Foundations ICU Scales

Block 2

qSOFA criteria

Altered mental status, systolic BP 100 or less, RR 22 or more

qSOFA score indicating high risk

2 or more criteria

Septic shock criteria (Sepsis-3)

Vasopressors needed to keep MAP 65 or more AND lactate greater than 2 mmol/L despite adequate fluids

Sepsis definition (Sepsis-3)

Life-threatening organ dysfunction caused by a dysregulated host response to infection

SIRS criteria

2 or more of: temp >38 or

MAP formula

(SBP + (2 x DBP)) / 3

MAP target in shock

65 mmHg or higher (60 minimum for organ perfusion)

Hemodynamic instability definition

SBP 90 or less or MAP below 60 with signs of organ hypoperfusion

Signs a fluid bolus worked

Improved mental status, HR, MAP, capillary refill, urine output

Signs of fluid overload

Dyspnea, crackles, pulmonary edema

CVP normal target

8-12 mmHg

Gold standard for pain assessment

Patient self-report

CPOT: score range

0-8 (4 items scored 0-2); higher >> more pain

CPOT: what it is used for

Pain in nonverbal/ventilated ICU patients

Behavioural Pain Scale (BPS): range

3-12

BPS: score that means unacceptable pain

6 or more (treat with analgesia and/or sedation)

BPS: 3 or less means

No pain

Numeric rating scale

0-10; quick, reliable, not for cognitively impaired

Verbal descriptor scale

Mild/moderate/severe; often preferred for older adults

PQRST

Provokes/palliates, Quality, Region/radiation, Severity, Timing

Ramsay sedation scale: range

1-6

Ramsay score 1

Anxious, agitated or restless

Ramsay score 2

Cooperative, oriented, tranquil

RASS pairs with which delirium tool

CAM-ICU

Riker Sedation-Agitation Scale: range and strength

1-7; flags dangerous agitation

Delirium screening tool in ICU

CAM-ICU

Delirium definition

Acute, fluctuating disturbance of attention and cognition

Burn size measurement tools

Rule of Nines or Lund-Browder chart (percent TBSA)