ASSESSMENT

OF THE SERIOUSLY ILL PATIENT

INITIAL ASSESSMENT RESUSCITATE, STABILISE
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BP, HR, RR, I/O, GCS, Na, K, pH, HCO3, worried nurse
CAB!
o Circulation: BP, tissue perfusion
o Airway: see-saw thoracoabdominal recession, stridor, RR, HR
o Breathing: RR, chest rise, pulse oximetry
Helpful initial investigations
o Pulse oximetry
o ABG
o Electrolytes, RFT
o CBC, clotting

SUBSEQUENT ASSESSMENT - UNDERLYING CAUSE

-

History & P/E

Investigations
o CaPO4, Mg
o LFT
o ECG, CXR

ACUTE RESPIRATORY FAILURE

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Type 1: hypoxic PaO2 8 kPa (60 mmHg)

Type 2: hypoxic + hypercapnic PaO2 8 kPa (60 mmHg) AND PaCO2 6.7 (50 mmHg)

FORMULAE
-

PAO2 = FiO2 (PB 47) PaCO2/R + F

P(A-a)O2 < 2.7 kPa (< 20 mmHg)
o Gradient between alveolar & arterial oxygen cause of hypoxia when hypercapnia is present

CAUSES
-

Low inspired oxygen concentration ( FiO2)

o High altitude
Hypoventilation
o Respiratory centre depression (drugs, anaesthesia, head injury, fatigue, encephalopathy
o Disruption of anywhere along pathway from brain
respiratory muscles
o Chest wall abnormalities
o Upper/lower airway obstruction
o Parenchymal lung disease ( lung compliance)
Ventilation perfusion mismatch (P(A-a)O2 > 2.7 kPa)
o Physiological shunting (pneumonia, pulmonary
oedema, pulmonary haemorrhage, confusion,
atelectasis)
o Anatomical shunting (TOF, EIsenmenger syndrome)
o Increased physiologic dead space (hypovolaemia,
pulmonary embolis, poor cardiac function
Diffusion abnormality
o Severe destructive disease of the lung (ARDS, severe
APO, Fibrosing disease)

INVESTIGATIONS
-

CAB, History & Exam

Severity: tissue hypoxia, increased respiratory effort, sympathetic response

Type of respiratory failure
Pulse oximetry (HR, peripheral pulse rate, SpO2): dark skin, false nails, nail varnish, lipaemia, bright
ambient light, poorly adherent probe, excessive motion & carboxyhaemoglobin
ABG

MANAGEMENT
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Sitting position
Oxygen supplementation
o Fixed performance device
Venturi masks [FiO2 = 0.24 0.5]
COPD patients kept at 90 94%
Reservoir face mask [maximal FiO2 = 0.7 on 15L]
Able to supply 100% oxygen
o Variable performance device
Nasal cannula [maximal FiO2 = 0.4]
Simple face masks [maximal FiO2 = 0.55 on 10L]

AIRWAY MANAGEMENT
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Recovery position
o Patient expected to rapidly regain consciousness
o Definitive airway protection not possible

AIRWAY MANOEVERS
1.
2.
3.
4.
5.
6.

Head tilt chin lift

Modified jaw thrust
Triple airway manoever
Two-man manoever
Oropharyngeal airway (Cx: mucosal trauma, worsening obstruction, displacing tongue posteriorly)
Nasopharyngeal airway (Cx: epistaxis, laryngospasm, aspiration, oesophageal placement)

BAG-MASK VENTILATION
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Squeeze only 50%, 12 14 breaths/min

Check for chest rise & air entry
Cx: inadequate ventilation (air leak), over-distention of lungs, gastric insufflation

ENDOTRACHEAL INTUBATION
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Method of choice for unconscious, apnoeic patient

Indications
o Acute upper airway obstruction
o Facilitation of tracheal suctioning
o Protection of the airway from macroscopic aspiration
o Respiratory failure requiring invasive mechanical ventilation

AIRWAY OBSTRUCTION
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S/S: inspiratory stridor, crowing, noisy respiration, choking, drooling, gagging, SOB, feeble cough,
respiratory distress, signs of hypoxaemia/hypercarbia, subcutaneous emphysema, dermal ecchymoses
refer urgently to ENT surgeon and/or anaesthetist
Foreign body obstruction
o Risk factors: ingested alcohol/depressants, wear dentures, elderly & institutionalised
o Mx:
1. Sharp blow to the back (repeat to max 5 times)
2. Heimlich manoeuvre (repeat to max 5 times)
S/E: vomiting, aspiration, fractured ribs, barotrauma, ruptured organs
3. Then alternate, while calling for help & making preparations for endotracheal intubation

BASIC HAEMODYNAMIC MONITORING

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Indirect clinical measures of tissue blood flow

o Conscious level
o Temperature of peripheries
o Urine output (> 0.5 1 ml/kg/hr OR >10ml/hr)

BLOOD PRESSURE
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Systolic high risk of bleeding

Diastolic poor coronary blood flow
Mean arterial pressure perfusion pressure of other organs
Non-invasive measurement
o Over-estimate at low pressure & tight cuff
o Under-estmate at high pressure & loose cuff
o Width of cuff should be 40% of circumference & length twice the circumference of limb
o Cx: ulnar nerve injury, oedema of the limb, petechiae & bruising, friction blisters, failure to cycle &
drip failure
Passive leg raise
o Rise in pulse pressure by 10% on passive leg raising patient is hypovolaemic
o Change patient from 45 head up 45 feet up position
CVP
o Helpful in determining the cause, but not necessarily in detecting a problem
o Measures right atrial pressure approximating right ventricular end-diastopic pressure (EDP)
o Difference in CVP measured before & 5 mins after fluid bolus
0 3 mmHg: underfilled
3 5 mmHg: adequately filled
> 5 mmHg: overfilled
o inaccurate in
Isolated left/right ventricular failure
Valvular disease
Severe pu lmonary disease
o Cx: pneumothorax, haemothorax, cylothorax, damage to vein/adjacent, vein thrombosis,
thrombophlebitis, infection, guidewire embolization, cardiac arrhythmias, haemorrhage

SHOCK
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Inadequate blood flow to tissue to meet demand

HYPOTENSIVE PATIENT
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MAP = CO x TPR = HR x SV x TPR

CO = HR x SV
Stroke volume is dependent on preload, afterload & contractility
In emergency, assessment based on HR, JVP/CVP & temperature of peripheries

CARDIOGENIC SHOCK
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Shock due to pump failure myocardia/valvular failure

Definition: persistent of shock despite correction of non-myocardial factor e.g.
o Hypovolaemia
o Hypoxaemia
o Profound acidosis
o Arrhythmias
Aim is to improve coronary perfusion
o Definitive therapy: PCI/CABG/thrombolysis
o Supportive: norepinephrine fluid in small boluses (~100 ml of crystalloid) TNG (normotensive),
dobutamine (normotensive/mildly hypotensive)

HYPOVOLAEMIC SHOCK
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Result of intravascular volume depletion

o Blood loss
o Third spacing (IO, pancreatitis, burns, peritonitis)
o GI loss (diarrhoea, vomiting, NG tube)
o Renal loss (DKA, DI)
o Skin loss (burns, exfoliative dermatitis)
Aim is to replenish fluid loss & treat underlying cause
Mild to moderate blood loss (<1L) replaced by
o Colloid (1 1.5 times)
o Crystalloid (1.5 2 times)
Severe blood loss replaced by blood products
Vasoconstrictor may be needed

DISTRIBUTIVE SHOCK
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Peripheral vascular distribution fall in peripheral resistance

Causes
o Septic shock
o Anaphylactic shock
o Acute adrenal insufficiency
Evidence of hypoperfusion may include mental status changes, oliguria or lactic acidosis

OBSTRUCTIVE SHOCK
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Caused by
o Cardiac tamponade
High CVP & low Bp
Pulses paradoxus
Mx: urgent pericardiocentesis
o Tension pneumothorax
o Massive pulmonary embolus
Mx: fluid therapy & vasoconstriction, norepinephrine

VASOPRESSOR & INOTROPES

** Immediately life threatening shock (systolic BP 50 mmHg or rapidly progressive shock) give epinephrine
0.1mg IV, repeated as necessary**
Drug
Inotropic Chronotropic VasoStarting dose
Remarks
(force)
(HR)
constriction



Dopamine
~5 g/kg/min
Not recommended in septic
shock if NA or adrenaline
available
Administered
through
central venous catheter

Norepinephrine minor
minor
0.05 g/kg/min
Administered
through
central venous catheter



Epinephrine
0.05 g/kg/min
Similar to norepinephrine


Dobutamine
vasodilation 0 20 g/kg/min Used with norepinephrine
in severely hypotensive
patients

ANAPHYLAXIS
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Severe, sudden onset allergic reaction to any stimulus

Diagnostic criteria (any 1 of the following)
o Illness involving skin, mucosal tissue or both PLUS 1 of
Respiratory compromise
Hypotension/shock

2 of following, occurring rapidly after exposure to likely allergen for that patient
skin/mucosal involvement
respiratory compromise
hypotension/shock
persistent GI signs
Hypotension after exposure to known allergen for that patient
absolute hypotension (systolic < 90mmHg)
relative (>30% fall in systolic BP)