Assessment and Stabilisation of a Critically Ill Patient

Dr.S. Vashisht Dept.of Anaesthesia Hillingdon Hospital

Assessment
Traditional history taking & examination is inappropriate Assessment and stabilisation should proceed simultaneously Priority given to detection of potentially life threatening conditions Life saving measures must be instituted rapidly

What Should I 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?

Assessing Airway Patency

Look forForeign bodies,secretions,blood in oropharynx Obstruction of the pharynx by the tongue Use of accessory muscles of respiration Chest expansion Paradoxical breathing

Listen forAbnormal upper airway sounds (stridor,gurgling) If airway obstruction is complete, breath sounds will be absent

Feel forExpired air

Assessing Breathing
Look forCyanosis Respiratory rate, pattern and depth Equality of chest expansion SpO2 in the context of the FiO2

Listen forWheeze,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 patients neurological status involves
Examination 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

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 adminiter inotropes 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

Early Warning Score(EWS)

3 2
Confused or Agitated

1
Responds to

2
Responds to

Alert

Voice

Pain

No Response

CNS Score Respiratory Rate Score Heart Rate Score Systolic BP Score Temperature Score

<8

9 - 20

21- 30

31- 34

> 35

< 40

41 - 50

51 - 100

101-110

111-130

> 130

< 70

71 - 80

81 - 100

101-199

>= 200

< 35

35.1 36.0

36.1 37.9

38.0 38.5

38.6 39.9

> 40

EWS call out cascade

Score > 0 Inform a doctor

Score 1 3 Increase frequency of patient observations to at least 4 hourly Score is 3 in one category contact Registrar for immediate patient review Score total > 3 Senior medical review / liaise with critical care team

Early Management
Relieve airway obstruction
Suction oropharynx Insert nasal / oral airway Administer supplemental O2 by mask

Intubate and mechanically ventilate

if spontaneous respiration is inadequate Or if gag reflex absent- inability to protect airway against aspiration

Support circulation with

Intravenous fluids Inotropic agents & vasopressors

General
Antibiotics Correct acidosis, hypo / hyperglycemia

Specific Criteria For ICU Referral

Airway
Actual or threatened airway obstruction Impaired ability to protect airway

Breathing
RR < 8 or > 30 Respiratory arrest Oxygen saturation < 90% on 50% oxygen or more Worsening respiratory acidosis

Circulation
Pulse < 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)

Neurological
Repeated or prolonged seizures Decreasing conscious level sufficient to compromise the airway and protective reflexes
Head injury Meningitis,encephalitis Intracranial haemorrhage Hepatic encephalopathy Drug overdose Neuromuscular disease such as M.Gravis, Guillain -Barre

General
Any 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 require haemofiltration 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 futile