Emergency and Intensive Care Medicine in Resource-Poor Settings

This chapter outlines basic principles for the care of critically ill patients in resource-poor settings, delivered as initial emergency care or subsequent patient management at the intensive care unit or high-dependency ward. These principles include close monitoring with proper alarm limits prompting appropriate action, use of both short- and long-term treatment plans, and good organization of the intensive care unit with accurate patient documentation. Infection prevention requires enforcement of strict hygiene rules, in particular on hand washing. Early start of enteral feeding in critically ill patients is beneficial and has only few contraindications. As in resource-rich settings, early mobilization and routine deep vein thrombosis prophylaxis are recommended. Setting-adjusted recommendations derived from the ‘surviving sepsis campaign’ guidelines can direct the management of sepsis in resource-poor settings. Early diagnosis and treatment of sepsis, including control of the infectious focus and a prompt start of antibiotics, reduce morbidity and mortality. In the absence of access to positive pressure mechanical ventilation, fluid resuscitation of septic shock should be more restrictive, which can imply earlier start of vasopressor medication. Routine use of glucocorticosteroids is not recommended, but in adult patients with refractory hypotension requiring high or escalating catecholamine doses, hydrocortisone can be beneficial. Mechanical ventilation should make use of lung-protective ventilation strategies, including the use of lower tidal volumes. Intensive insulin therapy is not recommended, since it is difficult to implement safely and carries a high risk of hypoglycaemia. Care for the critically ill patient requires an iterative process with frequent re-assessment of the patient’s condition, responses to interventions and treatments, and refining diagnoses and treatment goals.