Assessment of a Cri cally Ill

Pa ent
 A critically ill patient is one at imminent risk of
death -the severity of illness must be recognized
early and -- -appropriate measures taken
promptly early to assess, diagnose and manage
the illness.
 PHILOSOPHY OF MANAGEMENT
 The approach required in managing the critically ill
patient differs from that required in less ill patient
differs from that required in less severely ill
patients with immediate resuscitation severely ill
patients with resuscitation and stabilization of the
patient and stabilization of the patient ’s
condition taking s condition
 PRIORITIES
 1. Prompt resuscitation & adhering to advanced to
advanced life support guidelines
 2. Urgent treatment of life -threatening
emergencies such as hypotension, hypoxaemia,
hyperkalaemia, hypoglycaemia and dysrhythmias
 3. Analysis of the deranged physiology
 4. Establish a complete diagnosis as history &
further diagnostic results are available
5. Careful monitoring of the patient ’s condition and
response to treatment
 How To Recognize?
 CARDIOVASCULAR SIGNS
 1. HR
 2. BP
 3. PERFUSION
 4. OLIGURIA
 5. ARREST
 RESPIRATOY SIGNS
 1. RATE
 2. DISTRESS
 3. THREATENED OBSTRUCTION
 4. RISING PaCO2
 5. DECREASING SPO2
 6. ARREST
 NEUROLOGICAL SIGNS
 1.THREATENED AIR OBSTRUCTION
 2. SUDDEN DETERIORATION IN
CONSCIOUSNESS
 3. GCS
 4. ABSENT GAG/COUGH
 5. FAILURE TO OBEY COMMANDS
 6. REPEATED SEIZURES
 What are the steps to be followed?
 1.Initial assessment
 2.Immediate management
 3.Monitoring
 4. Initial investigations
Clinical assessment of cri cal
pa ent
 Assessment
 Traditional history taking & examination is
appropriate
 Assessment and stabilisation should proceed
simultaneously
 Priority given to detection of potentially life
threatening conditions
 Life saving measures must be instituted rapidly
 What Should Be Assess?
 A -Does this patient have a patent airway?Can this
patient vocalise/phonate?

B -Is this patient breathing adequately?Can

this patient speak in sentences without getting
breathless?

C -Is the patient perfusing his brain

adequately?Can this patient comprehend &
respond appropriately to questions
 Look for-Foreign bodies,secretions,blood in oropharynx
 Obstruction of the pharynx by the tongue
 Use of accessory muscles of respiration
 Chest expansion
 Paradoxical breathing

 Listen for-Abnormal upper airway sounds (stridor,

gurgling)
 If airway obstruction is complete, breath sounds will be
absent

 Feel for-Expired air

Assessing Breathing
 Look for-Cyanosis
 Respiratory rate, pattern and depth
 Equality of chest expansion
 SpO2 in the context of the FiO2

Listen for-Wheeze,crackles,bronchial breathing

 Bilateral breath sounds

Feel for (palpate/percuss)Position of the

trachea (central / deviated)
 Chest wall for surgical emphysema,crepitus
 Elicit dullness or hyper-resonance
 Assessing Circulation
Look for -Conscious level
 Capillary refill (normally < 2 secs)
 Colour and temperature of digits (cyanosed, pale, clammy, in
shock)
 Venous filling, including JVP
 Urine output
 Evidence of concealed or overt haemorrhage

Listen for –Heart sounds

 Blood pressure

Feel for –Presence, rate, quality, regularity of central &

peripheral pulses
 Disability
 Rapid assessment of the patient’s neurological status
involvesExamination of pupils (size,equality,reaction to light)
 Level of consciousness (AVPU)Alert
 Responds to vocal stimuli
 Responds to painful stimuli
 Unresponsive

 Common causes of unconsciousness include

 Profound hypoxemia
 Hypercapnia
 Cerebral hypoperfusion
 Hypoglycaemia
 Recent administration of sedatives, anaesthetic drugs
x
 Monitoring the Critically Ill Patient
 Institute the following –
 Pulse oximetry –SpO2
 Capnograph -EtCO2
 ECG –rate, rhythm, ischaemia, conduction
 BP (intra-arterial)-accurate real time BP
 CVP –to guide fluid therapy and adminiterinotropes
 Nasogastric tube
 Urinary catheter to monitor hourly output
 Critical Illness Is Recognised By…..
 Prodromal signs which warn of impending
physiological catastrophe
 Simple physiological signs –basis of Early
Warning Score of which the RR (respiratory rate) is
the most sensitive
 A score of > 3requires urgent medical review
 Have been incorporated into a “call out cascade”
to facilitate urgent medical review
 EWS “call out cascade”
 Score > 0 Inform a doctor

 Score 1 –3 Increase frequency of patient

observations toat least 4 hourly

 Score is 3 in one category contact intensivist for

immediate patient assessment
 Score total > 3 contact critical care team
Early Management
 Relieve airway obstructionSuction oropharynx
 Insert nasal / oral airway
 Administer supplemental O2 by mask

Intubate and mechanically ventilate ifspontaneous

respiration is inadequate
 Or if gag reflex absent-inability to protect airway against aspiration

 Support circulationwithIntravenous fluids

 Inotropic agents & vasopressors

GeneralAntibiotics
 Correct acidosis, hypo / hyperglycemia
 Specific Criteria For ICU Referral
AirwayActual or threatened airway obstruction
 Impaired ability to protect airway

BreathingRR < 8 or > 30

 Respiratory arrest
 Oxygen saturation < 90% on 50% oxygen or more
 Worsening respiratory acidosis

CirculationPulse < 40 or > 140

 Systolic BP <90 mm Hg
 Post cardiac arrest resuscitation
 Worsening metabolic acidosis
 Urine output < 0.5 ml/kg/hr
 Specific Criteria For ICU Referral(contd)
NeurologicalRepeated or prolonged seizures
 Decreasing conscious level sufficient to compromise the airway and
protective reflexesHead injury
 Meningitis,encephalitis
 Intracranial haemorrhage
 Hepatic encephalopathy
 Drug overdose

 Neuromuscular disease such as M.Gravis, Guillain -Barre

GeneralAny patient with an EWS score of 6 or above

 Any patient who is showing an adverse trend despite
treatment
 Respiratory Support in ICU
 Patients may be referred with
 Hypoxemia
 Ventilatory failure

 Treatment is mechanical ventilation for both the above

 Decision to ventilate is based on following criteria –
 Patient is exhausted (unable to speak in complete sentences,
using accessory muscles of respiration,confused)
 Blood gas results (PaO2 < 8.5 on 60% O2,PaCO2 >6.5,

 pH < 7.3 )
 Failure to institute IPPV will result in respiratory arrest
 Circulatory Support in ICU
 Circulatory failure can result from
 Impaired pump function of heart –low cardiac output
 Severe hypovolemia
 Septic shock

 Manifests as ( signs of impaired tissue perfusion)

 Reduced conscious level
 Cool peripheries
 Oliguria
 Increasing metabolic acidosis

 Treatment priorities
 Rapid replacement of fluids / blood (CVP monitoring)
 Inotropic support (intra-arterial BP)
 Support of Other Organ Systems
 Renal
 May requirehaemofiltration to deal with fluid and electrolyte
imbalance

 Neurological
 Treat fits, reduce intracranial pressure

 Haematological
 Correct coagulation defects with platelets, FFP

 Nutritional
 Total parenteral nutrition
 Enteral feeding
 The Postoperative Patient in ICU
 Surgery produces a temporary but predictable
physiological stress on the cardiovascular & respiratory
system which may need to be supported post-
operatively
 Following major complex surgery regardless of the
previous ASA status
 Following modest surgery in a patient with significant
cardio-respiratory disease

 Do not admit patients to ICU

 if the outcome is unlikely to be good
 Irreversible end stage disease
 Further treatment is deemed to be futil