.4)

Albumin
Normal Range : -2 : +2
Increased Value Means: Alkalosis
Decreased Value Means : Acidosis
Delta - Ratio
HC03 Jl uîj Anion Gap Jl "^bj Cm iJH Sr>b«s. jc SjU'LS*
AG measured - AG normal
HC03 normal - HC03 measured
H+ Jl jjSJ J sjbjl L-ijjj. ajJ JijxAj High Anion Gap Jl AiVU. J âJA ji
Pathologic Process Expected Delta Ratio
Lactic Acidosis 1.6(1.0-2.0)
Keto Acidosis 1.0 (0.8-1.2)
Kidney Disease Variable Depends On GFR
Methanol, Ethylene Ingestion 1.8-2.8
page 162
‫‪r- Chapter 5‬‬
‫‪echanicai‬‬
‫‪Ventilation‬‬
‫>‪Ventilator -‬‬
" All who drinks of this remedy willrecover except those

in whome it does nothelp, thereforp, it is obvious thatit fails
only in incurable diseases" j
-Galen-
Mechanical Ventilation
!
Mechanical Ventilator Basic Concepts
(1) Respiratory Ratel RR)

Number of respiratory cycles per minute (F) S4S.IJI Aiiajll J jjAjII Lj\JA lie
Normal range : 12-- 20 Cycle/ min
Above 20 C / M -> Tachypnea
Below 12 C/M - • Bradypnea
(2) Tidal Volume (Vt)

Volume of air that is delivered to or exhaled from the lung with each breath
JaJJI (jjiijll J Ujo TjAA jl AjJI Js.4A Jll olj<jJI AjaS
Normal range : 5 - 8 ml / kg (for ventilated patients it is usually set 6 -10 ml / kg )
Vti = inspired tidal volume Vte = expired tidal volume
(3) Minute Ventilation (M - V orV- dote )

Volume of air that is delivered to or exhaled from the lung per minute
RR Jlj tidal volume Jl ljj^ J^Ls. jc Sjbc jtj ii*.\J\ ajUijII J ajJI JajA Jll *UJI <U*S
V = Vt x RR
(4) Fraction of inspired oxygen (Fi02)
The percent of oxygen that is delivered to the lung

Ajjli Js.b Jll eljijJI J S4js.ja1I jjsjjiSVI AjjA
Normal range : From 21 % (room air) to 100%
Pa02 > 60mmhg Jl j) jl Sp02 > 90 % c^bj target Jl jjy A^ ^M^
IjS jV AcUu ja JSI sAaI jJSjjiSI % 100 Jc iJclA jjsjjaII Jsj j"-°\;-
i*aj JJ lw a1s*1u>j IjS jUcj Oxygen Toxicity lUosj jIm
bjjj (Jlaj 10'4*1j Suctioning , Chest Physiotherapy andother Stressful Procedure Jl
page 163
(5) Inspiratory Expiratory Ratio (I: ERatio )
Ratio of inspiration time to expiration time
jjjJ| Ljiijj (jjjjjjill L_l3j jjj Ajmill
Normal range : 1: 2 or 1:1.5
(6) Vital Capacity
Maximum volume of air that can be expelled from the lungs after taking j deep breath
jjajl jA*i ajJI Cy £j** <-£" <jl jA AooS •-'1
Normal range: 3 --5 liters
(7) Functional Residual Capacity (FRC)
Volume of air that is present in the lung at the end of expiration
jjjjl rjjs. 4«j AjJI JsJj AAUull olj<jil AjjiS
Normal range : 35 ml/kg
(8) Flow rate
The speed at which the tidal volume is delivered
AjJI jAb Jll plj^ll Ac ju.
Normal range : 40 -100 liters / minute
(9) sensitivity/trigge
The sensitivity is the effort required by the patient to initiate inspiration
AjjiJ 4sb jlAc aImjj (Joija1\ JJI Jjip all
page 164
(10) Sigh
Is a deep breathing that has greater volumesthan the tidal volume
It provides hyperinflation and prevent alveolar collapse (atelectasis \
Usual volume is 1.5 - 2 tidal volume
Usual rate is 4 - 5 times / hour
(11) Pressure limit
Limit the amount of pressure delivered to the patient
L?J "WJl Lb=J (JaljaW JkljJaAJall jl iAjsj 35 cm H20 laxâ Jc Xa <UajJaJ SenSOT Cf- '<>j~?-
alarm J«j*j Jb jj^ja Ja Ventilator Jl
(12)Volutrauma
Pulmonary infiltration due to high tidal volume
infiltration bLasj alveoli Jl JJ I-js. jjjs ajJI Jkb Jll *UJI jlsj* jJj Ul IJjAa SjAUi ^j
pulmonary edema jjjj
Volume Jl fcibj j* bjfLJ
(13) Barotrauma
Rupture of alveoli and production of air leaks due to high inflation pressure
rupture bL-ssj alveoli Jl JM lis. juSajJI JaU Jll «UJI iUij-a jjj Ul UaJa ij,Ua ui
air leak Lb^sj JUAj
pressure Jl ^bj j* b^"
COPD &ARDS Jl AjVU J Lb bJjA,
page 165
Indications of Mechanical Ventilation
> Bradypnea or apnea with respiratory arrest
> Tachypnea (RR> 30 c/m)
> Minute ventilation (ME) greaterthan 10 L/m
> Vital capacity < 10-15 ml/kg
> Acute lung injuryand ARDS
> Pa02 < 55 mmHg with oxygen therapy
> PaC02 > 50 mmHg with arterial pH lessthan 7.25
> Exhaustion andrespiratory muscle fatigue
> Neuromuscular disease
> Coma and severe shock
> Raised Intracranial pressure (ICP)
> Severe LVF
> Flail chest and cardiopulmonary arrest
Note
Mechanical ventilation is therapeutic just in respiratory failure conditions
( centralrespiratory depression)
Supportive ij^ Jm Ventilator Jlcji role Jl*m^ 5JU. J
— page 166
Types of Mechanical Ventilation
Ventilators Jl i> japJ ^^c *£
(1) Negative Pressure Ventilator
It applies negative pressure to the thorax by a vacuum for drawing airinto the lungs
Lungs Jl *!j<JI Jjs.4 Jc 4cUu Jblbj Lung Jl Js.b Negative Pressure j JA UJ AjjSa
invasive airway jbsjj Ja Ventilators Jl j- b £jll
Lack of Care Jl ^ aJSJa jjSI aaISj iron lung Jl a*Jj J&Ja a*jaIuijj js. JaU UJaj
(2) Positive Pressure Ventilator
> Use positive pressure to force gas into the lungs
> Require an artificial airways ( ETT or tracheostomy)
> Can be eithervolume cycled , pressure cycled or
time cycled ventilators
page 167
Types of Positive Pressure Ventilation
Positive Pressure Ventilation Jl l> t1J' 3 Ljjjc Ai
Pressure Cycled Time Cycled j
Inspiration is terminated
after a preset pressure Inspiration is terminated
inspiration to expiration
has been reached whena preset inspiratory
after a preset volume has
by the ventilator time has elapsed
been delivered
during inspiration
Advantage:
predefined minute volume
decreased risk of barotrauma
is guaranteed This type of positive
pressure ventilators is not

Disadvantage:
used in adult ICU but it is
changes in mechanical with decreasing compliance
used in the pediatric ICU
properties of the lungs or increasing resistance,
(resistance or compliance) tidal volume and
can lead to high pressure minute ventilation falls
page 168
Humidification System
(Jll *tjfJ! LJajij Jai ajI AjiAij warming and humidification system UJ Jajb ventilators Jl JS
Nose —II (j—a J "T>*; Warming and Humidification —II a_jUc jl j^jj—iUII jV a_uJ1 J_aIj
Endotracheal Jl uj Artificial airway ljSj* ^1 Ventilated Patient Jl <JW<=.j Oropharynx Jlj
AAajill ^La (yuJall jUuJI Jc (jjju ajI ja ajJI Js.b Jll *lj<JI CixIa IjS laI Jblbj Tracheostomy Jl jl
Warming and Humidification Jl jc Jj-"> System Aja jjb ?Ji jLS IjS jbic j acLa
HI lsc\1a uAuj^ll dry air lM J) sjjas. ajI ^ jiajj JljJIj
> Destruction of cilia which will results in retention of secretions
> Drying of mucous glands whichresults in mucous plugging of airway

> Reduction in cellular cytoplasmwhich results in reduced pulmonary compliance
I
and increasedwork of breathing
> Ulceration of pulmonary mucosawhich results in increased resistance and
hypoxemia
> Loss of surfactant which results in atelectasis and intrapulmonary shunting
> Hypothermia caused by heat loss
jSIjj U jjc ja ventilator Jc (J=jjJI Lbajl Jl ^jA-« IJS ui ljUluVI jUjcj

37 Jc AjcIA SjIjsJI Jajkij <biu iUliSj JUAi Ajij humidification system Jl l>
acUi • «.î JS jkLill oUll check J«*jj
page 169
(1) Volume cycled mechanical ventilation
lung Jl Ja-jj jbic specific tidal volume -"sj bl b g- jill J jl IjS Ji Ulj U uj
breath JS J
inflation of the lung at a constant flow rate lU*jj ventilator Jl Jblbj

ajJl Js.jj aIS ojjs-o aaI Jll volume Jl L° ^sJ
peak inspiratory pressure (PIP) Jlj* j*jj» Jllj breath JS J aJj tidal volume JlLsa Jblbj
; Ajljioî
Constant tidal volume <
jl Jjîs. J Js. AblS LjJS JAjjA AjJI JAA jbic U44sî LAl Jll cljjjl AjLoS jl Jixai
ventilator Jl a^jj cJa lung compliance Jl jl jl ^Jj airways resistance Jl

ajJi Ujjs-o aaI Jll «.lj<3JI ajjiS Jajj jbic jS-us pressure cs^' J3*^
• <\j ^ ir.
Risk of Ventilator - induced lung injury(VILI) <
alveoli Jl Js-b UirA iilij Jblbj ajJI JaU JaA<Jall i±ij AsAi
VILI Jl UjjJsJ Aj-ijc jjSi Jul, j^jjjJIJUlbj (P plateau )JlA^lulu Lis.1 Jll
•*-" £j-%> ventilation Jl Cy ,J £Jl'j
(A) Assisted - Control Ventilation (ACV)
ichronized intermittentmandatoryventilation (SIM

(B) Sync
page 170
(A) Assisted - Control Ventilation (ACV):

This mode consists of two modes of ventilation
• Assist Mode:
oiac JUu jSlj initiate the breath o-AH u^ma ljjjj o^jJ' LSi <lbJI Jj
ajI ventilator Jl cs-% ^j <Jjll breath Jl lUSj ajI jjSjj Ja& weak respiratory muscles
Lfr*"l Jm lsi aJUJI Jj preselected tidal volume Jl ajIouj breath Jl J-Sjj »j&Lu
breath Jl initiation / trigger lU- Jll ja patient Jl jV patient triggered breath
• Control mode:
breath Jl initiation JAu" J J=ijJl kJ»m Jll j* ventilator Jl breath Cf- '°J->c lsjj
controlled or time triggered breath U>»J JUu^j aJUJI Jj
aA jl jyn UJ Ajsa4 Jj patient triggered breath JaAj JUS1I Jc Jll wave Jl ui SjjjÎI J
ventilator Jl IjS j*j patient effort / trigger Jl JUjj bj wave Jl Jja jjs.j« negative deflection
ULa jikAj ventilator breath Jl Jaaj jjJI Jc Jll Sjj^ll Ul wave Jl J*S
bjAuA ui Jblbj effort to initiate the breath j J^** u^jJ' j^ negative deflection J
ventilatorbreath / time triggered breath
Tlme-Triggared
Breath
Ventilator Breaths
In ACV
A
; Al\jiAA
Allow minimal effort and rest for fatigued respiratory muscles patients <
breath Jl lUSja Jll ja ventilator Jlj u^' <-?•% <Jl i_w ij*ablj Uj j jujaW jjj jV
.^ Cy breath Jl J=*iA Jll j* ventilator Jl initiation lA"-4Jj
Risk of hyperventilation and respiratory alkalosis <

RR J' iijx Jblbj £J>jj jAAu JSUi breath Jl initiation J»j jS— jiujjLlI jV
ui aJasJII J LjsjUj hyperventilation <JL«j jS^> bj IjS waves Jl JS<i JUjj
SIMV J! mode Jl jJj <Jjj J^VI ji ^4ajL*JI Jlii jbic sedation J*** <Jjl j*
page 171
(B) Synchronized intermittent mandatory ventilation (SIMV)

This mode consists of two types of ventilation
• Spontaneous breath
ui aJUJI Jj JUIj JSaA Ajjiij (y UjaUj j-ajjJI spontaneous breath jc '"Jc lsjj
Jl >Jac ui

preselected tidal volume and rate bJ AAajjj spontaneous breath
ventilator Jl breath ^l J lUmjJ' u> J**! synchronization Jl (J <J >jj lMj

Jaxii Jll ja ventilator Jl ui ^LsJI J breath JjaU j^jjJI Jj Jlj JaAja Ja
. mode Jl iy^jk l?i »jj^Hj lUS JSAA breath Jl
Synchronized IMV
/ \ Spontaneous / \
/
/ \
\ /-\
Breaths
a\ /~\
/
I
\
Ventilator
\ «A
s\.imZLW-.
Breath
Note
- the major indication of SIMV isthe rapid breathing with incomplete
exhalation during assist- control ventilation
spontaneous breathing period during SIMV Jl C1jA b J i_4jjjJIj
riskof airtrapping Jl JIsja Jblbj alveolar emptying Jaj^J.îI-ik'ia
- SIMVcan increase the work of breathing and impair cardiac output in
patient with left ventricular dysfunction .
page 172
; AjI jiaa
> Allow spontaneous patient breath between ventilator breath

> Synchronization
> Increased work of breathing

> Respiratory muscle weakness
(2) Pressure cycled mechanical ventilation
lung Jl Js.b 4js.j« JU jbic specific pressure ^ bl b ^jJI J J IjS Ji LilJ U jj
ventilation Jl *Lul
j^jj* Jllj breath JS J AjAj peak inspiratory pressure (PIP) Jl Lja Jblbj
tidal volume Jl j*
: 4-" £j-% ventilation Jl l> ,j ^jJIj
(A) Pressure control ventilation (PCV)
J**a ventilator Jlj sjjU AAl Jll pressure Jl JJsjj aaI b mode Jl if*
J-Ojl jUic tyy flow Jl JUu AjIjJI J J*i decelerating inspiratory flow rate
7Lrt...iLj ' Ul .""-si hli-Vijj inspiratory time Jl IjS Jxj AcjmJ bj jU aaI Jll pressure Jl
inspiration Jl AjUJ J jjiJ d^ji ^l flow rate Jl JLS Ziiji
J***1 J*i expiratory time Jl Cy <JJ=i JUu inspiratory time Jl Jblbj
oxygenation Jl l>sjjj mean airway pressure Jl Jjjjj I^Sjj inverse ratio ventilation
• 4j|jlAA
Pplateau J'"^m ^' J^j alveolar pressure Jl J *^m ajI ^ ajj sjj- î •
riskof ventilator induced lung injury (VILI) Jl JIsjj Jblbj
Patient comfort •
jUSj UJa*jj Jll high initial flow rate Jl jj= jc "ij
longer duration of inspiration Jl
4j B ,r-
jlj J J^^sj (Jaa Jll decreased alveolar volume Jl ja Ai <_jjc JSI
lung compliance Jl o^ j airway resistance Jl
page 173
(B) Pressure support ventilation (PSV)
Is a pressure augmented spontaneous breath
ventilator J' Ajuiii 4Ab joijaW uâ U ajâi support aJuu jjj blj Ijs. <_jjU AjjiA jaU jjsjjJI
certain level of pressure to the inspiration circuit AjsA ( <Jja + jjsîSI ) CjIjU Jaxii
inspiration Jl l> l*J^ J^jJI ^> ij**ij comfort jj**ij ventilation Jl j***-* j^c
lJ pressure Jl L-iajjj ventilator Jl
lung inflation Jl ^ ajI j^jjJI ^<ujjj b mode Jl jl J PCV Jl l> ' '1'^jj
lUj J breath Jl i^Jjj Jll ja ventilator Jl jLS PCV Jl <jjSc Jc aAJjj Aisj J J
sjjsl* uAl Jll preselected pressure limit Jl
inspiratory time Jlj tidalvolume Jl J ^sja Jll ja jjajjJI Jblbj

primary weaning mode Jl ja b mode Jlj
; AjI jiaa
• Augment tidal volume

• Decrease inspiratorywork and provide comfort
page 174
(c) Continuous positive airway pressure (CPAP)
frUSI J ^ JSAj J .Ir. cs^LLi (^j-aJ >4Ji ^ positive pressure l> '"J-p jA AajjjI Ja
expiration Jlj inspiration Jl
JJJI *lj*ll fS4* ja ajj 4jjîU1Ij functional residual capacity Jl ijja ajI ja a! jAfc *i\
expiration Jl j*j <jJI Js.b
5 - 10cmH2O JJj CPAPJl^L-jbj
.... An opening must be attempted in the trunk of the trachea, into which
a tube of reed or cane should be put; you will then blow into this, so the
lung may rise again... and the heart becomes stronge "
Andreas Vasalius -
1555
page 175
(D) Airway pressure release ventilation (APRV)
u^ll J ls^hj high end expiratory pressure ij*j J ti^ spontaneous breath -jAUi jjsjjJI
pressure release ajauA Jll bj jA-all Jâj sjs.1j %ja b pressure Jl J^jj
? IjS j- SjjUII AjI i_jJa
iyki jL*Sj oxygenation Jl Cy^ 'J high pressure Jc UJ j^jJI Jll sjill
Co2 removal Jb ajL»c Jj^jj »ja pressure release Jl»Ja b>l collapsed alveoli Jl
high pressure Jc ^jiU da jll fJaxA (jaljAXt jl J^LiA UJ Aaaj jl mode Jl ^LjJojjJ ijl SjjA-all
pressure release Jl ajauiA Jll bj jUoi! Jjj pressure Jl o^ll J elaij 30 cm H20 AAuaj
C02 remova Jj TLAwJ ^juiic Aj3j J'jrixi AJ Aj4jUj
< o-J
AjI jj—
> Decrease frequency of opening and closing of alveoli

> Improve oxygenation in patientswith ARDS
:*ijic
> Cannot be used in severe asthma and COPD
inability to empty the lung rapidly **He ui ^VLsJI J jV

pressure release phase Jl *b!il
page 176
(E) High Frequency Oscillation Ventilation (HFOV)
Provides high frequency, low tidal volume oscillations
( 60 - 100 breath/min) jAS caija jj*jjSlj ( 1- 2 ml) JJa tidalvolume Jaij^ J***
W ojS (jaSjjlill AjIj t-jL
collapsed alveoli Jl j%j Jblbj high mean airway pressure <Jb*A ^4 oscillations Jl
gas exchange in the lung Jl aJ*c juisjj IjSjj
risk of alveolar over distension and volutrauma Jl dki low tidal volume Jl jb<Sj
•40
9*
X
HFOV -30
£
o
•20
1°
5 g
-10
<Ujjc
> High risk of barotrauma

> Hypotension due to high intrathoracic pressure
> Need for sedation
> Needs a special ventilator
page 177
(F) Bi-level / Biphasic positive airway pressure (BIPAP)
pressure Jl l> jj^«CmJ^ *&* jJ>^l L*a APRV Jb SjJj ja
jl jJaalo JSjiA Jj-ssjj jLSj high pressure Jc <JsjjJI AjsjII ^xa jlS APRV Jl aIU. J
Jc Aijl jAvo jjSja bjjc jisjjASI jl Jjloj jjiSjJI BIPAP Jl J jSlj jiUall Jjjjj jlS pressure Jl
aJU. ajjjuI jjjjj pressure Jl jl J=*« JSJi J^sjjj low level of pressure
inspiratory positive airway pressure (IPAP) Jb •^y^m high pressure Jl
expiratory positive airway pressure (EPAP) Jb Si^ low pressure Jlj
H??<u*SjjU1Iaj!ljAi
oxygenation Jl Jjjjj jJ JLilbj higher mean airway pressure than CPAP <J1Jjjj ajI
jALu jjc JSAj tidal volume Jl ijja jLaSj
low pressure Jc ij+ja clj\ J*a JoajaW jl JCUa baab J BIPAP Jl ly^Ja "-jj^llj
a Jll bj jjju pressure Jl !•£ jîll Jj ( 5 - 8 ) cmH20 Jm *AJ EPAP Jl ^y^m Jllj
( 8 - 20) cmH20 jjA ^4 J\> IPAP Jl
15
BIPAP
IPAP
10'
rmaaii
EPAP
Inspiratory Time
0—'
page 178
(I) Positive End Expiration Pressure (PEEP)
distal airspaces ( small airways and alveoli) Jl narrowing Lb<asjj expiration Jl ajL^j J
'U-ua Jllj closing pressure ija-j l_uu>j alveolar collapse lU*j JU* jjSaa Ul Jllj
3 cm H20 LuJj csjUj
'AiVU.j small airway obstruction as (COPD) Jl AjVU. J

1^ yb> JUA AjjA b closing pressure Jl reduced lung compliance as (ARDS) Jl
expiration Jl aJj J extensive collapse <JL»jj bj
expiration JlaJj J lung JlajA*a ventilator Jl pressure jc '»Jc ja -uJ ja PEEP Jl

.ÂjljJ j*dJa. expiration Jl jl J^m LJ Jllj ventilator circuit Jl J lya-y valve J,J* (jc
44=^11 pressure Jl lU>jj jbic jsi <JjjJI f^ ajI JJJc ventilator Jl ls-%? & \ii pressure Jlj
closing pressure Jl jc JA ajI j* lung Jl JAb pressure Jl j) ^ b pressure Jl <aAj

atelectasis Jb ajÂj Jll alveolar collapse Jl J-jj ja IjS jbicj
Sc\li j*ija1\ acIa closing pressure Jl AjJ lUj«j bLI l-jju^ clinical setting Jl J jVj
15 cm J! lUj LibJj 5-10 cm H20 Jc PEEP Jl uJ— •"»* LA.b
No PEEP
40-.
r20"»
0-1 0-1
page 179
Notes on PEEP
alveolar collapse Jl i^m low level of PEEP (5-10 cmH20 ) J' jl ^Ja Paul Marino
collapsed distal airspaces Jl £*al j! Jic^m high level ofPEEP (20-30 cm H20 )Jl ^
Alveolar recruitment Jb ajauA b effect Jlj
Aja jl JCLiA ui Jbuill Jc Jll Sjj*all J biab J alveolar recruitment J' ty^ja l$i »jj^JI
AiUal ixi jjJI Jc Jll ojjj^JIj posterior regions of both lungs Jl Jc lung consolidation
alveolar recruitment ofthe lung Jl *J*c ly^JiJ^j high PEEP
PEEP= 0 cm H20 PEEP=19cmH20
•Jaa b jjS*lb Alveolar recruitment <Jb«u jS— high PEEP J' J'j^l JS J J- <jS1j
risk ofventilator induced lung injury(VILI) Jl Jjjj alveolar over distension <Jb*j
LT^J alveolar recruitment J-*ja PEEP Jl '»Jbj J"' j* JJ* jiJj'j

1 alveolar over distension J-*ja
PEEP Jl ui yLJI J lung Jl j- jiJ *> 'J j^l jl* collapsed area Jl ^ M"^ Jc :a—jUÎ
^^ jjAua pjs. b j=j>sJI jlS J jSlj alveolar recruitment <JL«jj l?J collapsed area Jl iJIsjAa
Jl juAa JAj LrjSSc 0Jjjb JUa high PEEP Jl l5j yi^l' J negligible volume of lung
.VILI 'JLuuj alveolar overdistension <Jb*jA jSlj ui collapsed area
page 180
Care of Ventilator Dependent Patient
(jjjla Qe. fm b positive pressure ventilation LUyjJl J*** d^c Lvub

: lUaa uij variety of plastictubes
(1) Endotracheal tube
*a* 25-35 Cy C-JbA" W^J3 ^J1' <J

m
At
internal diameter Jl m^s. Jiaa U^lA size Jl jSlj
<«>5-10 l> zJdm Jllj hcî
»ba-o b JU 7 AjjAl Jjj Ul ylai
*a i U^bA (internal diameter) JaIJI Jaill jl
Jl Ji 8 jUsaVlj 7 (J UjSjA As.U. Jai adult Jl j^JA AjjAlb
smaller tubes impede clearance of secretions and create increased resistance when
weaning from ventilator
jjjÎI Jus.b Jc AcbuJb «lj<JI LJjua £-Uuj (jija jc LjcLu position J' j-° jSLu LjjSj U J*j *ji
proper position of tube Jl iy±Ji ui 'jj^-Jlj x-ray Jl IjS j*jj <jjUlU JSaa
neutral head position Jl J -
midline Jl J Tube Jl jjSja
above carina 3-5 cm jjSjaj
LfjAAaa. .JjclA AjjAVI jl JXi bbJ ji
right bronchus JlblUs Migration
chest movement Jl &J* jc L$aj*A lsJj
lAutAui J jUSj liljsJA Jll jjj 4s.lj side J-^ja
jjj sjs.Ij <bs.b J *lj,Jl ljjj^ jAuiiA stethoscope Jb chest Jl Ljjj-a
page 181
Jl Ji Ijs. JaA Asia. ,jlj
Selective ventilation of one lung results in
progressive atelectasis in the non-ventilated lung

oJ jjjjj ui ojjj-<JIj
jjja.Uk *Ji ui migration Jl ajISs. x1a\ jbic j

Atelectasis
of LeftLung j'Ij ,U"„ i .j.'iVI <LcLu tip J' JiJjj ilulj • Aais (Ijl
f»" 23 i> JSI ji females Jl ^jjAlb *** 21 Cy JSI Jaa

inflation of the cuff lU*j j.jV JJalc s4jSjll 4»uj males Jl ajjAIA
tracheal necrosis >JL«ja IjS jc : Ij jl jV 25 mm Hg ui*a Vinflation pressure Jl Jbuj
stethoscope Jb ch«;st Jl ljjâ xaJIj x-ray Lb*j L$jSJ U j*j j.Ji; Asia, ^b
(2) Tracheostomy
ventilator Jl Jc JjoAa j^jjJI jl aIU. J UjîA
jjCjJjjil Ja jjSI oAa!
More comfortable than ETT and also Easier access
tracheo esophageal fistula J Jajj ^Ll. j^jJI jl £jal> jUSj

esophagus Jl Jc LAAia UJ!^ trachea Jl jl J***
sub glottal stenosis jS—j fibrosis <Jb*j LjjI uj fistula Jl jj jUS JSbU c-jjiAL ETT Jl j^Sj
jjjS UJJCj
The cuff pressure should not exceed 25 mmhg

; cjjji 3 U><ua
- Temporary in Elective Surgery
- Permanent in Total Laryngectomy
-Emergency in Airway Obstruction
page 182
Suctioning
ICU Jl l«jJ \Jaxji Jll routine procedure Jl Cy^> Cy J^-'j suction Jl <
endotracheal tube Jl £bj inner wall Jl jl ljII* laUajI ljU.Ij4 Uua.1 jSlj
pathogenic organisms blja. biofilms Jc csjajj tracheostomy Jl jl
lung Jl Js.bl ui organisms Jl Jaja IjS IaJ suction Lb*A IaJ Ulj
ventilator associated pneumonia (VAP) Jl Uij4a Jc 4cUAj IjS laI Jblbj
no longer recommended pj-al suction Jl jl AJla guidelines Uijal aJc UlAj <
aLxI jjajjJl jSlj routine procedure for ventilated patients -S aIUuJ J
. stethoscope Jb bjj-a £*U» laIj respiratory secretions âa. aJ jl jjj aIU. J
stethoscope Jb bjj^> Ûj caIj respiratory secretions Âc ajj jl aJU. J ._lL
??ajI Juua
JaVI i jiajjJI u^j jJ?-SI %100 J fi02 Jl jaj suction Jl Jja aji Aj>U. JjI
Sp02 >95 %Jl iyî Ja jiajjiSI % 100aUIS Aiaj
guidelines lAjsJ jSlj endotracheal tube Jl Jab ajLAj saline Jl <.»:>'.' jAS o>b
jjiala L-JJjJIj (J4 ASjall
U>bj As.jjlli JILa js. Vj secretions Jl ^jJja ju Ij ajLAj cjjI Jll saline Jl jl •
pathogenic Jl Cy Ajlj<nimo jjjSj Jc jcUoja <uiaA laI Jll saline Jl jl •
jl cJla laLuuI Jll ljUIjJI j^ja j^j endotracheal tube Jl jb> Jab organisms
300,000 organism Cy '^J* 'îj0a »j«jAl. .J1«j j\aa saline Jl Cy J* 5 jla
!??? Abel jjajjfUll Jll AjIj ? juJI ,
cleaning of endotracheal inner wall IJ«jj secretions Jl
(3) Ventilator circuit
The ventilator circuit refersto the tubing that connects the ventilator to the
patient, as well as any devices that might be connected to the circuit.
The most common devices include heaters, humidifiers, filters, closed suction
catheters, and nebulizers.
page 183
: two types bA» Aja
single limb circuit : JjVl p_Jll

Uaa oJÎj AjjAl jc ojljc Ulj
inspiration Jl L*>a> J^»ajj Jll ^

j AjJ ja JJa bjjj b p_Jllj expiration Jlj
A aWiiiiH
dual limb circuit : Jbll p_Jli
jjAjjjl jc ojbc jAj Jbill pjill b
inspiration Jb <L-aLi sja.1j

,
expiration Jb aÛ. aaUIIj
*Uil jl L51xai valve LJ <»jA» ajjAI JSj
expiration Jl *Lul jja^> jjSJIj Jala expiration valve Jl j' Jâ inspiration Jl
Jab inspiration valve Jl jl Jâ
WiimiHifipr Position 30 cm before

iamer Position after /the Y-piece
the humidifier
Position at Position before
the ventilator the Y-piece
/Inspiratory
limb Y-piece Position after
I 4 the Y-piece
ETT
Expiratory limb
Ventilator
Filters Patient
page 184
!?? UU> AjI ujjl bl jA Jaj4 JIjaJIj
Ventilator circuits should not be changed routinely for infection control purposes. The
maximum duration of time that circuits can be used safely is unknown.

(£jjJ jai jSU* Closed Suctioning J«AjA la'i Jj JJ 5 - 3 ja JUu jAjJI )
Evidence is lacking related to ventilator-associated pneumonia (VAP) and issues of
heated versus unheated circuits, type of heated humidifier, method for filling the
humidifier, and technique for clearing condensate from the ventilator circuit
Although the available evidence suggests a lower VAP rate with passive humidification
than with active humidification, other issues related to the use of passive humidifiers
(resistance, dead space volume, airway occlusion risk) preclude a recommendation for
the general use of passive humidifiers
Passive humidifiers do not need to be changed daily for reasons of infection control or
technical performance. They can be safely used for at least 48 hours, and with some
patient populations some devices may be able to be used for periods of up to 1 week
The use of closed suction catheters should be considered part of a VAP prevention
strategy, and they do not need to be changed daily for infection control purposes. The
maximum duration of time that closed suction catheters can be used safely is
unknown
Nursing caring for mechanically ventilated patients should be aware of risk factors for
VAP (eg, nebulizer therapy, manual ventilation, and patient transport)
page 185
Ventilator Alarms
Ventilator Alarms Jl jy jAS fjj\ aJ
(1)Ventilator Inoperative
JUAi Ja IjS Ventilator Jl Ji ajI j Ja J AiijlS Ij alarm Jl l*J=
Cause: Ventilator Failure
Action : manuallyventilate the patient with AMBU bag and notify
technician J lsjL"j AMBU Jb J**J* lsjjAj vent Jl Jc Cy patient Jl lL-osja JJJc

Jb vent Jc patient J' lL-sJa J jUic t-uUllj aJ aJ AAill ljjAj
(2) Apnea
Cause: no spontaneous breath taken
spontaneous breath J Jabj Ja tJ^jJl
Action encourage patient to take a breath or give him a single breath and notify
AMBU bag Jb one breath aa! <ulacl jl jjij jab a_ 1patient Jl AJiAl
(3) Oxygen
Causes : oxygen supply s insufficient or not properly connected
Action manually ventilate patient with portable oxygen source z nd monitor oxygen
saturation
(4) High respiratory rate
Causes: anxiety, pain, hypoxia, fever.
Action: assure the patient and try to reduce anxiety, analgesic, monitor oxygen
saturation, administer antipyretic ( e.g : perfelgan )
page 186
(5) High pressure
Jir-t-i ajI jA jjaVlj JjVI ajjjjij t"ii.ill jIa« Jc iijjSlo Sjjuaj <UjjiA alarm Jl j* lJPJll
Change in resistance to gas flow
Causes Action
Increased secretions Suction
Kinked ventilator circuit or endotracheal tube

byJJ (JâjlA jjajjjl Jll L_lubVI j<lAjjAl J Ajj jl o\lxA Un kink tubing
oljjjl b-ia
Patient biting the endotracheal tube Place oral airway in the patients
AjjAVI (jjmJj) JoijaW mouth
Water in the ventilator tubing Empty water from tubing
Administer prescribed medication

(^r^ j«J») Bronchospasm
(bronchodilator)
ETT advanced into right bronchus Notify
(6) Low pressure
AjVU. J AijUij bj inspired tidal volume Jl jy Jai expired tidal volume Jl jl ajjuj
Causes Action
Disconnecting of tubing Secure all connection
Leak in the systemfrom a ( cuff leak) Deflate and reinflate the cuff
hole in the ventilator tubes Change the tube
leak in the humidifier Tightenthe humidifier
page 187
Failure to tolerate the ventilator
Fight the Ventilator ajJ Jji jbv. _,i Agitated bclA Patient Jl j! Jîa jAS bbal
W ,j,..\\ <ul . .U
jjSj Jb" poor tolerance Jl v¥" Ja heavily sedated orparalyzed jLS *Jcbj j^jJI J
Hypoxemia
Hypercapnea
Cardiovascular instability
? J jl L-iljinVlA i-Ja
If poor initial intolerance

Notifythe physician, and then we will:
•
Increase Fi02 to 100% and start manual ventilation

Check endotracheal tube position andboth lungs are inflated
Check ventilator circuit patency
Check ventilator is functioning correctly
Check ventilator parameters (Fi02, PEEP , I:E ratio , VT, RR..)
Check pressure limit settings
If tolerance occurs after previous good tolerance
The patient condition is deteriorating (bronchospasm , sputum plug , pain , tension

pneumothorax , pulmonary edema,....) treat the cause
There is a problem in the ventilator circuit and artificial airway
page 188
Weaning criteria
Clinical criteria
> Resolution of acute phase of the disease

> Adequate cough
> Absence of excessive secretions
> Cardiovascular andhemodynamic stability (HR < 140 b/m, SBP 90-180 mmhg
TEMP " > 36 and < 38 C ", HB > 70 withno evidence of hemorrhage)
Ventilator criteria
> Spontaneous breathing trial tolerate 20 - 30 minutes

> PaCO2<50mmHg
> Vital capacity > 10 ml/kg
> Spontaneous Vt > 5 ml / kg
> Minute ventilation < 10 Lwith satisfactory ABG
> pH>7.30
Oxygenation criteria
> Pa02 > 60 mmHg (without PEEP) at Fio2 up to 40%

> Pa02 >100 mmHg (with PEEP <8 cm h2o) at Fi02 up to 40%
> SaO2>90%atfiO2upto40%
> PaO2/FiO2>250
> PEEP<5-8cmH20
> FiO2<40-50%
Pulmonary reserve
> Vital capacity> 10 ml / kg

> Maximum inspiratory pressure > 30 cm H20
page 189 -
L
Weaning Process
Spontaneous breathing trial (SBT)
> You will see the physician uset -tube it-- piece) orCPAP
> You will just let the patient breath spontaneously up to 30 min
> And also we may use low level pressure support ( upto8cmH20) to augment
spontaneous breathing
Jii ji <1L=JI J well tolerated ^Lb jj=jjJI aJIj Jjj ljU.U. 3 Jl laLc J
a-uijjS &c\ii vital signs Jlj ABG J' <aJ1 J Consider extubation
£?Ji ?Ji lsJ AJbaJl J J11 not tolerated <J=-bj patient Jl j' Lb«a jl ^J3
aaU ijA ventilator Jl Jc
Note : onlyone SBT is recommended in 24 hour period
Pressure support ventilation (PSV)
> Usually started at a level of 5 -10 cm H20 ( up to 40) to augment spontaneous Vt

or spontaneous frequency < 25 min is reached
> Decrease PS by3 - 6 cm H20 intervals until a level closeto 5 cm H20
ABG &vital signs Jl J Consider Extubation Ja well tolerated ^^ j<ajjJI J

jujjjS IjilS
Usually Remember that weaning only during the day time
page 190
Signs of Weaning Intolerance
> Diaphoresis
> Dyspnea & labored respiratory pattern
> Increased anxiety, restlessness, decrease in level of consciousness
> Dysrhythmia
> Significant Increased or decreased in heart rate
> Significant Increased or decreased in blood pressure
> Sustained respiratory rate above 30 c/m
> Tidal volume < 5 ml /kg
> Sa02 < 90 %, Pa02 < 60 mmHg, pH < 7.35
> Increase in PaC02 ( > 50 mmHg )
page 191
‫‪Chapter 6‬‬
‫‪Lab‬‬
‫‪Investigations‬‬
‫— ‪Biomarkers‬‬
‫" ‪" Everything hinges onthe matter ofevidence‬‬
‫‪- Carl Sagan‬‬

Lab Investigations
Complete Blood Count ( CBC )

AiaUll j,4l! SjjjjS
Element Meaning Normal Range

JKlltll tjJuJall JJslJI
Male
Red Blood Corpuscles 4 - 6 Million / mm3
»lj*all j.411 CjIjS
(RBCs) Female
3.5-5.5 Million/mm3
White Blood Corpuscles

fl.'-JI ^jll CjIjS 4,000-11,000/mm3
(WBCs)
Differential WBCs
j_C Jj'l 11'oil j-Aj p J-i a—A I

Neutrophils -Ibbjjl bilaJI
4—JjASj |_Jj4_c. J 4 jjvlj-c 50 - 75 %
e4l Ja4 .au—jjal 7?\ Au a c li
Lymphocytes ^jlLjll b>jjl i_jl "JJJS J 4 (jjjal 20-40%

j> uaJI Ja4 j
Monocytes j5LA 3 - 7 %
Eosinophil 44<Ja*bJI bilall 1- 3 %

4; ...I.,.-* II Cii\ a, (j_j 4_jjA
Basophils hlcW bMaJI 0 -1 %
flj-aall jvAll AjIjS Jab 4ajj Male
j c Jjj umII j ft j 13-17 g/dl

Hemoglobin (Hb)
JjAjJI j_-o jj> .nSVI J_iJ Female
j. uiaJI <jl ' L_i lja-o ^ SI
12- 16 g /dl
«"> a4_JI I lHa 4 I 1nI Male : 40 - 50 %

Hematocrit (HCT)
Female : 35 - 45 %
Page 192
Lab Investigations
Complete Blood Count ( CBC )

AAallll »ll\ ljjjjS

JKlllSI Jxa1\ (JLuhl\ J-vaJl
150,000-450,000
Platelets (PLTs) 4jj<i4ll tAILÎI 44E
/Mm3
Mean Cell Volume (MCV) elboaJI aAl u^la jai IojaJa 76-100%
MCH (Picogram)
Cmj?-_n*l! jjj A" Ja 27-33
Mean cell hemoglobin
MCHC ( G / Dl)
.'jjj y^ oajjJI ViS \i Jajji iiA 4 '."' 33-37
Mean cell hemoglobin concentration
4ja_ualj jjill olj*aJI jUll AjIjS
A^y uj ul a ** " '-•J—*AJ

Reticulocytes 0.5 - 2 %
.>J.' ,„ij J li.ll 6-1 4J
L_LaAVI AjVL-Ja ji-ij-% ilil u—a
Men
ESR (mm/hour) j>4 11 lLiIj S L.1J ulj J4 Jt-0 0-5 mm/hr
Erythrocytes Sedimentation Rate ( f^-na jj_Sj jiaJj-JI j.jV ) Female
Up to 8 mm/hr
RDW Discussed ( page 207 ) 10-15%
Page 193
1 Lab Investigations
Liver function test

±ia!\ uiiUaj Jilaj

jui'itii Jxa1\ kixjai] JjjuII
jj_uSj 4_*j jjjj_lajaJI a4_A j--o jAAj total: up to 1.2 mg/dl
Bilirubin I—Ajac jl i'i j-» ) jj—aall J.4-JI Ljlj_S Direct:
( ?j i 120 - 90 j . 1 / 3 total bilirubin
SGOT(AST)
4_iSll l_jla j—a,\l 4_âljA Cil ujjl Up to 41 IU/L
Aspartate amino transferase
AiVLa ,^—3 jv4_ll ^j-J Uljl m<i 4_ljjjj

SGPT(ALT)
Alanine amino transferase
JUjll 4jS1I J^H] uj 4-411 bjl-ta OJj Up to 45 IU/L
Lf—^' lJjJ—41 cs—'JJ' jj—^' J—*

(Alb) oncotic pressure -li j=- Jj-Ji jaj
3.5-5 g/dl
Albumin ljj4—a i_u—uijj ji mall u 24 uaiijj
cellular edema and ascites
(Glob) OXJJ- JjiA Jl

2.5-3.5 g/dl
Globulin (jC\-JA\ jb_(}aJI ^ j_uS jj4 4_lj
TP
LJbllJJSlljAjjjl! 6 -8 g/dl
Total protein
Page 194
Lab Investigations
Renal function test
JH\ wiiUaj JJsu

juajjvil Jxa1\ <yuJa]| JjxaII
i_lA LJj_C.I j4_Sl |_j 111 ^ mj'ljl J-Aljjll

Creatinine 0.4-1.2mg/dl
KtlJNl r.ljJ.N
Urea jjjjjjll JJ-»jSj <bjLmJ Jljll jAl-ill ^^-A 20 - 40 mg/dl
IJI i Ulj, ilVlj «(jJ

CrCI (GFR)
90-120 ml/min
Creatinine clearance ( jAAbJll JjailaAjJ 1
(BUN) nitrogenous end product-li ^

10-20 mg/dl
Blood urea nitrogen protein breakdown Jl cyMb Jll
thyroid function test

yiill (Jillsj JJsu
FT3
3-7 pg/ml
Triodothyronine lAjkj 4jSj4ll $4*11 ja jji AjbjîjA
$4ill JMJcl jl <L<jLu (Âa I(j1->ni j«

FT4
0.8-2 ng/dl
Tetraiodothyronine
4 .Lola-ill s4 ill j « jj—Al jj_^jjA
TSH 4_j3j4ll o4_JJl 4j_4ll Jj—a4 j_iajJ 0.3-3 MlU/dl
Page 195
I Lab Investigations
1
cardiac enzymes
uM CAaiJl Jjlaj

j, f\'\r 11 yiull <bxjjJaJ| JjxaJI
<120n/m
(CK) Ciy >rn\\ LiA" 4-lla. ^J
â!\ i'iN,V-r.j (_jljj| C_L/LjaC.j ajjiaJI ,' iN ,u<-.
Creatinine 4 jjjj 4i ulj
Creatine -Ji >^jj 4jI ^ J-^jal <ciajiij LAlcb-u, 4-2 Jji (j-i
phosphokinase
(<Ukli -uu.) ATP -li tA J--aj jbAi^ J 5A l4 S4 «jj
fi ji 3 a «1
_j4ajlb 4j ajail -jj 'VI b
CK-MB < 5 % of CK
Ja ai LJ llll ljM ubc J i.14
<0.1 nm/m
JJ a ja jAjj Jj c. ojl ic \l
J JJJJ 4_i
Jl 3lbj b uiiJ ^J 1511 L-jl uac
Troponin 4ju Cjljclu, 4-2 Jjl J
J II (j 34j ajo 4 iisl
J 'iii \l S
infarction î^c J-^ ji 0la.-o Jj_kk b juiI $4 ol
t*-
<100n/m
JJJJJ fi' j c Sjl jc j A
lAvLuojlSI • «1* <Ula J
<_i_151l Ciy ,>,r. J_ab 4_Uall J—oajj ^ l -JjA 4Jj ujj
Myoglobin
i SLa w 94 jjjj 4 a.La Jji j Aj
I jlibl t_j 1J ^ <, Jj
Page 196
Lab Investigations
Lipid Profile
( <UU 12 fLu-all ?jlW ) JJAJJI JJaJ
(jtjjhll JjiloJI
J Ja4_ k4 i_j j,jo

e>*
jÂil 4__slAAI 4 jujibll 4j uJtVl

< 180 mg/dl
Cholesterol
jjall ^j 9lAAilj 4jj uij j Sj Slj
(risk > 200 )
_u,jjA 4 'li jjjlj__ujll i_il u<aj dS—LixJ
i i Vail 4_j4jAo1I 4_ia.bll Jul j-AJI jlj-a l_s—1c
j 4 jjjbll jjA4_
< 150 mg/dl
Triglyceride I fl,'^.'.' Ijj "^ i-Ailj
(risk > 200 )
fatty liver <*\ ^h ^' Lj>u. ^ ^-^jj
Jl (j 9Jjji uiiljSl! J «ajj < 130 mg/dl

LDL
Low density lipoprotein JjjLuLilJll 4; .•'• o4bjj LaLjsl* 4Abj JlAlbj (high risk< 100)
Jjj uJjSlI AA4 <_4 Sjo
ja4 iSlI
HDL
<bjlj5__u<all ojl uaxll j o<Laljaj—ul ju—J >40 mg / dl
High density lipoprotein
u Slj 4 iV 4__LUxo 4 34bj <M lj
<ia uijVl u 9Jjji—uiljSlI <_JJ—uj C.
Page 197
1
Coagulation Profile
"UjjjjiJI JjJLaJ

jjjaJxll J^l <jlu1o1\ JjJLill
Bleeding time LJUJjll JAJ 2-5 min
clotting time JalajJl cyj 5- 10min
PT bwjjjj^l Cyj
Prothrombin time 12-15 sec
IJaaJllI 4J0C Ac ju, j!a Alia lJjju )
PTT PTTJlj-J
Partial thromboplastin time 35 - 40 sec
( Ir-Jlll <uioc JabA uIa 4Ao i_ijxi )
INR ^jjb- prothrombin time Ji j>

International normalized 1-1.2
4jjj4ll jjjIjvoJI xa
ratio
Arterial blood gases
r all\ liljli JJaj
PH Acidity degree 7.35 - 7.45
pC02 Partial pressure of C02 in arterial

35-45
blood
HC03 Bicarbonate level 22-26
PaO? Partial pressure of 02 in arterial blood 80-100
Sa02 Hemoglobin saturation of oxygen 95 - 99 %
Page 198
Lab Investigations
Common tumor markers
ijuLill a\jji\ lAVVJ
Marker Significance
Normally < 40 mg / dl
Alpha fetoprotein (AFP) Increase in hepatoma and
germ cell tumors
Cancer antigen (CA) 125 Cancer ovary
Cancer antigen (CA) 15-3 Cancer breast
Cancer antigen (CA) 19-9 Colorectal & pancreatic cancer
SLE
Anti - nuclear antibody (ANA)

High sensitivity and low specificity
Ia4*aj negative ^JJ J j*aj
SLE
Anti - ds-DNA ( high specificity and low sensitivity)

SLE ui ^ positive 4jil jl î Jxai
Rheumatoid arthritis
Anti - CCP
( high sensitivity and specificity)
Anti - SCL 70 Scleroderma
Page 199
1
Electrolytes
(JjirjiJi) afljjjilVl JjJbvi
Na Sodium 135-145mmol/L
K Potassium 3.5 - 5 mmol/L
Ca Calcium 8.5-10.5 mg/dl
Chloride Chloride 95-105 mmol/L
Phosphate Phosphate 2.5 - 5 mg/dl
Magnesium Magnesium 1.5-3 mg/dl
Body Mass Index ( BMI)

( Body Weight / Height In Meters2)
Underweight JbAll jjji ja Jii < 18.5
Normal Ls*m^^jj 18.5-25
Overweight jyujJall Ja JSi 4jjj 25-30
Obesity (class 1) 4jaJI Ja JjVI 4ja.jol| 30-35
Obesity (class II) 4i40
Page 200
Miscellaneous
JJL JjfcJI J> <?i>
Pancreatitis ij- -*j I ALJjuo ' A4bjj

Serum amylase 50-150 lU/dl
J.4JI <j »jbj Jj-^jj amylase -Ji ui ^LaJi Jj
lipase Jl i^jiij J5a4jja I4S 4xj <cbj 48 »^*i
44. jjii4_ LJJ-

UHJ>
CRP
(C-Reactive protein )^ J ls Ul
< 0.6 mg/dl
C-Reactive protein \~ Si 4 jSII I lyja. J—al4 jj—A jAjj—J bj
• ...Jl v; •-' yAill Si-all AjLjLJIVI 4_!La y-S
oJlj——^.j-aJI fi-^L ^jaVl4.
ASO t5j4-£ 4jHaj 4_lla ^J jj-SAA ^lj jUJI ^ <200 lU/dl
streptococci group Abacteria Jl l>
PCT
4jjASj Ujlc Ij^-J lAb«-o juujall J 4J4bj JJJjJJ
<0.15ng/ml
Procalcitonin Indicate: bacterial infection
<Lo4aj_uiJj jJJ-Jll J-la4 j-« jAAj jAjJ-J J-A

D-Dimer <500 ng/dl
ojl yj LjUala jjj-Sj j-t i_i_ujSI jLAic boj«c.
HAV Hepatitis A virus HAV IgM
HBV Hepatitis B virus HBsAg
ELISA
HCV Hepatitis C virus positive JJ= Jj

jSLu jlAc. PCR lU*ja
Page 201
Test Precautions
AjlJo1\ JjM <j!ja.y 3u.pL\\ GlJaLjAVI
(—all J Jjiull
(<bibj 14- 10 j-AiVLall Jj53 ) 4cLu, 12S.lJj.b-JI
J Jill 4j& Vuj
( lUsVI j- )LjLcbj 8- 6 j- fM
ALwall jSuJI
( Ci\clui 10 - 6 l> ^VbJl Jj53 ) Lj^lu, 8 fb-JI JajAA
JSVl 4*4 jSJI
jxicUl .bii jjaAll ji JSVA JJ-jju Vj 4aj lil j^JI Aa.1 4juj JSVl pl-SjJ j. jAcUl ujbAal Jajluu
4UjJI Jj9 J^ll jj^JljJjlij -I 0J^ JSVl 0- cbAVI ^jj US ( Ja59 ,UI JjbL ^ )
JSVl Jc Aclui jujj
J.41I J jSbJI tri3uL0
( JVi 1Jic lAjcj )^ 150 (jc kiAjj\ <^sii ji; vduaj Ubio j,bi 3S4J cjbjjij Jjbj.
4x.U 14-10 fb-JI Ixi ^buJI J JaAJI Jot Jj •
( Acj, 12 - 8 ,.U— 4*J J^laJI SljJl )
( AjIcU 3 ) jbJAVI SJS JIJa ( jjjkll ) (.LajkjVI ja 4jV •
jbjaVI SJS JIJa JLj jjAAill jAIoj .
J^l JJJ lJc ibA lA4_j4aj juLj jj_Sjk A^j>. M>J1 ^ ^^j ^ _, ^ ^ ^J
jjjtbu Axi 4JJCj 4x.bj 4*4 4Jjcj 4cbj L-Luoj 4*J 4Acj
Jjjll 4jjc
J" '^J J *> >lj jjaLajJI J ,ja. J_,i Jjjjjj j.
Page 202
Lab Investigations
JaaJl Jjjll
Jjij_jJ| iHVL-! a- JXJVij ij-sj j-£i jj-j*Ji uj-^ ^^ c1^11 «-*J^ Jjl J-^'
, j j.jjJI jjSJ L-kaj VJa 4iUI <UJ1I J
. -bJuuia JSI 4jV 1Jij j.4 JJaj J-oC £JL 4jjbj Aajill LAIS bj
(TB / "lUI "jjJi MjJJ> Cf- '-^) d^ ^ ^ ^" f^1 3

j,jAl jjA J JaxA\ J\ Ajjt JS J-Jj cM1 J tWi
JjJI 4x. j jo
.JjAjb JjjII jrJwo Juij jjjbJIj JI-JI >bJb l4ja 44U4JI »UicSllj tS^Vl lU -
Û ..Jl UjjJI J_-oa4 aJi j^LjajJI ^J JôS Jji ^jli aJ\ AAâ Ja^JI Âjxll ^Jaxi j^JJ-JI -
. ji.la.jJI J -bsbll 4,loS1I d&l j^ J" ^ J J
Mjj_SjJI Cij-ai VÂa >ASVI ^-t jAcb^j J!>LA ^JJ_^ll „_!] *_AjJ! Jb—J lV- *-& -
^jASjII 44*11 4bJ jl
, Jjlalll Jj9 4X.U 48 jft J5J VS4J AjjJall LAblAaJI JC ^bloVI -
<lebj 24 J^La JjJI A-«a
JU1I fJJI ^^4 4*4 JjJI JS ôal Ji Aijll Jj>-j SbJI Sjj4 J 4JLAJI j-ji
, JuxJI Jl <1UjjI JJa] 1*3311 J JjJI Jaialj (4eU 24) ^J1 L^ J
4i4ll ^bUI JVJl
4jjj>o J Jli jj4J <bab—• JjJ 4Ac jb
aJI AC J jo
Sjljail 4jaj4 pLCjl fbii 4jjjJI 4aJ ji Jj-<aaj

(JaxaW J) JaJj f.JI icjjJ 4u^lA AjaLaj J ^Jj <— 10- 5 L> ^ L> SJ^ «*J
<CibjjAoj 4J4all
.Oil J5j ji 4j4aJb CM*1I JjSj JapJI SJS .bj) Ixi kl— jjjJaallj LjbcU 8-6L> ^ tU^J
Page 203 —
1
jljJI Ac jja
ibjjaJI LAbbjaJI jc, J-bAVIj JSVl Jc jAcLo JSLa J Jôll Jl Alixl\ Juaj ji J=,jAA
jlAAVI Ji i^Lj 48 jc J53 VSaA
L-LjjSjJI J35j L* UiliaJlj AAxJI (jo JiljJI j^loj UjV JUJaVI LjUaba J S4jlJl LjLjj*1I Jji Vj
jljJI JJiJtfJI
<0^>jjl ^J-îj JaJlj fjaJll g-ljii xia*. jc jjojjJI jAIoj ji ujaj 4AcIa 48 UJ jbJaVI lM
LJjjLJI 4Ab jljujj VLoS 444a ji jjjAjJ ji JLolli ji jjj^VI Jc ^Jaj *lj4 Jj
4jlblo abl 3 (jl' •**'
JSVl JjSj AjIj* S4c oUb ijû^JI 4*4 ^\^\ J> j^ jj ^ ^^

. L-jbJll 4JJC jjjj (JjLwaJ JjSj ji Slcljo xa
CL—II J jabj *U jlaj jbiilu,] jSbj . fjJI juij J jb*J| JJ ai,î\. <bjt JS jbj
J> j-Jlj jjji ) f4ll J <bj4VI jjSj
JM ji J Jjaj ale J\ AJLîli J5VI Jc fbi 5 S4J jJJkub eljJI -lajj ji t-Jaj -
jblaVI Jj9 4jilu,48 S4J
4ALill 4bi*l|j ,.|Jill ii| j* ^Lo, î 4aj *Ijjll 4£j=. Jj JjVI ^jll <Ujc ja! J; -
Ac J um oljAI JjLu j« ljIcLj S4c Jju
Jj 3jjjjJI Ljb oJjjlo oL_ll jjaxll
J JjJI £*a Jc 4AU Jjaj xa Jj*JI J lillj Jj ji Jj^jj uilaj i tiki *\cj J JjJI .Jaj Ju .
. ljIj4AJI 4ailSJ jÂll J ^J& Jail OVLa J j\axA\ / JAAjJI
tSjai 4JJC xa 4Jjjc. Jj4j3 j* jjajjJI aAJ JjJuJI jjall '.'-^ -
<Ltbj 48 jc 4jJ V SjjJ 4a^jl| j\ JjJI flij ^^ J^| Jj ijjJI Jl^j ^^ J .
jUb Jo*jJI Jl <Ubjjl Ji jjjjill J JjJI ,â>4 ji
Page 204
Lab Investigations
Prostatic Specific Antigen (PSA)

ijUAjjjJl ^jjj, j-aai jiSjJui ji jUaio JLajl jo JJaJI *!_>?•! J^ jj 10 O^jJ' t"^
Glycosporine
.jjll joSJill jjA J AlixW ..^... JJaA <bullo J«c Ac j JJaJI Ji 4>uj411 Ljbajlj jJljJI Jjbj j,Jc
( bluLo jl laliuo I
G6PD
J5VI Jc jfu, jjjo 4*4 V] 4_uAjvAl ujjja jiaJl J5j 4*4 JJaJI *ljaj ale JajiAA
Hydroxyprolene
Jc ^Jaj 4j-aLa <baLaj J Acl* 24 '"^ JjJI £^H f3 <cln 48 »^J lJ^'j f-^1 <> t^V1
J«uJI J jjaJjJI l,$,<il,,n) jiiola.
Helicobacter Pylori s^Ji ^Jja

lAIcIui 8 ("J-aj fbi 5 SJJ <bjaj*ail LAbLjaoj 44jjall LjbLkjJI jc ^bloVI
Valeenvl Mandelic Acid (VMA)

Catecholamine Metabolite That Increase In Pheochromocytoma
JjJI ^xoaj Ji bjj-Jlj jjjuijJIjblAlillj 4jVjSJillj Sjjllj JJJI JjlA jc <lcbj 48 "^ fcLu-VI
JjulJI jxi jjaJjJI la-Juill jja-ola. l$4 4_uaLa <ala.j J 4x.bj 24
5-HIAA (serotonin metabolite)

jJaUJIj j_oJlj jjlSJVIj AjIjjjSJIj cSjjSllj (jJjJIj cJjbVI JjlA jc AcIa 48 SjJJ-LtLoVI
JojuJI j* jjajjjl b-JuA jja-La l$i Suâla 4ja.laj J AcLa 24 JjJ £^J> al
Aldosterone, Renin
Renin J jAcbj S4J JJS JjJja* xa ISjall ji ajl\j Jl 3 SlJ 4j4lc AaoSj jdJI JjlA
Aldosterone J ^L-L. 4 sjJj
m-.$ ^1 ^-i jLLI hj-*> k>-^

Page 205
i Others
Lab Investigations
• Diagnosis of DKA ( Clinically )
ABG: metabolic acidosis
Random blood sugar: >300 mg / dl
Acetone in urine: positive
• Normal specific gravity of urine : 1005 - 1030
Fixed specific gravity at 1010 = severe renal damage
• Increased Bence Jones protein in urine: multiple myeloma
Other rare causes are
( Malignancy / amyloidosis / collagen diseases )
• Single test to diagnose thyroid disease: TSH
Follow up of response to anti-thyroid drugs by T3.T4
• Hypocalcemia with unionized Ca & normal ionized Ca
Hypoalbuminemia ( because unionized Ca carried on albumin )
• To check iron stores to diagnose IDA: we do ferritin level
Ferritin level reflects iron stores which are not affected by other factors
Iron deficiency anemia (IDA): decreased iron &ferritin
Anemia of chronic diseases: decreased iron & normal or increase ferritin
Sidroblastic anemia: increased iron and ferritin
Page 206
Lab Investigations
• Red cell distribution width (RDW) = 10-15%

Means variation in volume of RBCs
Used mainly to differentiate between IDA &thalassemia
•/ IDA: Increased RDW ( high variation in volume of RBCs)
/ Thalassemia : normal RDW (low variation in volume of RBCs)
JSA1I jijj tljâJI IjjLaJI JS Jc JjJ Jljj JajA
• Widal test: positive if

/ titre > 1 /160
/ Rising titre by 4 folds

/ If -ve 0 Ag : no typhoid
/ If H+ antigen is only positive this means old infection or post
vaccination.
• Diagnosis of diabetes insepidus:

^ Clinically:
Polyuria, polydipsia, nocturia

s Investigations:
24 hr urine volume: 3 L/ 24 hr ( up to 20 L )
Urine specific gravity : low ( < 1005 )
Urine osmolarity: low ( < 600 mosmol / kg )
Serum osmolarity: high ( > 300 mosmol / kg )
/ Others:
Blood glucose: to exclude DM

Serum electrolyte: to detect hypernatremia if dehydrated &exclude
hypercalcemia , hypokalemia as cause ofpolyuria
Water deprivation test: to confirm diagnosis of Dl
ADH: to differentiate between central and nephrogenic Dl
Page 207 -
Lab Investigations
( Red Capped Tube ) j~Vi ,ba*li cjIj -bjAVi (1)
h Kl *Aljo J tjb L?J 'n' 'i jL-J u, '" "J b"0L0J 4_9la. 4_jjjjl ^^Jn -
(serum) fjj-JI Jc Jjj^JI Jai jo

LjbjojjjJIj aJl tljojS JJlaj i_ill»II J j JJ : b-ol i^liiil -
lA jjc j Ljbjjjjillj CRP Jl UJ lSJî JJla-ij

(yellow tube ) *iJ-=> ^ja'i ^jj biu. -
Ja SjLo IJaljj Jja.jo jjj 4jJajj HKl jljo J Jc (JjJaJV
blood cells Ji l> serum Ji J^ jc 4cbjA bji jjj LjAJaj

LliLjjjill JJlaj J Lj.pl S'.nj jiSlj j>4 Jo 2 —10 j* •JaAJ jSbo -
4iij 15 SjJ iilJj Jj 4jLoa. J*j ijll liljaj jl ljJsj jl r J j»4c ^lajj -
j,Jl JS Jalajj Ja,
( Green Capped Tube ) j^Vi *Lk*Ji &\i -bjAVi (2)
lithium heparin Ji W J^Laiii *aaj sjU Jc ujâ ui ^jjVi
(LH) LJjj*-JI lAjboJalj
VAC
G6PDH Jl Uj JJ^JI J**i J b-o4aJAjj -
a*
cytogenetic uJ^ WjJ] ^ oJ^j

1
ABG -U LuJa jLajj
J Jo 5 •la.Lu -
^•P ojJAj l, ihli -r joj jSlj iJI ua J*J JolS JSAj 4jjAVI S4A Tjojj -
Page 208
Lab Investigations
( Lavender Capped Tube ) tyaûUailiLjii-bjAVi (3)
11 1 lj" ."I UW* 11 . \*'**\\ /. Ir. jjj Wii (_j.1 4
(EDTA) L_ijj*xli UjLuaiaij ethylene diamine tatraacetate Jl

iji'.VI _
1
(CBC) 4I0LSII j.JI Sjjj-a JJa3J JjSjj b-ol-laJAil -
1
(Cross matching) JM1 âLucj ( blood group ) jll JiLwas jJajj
r
J**
HBAICîJli J^Jij
al Jo 2 —5 j* •I3'" jSoo -
1 f.jJAj i_iJJj £• joj jSlj »Jl jcoa J*J jblSJ^jjA ^JjAVI Sja r joJj -
( Blue Capped Tube ) iSjjVi *Lk*ii ajIj ajjavi (4)
( sodium citrate ) j.jjjj<-<JI oljiu. Lj-j sjU Jc ^ jaA ^4 4jjjjVI

( al 1.8 + AjIJ-u, 2 ) JalaJI Joljc jjli Alia J Q\ 1 j>JI 4_loS JjSj AAa.
j>Jl tJjj JLoclj L-jLuijJI Ac ju, jjli Alia. J 5:1 j Jjj
Coagulation Factors jii Jakj JJjc jjli j L^4aiuu

fibrinogen factor —lij PT —h PTT —Ji b_*Ja Ujj_îij
D-dimer Jij
Jaj ualA 4 <y*l\ 1 ic jj Sj til JclA j»J II 4 jjc. j.jV Ul 'A >J4JÎ
4Jajih<i 4jl4jj1I Jc Jjuaaj jlAc
Page 209
Lab Investigations
(grey tube) l?j1-JI ^lî a\i hjJi\ (5)
Ilir^ryj
Ail IU
oJLa ^-ic. (_£jiaaj ^J <jjiJVI
sodium ji potassium oxalate J Fluoride oxalate
|;!|| Sb
! fc
i r
1 REF
IV- ^
jjSj jj*3 *auj 4jv J.JI J jjj?. jjbs jo*i diij fluoride
, jjSJail j.JI b!>la. dMjJ i_il5j] JjJa jc jjSJail

I
-I
Ul
" Learning never exhausts the mind "
• Leonardo da vinci •
Page 210
Lab Investigations
Urine analysis sample
urethra -Ma•*& 3kp.<JI AikiJl JS3 A-oUil Aibkill Îjj
jxiiaxj LJLaj jJju f.Lcj (jj Ûj-aSl ^J urine sample ^-J u1 cJ-Aaij •
4J4C.) 4j J\H\ pjaJl jj) 4J4jJI jaij JjJI (jo JjVI f.JaJI i_jjj t_ujj <;Uaij|
(clean catch mid stream urine ) o\ lt^ ^ j*j (sJ^j
Jj—Jl *_«a j J4 S (j_o 4 tj.1l J_a.| ,j_c J_Aai4 4_JjJI ajb ni'lll 4_JLa ^j-S •
Jj Jl *. <ua (JAl i. (j C lA 4C.I4J fijJa ujill J ,.-A j SJj
LjjJ d-^J I-j-S Ajuj 4_ajaj 15 - 20 ~a:L-^ l_i_/,11£j SjL mail J_isjj
Jjj jûi 20 J\y* J» ^j^ Lr4a_ui4J tommy syrine ( 50 ml syringe )
bjJMa, (Ja Jj-JI L_La_ui4j sAjAa 4jajj\jui J-uoJj IAS J-*J i<j 'l o(jnKMft J J J
Jja-jJlj (JjjIjjJIj I*jjjJai Lo Jju bija |jj
a to -11 <J CJ"l (_5—It 4 SjiJl a_ajj 0J_-afcj (jAa4J_-JI a_uil 4—jl_i£ Sjjj_Aa •
Jl ail ^ 9L_£C. jj J 4lib 4a. Jl aJI ^ 3J aa-Jl 4 jjxjl J—uij •

^•î Ja£ AcLa jMa,_J jl
Page 211
Lab Investigations
Cerebrospinal fluid (CSF) sample
Jjalll Ja A(jil\ AJb b 4a. J LaJI j J
•Jj 3J «*Jl u SI ^j uJl Jjl Jl 4 Ac J "lj] M =S

4£.bj • iu<aj (ja JSI (J liJjLaJJ
L-4jJ £Js (jaj JV(j 4a. 4 oSxa A 94Jai A ij.II J ijj •

SJja.1 oil 4 jjjJI Ajj jjj jl (jj £j\Jl ^j u<a*JI jb_$_Jl ,- 11
(_Jj_aill Jj—axll yj 4 ni.nK 11j 4_xjIjll 4 jiball aj_aa]| jj_j 4 'tj.11 i.t^ ,„ -j_4j
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Page 212
Lab Investigations
Blood culture sample
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Page 213
Lab Investigations
I
Sputum Sample
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Page 214
Lab Investigations
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" The journey of a thousand miles begins with one step "
Lao Tzu -
Page 215
‫‪I— Chapter 7‬‬
‫‪ICU‬‬
‫‪Procedures‬‬
‫‪Checklist -I‬‬
11 physicians think they do a lotfor a patient
when theygive his disease a name "
Immanuel Kant -
_| ICU Procedures
Oropharyngeal Airways (Guedel) Procedure
Uses
Relieve airway obstruction

oljjJI tija-o jlsjaj jo t »~»n
Provide short term maintenance of the airway
SjiuaS SJJ9 J dljjJI (^ja-o £j9
Facilitate removal of tracheobronchial secretions
JljjjJI (_Jja-oll till jl Jl <UIjl 4J0C jo Jj-uiJJ
Facilitate artificial ventilation
Prevent damage to the tongue and soft tissue of the mouth

aijl_j SjâÂj! fiî^Jl A_jJjC.yi j -jl ,-ill (Jx-aaJ 1 al* Â i_lcj pSlAa
Contraindication
Conscious or semiconscious patient: as the insertion will stimulate

the gag reflex and cause
patient to vomit
Page 216
ICU Procedures
1
Selecting the proper size of the Oropharyngeal airway
It extends from the

corner of the mouth to
the base of tongue.
Parts of the Oropharyngeal airway
Rigid body One-piece design Nine colour-coded sizes

To maintain a patent airway Withno separate inner Tomeet all patient
bite block - safer by design requirements
Soft tip
Reduces risk of
sSofter second material
Reduces the potential for Clear colour-coding
tissue damage dental damage For easy identification
Page 217
I ICU Procedures
Oropharyngeal Airway Performance Checklist
Assess the patient's need for oropharyngeal airway.
2. Wash hands and weargloves.
3. Place the patient in supine position with head tilt-chin lift or jaw thrust maneuver
(in caseof head trauma).
4. Suction the patient's oropharynx ifthere is bloody secretion or other foreign body.
5. Select the appropriate size ofthe oropharyngeal airway.
6. Hyperoxygenate the patient.
7. Insert the airway through one ofthese 2 techniques:
A. Insert the airway side down into the mouth, as the tip ofthe airway reaches
the posterior wall ofthe pharynx and rotate the device 180 degree into the
proper position.
B. Using the tongue depressor: insert the airway right side up to the oropharynx.
8. The distal tip ofthe airway should lie between the base ofthe tongue and back of
the throat, and the flange ofthe tube should sit comfortably on the lips.
10. Documentation (date, time, size oforopharyngeal airway and patient's response).
Page 218
ICU Procedures 1
(jL^Jk ji ji aji-11 (jjJA\ oA-a Oropharyngeal Airway —M ^b»i-»-jj Sj-S* u*-^
more flexible and made of rubber l** ^ j mouth -Jl J^ nose Ji l#> i>
long term maintenance ofthe airways jjkj
Oropharyngeal ^j- J> J*ijH& cJi Anesthesia -li u-a u>^ j-^1 V1-**3--!
Nasopharyngeal —M ^ tongue —^ ^j-W* gM u-^1 l3j-4; ls^^j* ^ jj-^>
UJ JaJ 4j| t nm
Selecting the propersize ofthe Nasopharyngeal Airway
Parts of the Nasopharyngeal Airway
flange
Inner
cannula
Page 219
J
Nasopharyngeal Airway Performance Checklist
ICU Procedures 1
1.Assess the patient's need for nasopharyngeal airway.
3. Inspect for smooth edges of the nares.
4. Lubricate the tip and outer cannula with water soluble lubricant (KY gel).
5. Suction excess secretions from nares.
7. Gently slide airway into the nostril, guide it medially and downward along
the nasal passageway.
8. Check the patency of the airway through:

- Feel for air movement overthe flange.
- Auscultate air entery bilaterally.
9. Check the correct placement through: holding the patient's mouth open,
controlling tongue with a tongue depressor and visualizing the tip ofthe
nasopharyngeal airway behinduvula
10. Secure airway in place.
11. Suction secretions if needed.
12. Reassess yourpatients respiratory status.
14. Documentation (date, time, size ofnasopharyngeal airway and patient's response).
Page 220
ICU Procedures
1
Endotracheal Intubation Procedure
^35-25 jazJJm V> W i^ ETT Jl
(5-10 mm) j-« cjIJJ'Jj U^>i inner diameter Jl ^^ Jc ^jjjj L$clA size -Jlj
7mm V^L (JÛ' Jasll) inner diameter Jl »^" lJ JJ 7mm <ijj'\ JJa UIaI tffAukj
8 mm J«aa JjAaLj 7 mm J> LJ«aaj 4j>U Jll adult Jl j^nill 4_ujjjL
Jl^ Paul Marino \& j* J-î <j_ji ljWa.1 J jV
Smaller tube impede the clearance ofsecretions and create increased airflow resistance
when weaning from the ventilator
Jjl LjJJ. lAjjAj j Jj JaVl Jc Jjl 4fle ujWi]Cy (^ ^ ICU J' J Jj" Jii^JJ oJ2 J^1 J"
Page 221
ICU Procedures
1
Proper Tube Position J VJL.
jl jyit, neutral position J j JA patient'shead Jl *J
Tip of ETT should be ( 3 - 5 cm) above thecarina or midway between carina & vocal cord
(hi_^lli ij-âjA inferior border of mandible Jl j! LaIa^ ui neutral position <-^l£
flexion or extension J-^ ,J^ J^l l>=jjJI Jj lower cervical spine (C5-C6)JljJ
2 cm displacement of the tip of ETT J ^ b head and neckJ *J-jL
( T4 - T5 ) **j-ll ciJ0 He Oljjxa ijLiA Chest X-ray Jl J Jl~ 4AU J* Carina Jl J
proper position Jl £^»Jj ui»j>Jlj
Page 222
1 ICU Procedures I
>u,-UJ- Jlill amigration 1*1—-»-u j! ls—* 2—)J5'^' £—*'—'^Ja ^—""> j—&1
AjJ Jj-a^ jl Jj_ui Wider, Shorter and More Vertical WjV bj Right Mainstem bronchus Jl
L_fJ J .^j >.w .^ more sharp L-JclA 4_jjlJl>JA Left Bronchus -Jl o"-£e i^Jc Migration
. Endotracheal Migration Jl ^J«c
1Migration Jl ijjaa.«ulj lJj
Jill Paul Marino
" Selective ventilation of one lung results inprogressive atelectasis inthe non-ventilated
lung"
UA 4Ua'ill TuJajA Ul SJJ-ÂIj
Endotracheal
J mm
Atelectasis
ol Left Lung
?? Ajj JjuAa b Migration Jl £aji*> <, 1WV1 jLAcj
Females JIajujAL 21 cm from the teeth t> J&l JiAi Ljl tip of ETT JI.Jaj^J^-1
Males J <^JL? b 23 cm from the teeth Cy J&j
at least 3cm above carina ^c\ii tip Jl JAjj Chest X-ray lUj (0^ •J1^ WJJ u *4-2
Periodic Chest X-ray J^ WJs
Page 223
ICU Procedures
Endotracheal Tube Insertion Checklist
1. Assess thepatient's respiratory status.
3. Hyperoxygenate thepatient.
4. Suction anyvisible secretions for better visualization of the vocal cords andclear
the airway.
5. Position the patient in Trendelenburg position with the head lower than
feet by 15-30 degree.
6. Administer sedatives and pre medicate as ordered.
7. Check ETT via inflating the cuff.
8. Lubricate the tube with KY gel.
9. Assist physician during insertion as required.
10. Attempt ventilation through the ETT.
11. Continue ventilation while inflating cuff.

12. Secure the tube in place.
13. Confirm placement through:
• Inspection of Bilateral symmetrical chest expansion
• Auscultation of airway Bilaterally
• Chest X-ray
• Pulse oximeter reading
• Water vapor on expiration
14. Documentation (date, time, ETT " Type and size").
Page 224
ICU Procedures
Tracheal Suctioning Procedure
Tracheal suctioning J**j c±u*. J iJaaj IJ£ ^jj jjjjlc

: JjVMHJll
biofilms oforganism «JJam JaUI «Jjl endotracheal tube Jl J ^ JSJj l-iUjjII ljjÎ
iiij.ja. AjâJ jjJj JULij trachea J Jaa Ljl Jc jcLajj djclu sJ^l suction J**a ua.1 LA Jllj
jl Jc. cixaJ\ guidelines Jl JS !•£ jAicj VAP ( ventilator associated pneumonia ) Jl
4JU. Ji *aaxi aji Ja liljl ^sjxAl routine procedure J 4JUAA.J JAjV jSJj suction Jl
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• AjJLill AJaiill
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; i_M,.tlj ul 4Jaiill lAttAa 4jJajj guidelines <Jja.l 4JJJI J JUj JaAAjll 4j«C Jf^JJJ b jl
JU> ja. Vj secretions Jl mj^ lA* ^J^ ^ <j^ saline Jl J •

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saline instillation Jl J^Jj VAP Jl <-Js^ <~=-J ijja J^hj ^Jh 300,000 j-
LoLA I' n 'lall
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Ljj>jj. JûJ secretions Jl <~ajia J^hj WAa*jj secretions Jl ajLaj. jjj sjjj?.jJI
^jj JSAu (J* j£lj ETT Jl lj* LjAAAj jjjLujjj JjAjiVI CjVjjJ l_jj=A JAj. JUlbj
Chest Physiotherapy J' Jc ^JiVlUjUcIj
Jc JUaj secretions Jl ^j^ ^j> Sodium Bicarbonate u^ J^> lJ" •
Organisms Colonization Jl
Endotracheal Tube Jl J (JbJ) 4j?.U J Jiho, cli Infection Control Jl J J&Ji Guidlines '-j-jJj
Chest Physiotherapy JljJM <Abjk J aaic\ dlj* 1Sick <JAc Secretion Jl J ^ lUj* J= :JJj*
Page 225 —
ICU Procedures
; 4jjl)j| ALiill
1
Tracheostomy Jl 4JL% J (Jlj 4jjUJI JaAAAl SJ=ui Nelaton Catheter Jl ^j ^Wmii; Jll sJwill
LjiMikj JjaJjJI £ja-h Nelaton Jl ji Jî Foley Catheter fljAAjL Suction Jl Jxi Jjl J^
^jajjJI jj^ J ojj^jj, Secretions ljj u! J^ JJ* JjVI J Blood JL*-« JAuj JJJc
Fresh ^-J <Jl J-â j.j!I jJ J lauj J 4iisJl J j£lj aIa Ljj>jAA laIj
. J^l Foley Catheter J' J-«AJ JUAj oojjJI ^j=a>j JjcLA sJajAill jj ja ûmllj
WjUI Suction Catheter(SC) Jl o-ti*J^J* : AjuIJl AJailll
(Outer Surface of SC) Jajiisll SJaAil ^jlill Jaill i_ima. Jc jaj*a 4jjiJLi jji jij\Jji\ ihJail
U.u 'A» lJ11 fJrH V^JI J J^h (Inner Diameter of ETT )<-jjjaJI 4_jjaI>u JaIjJI jJaEllj
caUjI <_Jjj 4jj <jjAVI jM o^j iJa-uili _Ji ^ju %50 LSjbAb j_^j ( SC/ETT ratio )
.La. yui LjcLA jALiill aaI£j 4jjAVI (3\4) Jju %75 J J^j Jaa j^jjj 4ouull J la!Lsj 2013 <Aj J
Line representing 1/2 of ETT inner diameter Line representing 1/2 of ETT inner diameter
Endotracheal Tube
Endotracheal Tub
Suction catheter on catheter
SC/EH equal 75% SC/ETT equal 50%
Lgjc ,JAjA 4jjL«-a LgJ ulj : 4JL51I 4ijall
Size of Suction Catheter (Fr) = [ (ETT size (mm) -1) x 2 ]

aIjUxII J jajxi& Jli 8 nim ^jjAI ljSjj> lyaj^ J Xa ,jxi
SC = [(8-l)x2] = 7x2 = 14Fr
(14 Fr) frljAaa. ojajj J«»"iin'ift Jjjj
Page 226
ICU Procedures
I!? Jj\ sJaJ^l^ u^j-J Hyperoxygenation J«j JjVI j»jV Suctioning Jl J«j L> Ji
. Fi02100% Jl jbA Jc laxâit, Jjj <£Jc Jll J£Ventilator Jl <> jj*j*4jI 4lU J •
AiuaJ Uj»j AMBU bag Jl J«aaa Ua JLu Ventilator Jl Jc J^Ja Ja JoijaW Jj •
. 5 Breaths ^J^j % 100 J=-LA Flow Jl JA->j Oxygen Source Jb
?? ciiVLa. J Hyperoxygenation with 100 %Oxygen Jl j- JibJa
retinopathy ^"-^j J^" ^j^3 »J^ %100 js-SV fj^j*- J rfi new born infants Jl •
SijJ, ijjk] %ioo Cm^£i ajiâjc J Cyanotic Heart Disease Jl ts-^J* CCU Jl J •
Preload to the Left heart side J' JjSjj Pulmonary Vascular Dilatation «J-*j. jj** 'J
Systemic Hypotension JL«jj
• ajjjuii 4jaijji
Cardiac Monitor Jl J Heart Rate Jlj Sa02 Jl Jc Wi J^ Suctioning Jl <M »U5l

jjajjî % 100 Jacij Suction Jl Jaj ui ^LJI J J" ^j J^ Saturation Jl jl ^ Jj
. Jc-lA Suction Jl J-J (Jul Ij>>-j»jj (j^JJ ^J Saturation Jl UjaJ o-ajjJl
jâlla, Ul 4jaiill <_iWli jLjCj
ETT Jl '.'•"•'• SJajjsili >.-.l..iil,ull (JjIUI jLAA) -1
Uji.Wll Jjuj Ji jJSvuiSi %100 (JaJjJ' *Uacj -2
JaAAull jUj lilicLA iJajuisll Jala jju JaAj lAIj aji -3
Continuous l£* Intermittent Suctioning JiAii -4
Jlj 10l> J^l yî »-j*IJI »jJl J Suction Jl Jaj ^jAm -5
Page 227
Types of suction catheters connector

ICU Procedures
I
Standard connector Thumb control connector Fingertip control connector
Different sizes of suction catheters
Page 228
1 ICU Procedures 1
Tracheal Suction Performance Checklist
l. Assess the patient's need for suctioning such as wheezing, crackles, cyanosis and
decreased Pa02.
2. Wash hands and wear disposable gloves.

3. Position the patient (Supine with headon one side).
Infants: 50 - 80 mmHg
4. Turn on suction machine to appropriate
Child and over 75 years: 80 -120
negative pressure.
Adult: 120 -150 mmHg
5. Open your sterile catheter and connect it to the tube of suction machine.
6. Pour about 100 cc sterile saline into a sterile container.
7. Hyperoxygenate the patientwith 100% oxygen.

8. Wear a sterile glove on yourdominant hand and clean glove on your
non dominant hand.
9. Suction small amount of sterile saline to check the efficacy of your suction device
and lubricate the catheter.
10. Insert the suction catheter into trachea Infant: 8 -14 cm

gently until resistance is met or the Child : 14 - 20 cm
patient cough then pull it back 1 cm. Adult: 20-24 cm
11. Switch on suction machine.
12.Apply intermittent suctioning.

13. Rotate the catheter gentlyduring suctioning.
14. Don't allow suction to continue more than 10 seconds.

16. Assess the patient's cardiopulmonary status during suctioning.
17. Flush the catheter between suctioning.
18. Reassess the patient.
20. Documentation [secretions (amount, color & consistency), time and any complications]
Page 229
1 ICO Procedures 1
Oxygen Therapy Checklist Procedure
Oxygen Source Jc uâjaW J^jja J 4JAL1 lis âj jjjjLc

•^Jj\ AJalUl
J3^ *bu jjluj maximum Jlj minimum Jl Cm IaXAj fill the humidifier "âki W *$a
• AjuIjlU AjaiJll
:4^jaAjA device l£ ^la flow rate Jl iy^J jijjc
Device The best Fi02 Flow rate
Nasal cannula 24 - 50 % l-6L/m
Simple face mask 40 - 60 % 5 - 8 L/m
Blue 24% 2L/m
White 28% 4 L/m
Orange 31% 6 L/m

Venturi mask
Yellow 35% 8 L/m
Red 40% 10 L/m
Green 60% 15 L/m
Non - Rebreathing mask 90-100% 10- 15 L/m
Hill aMui
4jAsuu jLuj IjS jV L-ilcU 6 U1*aa V4il (jijjjjl jLu jjajjiSi 100% Jc Joaja1\ jAjajA J
oxygen toxicity
Page 230
1 ICU Procedures
1
Simple Face Mask
Metal piececonforms
to shape of nose
From oxygen
source
Nebulizer Face Mask Venturi Mask
Non - Rebreathing Mask Nasal Cannula
VJ)
Page 231
ICU Procedures
Oxygen Therapy Performance Checklist

.Assess patient's signs and symptoms of hypoxemia.
2. Assess ABG and/or pulse Oximeter.
3. Prepare equipment.
5. Explain procedure to the patient.
6. Fill the humidifier reservoir until reach the determined line.
7. Connect flow meter to oxygen source, and check operation of flow meter and
humidifier.
8. Attach the oxygen device used (mask, nasal cannula ...etc.) with its connecting
tubing to humidifier and flow meter.
9. Turn on the oxygen flow meter to the prescribed flow.
10. Place the oxygen device into the patient's airway according to the type ofoxygen
device.
1. Simple and Partial Rebreathing Mask:
• Place mask on patient's mouth and nose then fix and tighten the elastic
bands behind the patient's ears.
12. Nasal Cannula:
• Insertthe nasal tips into the nares.
• Loop the plastic tubes of the cannula overthe ears and under the chin,
or place elastic band around the head.
• Gently adjust the plastic side.
13. Non Rebreathing Mask:
• Check the reservoir bag to be sure it is inflated (distended).
• Check the mask for leaks.
14. Venturi Face Mask:
• Choose proper Venturi jet adaptor.

• Attach one end of connecting tube to Venturi mask jet adaptor.
• Listen forthe "hiss"of the Venturi mask jet.
15. Attach the oxygen tube to the patient's clothes byadhesive tape.
16. Reassess the pulse Oximeter and respiratory status.
18. Documentation (type ofdevice, Flow rate and Spo2 ofpulse oximeter).
Page 232 —
ICU Procedures
Nebulization
Nebulizer 4,,.u J*xi lau^. J4Ax^4iA ^jjajj jjjjLc
COPD Jl LS&J Jaai 11*1j Alia. fr<M...l; jjîii^Li 4uiUll LJaAi JLaa 4jLc Jl J SJj^jjJI LliVLaJI J£
jLkj 4^jL> LJ«Ak jl j.jVj AjjAi JA-oj apnea Î.^m* jj^VIj 4^kll LjLc J ui ^l^1
W AAiJa Jaia JJjjJII >jj>j jjSj
jjôiSVl jJii J-« jjiAA Lai uujJI jj ^j Respiratory Physiology -Jl J <Jai> jâj iaAa
djic J.nyn (45-35 mmHg ) ^hvJJI J^1 l> e^1 J1^J? ^ ^ i# C02 Jl »^j j^j
j_aLj ^ÂAj Lung —II JJ-Au JL-ilAj £-Jl cs-J jj-^-j-Ji Respiratory Center —11 Stimulation
I—ja ^—ixi Hypercarbic Drive —h k^—>" lsIj l» M.'kH u^—^ ls—* bJ New Breath
.C02 J' '*+** SjMj s-f^ JaaAj aIjjc Respiratory Center Jl
(80 mmHg) -1 lU»J jJaaj XJ aJ\c jjShAaâ* ^ C02 Jl ^ COPD -II i>aj>* «JU. J
aJaxj LAjja. Lis.) jJa ^j 4_AUJl 4j_u1j1I ^^Jc jj_«j) j^X* jjSii 4_cLA Respiratory Center -Jlj
Stimulation J •-^;* J" JlAlLj jjJa jja^S1! 4ouijj JSja ojjc Jll C02 J' *+^ '-^ j^^L? 4jjlL>
Hypoxia Jl ij+j J Stimulation <J-«jj Jll ûJj Becomes Blind î Respiratory Center Jl
aJaxu tjjll j-& b L>ajj_All xic jja—£VI o-a^J j! JLa Ls_i»xj (Hypoxic Drive) -h hy-^m ls-^'j
l41a Jajjj <jjij jaU Ja Hypoxia JJa Ja -^ -^ *J±mj Respiratory Center Jl Stimulation
. Jaaa Nebulizer Jl jWw ^l^ JM1 ^V "J^"?J^ lJU^j apnea J
Page 233
Nebulization Performance Checklist

ICU Procedures
1
1. Assess the patient's vital signs & auscultate his/her chest.
4. Measure the medication precisely with syringe.
5. Explain the procedure to the patient.
6. Position the patient in semi-fowler position.
7. Teach the patient the technique of administration of medication by nebulization

(If Conscious).
8. Place the medication in the nebulizer cup. Place onlyone medication in the
nebulizer cup.
9. Turn on the nebulizer.
10. Position the mouth-piece of nebulizer in the mouth and lips around it orthe face
maskin case of unconscious patient.
11. Take a deep breath through the mouth.

12. Holdbreath for 3-4 seconds at full inspiration .
13. Repeat the cycle until allthe medication in the nebulizer has been dispensed or
as ordered.
14. Wash the patient's mouth after the treatment is completed.

15. Assist the patient with chest physiotherapy as needed.
16. Discard any medication left in the nebulizer.
17. Wash the mouth piece of the nebulizer & nebulizer cup.
18. Clean the equipment at leastonce daily.
20. Documentation [ medication (name and dose), time and patient's response ]
Page 234
1 ICU Procedures
Lwaj^kj atelectasis Jl ^j^ ^j to improve lung function <L«jiiuU jl (j a jr- Sjl ic jA

Rehabilitation âxi »ji Weaning Jl •j*j Mechanical Ventilator Jl Jc JkjajAa Jll jlalja!\
. Spirometry Jl fJAAAji
Alveoli Sacs Jl e%> W= IjjRegularly Deep Breath -jAIj ttlcLA jîjaW Jajj Spirometry Jl
. Opened l*J=- -^L^j
AjVLs. J jUS 4-oJiAjj
- Patients with breathing disorders: COPD (strengthen lung function)

- Patients with respiratory illnesses: Pneumonia ( helps keep lungs healthy while sick
and move fluid / pus affecting the alveoli sac )
- pre-opt and post-opt patients S^lj?Jl AjAL*1I j*jj Ji
? "oja all 4lftTj i.iij jlaljAXI (_jjajJAI
10 times every l to 2 hours while awake
? Aaqa AJasi nJaJ JJ jjLc
alveoli Jlj -j-j-aa expansion Igl "-"j: lung Jl jl lU^jj (Jll inspiration u^ -^ J*ij^^
atelectasis Jl^W* Jll I-jj Jî j^1* alveoli Jl L- JS deep Ij inspiration Jl j Jj ^> l£j jjsA
collapse lW*>j JÂ alveoli Jl J^j recoil to the lung "Ac J^jj expiration Jl J M
<ÎA mouth Jl J mouth piece Jl -^ u^j^1 iJ3-'' J! spirometry Jl jj^ JU^j
( jib Ja iaAA (jjju ) alveoli Jl j%* ijl',a j^ deep j Jjj inspiration J«j J*j <îJ jaUj
exhalation J*i j iyî <1Jij -^ mouth Jl J mouth piece Jl -A^l Lil jl J*
. IjK jiî« J Ija. SjjJiAA 4Jalc Ul ji
Page 235
1 ICU Procedures
Incentive Spirometry Performance Checklist
Assess patient's respiratory status.
3. Explain the procedure to the patient.
4. Position the patient insemi setting or setting position.
5. Attach flexible tubing to the spirometry's port.
6. Ask thepatient to exhale completely.
7. Ask the patient to seal his lips around mouth piece tightly.
8. Ask the patient to inhale deeply and slowly.. .making sure to keep the indicator
within normal range (not too fast ortoo slow).. .Piston will rise.
9. The patient needs to keep inhaling as deep as possible. ...until unable to hold
breath any longerand then hold breath for 6 seconds.
10. Exhale slowly and allow piston to fall before repeating again.
11. Ask the patient to repeat 5-10 breathes per session at minimum every hour.
12. Return thepatient to comfort position.
14. Reassess the patient's respiratory status.
15. Documentation (date, time and session number).
Page 236
1 ICU Procedures
Wrong Ways to usean Incentive Spirometer ?

- Blowing into the device (most devices will not work ifthis is done). «J ^
- Rapidly inhaling and exhaling offofthe device and not allowing the piston to
completely fall to baseline before repeating.
- Not using it often (less than 2 - 3 times perday).
How to Use an Incentive Spirometer
Page 237
1 ICU Procedures
Arterial Puncture Procedure
ABG <JJljj)i 4jjc i.i*. in'ift J 4_laaj IJS j^jjajj jjjjlc

• jjvi mm
-Jj Radial Jl j* SjJaA »Jaij jLSL, cUai Radial, Brachial or Femoral ko^> CJ** M>
. Femoral Jlj Brachial Jl
LjaÂ L. Ji aji J^j Radial Jl j* lihic Jll j^ji jLaJI Ju, Conscious o3^ l> ljÂa J
: jJJ^ jLAc lidocaine spray JJ j Locally jJj^ji4j>jjjoj jjSJjj 4_!ajA 30 JaAi
dia.ljj ,_!^j Lij^j jUic jjjjj Jajtj j,Jjli jiaijAU |ja. jja. Painful lsj<J«1I: Vji
JLHAj JL* Radial Artery Jl ^LA Flow Jlj Constriction lU^j* Involuntary XJ ai\ :IaLj
iijy Flow Jl JULjj jLjJJl Dilatation J-=^j* jJJu jJaci J j£lj aIa ^..n u^ Ja
, lJ'"l*> IJJ i '^ ..i** IjSjJ
; Ajjtill 4LSill
Cy JS' iJ^JA l5j ^LaJI Jj AAl jjjJA ilja.jA Ja J Jlj Aiixl\ LJc ljjxxjA SjU 4JJJJ-Q LjLaijjoi 4j2
Lithium Heparin J' j* 4l«AA ^j j\ij\ sjjcj jjjLJLSIIj j>jjJj^=> jjJjjJI uj jjJjj*!' l> PJ
ajiijA* jjjLujJI bLA, ^jSA. Jc Serum Na+, K+ Jl 4-uA Jc JU jl, 4jV (aJJ jjjLiJI)
. Serum K+ J' jjJ* jjjUJLUI dlJSj ivM^ jjc 4j>aj dJa*jj Serum Na Jl JjJja
; 4jjlill aUi'M
uaj pulse Jl u^ "JjI Jw« Ij jUic elbow J'j wrist Jl Aj=a Roller Bandage lUj-a <M W*&
• 4ju|J | AJalHl
^•jÂj JLsj 10 - 5 =jJ >-^clA 4Jjj>Jl ljûu L, jju Compression lUj >M Ij?. Ij?. ^
. anti coagulant Jc ^JA, oAjjJ J jllj 10 j* J£i (Jaaj Femoral <JjcLa 4jj*1I caLS J
: îjji ALm
1Qsja Cy JSI 4j 1Venous Vj Arterial <Jj^La 4_LuJl jjl ^j^

Venous Sample Jl o^ jt Pulsation <J JX& Arterial J jll £LA Flow Jl j* <j>U Jjl
_4AJI i,i->,h1i Jll Oil lMX»
cJl jjl j Jjj Venous Blood Jl La) jAL? j*J 4jj jJa, Arterial Blood J' U>Ij j Jll ^ 4j>L. ^Li
. Arterial Blood Jl J JjAjJI Oxygenated Hb Jl > IjS J ^jjJIj ^Lc
•c*^ ^ ' ***" u ^ Pa02 J' Jja jc *Jjj j Jj jL£ jS*,
Page 238 —
ICU Procedures 1
Allen's Test
(A)
clinched
I radial artery
V occluded
ulnar artery
released
ulnar artery radial artery and patent
occluded occluded
Arterial Puncture Technique
(B)
(C)
Page 239
1 ICU Procedures
Arterial Puncture Performance Checklist
[. Assess factors that influence ABG measurement.

2. Obtain history for any recent surgeries at site of sampling.
4. Explain the procedure and place a roller bandage.
5. Select the puncture site.
6. Perform Allen's test ormodified Allen's test (unconscious) in case ofradial artery
puncture.
7. Position the patient insupine position and position the pucture site:
• Radial: stabilize it over small rolled towel with dorsi-flexion about 30 degree.
• Brachial: hyperextended over rolled towel with wrist outward.
• Femoral: leg slightlyowtward with flexed knee.
8. Heparinize the syringe and needle.
9. Eject all air bubbles from the syringe.
10. Clean the selected site in circular motion with Betadine.
11. Clean the site with alcohol swab and allow, drying.
12. Locate pulsating artery.
13. Stabilize artery and bracketing the area ofmaximum pulsation with fingertips of
free hand.
14. Puncture skin slowly, holding syringe like a pencil, advance slowly with the
following angel:
• Radial and brachial puncture: 30- 45 degree
• Femoral: 90 degree angel.
15. Observe the syringe for flash back of arterial blood.
16. Ifpuncture is unsuccessful, withdraw the needle to skin level. Then advance it again
17. Obtain 1-2 cc of blood.
18. Withdraw the needle while stabilizing barrel ofsyringe.

19. Apply firm continuous pressure then gauze dressing.
20. Care of the blood sample.
22. Documentation (date, time, site ofpuncture, patient's Fi02 and ABG Results).
Page 240
1 ICU Procedures
Arterial Catheter Insertion Procedure
tjjjî jc. ha. Arterial Catheter J' W=
Invasive Blood Pressure (IBP) Jl W^ ^j^j
Continuous direct BP monitoring (more accurate than sphygmomanometer reading).
in ability to use direct BP monitoring as ( Morbid obesity- sever extremity burn).
Frequent arterial blood sampling
Dampened '"'v^' Uj&la s*iJill cluSI iM Jj-aa. J j\j\ LijmV^ ja j&\ li^j î
Arterial tine
Saline filled non-compressible tubing
Page 241
_| ICU Procedures
ilely. 6 JS check l$l«5 j»jllllV l*Ja
Pressure bag inflated to300 mmhg J' j' ^'
Fluid is presentin the flush bag J' j' lMj
acLa 24 JS jJAj Flush system is delivering 3-5 ml / hr J' j\j
1 J jj (J>au4 Waveform Becomes Dampened Jl ^1 &
1. Check the arterial line insertion site for catheter reposition.

2. Aspirate and flush the catheter as follows:
a. Attach a 10 cc syringe to stopcock closest to the patient.

b. Turn stopcock offto flush bag.
c. Gently aspirate; ifresistance is felt, stop and notify physician for replacement.
d. Ifblood is withdrawn, aspirate 3cc ofblood, turn stopcock offto the syringe and
discard the aspirated 3 cc blood.
e. Return the syringe to stopcock and turn the stopcock offto the patient.
f. Squeeze fast - flush device and fill syringe with 2 ml heparinized solution.
g. Turn stop cock offto pressure tubing system and open the syringe ofthe patient
h. Gently inject solution from the syringe into the arterial line.
Always monitor extremity distal to insertion site every 12 hour for color, warmth,
capillary refill, pulse and pain.
Page 242 ——
ICU Procedures
Arterial Catheter Insertion Performance Checklist
1. Assess signs and symptoms that warrant the use of arterial pressure monitoring.
3. Position the patient incomfortable position with adequate exposure and lighting
of the insertion site.
4. Performe Allen's or modified Allen's Test.
5. Place a roller bandunderwristif you choose the radial artery.
6. Palpate the radial artery pulsation.
7. Assist the physician with the catheter insertion as directed.
8. Once the catheter ispositioned, connect high pressure tubing with Luer-lok
adaptor to arterial catheter.
9. Ifdampened attempt to withdraw blood and then flush. Try to reposition the arm,
or catheter position may need to be adjusted.
10. Once the catheter is secured in place by physician, apply antimicrobial ointment.
11. Apply transparent dressing.

12. Record date and time of insertion onthe dressing, and puta warning sign not for
injection
12. Return the patient to comfort position.
13. Discard supplies.
15. Documentation (date, time, site of insertion, IBP and any complications).
Page 243
1 ICU Procedures
CVP Measurement Procedure
CVP J' jjl t''J.l~> J 'JaiJ liS Ttjjajj (jJJjLt

: JjVI AJaiih
Distal <-"! Jll o=JI J Jll Lumen Jl Jaaa CVP Jl oJ^ J IaJ 3 Lumens <J LjAc CVP Jl
<> jji 4tlA inner diameter Jl j.' J '-^ J sjjÎj â _,l jî jLu Jill J ajJ Jllj
IjJ Aclu Flow Jl JUljj ffci Jib Jai ^ji ja û (Âuu jjjiUll 2 Lumens J'
JjiiA lJ.ja jazijaW Jj La-La ^Ljill J aJxALa Jaa lumen J—al ji ^JUj
. s-f^JI lJJ lJjJ ^jj J11 lumen Jl (y ^Jj*
: Ajitiui AJaiill
jLAj jAS ^jU VVj JLiji ja Ja lAjJaij Check lUj ?jV <a« lWsja Jll Lumen Jl ljjaI U^
•d-Lc Jll jkj Catheter tip Jl Ac Hj*ja Blood Clot <ua J jV £^> Ja bj ^HAj <ua Saline
(jjajj^ll J^j (£aa uij Circulation Jl LjlAjj pUsh CJAac \£ laI ui <W J Occlusion
? ji^ll -U ljA. Pulmonary Embolism J <JtlA
Blood M=>-Ai JjLAij j^j 3 ^jj_u, J^j cijl jjja (ye aji^hi Check J-«ja >1 <Ja) 5—II
Push lU*j c_jaaa La) »jjc. Lumen <-ijJs Occluded <Ajj *JL*^ Lja-u. Ju J Lumen -Jl <>
. VVj JUji Lumen Jl <-iJ2 jUc cUai Flush Back Maneuver lUj 0s-" j Saline J^
^*
! lumen -li i> iÂjjUjiJ
Page 244
I ICU Procedures
• aJ1\j1\ AJaJalll
tU.j* Jaa cdclA CVP Jl u! i>jJJ' occlusion Jl ^jia. jj^j ^j ^^ âii11 L^**i d^c
CVP J' uaâ j medication L*J J=«A %ja JS ixi flush lWj J^ hep saline JL>
Jji JS ixi Flush ajj cWj îc N.Saline o^- JaVl £ JLy <1jjjJI J JSLAa, »Ac aLLA jîjaW Jj
; AxjIJl ALilll
jLu aj\ d^xA Ja t>i Flat Jm \ic^ LJy>J' u' <Jj^ ^J Checklist J (7) H*J '»j^1
^jjosj jSAlcj Lateral J^jJ'j ^ jS-"j 15-30 ^j1J Supine Ja lAs Zero Position
Open Heart J' ajVL> uj AjVL=JI jaa Jj \i* îc abdomen Jl Jc ah iJ^jJ' J ^J
Setting ,J>j>JIj «-£ fji CVP Jl Cardiac Patients Jl J^j Pulmonary Edema Jl A.VU.J
êro Line Jl -M^ i$i *&*& Jj Supine JJ. <a\ xJ JxiiiA n j*ija\\ ji Semi Fowler J
.Second Intercostal Jl He *JgLa
Phlebostatic
axis 4th intercostal space
Air-fluid
interface
(zeroing ,
stopcock)—Jo--j
Transducer-!L_ Carpenter level
Phlebostatic axis
B
Page 245
J ICU Procedures
• ^JuIjAII AialAl
11 Occlusion >Jac AjjsI J JJ lAâia
Ij Occlusion Jl l> lkJaa jLAc lumen Jl 'j* <1aAj guide wire Jl '. u>".' t_JJI JaÂ
Stroke or Pulmonary Embolism >J1«jaj LLa UJa bj
Occlusion Jl l> jAilau jUc Saline Jl -j-l> Push J**jj Saline LaHAj ajAj^ ^ry?jj Ûll jaxi
Stroke or Pulmonary Embolism <Ja»ja j LLk L*jL bj
? jlÎI AjI ljA,
Paul Marino -JLa U uj
J*ilL 4JjiAI ljLLLJI ljjJjjfljj jU-ajAlj tij Alteplase jjy\ rLlAiA
• J j' «JJ-«aaJA
J* 2 4Aa (jtin'ijoU* Jj> Jjjj Jll sterile water Jc JUll J^ja
? J J aLmAjA
J*i \a ixiIJiiij occlusion Wa Jll lumen Jl JAbajaajj JUll ,> Jaii J* 2 '.•^••••* -1
lumen Jl Cy J '.'•>"" vjA» La.i*jj aLL 30 SaJ JAAa -2
aLL 90 jUS ^jAAjja occlusion ^J <î jj lAjsIj Au^j Ji* J LaI ,_>ollk Juj iJL«-a <-,r.„ j .3
OCClUSion J <ai\ jl L-Jlj !*);•> mJj> J Lij ^-aiLi. lilUm i'iimi J JjjLj S^, ._^ ..,' JjUj lj£ .Ijuj
jAcLx. JU iJiîj lumen Jl JAb LjjLAj Alteplase Jl j* <a1j acj?. j.Îa
blood clot -J LjlL j j remove of drug solution J-«j jUa. aJJ.5 ( i-.,,^ JIIxa .-w.. j .4
Sjja.j^ LAlS Jll
CVC Jl jJJ jLA=. aLj ttiljl consider Jjj ij*ja occlusion Jl <jJj Ij JSCiija. J .5
Page 246
ICU Procedures
• Aja1LA\ AjalAll
?? tJJtfl oaIj ^LA CAill Jâii Vj cJaij PEEP Jl jj^ J CVP Jl oJi J! tH1 J*
jLic LU iiuill Jc jj. <lL<»sj JxkiiA A/C mode or CMV mode Jc <JcLA jixyJI J •
.PEEP J''<** j-Jai IjS ixij îc ^jjsja Jlj AiaLi jAU Ja Patient Jl ji CVP Jl uJ2
SIMV, CPAP, PSV... 5&> lsj Spontaneous Breath jaU jA ^li ^jJI jlS bi •
,Jl; <Ljajj jjalajUJxjj lilAJ jj JJJlij jaA* LJJill Jj-aij joiij Ul^JLaJI J
PEEP J' ^J âa r JJj CVP Jl (jj2* AAl >Ijjji U_j*c j

SolJll jaU JjAuAa j Aj>Li. J lUxa jJja Ja jjiALiuij jJLa Ventilator Jl AjLâ aai *Jj jl
• aajLwlII AialAi
.iULA J^kJI ^Jjj^ ^jll jj^jJI j-jAL fjV cs-Au Range «-» Mj ^'j Hj lA^> CVP -Jl klji
.(5:6) ji (10:11) \alyajy^J :C^âa'-^j
Page 247
J ICU Procedures
CVP Measurement Performance Checklist
I. Assess the patient's respiratory and cardiac status.
3. Select the appropriate CVC lumen.
4. Begin the IV solution such as normal saline or ringer.
5. Close the stopcock in the direction ofthe patient.
6. Allow the solution to pass via the manometer line.
7. Check the patency ofthe catheter and lumen through flush back or using a syringe.
8. Positioning the patient in an appropriate position.
9. If Flat: Put the manometer atthe mid axillary's line ofthe patient
(fifth intercostal space).
Folwers or Semi Folwers: Put the manometer atthe mid axillary's line ofthe
patient (second intercostal space).
10. Closethe stopcock in the direction of the solution.
11. Take the CVP reading when fluid stop fluctuate, (normal 5-15 cmHg).
12.Begin an I.V solution such as normal saline to flush the catheter or hep saline better
if not contraindicated.
13. Put the patient in comfort position.
15. Documentation (Date, Time, CVP reading and catheter insertion site).
Page 248
ICU Procedures
1
Cardiac Monitor
lAjju jjiAaIX. jaj ojSjJI aAcJ\ jXJ jaj i_kjjjull jc (jc. jLjj> Cardiac Monitor -II L»J=
jÎ £la Heart Rate -Jl d^ J^j j^-% ^J&- l^1 ?J j* <-^^* H>j ^j
Monitor -Jl f^ -^ oJi J*> ?jij Waves Jl JSJ j> jSi ^J^ ^1 ^Jl lJaî jai Jaa
Shockable Rhythm and Non Shockable Rhythm ^ <* u1 ciJ* <j*l£ ^d*- oJk
Ventricular Fibrillation (VF)-4)j Ventricular Tachycardia (Vtach) <A J^ ^ Jx
.ajjc. LJjxL ,JJj Ujjc j Atrial Fibrillation (AF) Jl <ih
>A vii; JjjAiSJVI Jj-j^J (>jV <-J«Jto. X*i jj^j Waves-1'j £j~> '^ ls-^ ,j<4>^ u^-^j
?? j\jj L_lJa ?L*â (j-&
Leads ^-""^ ^-^ ^J
White RA Right Arm Lead

Green RL Right Leg Lead
Black LA Left Arm Lead
Red LL Left Leg Lead
Brown VI Chest (VI)
Page 249
1 ICU Procedures I
Connecting Cardiac Monitor Checklist
2. Prepare the patients skinat sites of electrodes application.
3. Keep patient's skin dry.
4. Place electrodes on the patients.
5. Check cables and lead wires for fraying, broken wires or discoloration.
6. Plug the lead wires into the patient's cable.
7. Plug the patient's cable into monitor.
8. Connect electrodes lead wires, then connect electrodes to patients chest.

9. Turn on the monitor.
10. Adjust the monitor alarms and settings.
11. Record ECG strip from the monitor.
12. Discard the used items.
14. Documentation (heart rate, rhythm and any dysrhythmia).
Page 250
ICU Procedures
Pulse Oximeter
jjaj Lo)j Plasma -Jl (J Dissolved H cJjj^=lJ^ lJ jjh^j-cJ^ u^-^!

Oxyhemoglobin (Functional) û^j^W ls^ U>J-j Bound to Hemoglobin
.Carboxyhemoglobin <J^ C02 -h-Mj- Jta J& ohJVj^ ^J ji
Partial Pressure ofOxygen Dissolved in Arterial Blood l^ lsÎ Pa02 ^ *j

.ail <J Dissolved ^1 os^Vl ^ lj^jj <j*j
percent of Saturation of 02 Bound to Hemoglobin in Arterial Blood '-j nuj ^jj Sa02 ^c ''Jj
Pulse Oximeter -JW I^jJaUl ^JJIj Hemoglobin -h SJaAj- ^Jll jj*-«sSn aiî 1-u,^li.i ^
.Sp02 W*>
?? Pulse Oximeter Jl *»jli <uj ^
Sj_jc jiFinger II ^j—«p "pH cs—k- <J—^Jj ^—lil Probe j—° jj-SAj Pulse Oximeter —II
. Monitor Jl JAb Aj*.>« ,Jj Microprocessor j
^jjâll jAj^. Jjjj 2 Lights Emitting Diode »L«j Photo Detector l> ujSAj l^ Ij Probe Jl
Absorption ^!"-•->jjj 4jyAVl JXa. jau^ ^ j% dtf" lstM* J-A3 ^ ls%^ ^j^3 ,j^Jjj Ji' j*».Vl
Photo Detector -Jl j-* tiJ Ai_î.l ^-111 *j-jJI a-uS <j ,,r.n ^Jllj Hemoglobin -II J-jJ> j-c-
sjaAjJI jja_u£VI 5j_jA ^111 n^jjMonitor-II J ij-*.ja1\ Microprocessor -IIW*?JJ ,J-S ^j
.Sp02 l<j«'»': Jl' j"J?-j^JW
Ear Lobes, Fingers, Feet, Cheeks, Nose and Tongue Jl cJ> Probe Jl Jj—J jSî d^
JLîll ji jj_JI *!j_jj. ? ...Jl j-. ^L; J ^J jj>A£UVI Ja_Ai j_£jv« Adult —II j^ "'II<j_â11j
0ijc jj4j bJjLkll jl possibility -II jLie right upper arm -Jl L^j J-Â JULVI ^ L_ai
The Least Diluted by Shunt J Right Arm JlC-*j" Jll fJl j JJ Patent Ductus Arteriosus
.ajsJj Jâi JUAj Oxyhemoglobin ^«S jSI Jc uj^mj
Page 251
lOJ Procedunres
Light Emitting
Diode
Finger
Photodetector
Page 252
ICU Procedures
Connecting Pulse Oximeter Performance Checklist
1. Assess patient's capillary refill, arterial pulse and skin temperature.
2. Assess pulse oximetersensorsize and efficiency.
4. Clean the selected sensor site(usually index finger) and remove fake fingernail
and nail polish.
5. Insert Oximeter cable into the monitor.
6. Apply the sensor to the selected site appropriately (place the transducer " photo
detector" probe overthe patient's finger so the light beams and sensor oppose
each other).
7. Connect the sensor into the oximeter cable.
8. Set saturation alarms.
10. Document the value of Sp02 frequently.
-ulc. lJ^ja Liul Jl\ Part -II c\-a Temperature -Jl u! ^j*> "•» oeljijl jji-> jUk. Ia*. â
<*3Lui ajjj jajj-Jl caJIj Finger Jl Jc aL^ja x\a til (J***- jlj Normal jJ^ Probe Jl
_4jjji. Jli ^J*"*"' jl Ja*A L$j2jj (J\aa IjS jl
.Blood Pressure Jl t^ Cuff Jl kjc- d^y ^ J\ ^Jl t> **+> ^ Aj
Page 253
1 ICU Procedures 1
Capnograph
Patient's Breath Jl J Hj*.ja1\ Carbon Dioxide Jl <y$ lJaJ *i*l»>i jL$j> ja Capnograph Jl
.End - Tidal Carbon Dioxide (ETC02) Monitoring j Capnometry L&a. ,â^ ja j£i aIj
11 Capnograph Jl»J* <J Û>
ojL^Sj Infrared Source l> j>SAj b Sensor Jl Processor Jc Jj^J«j Sensor jc °Jac ja
. Infrared Detector AluÎIj
Absorption k\ ^~>jj C02 -Jl Jc u^-mj Infrared Source —II Cm* ZJ-*m *lj-*JI Aj^j 4*_iVl
. IJ^J '.'•"•>,'.' Processor Jl JLJLjj Detector Jl aIJAjj LjA« JLUIj
JU C02Jl jl âxa \iJLi Detector Jl IJjsIuja Jll Infrared Jl <j-S Jjja u^L^YI i\j J JUL,
?rJ•% •^-l JAaxl\ j
Sensor
Endotracheal tube
to patient
BectricaJ cord
Page 254
ICU Procedures
Capnograph wave
Phase 3: Plateau
End Tidal
CO.- Reading
Phase 1: Baseline Phase 1: Baseline
This is the baseline. Since no C02 is going out when a patient

Phase 1 Baseline
is breathing in, the baseline is usually zero.
C02 begins to travel from the alveoli through the anatomical

dead space ofthe airway causing a rapid rise inthe graph
The beginning
(so it measures the exhaled C02 from the alveoli mixed with
of exhalation
Phase 2
(rise)
the gas thatwas in the dead space. This part of the graph goes
up as the more concentrated C02gases from lower in the
lungsrise up past the sensor).
The sensor is receiving the C02-rich gasthat was in the

alveoli, which is a fairly stable amount, the graph levels off
Phase 3 Plateau into a plateau. The measurement at the end of the tide of
respiration, the peak measurement at the end of
phase3, is the EtC02 reading.
the patient inhales again, bringing clear air past the sensor, dropping the graph back
down to zero to start over again at phase 1.
Page 255
1 ICU Procedures
Connecting Capnograph Performance Checklist
1. Assess patient's vital signs and breath sound.
2. Wash hands and weargloves.
3. Assess Capnograph for proper connections and proper functioning.
4. Perform routine calibration through pressing thecalibration button on cardiac

monitor.
5.Connect the airway adaptor toendotracheal tube ortracheostomy tube and

Capnography.
6. Connect the Capnography sensor to cardiac monitor.
7. Ensure proper function (PETCo2 wave form and value observed).
8. Set Capnograph alarms.
10. Documente the PETC02 frequently.
Page 256
1 ICU Procedures
Bispectral Index Checklist (Bis)
Cardiac Monitor -h lU>Ja Extension jc ijjc Capnograph Jlj Pulse Oximeter Jl uj <ij lj
. Patient Jl p_LA Forehead Jl Jc LJ-ajA aû. Electrodes ^r^ jc »J^ j*j
Bispectral index nronitor - Bispectral index sensor
Real-time EEC
Current bispectral
index value—
Interface cable
Page 257
1
11aa\
ICU Procedures 1
Depth of Anesthesiaor SedationJl aia ljjjA jLk. -ujiaaaj
Regaining Consciousness orNot Îjj Patient Jl Ja ljjcIj
W Alji Aj\ Ljla
ilij^ jki iSixi eeg Jl Analysis J«A Patient's Forehead Jl Jc LJ^.jA Jll Electrodes Jl
.Degree ofAlertness Jl ^X. ja <j>j*j Cardiac Monitor Jl Jc Jlj jjAuIJX. jaj jJI
90-100 Awaken
70-90 Light to Moderate Sedation
60-70 Superficial Anesthesia
45-60 Adequate Anesthesia
0-45 Deep Anesthesia
Less Than 60 j Jj JsjjJI j' ^^ target Jl
? Ajjjbi<i« j!a Lo jA jUJl JlJjljIIj
Hyper orHypothermia °i-ac cH_eLA Patient —II j-J l?j »>JS J—*Ij*j JLauji_i_jjibLl j_j*
.^c^m Values Jl Jc- Jtu bJSj Hypovolemia »Ac J ja. ji Head Trauma »-^ J j
Page 258
ICU Procedures
Electrocardiogram (ECG)
ECG ( Electro Cardio Gram ) J**j a±i* J <!£> lis ^jaj jijjc
Relaxed «^^ J=a^ J±a W^ : JjV) 4JaiJll
Metal Object J J kî Jewelry j JJA

shaving aWia JLu lAAS jxA Jj bed side rails Jl J"J«
§®r
Vj: Fourth intercostal space right to sternum
V4: Left fifth intercostal space mid clavicularline

At the same horizontal line
V5: Left fifth intercostal space in the anterior axillary line
Left to sternum
V6: Leftfifth intercostal space in the mid axillary line
aa; fJaÂj breast Jl ^J* Vj breast Jl 6J JjjSlVi Acâ Ja female ^1*11 J ^Ja
A\-*l \
( Menopause ) <_JJ1 l>J oL^j Female Jl °'n aaI£ Ja According to the age : *-hJi\
A*.la, J J Axa JUa Ja '\i* ^jLc aIJ jjjjSUVI la*i Jaaj ljujj Ja \iThis is not a breast
IjS ?ri.îl ( Lactating ) JLilal Aj-iajA iIuLS J Luaji-aAj jAJ\ jJ jLuAajx ul lAjJI ljjLS J LaJ
lWj* Ij Breast Jl J ij>ja Jll jJll ji 11 <J eja ai*i jjJSVI lUJj Breast Jl ^J ^jV
Low Voltage 'JclA ECG Jl Jajj Effusion
Page 259
ICU Procedures
Limb leads Jl jSU : Mtiflii

1
AlS. Jlxl\ J ALu\!i ul jlJVI ji jljlVb AkjjxA Ixja
\ Left leg
RA
Yellow: Left arm
^ Right arm
J.r-iViA 4jJjv JjL«_j AlSuAc JJa ui*c t1 ?? jjia.Vl £- JJ-.VI JjA jSU.
i_jJUa JluA dclu ECG Jl IjS Jj-aVl a-4 ja».VI JjA IjjI (Jaa (Ja Lai
laicj
\11 (J ^c^ Lead Jl J*^ Burn »Ac jl jai*1a 'Xa j ( amputation ) Ja lWc- JoijaW J i_Ja
iJnliA knee Jl jJ ^j^ j;Lu Ja ankle Jl Jsi^-Jjl jLjj^l j* <UiJ i_jji Jc .... 5jUVI
L>a>LAj <jj jLjjJI lilL Jj-ajj femoral Jl Jc jjJSII Aoja ui *a\*1\ J Xa Jl* Jj J*lc J tJa
Crn^ J *Lij*Sll Ij^J»j j»JV I-jj Bipolar Limb Leads j»eÂ Lead I- Lead II - Lead III Lbie
ja ojsJj Alaii J *Lij$£ll \j*Ja fji Unipolar Leads *w>""! o'ji avR - avL - avF La)
" The best preparation for tomorrow is doing your best today"
- H.Jackson Brown, Jr -
Page 260
ICU Procedures
ECG Performance Checklist
1. Assess the patient for any alternation in cardiac status.
3. Askthe patient to remove any metals, jewelry, not to talk and relax.
4. Putthe patient in supine position andnottouch the bed side rails or foot board.
5. Expose onlythe necessary parts of arms, legs and chest.
6. Shave chest area if needed.
7. Identify the Lead Sites: Green : left leg

• Apply a small amount of gel on the electrodes. Yellow: left arm
• Strap electrodes around arm about5 cm above the (wrist, Red: right arm
ankle) with the plate of lead being on the inward surface. Black: right leg
8. Identify chest leads sites:

Apply small amount of gel to each electrode:
Vi: Fourth intercostal space right to sternum
V4: Left fifth intercostal space mid clavicular line
V5: Left fifth intercostal space in the anterior axillary line
V6: Left fifth intercostal space in the mid axillary line
9. Turn the machine on to begin moving the paper.
10. Record each limb lead for 3 - 6 seconds.
11. Assess quality of the tracing.
12. Disconnect the electrode and clean the gel off the patients using dry cotton.
14. Record the patient's name, age and diagnosis on your ECG strip.
15. Save the ECG strip on patient's file.
Page 261
‫‪ICU Procedures‬‬
‫‪1‬‬
‫‪Electrocardiogram‬‬
‫)‪(ECG‬‬
‫‪Page 262‬‬
ICU Procedures
CPR Checklist
CPR ( Cardio Pulmonary Resuscitation ) JajAAa J Alali lis^ j jjjjLe
:Jji\'*Mil\
"\i* Jl«i jjjLj \J ui <l=sjll (JjAjJI AjaA Backboard J' a**! IaI Ijs. Ijs. *$a Jiliu U Jji
.Chest Compression Jl J
• aJ\j1\ AjaiUl
• -
Extended <JcLA Elbow Jl J**j ^c^m Posture Jl '-^ f*-» Chest Compression d^ aaIj
.Shoulders Jl lJ* <Jj=Jy J1 j* 'Jc-J> Waist Jlj Flexed J"
• AjJLijI <iailll
J*lJ' jl J«i Jc- (JJlaj 3- 5 JS JjjJ Juuj 2 Cycles ^ Adrenaline J«a L"1 ^ '-'J2 f-^
2jLj ijA x*,jii LjjcLa Shock Jl J**H Shockable Rhythm I** Jll Vtach orVF 4"^ ^^L
Academia Jl j Acidosis Jl j* Arrest Jl s^ jV Sodium Bicarbonate J=*A Lul j»Ali j Jj aji

. (_JJ 4j.Vi«iK1I JjLcI jLuC l_ljLaA Jaau Lil JLllbj
Arrest JlAjÛ. J -uv=>w»j J* Guidelines Jl£»•*»•! <_k>}La Atropine Jl^JL?
; AjuIJl 4LH1I
Ljjk JiAiA Ja ui AjYUJI fU 5 Ha\ 3 W^La GCS Jl *aI* Xa uj No CPR Jl ^VU

iUjjjjJl ^j ajILaII Antibiotics Jl J& ls^ La£>Uaj we just leave him die in peace jSlj
.(DNR) "Jc v"SAj oûjJI J'\ Jc Coast Jl J& jU*^jJ1 o^J ^J1 tj^j ^LAjilj
" In the successful resuscitation of the arrested patient,

you have achieved yourgreatest victory "
-M.H.Eid-
Page 263
ICU Procedures
I
BLS Healthcare Provider
Adult Cardiac Arrest Algorithm—2015 Update
Verifyscene safety.
Victim Is unresponsive.
Shout for nearby help.
Activate emergency response system
via mobile device (Ifappropriate).
Get AED and emergency equipment
(or send someone to do so). Provide rescue breathing:
1 breath every 5-6 seconds, or
about 10-12 breaths/mln.
Normal No normal • Activate emergency response
breathing, Lookfor no breathing \ breathing, system (ifnot already done)
Monitor until has pulse or only gasping and check has pulse after 2 minutes.
emergency pulse (simultaneously). • Continue rescue breathing;
responders arrive. Is pulse definitely felt check pulse about every
within 10 seconds? 2 minutes. Ifno pulse, begin
CPR (go to "CPR" box).
• If possible opioid overdose,
No breathing administer naloxone If
or only gasping, available per protocol.
no pulse
By this time In all scenarios, emergency

response system or backup Is activated,
and AED and emergency equipment are
retrieved or someone Is retrieving them.
CPR
Begin cycles of
30 compressions and 2 breaths.
Use AED as soon as it Is available.
AED arrives. I
V . . ; ..'
Check rhythm.
Shockable rhythm?
Yes, No,
shockable nonshockable
Give 1 shock. Resume CPR Resume CPR immediately for

Immediately for about 2 minutes about 2 minutes (until prompted
(until prompted by AED to allow by AEDto allow rhythm check).
rhythm check). Continue until ALS providers take
Continue until ALS providers take over or victim starts to move.
over or victim starts to move.
v
. • 2015 Amonc.m H.miI A-jsCH-ution
Page 264
1 ICU Procedures
Adult Cardiac Arrest Algorithm -2015 Update
> Push hard (at least 2 inches

(5 cmh and fast (100-120/min)
and allow complete chest recoil.
Start CPR
• Minimizeinterruptions in
• Give oxygen compressions.
• Attach monitor/defibriltator
» Avoid excessive ventilation.
• Rotate compressor every
2 minutes, or sooner itfatigued.
i Ifno advanced airway,
Yes
Rhythm 30:2 compression-ventilation
ratio.
r shockable? 1 • Quantitative waveform
VF/pVT Asystole/PEA capnography
- IfPetco., <10 mm Hg, attempt
to improve CPR quality.
T » Intra-arterial pressure
- Ifrelaxationphase (dia
Shock stolic)pressure <20 mm Hg.
I
CPR 2 min
attempt to improveCPR
quality.
Shock Energy for Defibritiatio

• IV/IO access
• Biphasic: Manufacturer
recommendation(eg. initial
dose of 120-200 J); if unknown,
use maximum available.
No
Second and subsequent doses
Rhythm should be equivalentand higher
shockable? doses maybe considered.
• Monophasic: 360 J
Yes
Shock
6
1
CPR 2 min
10
CPR 2 min
> Epinephrine IV/IOdose:
1 mg every 3-5 minutes
• Amiodarone IV/IO dose: First
dose: 300 mg bolus.Second
dose: 150 mg.
• Epinephrine every 3-5 min • IV/IO access
• Consider advanced airway, • Epinephrine every 3-5 min Advanced Airway
capnography • Consider advanced airway,
capnography i Endotracheal intubation or
supraglotticadvanced airway
T i Waveform capnography or
Ho Rhythm Yes capnometry to confirmand
Rhythm
monitorETtube placement
shockable? shockable? i Once advanced airwayin place,
give 1 breath every6 seconds
Yos (10breaths/min) withcontinuous
chest compressions
Shock
8 I 11
Return of Spontaneous
Circulation (ROSC)
• Pulse and btaod pressure

CPR 2 min CPR 2 min 1 Abruptsustained increase in
• Amiodarone • Treat reversible causes Petco, (typically ^40 mm Hg)
• Treat reversible causes • Spontaneous arterialpressure
waves with intra-arterial
monitoring
Rhythm
• Hypovolemia
shockable? • Hypoxia
12 • Hydrogenion (acidosis)
• Hypo-/hyperkalemia
Go to 5 or 7 • Hypothermia
• If no signs of return of
• Tension pneumothorax
spontaneous circulation
• Tamponade, cardiac
(ROSC), go to 10 or 11
• Toxins
• If ROSC, go to • Thrombosis, pulmonary
Post-Cardiac Arrest Care • Thrombosis,coronary
O 2015 American Heart Association -
Page 265
ICU Procedures
Adult Immediate Post-Cardiac Arrest Care Algorithm-2015 Update
Return ofspontaneous circulation (ROSC) Doses/Details
Ventilation/oxygenation:
Avoid excessive ventilation.
2
Start at 10 breaths/min and
Optimize ventilation and oxygenation titrate totarget Petco2 of
35-40 mm Hg.
• Maintain oxygen saturation >94% When feasible, titrate Fl02
• Consider advanced airway and waveform capnography to minimum necessary to
• Do nothyperventilate achieve Spo2 ^94%.
v.
IV bolus:
Approximately 1-2L
nonnal saline or lactated
Treat hypotension (SBP <90 mm Hg) Ringer's
• IV/IO bolus Epinephrine IV infusion:

• Vasopressor infusion 0.1-0.5 mcg/kg perminute
(in 70-kg adult7-35 meg
• Consider treatable causes
J perminute)
Dopamine IV infusion:
5-10 mcg/kg perminute
12-Lead ECG: Norepinephrine
STEMI IV infusion:
Coronary reperfusion OR 0.1-0.5 mcg/kg perminute
high suspicion (in 70-kg adult7-35 meg
of AMI perminute)
Reversible Causes
No
" " Hypovolemia

Hypoxia
Initiate targeted j No Follow Hydrogen ion (acidosis)
temperature management commands?
Hypo-/hyperkalemia
1
Hypothermia
Tension pneumothorax
Yes
Tamponade, cardiac
H if
Toxins
Thrombosis, pulmonary
Advanced critical care
Thrombosis, coronary
©2015 AmericanHeart Association V_
Page 266
1 ICU Procedures
1
Pericardial Shock
pericardial Shock ( DC Shock ) Jaxii J HaL lis âj jijj*-

: jjj\ 4LLI1
: jjyJ* jc %J-ic (j* D/C shock V"1 j*
LJijZ>\ cjja, J Jai Cardiac Arrest u^ J^- Ui jl UU** uij Defibrillation Jâi*\ "D" -
Jhc\ aJX ( pj £j*a Ja Jlj ji& (.lijj. aJ lJls1\ ) Pulse JX Ja pulse -Jl
i_ilill î jUic Jja. 360 tSU*- lU>jj Cm** ( 2 joule/kg ) '<>jiJ <^ Defibrillatory Shock
t AjxjjJa »Jj- "" ^-î P^Ji
Shock U^«j f»jV jLîiU ^jj Shockable Rhythm ^ ^ ji <_ij*j ^j^ JWIjj
;Jonnj lS-^J ^ll\xa x*.ji jluic
Pulseless Ventricular
Tachycardia
(Vtach)
Ventricular fibrillation
(VF)
fine or coarse <-&£ *L>->
JjVI CPR J^ aji jlâi*\i uij Non-Shockable Rhythm ^Hc aJ j\ a^ji lJj*j ajij
:l\aa\j uij Shockable V^ &** ^ J V) Shock JJaxiAj
A systole
(absence of electrical and
mechanical activity)
Pulseless electrical activity Pulseless Electrical Activity (PEA)

(PEA)
pulse
t^jlx. rhythm J £» k^j^m uij
pulse »!** i_w^> j^j Note that PEA can look like any rhythm (any organized
electrical activity), but If no pulse It Is PEA
Page 267
ICU Procedures
Ajdl] 4jaiill
1
ij*j* jjyJ pulse -II <1aoa* Jj JUJ; jjiu ^.nt JHW uij Cardioversion Jâi*\ "C" -
l)j* 100-50 ui*z VSjjix-a aaJl Cardioversion Shock Jaxi lii 4«hru jjc. »jj^ jUj
Amiodarone -II lSJ 4^ jJa \+*Xxs Stable jj^ Ul h ui Dysrhythmia Jlj

Loading dose and then Maintenance Dose <" J**m Cordarone -SI ja <i« lsjUjII (""VIj
: Cm^-j* Jc Jia k^cj Unstable jj& ji Dysrhythmia -II j) ji
uj Retrograde Amnesia Jaxi cAJ\ jiL Jj Sedation Jaxi -.Jjyi
Midazolam (Dormicum) - Propofol -II
. Jjt- 50 u^ VilaiJAi <jjj*S Ai*Jh jelu Shock -II Jac\ J\ Ji .Ajlul
u J**"'
Supraventricular
tachycardia
(SVT)
Atrial Fibrillation iUw-JI *J|/«J|/«V/WJ|, (^xJU-v^
Unstable Ventricular
If
tachycardia with pulse
ShOCk Jaxi UJjS 1.1a. ^

. LjlcU 8 JSVl £ fjLa jj£j JaljA\ ji •
. <£.U 48 i_i ULs Digitalis -II <-JajJ •
.Shock -II Jjs Synchronization -II <JA*. JJki aJij •
.tdfcUj (j^Jj^l! jja. i_iiuuA V)j KY gel -II (jr—2 (jcj •
Page 268
ICU Procedures
Pericardial Shock Performance Checklist
[. Wear gloves and remove all metallic objects from the patient and dentures.
2. Place a back board under the patient.
3. Bring crush cart to bed.
4. Prepare paddles with proper conductive agent ( gel).

5. Place one paddle at the heart's apex just to the left ofthe nipple in the midaxillary
line. Place the other paddle just below the right clavicle to the right ofthe
sternum.
6. Place the synchronizer switch offand charge defibrillator paddle as prescribed.

7. Apply suitable pressure to each paddle against the chest wall.
8. State "All clear" and usually verify that all personnel are clear ofcontact with
patient bed and equipment.
9. Depress both buttons on the paddles simultaneously and hold until defibrillator
fires.
10. Assess for the presence ofa pulse and observe for conversion ofthe
dysrhythmias.
11. If unsuccessful, immediately charge paddles to 200 to 300J.
12. Ifsecond attempt is unsuccessful immediately charge paddles to 360 J.

13. If third attempt is unsuccessful initiate ACLS.
14. Reassessthe patient's pulse.
15. Assess the patient's ECG rhythm oncardiac monitor.

16. Clean defibrillator.
17. Discard supplies.
[8. Remove yourgloves and wash hands.
19. Documentation.
Page 269
ICU Procedures
Blood Transfusion Procedure
ICU -IIJ UWu Jl\ Procedures -II J**\ j* Blood Transfusion -II *Jac jixi
<_ijâxi jali Reaction J J^*J <-a*4 Very Close Observation i*&*A ui *Jax1\ Uij
"<ajaa Ucli Rate -II Zcjaai <i\ dijaj Jjia_« IaIxa lfAai »Jij \i* Aijai jjli Packed RBCs -II UaL
X-a (JaSc iSJe ?iA\ xâ J_cliu4 J^ A_Ji Normal Saline—II W> J-^ Jj-k- 0 a<lh jJ,
aÎaW nu\ ^ Jclihi Auk ^Jli ?jiaJS1\ Ringer's Jlj Hemolysis ofthe RBCs d-a Glucose -1'
(iljaiuilj jJX\ ja±i ^j jlliVI UjA ffrL-ajlj ?i!l LJaj l-lu^j jiu oJj ?jJI (jjia ^j Sjj^jJl UU-; II
.?ii j*Ji« j^ki ^ jLli j«Jxa Jii jjSj duaj pghih'iij Stopcock (3 way)
Aijti (Jixa1\ ijji (Jaa liixi Close Observation lUjj Ij* ^ ^^ J-^' jj&> j»JV îaj 20 Jji
Still SlOW *Ajajl jai
Jâ uij Signs OfTransfusion Reaction -II &•*-* fjUIIIV M»
Headache (First Sign)
Back Pain ( Second One)
Nausea and Shortness of Breath
Fever and Chills
Pain or Burning Sensation at the Transfusion Site
Swelling and A large Bruise at the Transfusion Site
Transfusion Reaction <Ûa Jâa. Ja J ji* ?i\\ j*£ J*xi Uj*j ^jUa.1 LuUli uj Jj-ill Jaxi
Aaa jnK'n 1.1a Ixij AcLa 24 °1a1 Cilxi »jjl jj. i- jlii Jialaj
Page 270 —
ICU Procedures
Blood Transfusion Performance Checklist
Wash hands and wear gloves.
3. Warm up the blood bag to a suitable temperature before giving itto your patient.
4. Check the blood bagfor expiration date and any gas bubbles.
5. Compare the patients name, number, blood group and Rh Incompatibility.
6. Measure the patient's vital signs before transfusion.
7. Insert IV line ina normal saline bag and blood transfusion setinthe blood bag.
8. Hang both bags on IV pole and connect them together into the same line using
3 way stopcock in case of Packed RBCs.
9. Start infusion from both solutions by adjusting the slowest possible drip of saline
with the highest possible drip of Blood.
10. Adjust the flow rate atabout 20 drop per minute for the first 15 minutes.
11. Stay with the patient for the first 15-20 minutes, and monitor signs &
symptoms of transfusion reaction.
12. Ifno signs ofreaction appear within 15 minutes, adjust the flow clamp to the
ordered infusion rate.
13. Monitor the patient's vital signs throughout the transfusion procedure.
14. After completing the transfusion, put on gloves and remove the used infusion
equipment and dispose it.
15. Continue monitor the patient closely for signs ofreaction for 2 - 6 hours later.
16. Documentation (date, time, blood goup, flow rate, and any reaction appears).
— Page 271
1 ICU Procedures
Blood group Gives to these groups Receive from these groups

0" All 0" only
0+ AB+,A+,B+,0+ 0" and 0+
A" AB",AB+,A+,A" 0"and A"
A+ AB+andA+ 0",0+,A",A+
B" B",B+,AB",AB+ 0" and B"
B+ B+ and AB+ 0",0+,B",B+

AB" AB" and AB+ 0",A",B",AB"
AB+ AB+ only All
jâll Uil aaH acjiai Aâjxi gli*A Ciilj Massive Blood Loss »-^ a^j^l jl Û. Jxiiini jysi\
.laii U15J J*xi Blood Group JS jl
Caregiver.
Blood Transfusion
Page 272
ICU Procedures
NGT Insertion Procedure
NGT ( Naso Gastric Tube )^J* J ^»«j li* iy^J oijJc

; JjVI *±&1\
liic-Uj J*ija\\ J Jlj iaia olaJj All* gln'iuiU îe. nOSe J' j* S-^J^ ^VlaJI JS ^ UJa
oral mSj2 fji ui ÛJI ^ U^* head trauma °Hc J jji jS^ ji basal skull Fracture >Hc
. nasal mSjjjUj] UL Ui« £ji**j
• 5_ulSJl 4L&UI
(Jaa ui "*a\*1\ Jj UjjSjj v*-=j agitated jjSj j\aa Uc.li j^jJI ji ^j <1SA« ^^ uUai
; (jjVIS i-ijâjj
^jjî rigid jjSj UjI '*•;-•; ALL 10 - 15 HaI A*X1\ J LJiiaJ (Jaa JjIjll Jail.nl U Ji -
. UjjSjj L>Ja jlu JUlUj UjSjj JjUj Ul
. a£j*1\ (ja Ajiiuj tongue -II <a A^ jUc oro-pharyngeal airway J«j^j (Jaa -
Ujjajj Jûj tongue -II jiîi \ij jjSjljj »m 3 - 5 v jjfejj ^-V J**J jLw -
: mail ma
earlobe Jl nose -II j- <iUJI jAJii <M jjjL jc Jiia J JoijaII Al*iii Jl\ jj*\\ jMa jaa.
umbilicus -Jlj xiphoid -II Cm midpoint -II J=J uâ adult jlj xiphoid process Jl U>j
AaX-i jIcUj jMa1\ ii*ij
• Atui^l mill
J ,Jl\ jUic tilted forward jjSi head -II Û. ^J sitting position jjSj »ji Û> oû^l
Trachea -U tube -II Jj^ '^J J&j airway Jl i3li
. JI&a x*j aji Resistance d^*- J Ulail cii\j
Page 273
Ryle's tube different head types

ICU Procedures
1
Funnel head Capped head
Ryle's tube sizes
• LightGreen
m9 Blue
m \m Black
12FG White
G \W Green
m 0 Orange
m\W Red 20FG Yellow

m3 violet
24FG Light Blue
Page 274
ICU Procedures
NGT Insertion performance Checklist

1. Assess the patient's need for nasogastric tube insertion.
3. Place the patient in high fowler's position (sitting) with the head tilted forward.
4. Stand on the right side of the bed.
5. Drape a towel around the patient's chest and shoulders.
6. Check the patency ofthe nares by check the air motion ofthe nostril while
the other is closed.
7. Estimate the length oftube to be inserted bymeasuring the distance from the tip
of the nose to the earlobe and then to the 3 - 5 cm below xiphoidprocess and
mark this length with tape or ink.
8. Lubricate 6-10 cm of distal end of the tube by K Y gel.

9. Insert the tube into the selected nostril
10. Position curved edge ofthe tube downward and direct the tube along the base of
nostril.
11. Instruct the patient to swallow during insertion (if conscious).
12. Remove the tube immediately if resistance is found orthere are signs of distress
or cough.
13. If no resistance, continue to pass the tube until marked position is at the rim of
the nostril.
14. Check the placement of tube through:

a- Connect 50 ml syringe to the tube and aspirate gastric content,
b- Inject 15 - 20 cc ofair into the tube while auscultate with a stethoscope
over gastric bulb.
15. Secure the tube

17. Documentation (date, time, size of inserted tube and patient's response).
— Page 275
ICU Procedures
Ji
Steps of Nasogastric tube insertion
ADVANCE THE
NGTUBE UNTIL
YOUREACH THE
DESIRED LENGTH
OFINSERTION
IMWKTOWUDSOCOTUT)
SECURETHE
NGTUBE
Page 276
ICU Procedures
Jl.
Enteral Feeding Procedure
Enteral / Ryle Feeding Jaxii J ilahîi ^jaj jijj\e

• Jjj\ 'aM2\
: (yja(jc HVj stomach Jl J^ XijuJj JjIjll jUU (ja i<ki aji a*\* jj
JXi JaS/l i j Gastric Content J%> u^jj^1 4^-^j o^jh Tommy Syringe J^J -
IN Uj] JJj *i ImI.ia'ij cjjIj Resistance
Stethoscope JU »W Jj^ Cij^ xaauj Jjljll Jib »Ija ^ 20 - 15 j* Cm^ J -

11 Stomach Jl j£* J-^ tslj! v^
2 Fingers Downward ^j^jja Xiphoid Process Jl kyâ J\ Sternum A\ J ilaii j*\ cy

( JUill Aja.U £jlj~a 3 ^jaij Ci*i\ juuUa JjiiA ) 3 Fingers to the Left Ujjuj
. IjiiU* Stomach Jl 3Jj Epigastic Region Jl J î\ \iii
• aJ\j1\ 1lM2)
?? -ul i_jL (iixa\\ Jab jja.^ jW\ JjUJI aiaa ) Gastric Residual Volume Jl •"»* *ji
Uil Cli\j AcLa J£ (Ja 200 ^J IJ^JJ-JI J Li-AXAl LucUj SAj-laJ! Au61\ ja lj'l*ii | AiAaH AuaiL •
AulxlW ja jd j % 50 Oxua J Lula . lali J ISO Jaxii Ua.1 \li Jul J 50 £\xa xlL CjJa^,
. jJLuj AlAa. u-LwiA Ja Ul ÛJI ^ Jul 1AlLA\
Julul J" J JA*1 J Uj) AlaJiA (JJa ilxl\ jâ* iJ hni (_J.ikv jjJaa.1 jl jiual jl ; jjli <U*njJU •
. Feeding J3*^ J^j ^^ ^J* J1 ^J "<^m Hematemesis lJ Ji ^"
• £^l AJaiill
Bag j^ ji Tommy Syringe a *J**m a£ *U« UcUj Enteral Feeding Jl j! lk'jj^JI

JaSs acLa 18 Jilijj diabetic oô-J! j5 Diazone Jl J Fresubin Jl lsj
. UUs 6 J 12 j"> (JJIUIjjjSj Jjj cAcLa 6 Jl j) dâiij ^1Û» 6 £4j# o^j^lj
Page 277
ICU Procedures
Enteral Feeding (Gavage) performance Checklist
l. Check bowel sound, Gastric residual volume, Nasogastric placement.

2. Wash Hands and wear gloves.
3. Explain procedure to the patient.
4. Elevate the head of the bed to 30-45 degree.

5. Ensure appropriate Endotracheal tube cuff pressure if present (20 - 30 mmHg).
6. Cover patient's chest with a towel or pad.
7. In case of Tommy syringe:

• Clamp the distal end offeeding tube &Remove the syringe.
• Remove the plunger and attach the syringe tothe distal end offeeding tube.
• Fill the syringe with prescriped formula.
• Open the feeding tube.
• Letthe fonnula flow by the gravity.
• At the end of feeding, flushthe tube with 20-30 ml water.
• Cover the end ofthe feeding tube with its plunger orcap.
8. In case of feeding bag as ( Diazone - fresubin):

•
Attach the connector end of the feeding bag administration set to distal end of
feeding tubeand tapethe connection.
• Set prescribed infusion flow rate.
• Label Enteral feeding bag with started date andtime.
• Change the bag and set every 24 hours.
9. Return the patient to comfortable position after 1/2 hour .

10. Administer mouth care every 2-4 hours.
11. Rinse all reusable equipment with warm waterand remove it
12. Remove gloves and wash Hands.
13. Documentation ( Date, Time, Amount, type offormula and any complications)
Page 278
ICU Procedures
1
NGT Lavage Performance Checklist
1. Assess the patient's need for lavage.
2. wash Hands and wear gloves.
3. Standon the right side of the bed.
4. Aspirate gastric contents using irrigating syringe.

5. In case oftoxic agents ordrug overdose, send a specimen for analysis.
6. Instill 50 to 200 cclavage fluids into the tube using irrigating syringe.
7. Aspirate gastric contents through irrigation syringe or allow gastric contents to

drain by gravityinto drainage bag.
8. Continue lavage until returns are clean and free ofclots (in case ofhemorrhage)
or free of toxic agents (in case of drug overdose ortoxins).
9. Reassess the position ofthe tube each time before instillation ofmedication or
lavage solution.
10. Remove the nasogastric tube if not needed as follows:

• Clamp the distal end ofnaso gastric tube .
• Remove the tape on pateint's nose around the tube gently.
• Ask patient to take a deep breath and hold it.
• Pull the tube out slowly and gently.
11. Putthe patient in a comfortable position

12. Assess the amount and color of gastric wash or drainage fluid.
14. Documentation ( Date, Time, amount offluid, patient's response).
Page 279
‫‪1‬‬ ‫‪ICU Procedures‬‬
‫‪I‬‬
‫‪Page 280‬‬
ICU Procedures
TPN Checklist
1. Assess the nutritional status of the patient.
2. Check TPN solution for cloudiness, turbidity and expire date.
4. Clamp the distal tip of central venous catheter.
5. Clean the catheter tip with alcohol swab (Chlorhexidine 2%).
6. Place IV administration set into infusion pump and label it with started date & time.
7. Connect IV administration set to TPN bag.
8. Tape the connection and open catheter clamp.
9. Setprescribed rate of infusion on pump and startpump.

10. For cycled TPN:
a. Infuse TPN for 1st hour at rate 50-80 ml/hthen gradually increased over 24
hours.
B. One to two hours prior to end of TPN cycle, decrease rate of TPN infusion to
half.
11. At the end of TPN infusion turn off infusion pump, clamp IV tube.
12. Heparinize thecatheter and the multi lumens evey 24 hours.
14. Documentation (Date, Time, type of formula and infusion rate/hr)
BUN Jl '*+*> Jc Check JxijUSj Na+ &K+ Jl L-j^j serum electrolytes Jl Jc &ap Lib
jjli yJll lUjII yj IV solution ojî j oiiil <JX* j-. a^jOa tub CVC -Jl Jc M*j aJi
. ^ AiiJ formula Jl
Page 281
I ICU Procedures
Enema
Enema-Jl i> c\j\ 3 U-jj& <J

u^j-^l j«^ ^1J To prevent the release of feces aIaxIai b p_ jJIj
Cleansing
Colonoscopy JAxii JoijaW jl ji aIixa Surgery J Ûj
Enema
500 ml Normal Saline m ULxi.uij
Ui* y-U.VI t>=>ll ji Constipation °iic JoijaI UL*ii ,_sjj
ftUac] ^jL jc ^j Feces Material Jl jlj^! ja
Carminative
ua i\ja\\ ji Glycerin or Magnesium Sulfate
Enema
Stimulation of Intestine Peristalsis lUxii
100 - 200 ml -iU>u (Jaaj Feces Jl £j> JUiUj

to administer medication / oil into the rectum Ul
Constipation u^ J Lactulose J=c\ j\ Xa uj

Retention / Hepatic Encephalopathy Jl Oil* uj Elevated Ammonia Level ji
Medication Bowel Inflammation jiJc J Steroids J*c\ J\ j
Enema Locally UaJUi duaj Antibiotic Jaxi ^H*aj lower GI infection ^Hc J j
tAclii JoijaW J*ii lM (jiJa jc. Retention Jl Jc JiaUij
iaisA 30-60 '°ia1 enema Jl *4 Trendelenburg Position
IjUt'imiu Jl\ "eJajAilll Ai, n.'iiU
Adult 14-30 French
Child 12-18 French
Infant 12 French
Rectum -SI J*b ( 7.5 - 10 cm) Jl>* ^ 3-4 inch ^ J^jj & Sjkuillj
igj TJAwlAjl JjK w 4-JJ&
Adult 750-1000 ml Adolescent 500-700 ml child 300 - 500 ml
toddlers 250-300 ml Infant 150-250 ml
Page 282
ICO 1
Left side lying position with patient's right knee bent -II J* Position d-^
Rectum Jl £^ Anatomy -Jl £* J*^ l^ ^ C
(45 cm) Jbj* J** 12 - 18 inch o&w patient's level -Jl <> bag Jl £l£y!
.Jâ (20 cm) W&^jl Ja* Retention Enema J**j* <&l <^ Jj
Hepatic Encephalopathy Jl ^VU ^ Enema -Jl <^tu S»*aVi aj] ja ^Sjb JI>JIj
Ammonia (NH3) -Jl g% small intestine -Jl J Protein -Jl j^& -*4
. Urea J W^jp^ ^ ti^3 i> k^ uâJI ^J^ ^ J^ jj2 m4h -^lj
Ammonia -Jl ^ J^J ^JJ^ Uj>«Vi Jj*j jiLi Jaa i&\ Liver Failure Jl tr^j* ^
<1jU. j* jixa lj\ jiiiij Blood Brain Barrier JJ J^»As <jJ»^ UjÛll ^ lîwij.jjjjj
Accumulation of Ammonia Jl ^"j Glutamine W>! »û» 5^ ^^ <^ J^j
J-J^j Bad Effects ^ jj%? bj Accumulation <La^j Glutamine Jl ^Jw* ^=ji
Cerebral Edema, Astrocyte Damage and Impaired Synaptic Transmission To The Brain
UjOLd
1st line oftreatment ofhepatic encephalopathy Jl j* Lactulose Jl py

aj^Jjj metabolism ^1-^j.i non absorbable disaccharide Jc SjUp jU-aiaU \i3
a—c.j^*a ojj—ufi j—« ^j—yjj Lactobacillus Acidophilus V—">j'—1J0*
Acidification of bowel lumen (J**#^j Short chain fatty acids-Jlj-*
: (Ja*.\j* jMi.(ja ammonia Jl Cy cm^m J^-ij
Ammonia Jl CjJh J\ kJ^ dh b ^ÛJl Li*J\ jl; Vji
Bowel Jl i> Ammonia Jl £& Absorption Jl &*#: ^
Lactulose Enema
One liter oftape water **^j 300 ml Lactulose j^mix lU*J

20 cm uJ* Patient J't> bag Jl ^J1 d J^ Retention Enema j^J^j
, aUS. acLa HA Trendelenburg position J ^^ J^; ^tu o^jJI iP&j
- Page 283
1 ICU Procedures
i
Enema Performance Checklist
1. Wash hands with soapand waterand weargloves.
2. Prepare the necessary equipment.
3. Make sure thatthe water temperature is between (37 - 38.5 C)then fill theenema
bag and close the enema tubing clamp.
4. Place a towel underpatient's.
5. Position the patient onhis left side and bend his right knee (other useful positions
include : right side position, knee chest position and back position).
6.Lubricate the tip ofthe enema catheter with KY gel before inserting it into the
patient's rectum and ensure that it is free from any clogs orkinking.
7.Insert about (3-4 inches) from the lubricated tip into the patient's rectum.
8. Release the enema tubing clamp.
9. Monitor the patients for any signs of cramping as abdominal muscles tension,
stop the flow and ask your patient totake several deep breath and continue your
enema once thepatient becomes comfortable again.
10. Remove the tip ofthe enema from the patient's rectum once the device is empty.
11. keep the patient inposition after enema for about 30 - 60 minutes (retentio).
12. Dispose yourequipment andremove gloves.
13.Washyour hands with soap and water for at least 15 seconds.
14. Documentation (Date, Time, type ofenema and amount offluid used).
Page 284
ICU Procedures 1
Urinary Catheter Insertion Procedure
Urinary Catheter '-Jj* J ^ 1^ iy^J J,jjc

:JJi\'Alsm
JJ 7Sj-J Uo£jj J-Jaij uij Foley Catheter -II «-a Ujîi jj£ fJjJ Ujj- aJ Ji (JJ-c Lxja
. xulJi 4 "o1a\ Ui£jj JjJajj uij Silicon Jlj
:aJ\j1\ aLaHI
JUjll auaAi Urethral Meatus Jl Cleaning and Disinfection J«j aji \+iiJ U Ji
. Soap and Water then Betadine Jl Ji*aA> bj Perineal Care lW^> Female Jl *oâj
:3JjjT511 AJaAjil
KY gel Jl !•£ u^ Catheter Jl Jc -^ J* Penis Jl J^b KY gel Jl J** H male Jl ^\* J

Urethra Jl pj^- J^y* j UjUI JaAiA Ja
:aju\J\ aJ&1\
??ajI J**ja Resistance Û-o J*<aa jl Ukiu cjjIj
? Jâ-u ,^111 AjI <_jla UlaJJj MOUth Jl t> U"»J ^ jUJI JaJj ^ 1 x*.Ji
aau* J Jl\ Sphincters Jl J^l Relaxation J^*m Mouth Jl j*irn^ i^ki oîj^ ^
UjjSjj jJai JUlUj juijA Urethra Jl J ij*ja1\ Ja^*\\ )iiij
(AAj*ii) cl jiUuall JJSJ Ul Ujjjjl j> Aaia \li Cii\ lJuxi U3la.Jj Aggressive Oih L-ii\ J Ujj
False Passage J^j *Uaj j« ^j*!* jl
;AJuulaJl AJalUI
Jja.j-11 JjJI Ja Jjiu JL. JjJ Jûuj Ul ^jXJjJall jîalll jV JjJ ^J^* fjHHV Uk-&> U Jja^
;jU.:.ii j ?j\y* aAi 20 J* Jjj ij3* jja J^ j*i îUbVU jjjja.j- ajj^ J^jj jSlj kUJI Jib
. Jjj i,ij^'iti ^jV Bladder Jl °j^ ^*i cA*i
SjLJI j-Uj âjaJI (,).,«*> (Îc. (JJjii N. Saline J 5- 15 Cy Cm*m Internal Fixation Ul J«j jUic.
18 j 16 Ul sjkuiJ^tiuaij Adult UcjjU ^jA\ JkxA ji J 10 mJ*1^ MÛll t5* l-HJ
, j jUUI j* JajliJc Adhesive Tape a External Fixation J«j aJij
;iji*H\ AJaJIll
, o^j^l Jc AiyH ^1 UUj ^ji^j jjj-JI s-uU. Jc Urine Bag Jl J*a ?ji
Page 285
Urinary Catheter Insertion Performance Checklist

ICU Procedures
1
Wash hands and wear gloves.
2. Explain the procedure and show respect to the patient.
3. Position the patient onhis back with legs slightly apart.
4. Select the proper catheter size (females: 12 - 14 french - male 16-18 french).
5. Test catheter balloon by injecting 10 ml sterile water orN.saline then aspirate it
and leave syringe attached to catheter port.
6. Attach the catheter to the collecting bag

7. Start cleaning and disinfecting the urethral meatus
In case ofmale : hold penis and retract the foreskin then start cleaning using
circular motion from thepenis tip downward to the scrotum
In case of females : clean the far thigh upward and downward then clean
the near thigh upward and downward and finally clean the
libia majora and libia minora from upward to downward.
8. Lubricate catheter tip with k y gel in case ofmen inject the gel into urethra.
9. Start inserting the catheter into the urethra using gentle circular motion (In case
of male: hold penis and retract skin then insert it).
10. Insert catheteruntil you find urine instillation then insert additional 3-5 cm.
11. If you found resistance ask patient to take a deep breath from his mouth then try
again , if resistance persist pull catheter backandnotify.
12. Inflate the balloon using 10 ml sterile water or saline and ensure that it
cause no pain.
13. Attach urine bag to the bed frame with hook or strap it with tape and it should be
lower than the bladder level.
14. Fix the catheterto the inner thigh using non allergic tape.
15. Remove gloves and dispose it.
16. Wash hands.
17. Documentation (Date, Time, type and size of catheter, urine color).
Page 286
ICU Procedures
Routine Care of Urinary Catheter
1- Make sure that the urine is flowing out of catheter into the urine bag.
2- Keep urine bag below level of patient's bladder.
3- Make sure that the urine bag does not grag and pull onthe catheter.
4- Don't tug or pull the catheter.
5- Make sure that catheter is not twisted or kinked.
6- Empty the urine bag every 1hour orwhen it is 2/3 full.
7- Make intake and outputchart each hour.
8- The normal urine output is 0.5 - 1 ml / kg / hour.
Note
.Intra-Abdominal Pressure Jl u*& ai\ jl J Catheter Jl J^j^ja Cu\ J
. Saline or Distilled Water J* 50 JjVI UUa. J*n aji: Vji
,»jj IjajaJA a^li -(j"'-" JlI\ 50 Jl JJÛ jjalc \f\\,r,jJ liliV Jill 3-5 »A«J Uiu Jjli Jlaki ; UjU
.disposal Ul J«j liixij jaiii*\j ijA ULmiUA SjkuilU UL^jIa ^l Stopcock Jl: 15115
.Greater Trochanter Jl He jjui <£c\ji Zero Line Jl: Wj
Intraabdominal hypertension *jc jjiu b 12 - 20 mmHg j* Jj 5 - 7 mmHg jJm ul ^jjJaSI
Abdominal Compartment Syndrome *Jc Jjaij b20 mmHg j* Jc\ J
Page 287 —
ICU Procedures
1
Bladder
Inflated balloon
.'balloon Prostate
bladder opening*
Catheter
'»urine drainage port
balloon port volume of fluid recommended to inflate baloon
Page 288
1 ICU Procedures 1
Hot and Cold Applications
__.Uj Patient —II U_i U_$J l_hv. ...I j__iU_i j] JjJ-> Cold Compresses -Jl j-c (J£j_a jJ
11 Feverish ill* xa Jlxiii Jj] j* JJi JI>Jlj Feverish jjya
; Jji\ A__l
.. 6£__» JJ*a Aa.U>j jSJj Cold Agent c?i £L_4

^j a_JU.1I (___ U__jc a_j3 J* Left L_uUllj Right S--sJj Neck—««—k <^-- <_—SI -
Jugular Veins ^J J^j Carotid Artery
AxillaryArtery<J^- ji a_j_*1I «-«jV Left M5Mj Right »^-lj Axilla -J' --^ <*-» uJ®j -
Axillary Vein **J J^j
FemoralArtery **-*> ui^-^1J Ji Left M^j Right "»--lj Femoral Triangle Jl Jc jmJ -
.Femoral Vein **J J^j
a_ f—aJI J ij*ja!\ ?_ Cooling ——c- —Jl l^j
Anterior superior
iliac spin*-—_ V^
L
I
txtanuri iliac vein
Inguinal ligament
Femoral triangle
- btcmol corotidartcrv
~ Externalcorctidortery
" Externa! jugular vein
" Internaljugularvein
Commoncarotidartefy
-- SteroalekkxTOitokJ m_dt
Femoral arteryand femoral vein Axillary arteryand axillarvein Carotid arteryandjugular veins
Page 289
ICU Procedures 1
; Ajj_l A__l
11 Jj\ Cooling VlWja uij sJ= c^=JI £& Organs Jl ^ a_1 aK e_ Cooling —-^ U> _j
150-250ml N.saline Îj^-Bladder-II ^(J*1^ UrinaryCatheter s^j-^-^ lh=jj-JI jJ

. aMi 15 ixi l$*ikij Catheter Jl J^j Cooler than body temp jjSj
100-250ml N.saline JJ* Stomach -Jl J j*1* NasogastricTube <^j* ^Lu J^j-aW J
Gastric Contents Vj Afcjli Stomach Jl Ja JjVl L^jAi Uj*j Cooler than the body temp jJi
AliSJ J 5 Ixi I*^ "'a* a In\aa"\ «
. Cold Saline / Water m WJ**ja Enema lUxu u^>JI J

. Cold l*jJa Juii Perfelgan, Saline, Flagyle Xa uj JJ*a j aa.U deli o^jjJI jl
; AjIUII Ajaijll
Outside Surface ofSkin Jl ^ aJ UJ£ Internal Organs Jlj «& ?i\i Cooling ai>c L j*j
. Cooler Ujlja.i*.ji j\*it infill Au.nlU Aa.U. Jji.
Cold Blanket j Ji*ua\ (jijL jc ajjU ALjla aJj -
.J=*i Fever Jl Oil* J Cold Compresses JlJ-jlUj jai Ja

Vasoconstriction ofBlood Vessels J—«jj l~J>i Swelling Ai—ic j_l jl <£ \i\*.- ...i j <..
.Cut Down UL*. JUlUj JuiBlood Flow Jl JUlUj
.Nose Bleeding ( Epistaxis), Sprains andStrains Jl ^VLa J jLS igUWy
Cotton uO yj^ ^ ajj ,^k jSlj Skin Jl<>> Direct u_£» j^Cold Application J*xi LJ <?>U». *»<
.Aijli't (jiLoS AxJaS jl (jiLi jl Mia
Page 290
‫‪Chapter 8‬‬
‫‪ICU Tips‬‬
"When we all thinkalike, thenno oneis thinking "
- Walter Lippmann-
miscellaneous
1
Glasgow Coma Scale (GCS)
Uj*c jjjjajJl (îjall Level of Consciousness Jl ad jUicaIaxIai Scale Cf- '"Joe °i <
. Traumatic Brain Injury Jl Oil* J lûaaj |CU Jl J
Intubated or not ^Hc aIUII t\j^ aai*i^ j\aa Jl\ ( jixa1\) jjjaJi jc .Kr,A Ua.1 ua <
AjjjLuil j.îljr. 3 Cy jJaa£ ji >
Eye (1- 4score ) Motor (1-6 score) Verbal (1-5 score) or Grimace (1-5 score)
ai*iiMi ui 4JUJI J Endotracheal Tube *J_y im* Uj) jxai Non-lntubated &*c <1UJI jl
.LOC Jlfjijj^j jUic Eye -Motor -Verbal J'
jjii4 Jia ui <1UJI J Endotracheal Tube '*Jja Uil jxai Intubated ^jj& <!UaJl jl Ul
Eye - Motor - Grimace Jl a^'uM ji a1\*1\ Jj ETT Jl ij*j '."mi Verbal Jl J---"
. UcUj aJjiill J
. jl$i jLsa JJa 3 ji Score Jaij 15 ja Score trî <
^Înterpretation -UajuuIU ^
15 : Refers to Fully Awake Person ^
13-14 :Minor Conscious Disturbance J (conscious )
9-12 :Moderate Disturbance (semi conscious)
8 : Sever Disturbance*
3: Deep Coma J ( ""conscious )
ETT s-^j2 aji Jii Ua 8 acUj Score Jl J=ijA j j) Oilj&Ji Guidelines Jl i-ai*\ <
. Ventilator Jl Jc aU.jjj
J-33- j^tr^NO CPR (DNR) <Jc jjiu Jllc \iJj 3 ja ji'\ HaI 3 jl£ Aelii Score Jl J <
JJ*J Ji uima cJ** UaiUAj "We Just Leave Him Die in Peace" Ja-iiiA Ja Arrest
Coast -Jl JJL jUc AjjJi Lyx*.j\ ajjjI Jaxij pUyjllj ÛijjjJI uj aJUJI antibiotics -il
, (jiaJjxll JaI Jc
jCs juLaJ
; Ua AjjAjII SjcUIIj <

•The GCS is best used for Non-intubated, Non-paralyzed, Non-sedated patient.
Page 291
‫ﺇﺫﺍ ﺍﻧﺗﻔﻌﺕ ﺑﻬﺫﺍ ﺍﻟﻛﺗﺎﺏ ﻟﻁﻔﺎ ﺍﺩﻋﻡ ﺗﻁﻭﻳﺭﻩ ﺑﺷﺭﺍء ﻧﺳﺧﺗﻙ ﺍﻟﺧﺎﺻﺔ‬ I
1 ^•i yTi j ffl EZr^H
miscellaneous
I I
AjjIIuj i j v aJ AajiLa Ajjc 4

Spontam jTlTT^^H
J la* (jii LJjA-all *UjJI xa UJiilJj CljjâW xa AJJC £%]
To verba 3
.LkaJU AjIc (jiLaaaio jUlic ^jU JjSj (Jaa AjI liljUjc)
^ A A* isuxi ^Ja Ji\ Jâiij aM\ x-A AJJC jlijJ
Ear Lobule Jlj Forehead or Orbit Jlj Finger nails Jl 2
.4ilc ?lja Mandible Jlj Nipples Jl JX ua
No respc nw^l . Aa.Uk J jl LJjjâll jl JX f-\jui Aiic ^6ku Jla 1
.((^jIc Jaluj fX*\\ lju ) /_Jjlc liljk ^JjU^JJ 5
Confused Uaa ji ?ua $\yA t&jU) \±\ Ixij iji Ixki J'ju AjUi 4
Inapprop (^1jîc JX) Aâxjj AiX. JJa JX jjai 3
Incompr* .(aXili f$A$ll) aj$*A (Ja aX 2

sounds
No respo .(jail* Ajl all nl Jiâ 1
Spontaneous .Tube Jl Sucking J^ji iy%i ^" -M^* 5
responds to to .Spontaneous Jl Cy J*1 J&m Jmj 4
Vigorous grin- Ajx_L-a A_ij £aXj \u* A-iiic AlilaijJ ^Ûa J\ Aui jl
3
.Aljlli\ jlaxlij
AJaj Jc Ui,,. i jxiiajAjjî ^^JA Jl Aj2 J 2
MW 1*1^4-1*1
.(jta\l* AjLalu] JiAa 1
•5JWM^^.\^^^^ffiH (,A-\r. J.,,*\\ aâjl liljajjj 131ixqA*l* Aio dulla jl 6
Localizes pain Mandible Jl J Painful Stimulation aL«jcj1jUj1

5
stimulus lihjl jxjj jLic ojjI ' iiilii Aj5!jUa
Mandible Jl Cy 4^1 oJa jUic oajI ^jjj jii jlo
Withdraws fr "'llll' 4
jji'>i~. Aaja* ^* u J glajjS
Abnormal fie xion Internal Rotation of Shoulder and il**i °jj 'rlrt
3
pain (decort cate .Painful Stimuli J' aJjLcjl Clench His Fist
Abnorm; il extensio d-*aj Extension of Elbow and Leg *^11«ja
2
pain (dec:erebrate) .Adduction of the Arms
, 1^(1 ^ <t ll % Uill , IiHO/i
No resp onse 1
Page 292
miscellaneous
1
Pain scales
1-Verbal Pain Scales
A - Simple Descriptive Pain Scale
A. Simple Descriptive Pain Scale
r.: U id Modoste Acist

Pain Pain ri'- Fain Pain
B - The Numerical Pain Scale
0-10 Numeric Pain Intensity Scale *
I—I—I—I—I—I—I—I—I—h
5 6 7 8 9 10
No Moderate Wont
pain pain
Conscious Patientd\ ^ ^.vsimn Jjjj
Page 293
miscellaneous
1-Non-Verbal Pain Scale
Face Scale
2 4 6 8 10
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST
• I • I » I I 1 1 1
0 2 3 4 5 6 7 8 9 10
No pain Mild Moderate Severe Worst pain

imaginable
Behavioral Pain Scale
Behavioral Pain Scale (BPS) 3-12

Item Description Score
Relaxed 1
Facial Partially tightened (eg, brow lowering) 2
expression Fully tightened (eg, eyelid closing) 3
Grimacing 4
No movement 1
Partially bent 2
Upper limbs
Fully bent with finger flexion 3
Permanently retracted 4
Tolerating movement 1
Coughing but tolerating ventilation for

Compliance 2
most of the time
with ventilation
Fighting ventilator 3
Unable to control ventilation 4
Unconscious Patient -Jl ^ a*i±-\iAh dj^j
Page 294
^J-lsâ Îjj (JaijyW Ja ^Sa.1 jLi& A-oikloU Scales J' t> ^ p_jjjl
Immediate, Urgent or Delayed Care
Glasgow Coma Scale (x) Systolic Blood Pressure (y) Respiratory rate (z)
GCS Points SBP Points RR Points
15-13 4 >89 4 10-29 4
12-9 3 76-89 3 >29 3
8-6 2 50-75 2 6-9 2
5-4 1 1-49 1 1-5 1
3 0 0 0 0 0
(+Y+Z) lJv.j°a\ p_tu score -Jl ^r4^ \& -j*j
12 = Delayed 11 = Urgent 10 or Less = Immediate
The Revised Trauma Score

Glasgow Systolic Blood Respiratory
Coma Scale Pressure Rate RTS
(GCS) (SBP) (RR)
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
Page 295
miscellaneous
Bundles
VAP bundles
Elevation of the bed 45 degree.

Daily sedation vacations and assessment of readiness to extubate.
Peptic ulcer disease prophylaxis.
Deep vein thrombosis prophylaxis.
Daily oral care and eye care with chlorhexidine 2%.
Change patient position frequently.
subglottic suctioning.
CLABSI Bundle
Remove unnecessary CL.

Following proper insertion practices.
Complying with hand hygiene recommendations.
Adequate skin antisepsis sites.
Choosing proper CL insertion sites .
Performing adequate hub / access port disinfection .
CAUTI Bundles
• Insert catheter only for appropriate indications.

• Leave catheters in place only as longas needed.
• Ensure that only properly trained persons insert and maintain catheters.
• Insert catheter using aseptic techniques and sterile equipment.
• Following aseptic insertion , maintain a closed drainage system.
• Maintain unobstructed urine flow (no kinking, bag below waist, periodic
empting).
• Hand hygiene and standard ( or appropriate isolation ) precautions.
VAP: Ventilator Associated Pneumonia
CLABSI: Central Line Associated Blood Stream Infection

CAUTI: Catheter Associated Urinary Tract Infection
Page 296
miscellaneous
Maximum Duration
Every 72 hour is recommended but if there is no

Peripheral evidence of localized phlebitis (pain, erythema and
swellingaround insertion site) you can leave it in place.
Every 15 days is recommended and new Studies shows
that routine replacement does not reduce the chance of
IV lines
Central line catheterrelated infections and even if you found
erythema around catheterinsertion site (erythema alone
is not evidence of infection).
1 If there are signs ofinadequate perfusion orthere
Arterial line
are signs of infection.
Condom 12 hours is recommended.

Urinary
Foley Every 7 days is recommended.
Catheters
Silicon 4 weeks is recommended.
12 hours is recommended and if you use the closed

Suction Nelaton cath
suction system every 3 days.
Nasal cannula
Oxygen
Simple face 1day is recommended.
Therapy mask
nebulizer
Endo tracheal 1 week is recommended and

tube (ETT) When it is plugged with secretions.
Intubation Tracheostomy insertion after 2weeks for ventilated patient and

(TT) your role isjust suctioning and routine care.
Ventilator \ 14
.. days
. is the routine policy
,. or .be,solid
. . .blood
, . or secretions.
••• circuit '
Anesthesia Epidurals When there is no pain exist (By Anesthesiologist).
Upto one month but it is routinely changed with

Feeding Ryle
the presence of obstruction.
Tubes
Gastrostomy According to surgeon order.
i
Page 297
miscellaneous
Crash Cart
i^clu Ideal -II ^mpj^ d-cj UakJ** jc JSiii in H*\j i lJlujxH] jc ajc Crash Cart -II '^Ja
.dljinnniall J AajjAll Jl\ (JC Jal\\ (_>aij
Two sides f^l*- j Three parts J) ^Jiu Ua.1
1-The Upper Part (Top)
ECG Machine -1'j Defibrillator Jl Xauj Large Equipment -II <>• (iJ33* ,JJ ^J^] 'J^1
. *cjii Oxygen Tubing System -Uj Face Mask -II °^j AMBU bag -II Jc j^>ujâj
2-The Middle Part (Drawers)

Jili cmcjy c'jj' 5 Jc uJâ ,jj
A. First Drawer i'iVI -. i\.\„.'< ,.„1 \i HI 2 i^VirJ < l'--L;i •U.nh.
( JjVI JjJI ) Adrenaline, Atropine -II u?j EmergencySituations -II
Cannulas-llj Syringes -II uj ) IV supplies -II J-* Jc uyA*u bJ

B. Second Drawer
Tongue Depressors -II Jc d^ ujiâj ("A ^ *H 4cl_>jli IVsets -Uj
(jm Cjii)
Adhesive Tape-lij
Airway Management -Il ^ 1^1*1^ Jl\ cjIjjVi J£ (îc. uJâ \ij

C. Third Drawer
Endotracheal Tube—Uj Oro/Naso Pharyngeal Airway —ilisj
(jiU\ £JJI)
Magill Forceps -11j Laryngoscope -IIj Laryngeal Mask -11j I^jLAjLj
w—a i^w;—uui u—111 instruments Trays —II u—^ tij—^ ,jj
D. Fourth Drawer
Venous Cut-Down —11 a\ji\ X-^ uj Emergency Situations —II
(yljH jjJI )
Tracheostomy -11 j Arterial Line -II J Central Line Insertion -11 J
E. Fifth Drawer
Suction Cath , Urinary Cath (Foley - silicon) , -11 uj ICU -11 J
( jaa\*1\ Zjl\\ )
. a^lcHi a11\*a1\ liLa\1Ai ngt, ChestTubes
Page 298
miscellaneous
3- The Lower Part
\Jaxi All u ill J A*a1\ plj il j a pj j J—a J a j—Vi\ (_5 \c A J*j u lc- UJ—:"kJJ 'JJ
ls—^ lsj—"âA—»J *i\—^V^ l—*jiPj N.saline, Dextrose —II uj ICU —11 u—a
.Different Sizes of Sphygmomanometer Cuffs
Two Sides W <j»jjj ^j* ^ ii jj
Crash Cart -11 Cm t-^ ^J Cardiopulmonary Resuscitation Board Jc ujiâ J^1 side -11
Side -IIJ lJ* kc^ Back -Il J ij+ja Ij Board -11 Jm
MjiW iJJ LY^ d^* d^J Portable Oxygen Cylinder Jc uJAâ CmJ^ side -11
aUS. UjcIjj Equipment and Drugs -II J£ j] jSLu »jij shift J£ Jîi Crash cart -II u1 u^j^
Page 299
miscellaneous
Pressure Injury
pressure Ulcer J Bed Sore lVl> Decubitus Ulcer W^ t£ W«

National Pressure Ulcer Advisory Panel (NPUAP) Jl c&j
. LjcUj trAUJi j* Pressure Injury îk^Ji £j*J j&ji
Unrelieved Pressure **p Skin Integrity Ji ^ Breakdown <> î^ c^

^k. Jaijjajj yili ji Bony Part of the Body i*j- j^ jj*-* -J ^ Ij pressure Ji
. i\*l\ Jc Jaiâi Adjajj Ujjtj Splints Jl isj ^" ^ »_#*•' ji Skin Ji
Epidermis and Dermis JJ Û J& Blood Supply Ji J%> b Pressure Ji

Skin Injury d^xj&ij
Risk Factors for Pressure Injury Development
Poor nutrition and Hydration Skin Integrity Ji JV «^j] h ji

Jc Pressure Jl ijja ^
Immobility
Dominant Areas Ji
JLjJIjj JVIj (j"*>jft Jaa Alî
Lack of sensory perception
Jha\\j L-lLwaC-VI (s^J-* iSJ Îj^"',)^ (Ja
Moist LtJ^c A*l\ Jlai \i ji
Incontinence of urine or stool
Skin Integrity J> JI^j
Medical conditions affecting blood
flow such as diabetes and vascular Risk of Skin Damage Ji ijjj ^V
disease
Page 300
‫‪miscellaneous‬‬
‫‪Page 301‬‬
miscellaneous
Stages of Pressure Injury
Stage 1
l\*l\ TUajuiJ JaiLi Jja*1 (jC "ajllC
A-\ ui'iÛ iA"\(J\ j\ (JAlLij
skin is intact
Stage 2
Partial loss of the dermis.
subcutaneous tissue(SC) Ji ^J& j* lw

blisters *J ^ ^ j
Stage 3
With FULL loss of the skin tissue.
SC tissue (fatty tissue) J> <-j>53 un

wound edges may be "rolled" Ji
Bone, tendon and muscle NOT visible Ji ua
Stage 4
FULL loss of the skin tissue that will
expose bone, muscle, tendon, and

ligaments.
Page 302
‫‪miscellaneous‬‬
‫‪Stages of pressure injury‬‬
‫‪Page 303‬‬
miscellaneous
Prevention of Pressure Injury Development
Keep skin dry and clean

i_iU,j LJjaJ J*l\ Jc AJkil*A\
Make sure the patient has clean linens

jjjJI AjXj AiLkj ja j&IjjI
Make sure the patient wearing a clean gown

i tjiVi (jjlj> ijAji o^yjî' CJ l>* JÛI
Maintaining good nutrition and fluid intake

(JjIjjjJI (ja ojj2j 4_La£ Jjl-"J lJVJ^ Aj*Aâl\ aJix1\\ (ja lalu\
Turning the patient every 2 hours but obese patient every 1 hour
Aclm (J£ Jul AIaui olic (Joija1\ Jj (JjjcLuj (jU JcijA\ i_iml (ja l£,li\\
(j*ija1\ ujJiil jiS/i\ i*l\ jij\
Routinely assess the skin integrity that comes into contact with
medical devices
Ujjc.j splint J' isj ^JJi »j*^^ lh-°^Ji J^ cs-^jjî f^'
Use the air mattress for all patients in ICU

't>J>jA\ AJ[ixl\ ûJajA »"••>' AjjIj^jI AJja1\ JLmluil
Page 304
1 miscellaneous
1
Treatment of Pressure Injury Development
W^ stage Ji m^ Jc lj&*1a \jn\j J& pressure injury Ji zjX- (j>»

Jjja jc gXu\ Ji J^jVI Ma <Â JjVl 'a\*.ja1\
Turning patient's position every 2 hours
Give proper amount of protein diet and vitamin A & C
Stage 1 Drink plenty amount of water
(jij^yi) ;ujai j\ *j*i\ j±i jji* jsîi j&j
Ji\ji jjjjoiII (jVniKina aJ jîaJ Ca\1a
(^JJJj all) 3 —1 a*Jo1 (JjUJI (î (JJ 2»kjJIj
(jjj 4ilâVLi JjVI <kjJl CjIjks. (jAli
isj imiJ Drying -J^j N.saline mcj^1 J"*1**
Fucidin *+ <Jakj (Jaaj Mebo Cream JU«j-Ij
ij+j isj Aware of Signs of Infection W^ 4J=»j
Stage 2
(Pus, Fever or Redness)
Consider Debridement j ^j c j^1 J*- *%=• ^bJ
UjjSJt jaJ aJ\ua 4'il-iu LuV JUijJ <J>J1 4ûU^1 fjV jV
AJjLuil 3 —fLlI 3 (j"0 J*1"1'".).1 l-JJJ^l l-fj-?'^'- Ja a1*ja1\j
J\ AJLôili AjjIjIIj JjVl <kj-JI ill!jlaa. (JaSLA
"jjc-j Bivatracin Ji isj Antibiotic juî fjiiiv
Special Ulcer Bed jl Air Mattress J^*î *JW
ICU Jl J ^c Cn. jl
Stage J^ '''I (JaC —LjjJlA jjj '" . (j-*& (J«IT' inlft
3 and 4 jjjii jjLA j-«iauA Bivatracin Jij Mebo Ji t* <0^
Jl jA jjl (jaJ*.ja1\ pXJ Alil*l\ (jja\\ (jAAâ (ja
jut** j* \uiic jja bj Hyperbaric Oxygen Therapy
jjî 3 J j$J> t> ^ki i&jyc Stage 3 mî J
Aiut oiaI Jj-aLj jjqaa 4 Jji cy jsiii (Jaa Uijii u^-iUa stage 4 i-»ji
Bepanthen Plus oU JPh d^-ôi ajj^ (>i& ^jali ^1 -j*j Jî j_J u_& u^">
.ilsJ! jjl (jjutaaj OSjll (_>uij Jj Jja* IIJoa ji
Page 305
A miscellaneous
1
Patients Position in the Bed
UetjJ Staff J' 1a1aJl\ • V'iNlj ICU -I' J Ij-^ o^j?.jJI fJ.JaljJ! j>aI (ja 1*\j \l LxJa
b p ji^sjaI! (Jag ii
^jiaj ujaj Bed Sores Jl dj^. i.n->n jlic
24 - Hour schedule for positioning
(1) supine position

Back lying position with head and shoulder slightly elevated
j^Jall jJaaa (JC jja (jAxSlAja AjCijJj AjoiIjj aj$ia Jc aAli JoAjaI]
Promote comfort especially for head and shoulder
a] x^j jâi \i Abdominal Surgery lUc j^j* j

Relaxation of Abdominal Muscles J**#4fl
Obstructive Sleep Apnea (OSA) Ji (jj^jy

Apnea Jl ^jj-j^ <âja jjjjj <jV b *âjll j Ij-oIjj ajj pJaa
Lung Volume J' u%i Airway Position Jl jl j* '•£ J wJ'j
Dilate Enough Wj! j-^ <_> ^j3' ^-^ Respiratory Muscles Ji ^*^ ^W"j
Airway Collapse Jl Compensation lU*j jUi&
Does Not Allow The Lung to Inflate Completely <ji ^ jb£ <ljjc (ja
Lung Ji J^b î jjj Secretions Ji j] J* ^ ^ j«* JUi^j
Elevated Intracranial Pressure »^j& l^j* î M»
Cardiac Surgery <> £j^ ji Pulmonary Edema ^ ji
Supine (&£j**
Page 306
miscellaneous
(2) Prone Position
Abdomen lying position with head turned to one side

AllXA Au*.li Ji (i.">) Jc <Uuljj Allai Jc alii J*ija1\
Aj\ •""/'I JJJ^ illbuljJ Aj (j\ ji <Lal.la.iuil ajg \"\ <—Jfui \l XjâJ\
ARDS Ji î* j Oxygenation Ji ^ -> cm^

Bilateral lung disease Ji cJ&j Diffuse Lung Injury Ji iivia.j
Functional Residual Capacity Ji ijja

Alveolar Ventilation Ji Cmîj
Ventilation - Perfusion Matching Ji Cmîj

Posterior Lung Atelectasis Ji cJ& cfej
Respiratory Mechanics Ji J£ j**# j* Jâi*L
ETT JJ Close Observation J**- £&& aji <l>jjc UjL

<bj^ ^j,^, ^jja Enteral Feeding Ji Jc J& Ai\ jU^j
TPN »jij for Aspiration J\c Risk ^ ji
Prone position
Page 307
miscellaneous
(3) Fowler's Position
This is the standard patients position in the ICU

The patients is seated or semi seated with knee either bent or straight
euXa-a jl <Lujia (jjSj j! La! Aj.J\j (jJLa. <Lboi / (jJLa. JaijaI!
Enteral Feeding Jc J*^ iJcii o^li j\ <iu j* tpuvyi Jc ^j Jâi _>* i*Ja
Risk of Aspiration Ji uj u%i (JSj Swallowing Ji Jw *di
NGT J' d-^ J^C -k*LaJ <Ul <_Jc ucLuUJ <Ul AjLîli
Chest Expansion JJ Jî '^j jjv-a Fowler's Position Jl M=
ARDS Ji ^VLa. j J^j Oxygenation Jl <>*£ ^Jj
Pneumonia ji Dyspnea <&•* j] ^ ^ J^Vi t^j11 j*j
Tension on Abdominal Muscles Ji Ji^ Fowler's Position Ji cJ&
Drainage Ji Crnâ d^j ^ja J° Abdominal Surgery d^c iJnjy J J^j
Uterine Drainage Ji cmî j* Postpartum Woman Ji J
pLuajl 4 J ,-""'' '„'.'

Low Fowler's Position (15-30 degree )
Semi Fowler's Position (30-45 degree )
Standard Fowler's Position (45-60 degree )
High Fowler's Position (60-90 degree )
Page 308
miscellaneous
(4) Sims' Position
Semi Prone Position (upper arm flexed at shoulder and elbow and
lower arm behind patient with front leg is flexed and the other is
extended).
<LaLa! (jiilSjll Jii xa Aj\*. J*iJ <LaLa! JJC Ijjll .la.!j <Uia. Jc aAli J*ljA\
Standard Position for Enema
Bended j_£j Right Kness Jij Left Side Ji Jc £c\j j=aja\\ J*ii
Rectum Ji fja Anatomy Ji Jc -^^ uJ^ ^ î
Standard Position for Rectal Examination
Ji Jc pressure Ji J^jj <j1 aj!jaaa (ja jla£

Sacrum and Grater Trochanter of Hip
Promote Drainage from Mouth
Page 309
miscellaneous
(5) Trendelenburg Position
The patient lying supine with feet higher than head by 15 - 30 degree
(jjj\ jJxaa (ja Jc\ jjiu aik\\ jJuaa (JAl jllC flat ejj=> Jc alii jjJUJ (>3JjJ!
Hypovolemic Shock Ji î* j jaVIj JjVI <UL

Maintain Blood Flow to Brain ^! j^-V j4? Jj^ d^c
Valsalva Maneuver lU-a &\ <uu ^ jL£ <lU*i

SVT ^JLaJ Cardioversion J^jjL^
Internal Jugular *ij- Cental Line m^> jJ cJ& -d**!*

Upper Central Veins Jl Distension J**^ ^ Subclavianji
t_i£jjll <UiaC lilU-a Jg-uijS
ETT m^>a J position J^l j*
<tia jJCjJ <Lj3
Trendelenburg Position Reverse Trendelenburg Position
Page 310
miscellaneous
Chest Physiotherapy (CPT)
mobilization J-<J cJ^- iûi^ ui therapies <cja*a jc SjLc > Chest Physiotherapy -li
large amount of secretions jmac î ^ j^ L-ajuaij pulmonary secretions -il
. ineffective cough ji
Chest Percussion, Vibration and Postural Drainage -li ^j "Wj jrn^c 3 j jjuu
Suction J-<«ja bj*.) ji Productive Cough J-«jj j°ij-& ui Therapies -li J-^ L_* i-*aj
Secretions -li (y u^j jUic Ability to Cough »jjc (jii-j Comatosed LictL J^J^ J
Contraindications
Increased ICP Recent spinal injury

Unstable head or neck injury Rib fracture
Active hemorrhage Flail chest
Hemoptysis Thoracic surgeries
Page 311
miscellaneous
Chest -il uaJ Physical Examination J^*j »ji Chest Physiotherapy Jl uima b« jj
JjVi UjIc j^jj jL« Chest x-ray lUc u^jî jIj Fractures lA^ u!j Ribs -H <!!•*• (> -Sluj
.Saturation Jij Blood Pressure Ji Jc J&] JJj Vital Signs -li d^ ^j^j
3 Techniques jp »jIjc > uijS u ^j

1. Percussion / Clapping / Cupping
J-î uh! u^j-î Rhythmically Clapping on The Chest Wall lU*jj Ljj] j-c SjLjc bj
Larger Airways lJ\ *-£ h-aJJa îi Ls-i ^Jii jLUi j_^ Mobilization of Secretions
.Expectoration -li aJac oJai Clu*i
Fingers and Thumb Touch Each Other -li ji JXi Ai\ j>*ai Cupped &i4 Jjij
vigorous striking the chest wall alternately J-*! uâj and the hands are cupped
no pain Jh u^y J* Jhj^j hollow sound ,^-j* ^ &*& cJ\ J
CO
T3
Don't percuss
C
o
o
o
over the spine,
co
o
CD sternum,
o
CO stomach or
lower back as
CD
CO
CO
D
trauma can
B
0)
a
CO occur to the
CD
spleen, liver, or
x:
o
CD
CD
kidneys
Page 312
miscellaneous
1
2. vibration
directed inward against the chest 4pL> cJaxu gentle, shaking pressure jp "»jL« Ijj
larger airways J] aJ h*.\jia Jl\ jsa\ ja mobilization of secretions lUJ Ji jaja
flat jjm dab percussion -li uj expectoration Jl *Jc oJai Oi*i
expiration Ji aJj j jjii i^cii perform Jlj
Vibration Technique
Page 313
miscellaneous
3. postural drainage
cUci yj] ja Ljia j^l-'vi c^jiSij Uji u^j-JI uJ^ different positions ai*ixa j\ jc sjWc >
(j_j> (j_c facilitate the drainage of secretions from the bronchial airways
GravityJi
postural drainage ij*^ U—j-Ji J£ j*
nebulizer ^Luua. j bronchodilatorJ>xi <ws u Ji fjVj
îjli ^jiu^ (ja JJ ?M uJaajji C-o*i Trendelenburg position Ji ja aai*1ui x^j j&\
gravity Ji &J* jc mobilization of secretions Ji j^mJ^hj
auscultate
c
o
-*-»
CO
the
o
a
T3 client's
CD
1_
CO
CO
CD
T3
CD lungs, and
CD
C
sz Lateral and medialsegments of middle
•4-<
E lobe
compare
c Apical segments of both upper lobes
m
c T—
CD o
the
E
CD o
L.
•*-<
*
1_ Posterior segment ol right upper lobe findings
c o Superior and inferior segments of the
CD M- lingula lobe
•4—'
CD to the
a
CD
SZ
•*-» baseline
CD
>
CD Posterior segment of the left upper lobe
SZ
Apical segments of both lower lobes data,
Page 314
miscellaneous
Diagnosis of death
> Inspection
• NO spontaneous body movement.
• NO respiratory movements for at least 1 min.
^"iiii Ixijui ^j^J.-T.ll ^1 JajJLi
jûiaJl (.1 ja.1 jo c-ja. j\ J A<,j* Vj jaH\1\ Jc Jjj ji-all AL\j* j\ lj*J ?lc
> Palpation
• NO carotid pulse for at least 1 min.
AAjll jlljZi J Jail lj*j a1C
> Auscultation
• NO heart beat over pericardium for at least 1 min.
• NO breath sounds over chest or trachea for at least 1 min.
(jjijjll Vj i-^l CilijUal LJjjâ lj*j ale
> Eye
• Dilated fixed pupils
Torch JL| f-JaaiII i.n^li.n Vj jJ*ll All* pLuul
> NO corneal reflex
reflex closure of eyelid ai*i Vcornea J\ Jc Jul 'Axial jijai He
> NO corneal luster
\J\j*\ Jaxi J c-luaJJ WaHc JAl*l J9j AllJl\ jjual IjLc
> NO vestibule-ocular reflex
eyeball Jl J ^J i*-\ia Ijluu jl Iuai j^-wll ja\j iJjj^j jjc

i-'lltjl'ltil (jjxll liljaJJ <LuuJall l_ijjiall J
If Diagnosis of death is unconfirmed: start CPR
tijjill Jlxii\ \li\ ja. <LaJ (jâJllI jl (jâill e-Lui '-<;<.' J
Page 315
miscellaneous
Units and conversions
1 grain 60 mg
1 ounce 30 mg
1 pint 500 ml
1 quart 947ml
1 teaspoonful 5 ml
1 tablespoonful 15 ml
Iteacupful 120 ml
1 1
1 gram 1000 mg
1 mg 1000 meg (ug)
1 mcg(ug) 1000 ng
Celsius gC = 5/9 ( T -32)
Fahrenheit T = (9/5°C) + 32
37X = 98.6T
Page 316
miscellaneous
ICU abbreviation
High Frequency Oscillation

ICU Abbreviation HFOV
Ventilation
I:E
AL Arterial Line Inspiration: Expiration Time Ratio
Ratio
CVL/ Central Venous Line/
CVC Catheter
IMV Intermittent Mandatory Ventilation
DC Defibrillation / Cardioversion VE Minute Ventilation
ECG ElectroCardio Graph PEEP Positive End Expiration Pressure
EEC ElectroEncephalo Gram PCV Pressure Control Ventilation
ETT Endotracheal Tube PSV Pressure Support Ventilation

Mechanical Ventilator/
MV RR Respiratory Rate
Ventilation
NGT NasoGastric Tube SBT Spontaneous Breathing Trial
PC Peripheral Catheter Synchronized Intermittent

SIMV
Mandatory Ventilation
UC Urinary Catheter VAP Ventilator Associated Pneumonia
Ventilator Related Abbreviation VT Tidal Volume
A/C Assisted Control Mode Monitor Abbreviation

Airway Pressure Release
APRV BLP Blood Pressure
Ventilation
ASB Assisted Spontaneous Breath DBLP Diastolic Blood Pressure
Bi-level / Biphasic Positive

BIPAP HR Heart Rate
Airway Pressure
Continuous Positive Airway
CPAP RR Respiratory Rate
Pressure
Saturation of 02 bound to
Fi02 Fraction of Inspired Oxygen SaO,
Hemoglobin
FRC Functional Residual Capacity SBLP Systolic Blood Pressure
Page 317
miscellaneous
EC G relates abbreviation SVT Supra Ventricular Tachycardia

—.
Atrial Fibrillation /
AF VF Ventricular Fibrillation
Atrial Flutter
AVF Augmented Voltage of Left Foot WPWS Wolf Parkinson White Syndrome
AVL Augmented Voltage ofLeftArm ABG Related Abbreviation
AVR Augmented Voltage of Right Arm ABG Arterial Blood Gases
IVR Idio Ventricular Rhythm HC03 Bicarbonate Concentration
Partial Pressure of Oxygen Tension

LAD Left Axis Deviation Pao2
In Arterial Blood
Partial Pressure of Carbon Dioxide
LBBB Left Bundle Branch Block PCo2
Tension In Arterial Blood
Saturation of Hemoglobin With
LVH Left Ventricular Hypertrophy Sao2
Oxygen
MAT Multifocal Atrial Tachycardia Lab Investigations
MI Myocardial Infarction CBC Complete Blood Count
PAC Premature Atrial Contraction CRP C - Reactive Protein
Premature Ventricular
PVC ESR Erythrocyte Sedimentation Rate
Contraction
RAD Right Axis Deviation HB Hemoglobin
RBBB Right Bundle Branch Block HCT Hematocrit
RVH Right Ventricular Hypertrophy PLT Platelets
SSS Sick Sinus Rhythm RBCS Red Blood Corpuscles
Vtach Ventricular Tachycardia WBCS White Blood Corpuscles

———
Page 318
miscellaneous
I
SGOT/
Aspartate Amino Transferase General abbreviation
AST
SGPT/
Alanine Amino Transferase ABD Abdomen
ALT
ALB Albumin ACLS Advanced Cardiac Life Support
TP Total Serum Protein AKI Acute Kidney Injury
BUN Blood Urea Nitrogen Acute Respiratory Distress

ARDS
Syndrome
CRCL Creatinine Clearance AVN Atrioventricular Node
CK Creatinine Phosphokinase BE Barium Enema
T3 Triodothyronine BCLS Basic Cardiac Life Support
T4 Tetraiodothyronine BMI Body mass index
HDL HighDensity Lipoprotein BMR Basic metabolic rate
LDL Low Density Lipoprotein BMT Bone Marrow Transplant
ACT Activated Clotting Time Bx Biopsy
Activated Partial
APPT Cc Chief Complain
Thromboplastin Time
PT Prothrombin Time C/F Chills / Fever
PTT Partial Thromboplastin Time CHF Congestive Heart Failure
INR International Normalized Ratio CHD Congenital Heart Disease
Chronic Inflammatory
PCT Procalcitonin CIDP
Demyelinating Polyneuropathy
Page 319
miscellaneous
CKD Chronic Kidney Disease GBS Guillain Barre Syndrome
Chronic Obstructive
COPD GCS Glasgow Coma Scale
Pulmonary Disease
CP Chest Pain GTT Glucose Tolerance Test
CPM Central Pontine Myelinolysis gtt Drops
CT Computerized Tomography HE Hepatic Encephalopathy
Cerebrovascular Accident HIT Heparin Induced

CVA
(Stroke) Syndrome Thrombocytopenia
Hyperosmolar Hyperglycemic
CXR Chest X-Ray HHNK
Non-Ketotic Coma
DDX Differential Diagnosis HT Hypertension
DKA Diabetic Keto-Acidosis IBB Invasive Blood Pressure
DM Diabetes Mellitus ICCU Intensive Cardiac Care Unit
DNR Do Not Resuscitate ICH Intra Cerebral Hemorrhage
DOA Dead on Arrival ICP Intracranial Pressure
Dx Diagnosis ICU Intensive Care Unit
ECT Electro Convulsive Therapy IHD Ischemic Heart Disease
Extracorporeal Membrane Injection

ECMO Inj
Oxygenation
FFP Fresh Frozen Plasma 10 Intraosseous Infusion
Fx Fracture I&O chart Intake and Output Chart
Page 320
miscellaneous I
IRS Infrared Spectrophotometry MRI Magnetic Resonance Imaging
IS Incentive Spirometry MS Multiple Sclerosis
Idiopathic Thrombocytopenic
ITP NCP Nursing Care Plan
Purpura
IU International Unit NGT Nasogastric Tube
IVIG Intravenous Immunoglobulin NICU Neonatal Intensive Care Unit
In vitro In the Laboratory NPO Nothing per Mouth
In vivo In the Body NSR Nonnal Sinus Rhythm
JVD Jugular Vein Distension N/V Nausea / vomiting
K+ Potassium OCD Obsessive compulsive Disorder
KCL Potassium chloride OSA Obstructive Sleep Apnea
KUB Kidney, ureter, bladder(x-ray) PE Pulmonary Embolism
LOC Level of Consciousness PICU Pediatric Intensive Care Unit
MI Myocardial Infarction PIH Pregnancy Induced Hypertension
MICU Medical Intensive Care Unit PKD Polycystic Kidney
MRB Manual Resuscitation Bag PTSD Post-Traumatic Stress Syndrome
Page 321
miscellaneous
qAM Each Morning TIA Transient Ischemic Attack
qPM Each Evening UC Urinary Catheter
qd Once A Day UO Urine Output
qhs At Each Bedtime US Ultra Sound
qod Every Other Day UTI Urinary Tract Infection
q2h Every 2 Hours VILI Ventilator Induced Lung Injury
ROM Range of Motion Exercises CLD Chronic Liver Disease
RX Prescription IHD Ischemic Heart Disease
SAH Subarachnoid Hemorrhage AST After Sensitivity Test
SAN Sino atrial Node
SICU Surgical Intensive Care Unit
SOB Shortness of Breath
STD Sexually Transmitted Disease
TAB Tablet
TB Tuberculosis
TBI Traumatic Brain Injury
TBSA Total Body Surface Area
Page 322
‫‪References‬‬
1 References
••mMI (WHf 111 pHri *^l^^BijpBl^Br "^BW^ JH^^^^^f
1. Marino, P. L (2013). Marino's the ICU Book. Lippincott Williams &Wilkins.

2. Kollef, M. H., Bedient, T. J., &Isakow, W. (Eds.). (2008). The Washington manual of
Critical Care. Lippincott Williams & Wilkins.
3. Sole, M. L, Klein, D. G., Moseley, M. J., Brenner, Z. R., &Powers, J. (2009).
Introduction to critical care nursing. 5th Edition St. Louis, Mo.: Saunders, c2009. xix,
748 p.: ill.(chiefly col.); 27 cm.
4. Creed, F., & Hargreaves, J. (2016). Oxford Handbook of Critical Care Nursing. Oxford
University Press.
5. Massachusetts General Hospital, &Hurford, W. E. (2000). Critical care handbook of

the Massachusetts General Hospital (pp. 613-5). Philadelphia: Lippincott Williams &
Wilkins.
6. Allen, D. M. (2011). ECG interpretation made incredibly easy!. T. S. Diehl (Ed.). W.

Kluwer/L Williams & Wilkins.
7. Cutler, J. M. (2010). Critical care nursing made incredibly easy. Wolters Kluwer
Health/Lippincott Williams &Wilkins.
8. Varon, J., &Fromm, Jr.(Robert E.). (2014). Acute and critical care formulas and
laboratory values. Springer New York.
9. Hasan, A. (2010). Understanding mechanical ventilation: a practical handbook.

Springer Science & Business Media.
10. Jones, J., & Fix, B. (2014). Critical care notes: clinical pocket guide. FA Davis.
11. Mallett, J., Albarran, J., & Richardson, A. (Eds.). (2013). Critical care manual of
clinical procedures and competencies. John Wiley&Sons.
12. Russian, C. J., Gonzales,J. F., & Henry, N. R. (2014). Suction catheter size: an
assessment and comparison of 3 different calculation methods. Respiratory care,
59(1), 32-38.
13. Hahn, M. (2010). 10 considerations for endotracheal suctioning. J Respir Care Pract,
23(7), 32-33.
Page 323
I References I
L^yu^ ^-Hi^n ljâ uaji t£-^jji («-d j jUa*
1. Lexi.com
2. Medscape .com
3. uptodate.com
4. wolterskluwercdi.com
5. drugs.com
6. rxlist.com
LaJfeghJI f ^BBag^ Jjl ibmai 4mmSi£i& (UaaatoO^ ^J^Âft
1. World Health Organization. (2011). Pulse OximetryTraining Manual. Retrieved from
http://www.who.int/patientsafety/safesurgery/pulse oximetry/who ps pulse oxymet
ry training manual en
2. World Health Organization. (2018). COPD managment. Retrieved from
http://www.who.int/respiratory/copd/management/en/
3. Maggiore, S. M., Lellouche, F., Pigeot, J., Taille, S., Deye, N., Durrmeyer, X.,... &
Brochard, L. (2003). Prevention of endotracheal suctioning-induced alveolar
derecruitment in acute lung injury. American journal of respiratory and critical care
medicine, 167(9), 1215-1224.
4. New, A. (2006). Oxygen: kill or cure? Prehospital hyperoxia inthe COPD patient.
Emergency Medicine Journal, 23(2), 144-146..
5. Cook, D. J. (1990). Clinical assessment of central venous pressure inthe critically ill.
The American journal of the medical sciences, 299(3), 175-178.
Page 324
References
6. Miller, Martin R., J. A. T. S. Hankinson, V. Brusasco, F. Burgos, R. Casaburi, A. Coates,

R. Crapo et al. "Standardisation of spirometry." European respiratory journal 26, no.
2 (2005): 319-338.
7. Gattinoni, L, Caironi, P., Cressoni, M., Chiumello, D., Ranieri, V. M., Quintel, M.,... &
Bugedo, G. (2006). Lung recruitment in patients with the acute respiratory distress
syndrome. New England Journal of Medicine, 354(17), 1775-1786.
8. Miner, J. R., Heegaard, W., & Plummer, D. (2002). End-tidal carbon dioxide
monitoring during procedural sedation. Academic Emergency Medicine, 9(4),

275-280.
9. Jeffries, P. R., Woolf, S., & Linde, B. (2003). Technology-based vs. traditional
instruction: Acomparison of two methodsfor teaching the skill of performing a 12-
lead ecg. Nursing education perspectives, 24(2), 70-74.
10. ZHU, W., HU, K., FAN, X., & LIU, C. (2007). 30 Body-Turning for the Prevention of
Pressure Ulcer. Journal of Nursing Science, 22, 036.
11. Prasad, S., Dhiman, R. K., Duseja, A., Chawla, Y. K., Sharma, A., &Agarwal, R. (2007).
Lactulose improves cognitive functions and health-related quality of life in patients
with cirrhosiswho have minimal hepatic encephalopathy. Hepatology, 45(3), 549-
559.
Page 325
References
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Page 326
Contact with the Author
Mob: 01021510215
E-mail: dr.mhmiel@yahoo.com
Fb: fb.com/dr.mhmiel
I ISRN 978-977-655146-6
ISBN Q7R
9 789776 551-166
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THE

ICU Basic Practical Notes

Mohamed Hesham Eid

Critical Care and Emergency Nursing Department

Faculty of Nursing - Mansoura University

The intensivist: h.iigil flj.till i~JiKg

Copyright © 2019 Middle East &El Marwa for Publishing &Distribution.

ISBN: 978-977- 6551- 46-6

Publishar: Middle East & El Marwa for Publishing & Distribution

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Chapter 2 : ICU Drugs

Chapter 4 : Arterial Blood Gases

• Basic Concepts of ABG 141

• Elements of ABG 145

• ABG Interpretation 146

1 Anion Gab 158

« GAB GAB 161

• Delta Ratio 162

Chapter 5 : Mechanical Ventilation

Chapter 6 : Lab Investigations

Chapter 7 : ICU Procedures

• Oropharyngeal Airways 216

1 Oxygen Therapy 230

• Incentive Spirometry 235

1 Arterial Puncture 238

• Arterial Catheter Insertion 241

Urinary Catheter Insertion

Glasgow Coma Scale 291

• Pain Scale 293

« Revised Trauma Scale 295

• Maximum Duration 297

« Crash Cart 298

• Bed Sores 300

• Patient's Position in the bed 306

• Chest Physiotherapy 311

• Diagnosis of Death 315

• Units and Conversions 316

• ICU Abbreviations 317

‫‪r— Chapter 1‬‬

" In clinical matters, ignorance canbe dangerous

butignorance of ignorance can be fatal"

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