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Learning objectives
After reading this article, you should be able to:
C
recall the abnormal clinical signs associated with a critically ill
patient and common patterns of presentation
C
describe a logical and systematic approach to the assessment
of an acutely unwell patient
C
discuss the clinical importance of the Chain of Response and
early-warning systems in the recognition of the critically ill
Laura C Robertson
Mohammed Al-Haddad
Abstract
Critical illness is a life-threatening multisystem process that can result in
significant morbidity or mortality. In most patients, critical illness is
preceded by a period of physiological deterioration; but evidence
suggests that the early signs of this are frequently missed. All clinical
staff have an important role to play in implementing an effective Chain
of Response that includes accurate recording and documentation of
vital signs, recognition and interpretation of abnormal values, patient
assessment and appropriate intervention. Early-warning systems are an
important part of this and can help identify patients at risk of deterioration and serious adverse events. Assessment of the critically ill patient
should be undertaken by an appropriately trained clinician and follow
a structured ABCDE (airway, breathing, circulation, disability and exposure) format. This facilitates correction of life-threatening problems by
priority and provides a standardized approach between professionals.
Good outcomes rely on rapid identification, diagnosis and definitive treatment and all doctors should possess the skills to recognize the critically ill
patient and instigate appropriate initial management.
A e Assessment of airway
Laura C Robertson MBBS FRCA is an Anaesthetic Registrar in the West of
Scotland, Scotland. Conflicts of interest: none declared.
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INTENSIVE CARE
pH 7.2:
116.1 (7.11906.1)
Figure 1
<45% Y
d
d
d
e
30% Y
<40
<9
<35
e
15% Y
41e50
d
d
e
15% [
101e110
15e20
d
Voice
30% [
111e129
21e29
>38.5
Pain
>45% [
>130
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Unresponsive
Subbe CP, Kruger M, Gemmel L. Validation of a modified Early Warning Score in medical admissions. Quarterly Journal of Medicine 2001; 94; 521e6.
Table 1
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INTENSIVE CARE
B e Assessment of breathing
Adequate respiratory function requires an intact central respiratory drive, respiratory muscle activity, sufficient surface area for
alveolar gas exchange and adequate pulmonary circulation.
Impairment of any of these can cause respiratory embarrassment. Clinical assessment using a look, listen, feel approach is
advocated. Tachypnoea can imply respiratory pathology but is
also a sensitive early indicator of acute illness, occurring as the
body attempts to correct metabolic acidosis secondary to poor
tissue perfusion. Peripheral oxygen saturations should be recorded, but pulse oximetry can be unreliable, falsely reassuring and
does not indicate adequate ventilation. Arterial blood gas analysis should be performed if time allows.
Differentiating between the two types of respiratory failure
can aid diagnosis and management. Type I failure (PaO2 <8 kPa
(60 mmHg) with low/normal PaCO2) is normally due to V/Q
mismatch. The cause can be lung areas that are perfused but
not ventilated (e.g. in pneumonia, atelectasis, pulmonary
oedema) or ventilated but not perfused (e.g. pulmonary
embolus). As a consequence of this mismatch, simply
increasing the FiO2 may not resolve the hypoxaemia. In severe
cases type I respiratory failure may progress to type II failure as
muscle weakness develops due to fatigue, hypoxia and
acidosis. This requires urgent intervention and consideration of
invasive ventilation. Type II respiratory failure represents
a decrease in alveolar ventilation, causing hypoxaemia (PaO2
<8 kPa (60 mmHg)) with hypercarbia (PaCO2 >6 kPa (45
mmHg)). This can be due to central causes (e.g. intracranial
haemorrhage, opiate drugs), chest wall abnormalities (e.g.
kyphoscoliosis, trauma, obesity), neurological or muscular
disorders. Patients with advanced chronic obstructive pulmonary disease often display chronic type II respiratory failure,
with compensation of hypercarbia through renal bicarbonate
retention. In these patients arterial acidaemia is a more sensitive marker of acute deterioration than absolute PaCO2 value.
In type II respiratory failure increasing the FiO2 will improve
hypoxaemia but correction of hypercarbia requires an increase
in alveolar ventilation and management of the underlying
cause. Critically ill patients who do not improve with simple
increases in FiO2 may benefit from continuous positive airway
pressure, non-invasive, or invasive ventilation. This should be
discussed with a senior clinician.
C e Assessment of circulation
Shock occurs when the oxygen supply to organs or tissue is inadequate to meet their metabolic demands. Adequate perfusion
requires the presence of an appropriate circulating volume of blood
with a sufficient amount of pressure to reach the vital organs.
For a full description of the different patterns of shock see
Causes and Investigation of Shock, Anaesthesia & Intensive Care
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INTENSIVE CARE
REFERENCES
1 McQillan P, Pilkington S, Allan A, et al. Confidential enquiry into
quality of care before admission to intensive care. Br Med J 1998;
316: 1853e8.
2 Zimmerman JE, Knaus WA, Sun X, Wagner DP. Severity stratification
and outcome prediction for multisystem organ failure and dysfunction.
World J Surg 1996; 20: 401e5.
3 McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to
intensive care of patients on general wards: are some cases potentially avoidable? J R Coll Physicians Lond 1999; 33: 255e9.
4 Department of Health. Competencies for recognising and responding to
acutely ill patients in hospital, http://www.dh.gov.uk/publications; 2009.
FURTHER READING
National Institute for Health and Clinical Excellence. Acutely ill patients in
hospital: recognition of and response to acute illness in adults in
hospital (NICE guideline no. 50). London: National Institute for Health
and Clinical Excellence, 2007.
National Patient Safety Agency. Recognising and responding appropriately to early signs of deterioration in hospitalised patients. Ref no.
0683. London: National Patient Safety Agency, 2007.
Smith GB, Osgood VM, Crane S. ALERT e a multiprofessional training
course in the care of the acutely ill adult patient. Resuscitation 2002;
52: 281e6.
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