RECOGNITION AND ASSESSMENT OF THE SERIOUSLY ILL PATIENT

Suparto
Anesthesiology Departement UKRIDA

INTRODUCTION

An ounce of prevention is worth a pound of cure

Early identification of patients at risk for life-threatening illness makes it easier to manage them appropriately and prevent further deterioration. The longer the interval between the onset of an acute illness and the appropriate intervention, the more likely it is that the patients condition will deteriorate, even to cardiopulmonary arrest. Critical illness is often associated with

Inadequate cardiac output Respiratory compromise Depressed level of consciousness

 Recognizing

seriously ill patient usually is not difficult

Young and otherwise fit patients may be much slower to exhibit the signs and symptoms of an acute illness than may elderly patients with impaired cardiopulmonary function.

Patients seldom deteriorate abruptly, even though clinicians may recognize the deterioration suddenly

ASSESSING SEVERITY
How

sick is this patient? What physiological problem needs to be corrected now to prevent further deterioration of the patients condition?

Vital signs: pulse rate, RR, oxygenation, temperature, urine output Other spesific physiological variables ex: bacterial infection

The goal is to recognize that a problem exists and to maintain physiological stability while pursuing the cause and initiating treatment

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT

Phase I
Initial ContactFirst minutes (Primary Survey) What is the main physiological problem?

Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Structured examination of organ systems Resp system

Examination

Look, listen, feel (Basic elements) Airway

Breathing & Oxygenation

Circulation

CVS system
Abdomen & genitourinary tract

Level of consciousness

CNS & musculoskeletal system

Endocrine & hematological system

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT

Phase I
Initial ContactFirst minutes (Primary Survey) What is the main physiological problem?

Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? More detailed information

History

Main features of circumstances & environment Witnesses, relatives Main symptoms: pain, dyspnea, weakness Trauma or no trauma operative or nonoperative Medication or toxins

present complaint past history, chronic disease medication & allergies Family history systems review

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT

Phase I
Initial ContactFirst minutes (Primary Survey) What is the main physiological problem?

Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Case record and note keeping Examine medical record Formulate spesific diagnosis or DD Document current events

Chart review, documentation

Essential physiology, Vital Signs Heart rate, rhythm Blood pressure RR & pulse oximetry Level of consciousness

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT

Phase I
Initial ContactFirst minutes (Primary Survey) What is the main physiological problem?

Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Laboratory blood tests

Investigations

ABGs

Blood glucose

Radiology ECG

Microbiology

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT

Phase I
Initial ContactFirst minutes (Primary Survey) What is the main physiological problem?

Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Refine treatment, assess responses, review trends

Treatment

Proceed in parallel with the above

Ensure adeq airway & oxygen

Provide IV access, fluid Assess response to immediate resuscitation Call for more expirienced advice and assistance

Provide support for spesific organ systems as required

Choose most appropriate site for care Obtain specialist advice and assistance

ASSESSMENT OF AIRWAY

Causes of Obstruction Direct trauma, blood, vomitus, foreign body, CNS depression, laryngospasm, inflamation

Look

for

Cyanosis, altered respiratory pattern and rate, tracheal tug, altered level of consciousness Noisy breathing (stridor, wheezing, gurgling); complete obstruction results in silence

Listen for

Feel for

Decreased or absent airflow

ASSESSMENT OF BREATHING

Causes of inadequate breathing or oxygenation

CNS depression Depressed respiratory drive respiratory effort muscle weakness, spinal cord damage, pain, chest wall abnormalities Pulmonary disorders: pneumothorax, hemothorax, COPD, asthma, pulmonary edema

Look for

Cyanosis, altered RR and respiratory pattern, O2sat Dyspnea, inability to talk, auscultation breath sounds Symmetry and extent of chest movements, position of trachea, abdominal distension

Listen for

Feel for

ASSESSMENT OF CIRCULATION

Causes of Circulatory inadequacy

Primary (directly involving the heart): ischemia, arrhythmias, valvular disorders, cardiomyopathy, tamponade Secondary (pathology originating elsewhere): drugs, hypoxia, electrolyte disturbance, sepsis, blood loss

Look for

Coolness, pallor, hemorrhage, altered level of consciousness, dyspnea, urine output

Altered heart sounds Pulses (assessing rate, quality, regularity, symmetry

Listen for

Feel for

RESPIRATORY SIGNS
Respiratory arrest Threatened or obstructed airway Stridor, Intercostal recession, paradoxical breathing RR <8 or > 35x/min Respiratory distress: use of accessory muscles SpO2 < 90% on high concentration oxygen PaCO2 >52.5mmHg

CARDIOVASCULAR SIGNS
Cardiac arrest Pulse rate < 40 or >140x/min Systolic BP <100mmHg Poor peripheral perfusion Evidence of inadequate oxygen delivery metabolic acidosis, Hyperlactate Poor response to volume resuscitation Oliguria < 0.5cc/kg/hr (check urea, creatinine, K+)

NEUROLOGICAL SIGNS
Threatened or obstructed airway Absent gag or cough reflex Failure to maintain normal PaO2 and PaCO2 Failure to obey commands GCS <10 Sudden fall in level of consciousness (GCS by > 2 point) Repeated or prolonged seizures

Even normal vital signs may be early indicators of impending deterioration if they are changed from prior measurements Tachypnea is the single most important indicator of critical illness The presence of a metabolic acidosis is one of the most important indicators of critical illness

KEY POINT
The basic principles are summarized as the ABCs of resuscitating the severely ill patient- should proceed regardless of the situation The clinical history, physical examination and laboratory tests should aid in clarifying the diagnosis and determining the patients degree of physiological reserve It is particularly important to assess trends in patients vital sign and physiological parameters as they undergo treatment

KEY POINT
Early identification of a patient at risk is essential for preventing or minimizing critical illness The clinical manifestation of impending critical illness are often nonspesific. Tachypnea is one of the most imporatnt predictors of risk and signals the need for more detailed monitoring and investigation Resuscitation and physiological stabilization will often precede definitive diagnosis and treatment of the underlying cause

A detailed history is essential for making an accurate diagnosis, determining a patients physiological reserve, and establishing a patients treatment preferences Clinical and laboratory monitoring of a patients response to treatment is essential