Assessment of the

Seriously Ill Patient

 Objectives
• Early identification of patients at risk
for life-threatening illness
• Recognize early signs of critical
illness
• Review the initial assessment of
critically ill patients
 Why identify patients
at risk?
• Easier management with simpler
interventions
• Prevent further deterioration
• Provide time for investigation and
treatment
 Challenging Patients
• Young, fit patients
• Immunosuppressed patients
• Debilitated patients
• Patients with abrupt deterioration
• Patients with limited reserve
 Risk Assessment
• Background health
• Severity of acute physiology
– Vital signs
– Other clinical monitoring
– Trends and rate of deterioration
• Goals
– Recognition that problem exists
– Maintain stability
 Risk Assessment
• Making a diagnosis
– Often secondary to treatment of
physiological abnormalities
– Investigate while stabilizing
– Requires disciplined approach
 Assessment
• Primary survey
– What is main physiological
problem?
– First minutes of initial contact
• Secondary survey
– What is underlying cause?
– Subsequent reviews
 Assessment of the
Seriously Ill Patient
• History
• Physical examination
• Chart review and documentation
• Investigations
• Treatment
 Patient
• 54 year old diabetic with shortness of
breath
• 3 days postoperative for
laparoscopic cholecystectomy

What history would you obtain initially?

 Initial Survey
• History
– Main symptoms
– Physiological abnormalities
– Co-existing illness
– Major surgery
– Severe hemorrhage/transfusion
– Lack of improvement
 Patient
• 54 year old diabetic with shortness of
breath
• 3 days postoperative for
laporoscopic cholecystectomy

What additional details would be helpful?

 Secondary Survey
• History
– Past history, chronic diseases
– Psychosocial issues
– Medications/allergies
– Family history
– Ethical/legal issues
– Systems review
 Patient
• 54 year old diabetic with shortness of
breath
• 3 days postoperative for
laporoscopic cholecystectomy

What parts of the physical examination

would you concentrate on initially?
 Initial Survey
• Examination
– Airway
– Breathing
– Circulation
– Level of consciousness
 Secondary Survey
• Examination
– Respiratory
– Cardiovascular
– Abdomen and genitourinary tract
– Central nervous system
– Musculoskeletal system
– Endocrine, hematologic systems
 Patient
• BP 100/40 P 96 RR 26 T 37.8º C
• Pulse oximetry 92% on 2 L cannula
• Appears anxious, slightly confused
• Bibasilar rales
• Decrease bowel sounds, distended
abdomen
• Warm extremities
Which findings are most concerning?
 Airway/Respiratory
System
• Observe mouth and chest
• Respiratory rate and pattern
– Tachypnea is the single most
important indicator of critical illness
• Use of accessory muscles
• Level of consciousness
• Oxyhemoglobin saturation
 Circulation
• Peripheral pulses and blood
pressure
• Evidence of decreased perfusion
• Most common cardiovascular
disturbance in the seriously ill is
hypotension caused by hypovolemia
and/or sepsis
 Patient
• BP 100/40 P 96 RR 26 T 37.8º C
• Pulse oximetry 92% on 2 L cannula
• Appears anxious, slightly confused
• Bibasilar rales
• Decrease bowel sounds, distended
abdomen
• Warm extremities
What information from the chart would
be helpful?
 Chart Review and
Documentation
• Initial survey
– Vital signs
– Fluid balance
– Inspired oxygen concentration
– Medications
– Invasive parameters
 Chart Review and
Documentation
• Secondary survey
– Review medical records
– Document current events
– Document diagnosis and treatment
rationale
 Patient
• BP 100/40 P 96 RR 26 T 37.8º C
• Pulse oximetry 92% on 2 L cannula
• Appears anxious, slightly confused
• Bibasilar rales
• Decrease bowel sounds, distended
abdomen
• Warm extremities
What investigations should be ordered?
 Investigations
• Guided by history and physical
examination
• Standard biochemistry, hematology,
microbiology, radiographs
• Arterial or venous blood gas
• Lactate level
Metabolic acidosis is an important
indicator of critical illness
 Patient
Previous exam Current exam
• BP 150/90, HR 70-80, • BP 100/40, HR 96,
RR 16, T 37.8 RR 26, T 37.8
• Pulse ox 97%(RA) • Pulse ox 92% on 2L
• Distended abdomen • Distended abdomen
• Warm extremities • Warm extremities
• WBC 16,000/mm3 • WBC 21,000/mm3
• BUN/creatinine norm • BUN/creatinine
• ABG 7.3/30/65
What now?
 Information Action
• Ensure physiological safety
– Oxygen
– Intravenous access
– Circulatory support
• Determine patient’s reserve
• Assess likely diagnosis and
treatments
 Information Action
• Refine treatment
– Assess response to treatment
– Provide organ system support
– Determine best site for care
–Call for advice and assistance
 Key Points
• Identify patients at risk early
• Recognize signs of critical illness
• Stabilize first, then determine
diagnosis
• Obtain detailed history
• Monitor response to treatment