Early Recognition Critical Illness

by Scoring System and Case Example

Irvan Setiawan
Pendahuluan
Penyakit Kritis

Gajic O, et al. Curr Opin Crit Care. 2018; 24(5): 394–400.

Pendahuluan

Chain of Prevention
Advanced Life Support
Cause of Deterioration & Cardiac Arrest
Airway Obstruction
• Total or partial obstruction, that leads to cerebral or pulmonary edema, exhaustion,
secondary apnea, and hypoxic brain injury, and eventually cardiac arrest.

• Causes:

CNS depression, foreign body, trauma, laryngospasm or bronchospasm, OSA

• Recognition

Conscious pts complain di cult to breath, chocking, distress

Stridor, gargling (partial obst), abnormal chest-abdominal movement

• Management

• Treat the cause

• Give 100% O2

• Simple airway maneuver

• Consider patent airway placement

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Cause of Deterioration & Cardiac Arrest
Breathing Problem
• Acute or chronic, moderate to severe, leads to hypoxia —> arrest

• Cause

• Respiratory drive, due to CNS depression

• Respiratory e ort: resp muscle weakness or nerve damage, restrictive chest

wall, chest trauma, pain

• Lung disorder: infection, aspiration, ARDS, pneumothorax, hemothorax

• Recognition

• Shortness of breath, LOC ↓, cyanotic

• Desaturation, pO2 ↓, pCO2 ↑

• Management

Oxygen, invasive or non invasive ventilation

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Cause of Deterioration & Cardiac Arrest
Breathing Problem
• Acute or chronic, moderate to severe, leads to hypoxia → arrest

• Cause

• Respiratory drive, due to CNS depression

• Respiratory e ort: resp muscle weakness or nerve damage, restrictive chest

wall, chest trauma, pain

• Lung disorder: infection, aspiration, ARDS, pneumothorax, hemothorax

• Recognition

• Shortness of breath, LOC ↓, cyanotic

• Desaturation, pO2 ↓, pCO2 ↑

• Management

Oxygen, invasive or non invasive ventilation

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Cause of Deterioration & Cardiac Arrest
Circulation Problem
• Cause

• Primary heart problem: arrhythmia (ec ischemia/infarction, heart block,

electrocution, drug), heart failure, tamponade, cardiac rupture, myocarditis,
hypertrophic cardiomyopathy.

• Secondary heart problem: hypoxia, tension pneumothorax, hemorrhagic

shock, septic shock

• Recognition

chest pain, shortness of breath, syncope, tachycardia, bradycardia,

tachypnea, hypotension, CRT >, LOC ↓, oliguria.

• Management

Treat underlying cause

The Role of EWS

• Tools used to recognize the early signs of clinical deterioration in order to

initiate early intervention and management, such as increasing nursing
attention, informing the provider, or activating a rapid response or medical
emergency team.

• Delays in treatment or inadequate care of patients on general wards:

• ↑ admissions to ICU

• ↑ LOS

• ↑cardiac arrest or death.

The Role of EWS
The evidence
Outcome Study Without EWS With EWS

ICU admission 1 1.8% 0.5%

Hospital LOS 2 19 day 16 day

Hospital LOS 3 51 day 26 day

ICU LOS 2 3.0 day 2.6 day 1.Mitchell IA, McKay H, Van Leuvan C, et al.
Resuscitation. Jun 2010;81(6):658-666.

ICU LOS 3 9.7 day 6.9 day

2.Green AL, Williams A. Intensive Crit Care
ICU LOS 1 4 day 4.8 day Nurs. Oct 2006;22(5):274-282.

3.Jones S, Mullally M, Ingleby S, Buist M,

Post ICU mortality 4 5.7% 3.5% Bailey M, Eddleston JM. Crit Care Resusc.
Jun 2011;13(2):83-88.

30-day Mortality 2 33.9% 34.5%

4.De Meester K, Das T, Hellemans K, et al.
30-day mortality 3 9.5% 7.6% Resuscitation. Jul 14 2012
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“A healthy person has a thousand wishes,
a sick man has but one”
Agnes Karll Schwest Krankenp eger, 1968
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