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Part 1 General

Recognizing the unwell patient

Critical Care Medicine at a Glance, Third Edition. Richard Leach. 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Recognizing the acutely unwell patient

Early recognition that a patients condition is deteriorating is
essential and should initiate immediate action to correct abnormal
physiology and prevent vital organ damage (e.g. brain). Clinical
severity may be obvious from the end of the bed: as in sudden,
catastrophic events (e.g. pulmonary embolism); presentation with
established severe illness (e.g. emergency room); or in advanced,
previously unrecognized, deterioration on the ward. In these cases,
organ damage may have already occurred but immediate action
prevents further injury. It is the failure to recognize progressive
deterioration (e.g. worsening physiological variables), and to initiate preventative action, that is a common and unacceptable cause
of harm.
Identification of at-risk patients (e.g. post-operative) allows
complications to be anticipated and prevented. At-risk patients
must be monitored, deterioration recognized and appropriate
action initiated. Simple physiological parameters including temperature, blood pressure (BP), heart rate, respiratory rate, urine
output and conscious level correlate with mortality. One, two or
three abnormalities correlate with 30-day mortalities of 4.4%, 9.2%
and 21.3% respectively. Early warning scoring systems based on
these parameters (Figure 1a) promote early detection and trigger
interventions aimed at preventing cardiac arrests and critical care
admissions.

Assessment of the acutely ill patient

A normal response to the question Are you alright? indicates that
a patients airway is patent and that they are breathing, conscious
and orientated. No response (e.g. coma) or difficulty responding
(e.g. breathlessness) suggests serious illness. Immediate assessment and management of these acutely ill patients are summarized
in Figure 1b. They aim to ensure patient safety and survival rather
than to establish a diagnosis. Assessment starts with detection and
simultaneous treatment of life-threatening emergencies. It uses the
ABC system: A Airway, B Breathing, C Circulation, in this
order, because airways obstruction causes death faster than disordered breathing, which in turn causes death faster than circulatory
collapse. Appropriate life-saving procedures or investigations are
performed (e.g. airway clearance, tension pneumothorax decompression) during examination (i.e. before the next step). Simple
monitors (e.g. saturation, BP) are used to assist assessment when
safely possible.
Airway (Chapters 5, 11) Obstruction is a medical emergency and
unless rapidly corrected leads to hypoxia, coma and death within
minutes. Causes include aspiration (e.g. food, coins, teeth, vomit),
laryngeal oedema (e.g. allergy, burns), bronchospasm and pharyngeal obstruction by the tongue when reduced tone causes it to fall
backwards in obtunded patients.
Complete obstruction is characterized by absent airflow (feel
over the patients mouth), accessory muscle use, intercostal recession on inspiration, paradoxical abdominal movement and absent
breath sounds on chest auscultation.
Partial obstruction reduces airflow despite increased respiratory effort. Breathing is often noisy, with stridor suggesting laryngeal and snoring nasopharyngeal obstruction.

Simple measures correct most airway obstruction. Suction removes

blood, vomit and foreign bodies. Obstruction by the tongue (i.e.
during coma) can usually be prevented by chin lift manoeuvres or
insertion of an oropharyngeal (Guedel) airway. Occasionally
endotracheal intubation or, rarely, emergency cricothyroidectomy
are required.
Breathing (Chapters 5, 11) The most useful early sign that breathing is compromised is a respiratory rate 8 or 20/min, whereas
central cyanosis is usually a late sign. Examine depth and pattern
of breathing, accessory muscle use, abdominal breathing and chest
wall expansion. Abnormal expansion, altered percussion note (e.g.
hyper-resonance), airway noise (e.g. stridor) and breath sounds
may determine the cause of underlying lung disease (Figure 1c).
Saturation (Sao2), measured by pulse oximetry, and inspired
oxygen concentration (Fio2) should be recorded. Arterial blood
gases (ABGs) provide information about ventilation as well as
oxygenation (i.e. normal Sao2 with high Paco2 due to poor ventilation). The Sao2 should be >90% in all critically ill patients. Respiratory acidosis (pH<7.3, Paco2>6.7 kPa) or hypoxaemia despite
high flow oxygen therapy (Sao2 < 90%, Pao2 < 8 kPa) requires
urgent intervention. Treatment depends on cause (e.g. chronic
obstructive pulmonary disease [COPD]) and is discussed in later
chapters.
Circulation (Chapters 5, 8) Assessment includes central and
peripheral pulses (i.e. rate, rhythm, equality), BP, peripheral perfusion (e.g. limb temperature), urine output and conscious level.
Initially BP is maintained by compensatory mechanisms (e.g.
increased peripheral resistance). Cardiac output (CO) has to fall
by >20% (i.e. equivalent to 1 L of rapid blood loss) before BP falls.
Thready, fast pulses indicate poor CO, whereas bounding pulses
suggest sepsis. Capillary refill time is usually <2 secs and prolongation suggests poor tissue perfusion. Metabolic acidosis (base excess
>4) and raised lactate (>2 mmol/L) on ABG may be due to
tissue hypoxia. Hypovolaemia should be considered the primary
cause of shock, unless there is obvious heart failure (i.e. resuscitate
hypotensive patients with cool peripheries and tachycardia with
intravenous fluids [Chapters 9, 11]).
Disability Neurological status is rapidly determined by pupil
examination and assessment of conscious level using simple
systems (Figure 1a) or the Glasgow Coma Scale (Chapters 3, 72).
Exclude hypoglycaemia, ischemia and injury (e.g. hip fracture) in
every patient.
Full patient assessment When stability has been achieved and
assistance summoned, a thorough history and examination is
required. Review the patients notes, treatment, investigations and
charts. Trends in physiological parameters are often more useful
than isolated values. If a diagnosis has not been established,
arrange further investigations as appropriate. Document and communicate a clear management plan.
Management of the acutely unwell patient often involves
several teams (e.g. medicine, surgery, critical care) but should be
a seamless process in which co-operation, communication and
patient interests are foremost. Treatment should occur in
clinical areas where staffing and technical support are matched to
patient needs.

Pearl of wisdom
Monitoring of simple physiological parameters reliably identifies
early clinical deterioration

Chapter 1 Recognizing the unwell patient

n the acutely unwell patient, assessment of deranged physiology

and immediate resuscitation precedes diagnostic considerations
because incomplete history, cursory examination and limited
investigation often preclude classification by primary organ dysfunction. It is this initial diagnostic uncertainty and the need for
immediate physiological support that defines critical care
medicine.

Part 1 General

Managing the critically ill patient

Critical Care Medicine at a Glance, Third Edition. Richard Leach. 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Organization

Admission and discharge guidelines

Aggressive hospital treatment may be inappropriate in advanced
disease and patients must be allocated to a ward appropriate to
their needs and prognosis. Resuscitation status should always be
documented. Admission and discharge guidelines for ICU/HDU
facilitate appropriate use of resources and prevent unnecessary
suffering in patients who have no prospect of recovery. Factors
determining ICU/HDU admission include the primary diagnosis,
severity, likely outcome, co-morbid illness, life expectancy, postdischarge quality of life and patients or relatives wishes. Age alone
is not a contraindication to admission and each case must be
judged on its merit. If there is uncertainty, the patient should be
given the benefit of the doubt and active treatment continued until
further information is available.
Discharge occurs when the patient is physiologically stable and
relatively independent of monitoring and support. Avoid out-ofhours and weekend discharges and ensure a detailed handover.
After family consultation, withdrawal of therapy may be appropriate in patients with no realistic hope of recovery. When feasible,
organ donation should be tactfully discussed. Management must
always remain positive to ensure death with dignity (Chapter 29).

General supportive care

Optimal care is delivered by a multi-skilled team of doctors, nurses,
physiotherapists, technicians and other care-givers. Figure 2 illustrates important aspects of general management. Prolonged bed
rest predisposes to respiratory (e.g. atelectasis), cardiovascular (e.g.
autonomic failure), neurological (e.g. muscle wasting) and endocrine (e.g. glucose intolerance) problems. Fluid and electrolyte
imbalance (e.g. Na+, K+, Ca2+ depletion), constipation, infection,
venous thrombosis and pressure sores also occur. The importance
of skilled nursing in the care of these patients cannot be overemphasised. Assessment, continuous monitoring (intervention),

Severity of Illness Scoring Systems

Severity of Illness Scoring Systems (SISS) predict outcome and
evaluate care in ICUs and HDUs. Two have been validated and are
widely used:
APACHE II (Acute Physiology and Chronic Health Evaluation)
measures case-mix and predicts outcome in ICU patients as
a group. It should not be used to predict individual outcomes.
Scoring is based on the primary disease process, physiological
reserve including age, chronic health history (e.g. chronic liver,
cardiovascular, respiratory, renal and immune conditions) and
the severity of illness determined from the worst value in the
first 24 hours of 12 acute physiological variables including rectal
temperature, mean BP, heart rate, respiratory rate (RR), arterial
Pao2 and pH, serum sodium, potassium and creatinine, haemocrit,
white cell count and Glasgow Coma Score (GCS; Chapter 72).
Predicted mortality, by diagnosis, has been calculated from large
databases, which allows individual units to evaluate their performance against reference ICUs by calculating standard mortality ratio
(SMR=observed mortalitypredicted mortality) for each diagnostic group. A high SMR (>1.5) should prompt investigation and
management changes for specific conditions.
SAPS (Simplified Acute Physiology Score) is similar to APACHE
II with equivalent accuracy.
Pathology Specific Scoring Systems (PSSS) can be used in CCM.
Trauma Score (TS) assesses triage status based on RR, respiratory effort, systolic BP, capillary refill and GCS. TS is related to
survival in blunt and penetrating injuries. A high score prompts
transfer to a trauma centre. Revised TS: uses only GCS, RR and
systolic BP. It is less suitable for triage but improves prognostic
reliability.
Abbreviated Injury Scale assesses multiple injuries and correlates with morbidity and mortality.
Other PSSS: include the paediatric trauma score, neonatal
Apgar score and GCS (Chapter 72).

Cost of critical care medicine

Measuring costs is complex. In ICU/HDU, the most widely used
system is the Therapeutic Intervention Scoring System (TISS),
which scores the overall requirements for care, by measuring
nursing activity and interventions. TISS correlates well with staff,
equipment and drug costs and can also be used as an index of
nurse dependency. Most (>50%) ICU expenditure is on labour
costs (e.g. constant bedside nursing). Drugs, imaging, laboratory
tests and supplies account for 40% of spending. Current estimates of daily (basic) ICU costs vary from 800 to 1600 in the
UK. HDU costs are 50% and general ward care 20% of ICU
costs. The USA spends 14%, and the UK 9% of gross domestic
product (GDP) on healthcare with ICU/HDU costs of 7% and
45% respectively.

Chapter 2 Managing the critically ill patient

Critical care wards provide monitoring and treatment for patients

with potentially reversible, life-threatening conditions that are not
available on general wards. Patients should be managed and moved
between areas where staffing and technical support match their
severity of illness and clinical needs. Five types of ward area are
described: (a) level 3: intensive care units (ICUs); (b) level 2:
medical/surgical high dependency units (HDUs), post-operative
recovery areas, emergency resuscitation rooms; (c) level 1: acute
admission wards, coronary care units; (d) general wards (e) selfcare wards.
Critical care medicine (CCM) encompasses the initial resuscitation, monitoring, investigation and treatment of critically ill
patients in level 23 wards. These patients usually require a high
degree of monitoring and nursing support. Level 3 patients
are often mechanically ventilated or have multi-organ failure.
Level 2 patients may need invasive monitoring (i.e. arterial line),
non-invasive ventilation, inotropic support or renal replacement
therapy. Level 1 patients usually require non-invasive monitoring
(e.g. electrocardiogram [ECG], saturation, blood pressure [BP])
and close observation. There is considerable overlap between level
1 and 2 patients. Provision of level 2 and 3 care varies from 25%
of hospital beds in the UK to >510% in the USA.

drug administration, comfort (e.g. analgesia, toilette), reassurance

and psychological support, assistance with communication, advocacy, skin care, positioning (e.g. to prevent aspiration, atelectasis,
pressure sores), feeding and early detection of clinical complications (e.g. line infection) are all vital nursing roles that have a
profound effect on outcome. Nurses also provide essential support
for relatives, doctors, physiotherapists and other care-givers (e.g.
technicians).