IntroductionChapter 1

Critically ill care and nursing has evolved over the last couple of decades into full pledge specialty. Critical care nursing requires not only knowledge and understanding of the human physiology, but also special procedure skills and wisdom to handle technology, knowledge and medical advances judiciously. The practice of critical care nursing is essentially team work and training, involves the health restoration functions for the individual patients and handling of the families and clients response to their illness in their hours of utmost need.

The critical care team includes a diverse group of highly trained professionals, who provide care in a specialized area known intensive care unit (ICU). This team works toward the best outcome possible for seriously ill patients. All members of the team may be asked to teach patients and their families various strategies to improve health, healing, coping and well-being, specific to their area of expertise. Members of the team include:

Critical care nurses provide a high level of skilled nursing for total patient care and often facilitate communication among all of the people involved in the care of patient. Their expertise and continuous presence allows early recognition of subtle, but significant changes in patient conditions, thereby preventing worsening conditions and minimizing complications that arise from critical illness or injury. Because of their close contact with the family and patient, critical care nurses often serve as the patient's advocate and become integral to the decision-making process of the patient, family and critical care team. Additionally, some critical care nurses are recognized as a critical care registered nurse (CCRN) (with special training). They have received more specialized education, training and testing and are certified by the authorized authority.4

Intensivists may be assigned to the ICU on a full-time basis and work with other critical care team members to provide their patients with ongoing and consistent care. It may also coordinate the administrative environment of the ICU by setting policies, developing protocols and facilitating communication among primary care physicians, specialists, patients and their families.

Dietitian is a vital part of the medical team that consults with physicians, nurses, therapists and family members in the ICU. The registered dietitian works to improve the nutritional health and promotes recovery of the critically ill or injured patient.

A social worker is a licensed professional that works with the ICU interdisciplinary team to provide a link between treatment plans for the critically ill or injured patient and family members. Special knowledge that is acquired through formal—professional and social work education, welfare policies and services, and social welfare systems and community resources guide the practice of social work.

Respiratory therapists work with the critical care team to monitor and assists with airway management of the critically ill patient. This may include oxygen therapy, mechanical ventilation management (breathing machine), aerosol medication therapy, cardiorespiratory monitoring, patient and caregiver education.

The physical therapist provides services that restore function, improve mobility, relieve pain and prevent or limit permanent physical disabilities. The occupational therapist is trained to make a complete evaluation of the impact of disease on the activities of critically ill patient.

There are varieties of environment factors that affect patient on ICU or critical care area. They all interact with each other and can have significant effects on the health, well-being and outcome of critically ill patient. A lot of time, effort and money are invested in the technologies advances of critical care unit and also involvement of dedicated sympathetic multidisciplinary team.

Recognition that time is critical factor in determining whether an individual can survive trauma is old one. Baron Larry developed a system to expeditiously remove the wounded in Napoleon's armies from the war field more than 200 years ago. The concept used today in prehospital care is exactly the same as Larry's.7

The aims of prehospital care in critically ill patients include:

The retrospective component involves the development of continuing education program to bring new information to attention of the system's EMT. Continuing education in trauma care should include prehospital trauma life support of basic trauma life.8

Extrication problems are acute in railway accident, house collapse and air disaster, although it does not pose much problem in road traffic accident. Cervical spine should be protected with rigid collar and patient is extricated and loaded on the stretcher in a single piece.

With airway begins the ABC of resuscitation, i.e. airway, breathing, circulation. Airway must be cleared of blood, mucus, vomit, foreign body or dentures. Tongue is pulled out and jaw braced forward and oropharyngeal airway placed in situ. In unconscious patient, endotracheal tube may be inserted to obtain positive airway control. In desperate condition, a 16 gauze needle pushed in cricothyroid space and connected to oxygen at the rate of 10–12 L/min.

Once the airway is cleared, the patient's respiratory effort is observed. Any sucking chest wound is closed by applying adhesive dressing and closing on three sides with adhesive plaster. In suspicion of tension pneumothorax 916 gauze needle with a finger stall at the other end with a small hole is pushed into second intercostal space. Patient with chest trauma if not contraindicated due to other injuries should travel propped up.

Most trauma patients have bleeding either external or internal. Pressure dressing is adequate for external bleeding, in case external bleeding not assessed by pressure dressing, pneumatic tourniquet should be used which can released intermittently.

In case of cardiac arrest:

Eviscerated of viscera not only give a ghostly look but also increase the shock, bleeding and subsequent infection. Clean sterile towel is enough to cover these and bandage loosely strapped and no attempt made to push intensive to avoid strangulation and twisting.

The aim of transport is to decrease the time lag between the accident and definitive care. Prehospital transport systems are:

Prehospital care is still in its infancy in India as compared to Europe and western countries. A large number of rural road accidents occur due to nonavailability of immediate care and delay in transport for definitive care to hospitals.10