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
