Assessment and Stabilisation Critically Ill Patient

7/31/2019 Assessment and Stabilisation Critically Ill Patient

1/18

Assessment and Stabilisation of aCritically Ill Patient

Dr.S. VashishtDept.of Anaesthesia

Hillingdon Hospital


2/18

Assessment

Traditional history taking & examination is

inappropriate

Assessment and stabilisation should proceed

simultaneously

Priority given to detection of potentially lifethreatening conditions

Life saving measures must be institutedrapidly


3/18

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 withoutgetting breathless?

C - Is the patient perfusing his brainadequately? Can this patient comprehend & respond

appropriately to questions?


4/18

Assessing Airway Patency

Look for- Foreign bodies,secretions,blood in oropharynx

Obstruction of the pharynx by the tongue Use of accessory muscles of respiration

Chest expansion

Paradoxical breathing

Listen for-

Abnormal upper airway sounds (stridor,gurgling) If airway obstruction is complete, breath sounds will be

absent

Feel for- Expired air


5/18

Assessing Breathing

Look for- Cyanosis

Respiratory rate, pattern and depth

Equality of chest expansion

SpO2 in the context of the FiO2

Listen for- Wheeze,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


6/18

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


7/18

Disability

Rapid assessment of the patients neurological statusinvolves

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


8/18

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 adminiterinotropes

Nasogastric tube

Urinary catheter to monitor hourly output


9/18

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 mostsensitive

A score of > 3requires urgent medical review

Have been incorporated into a call out cascade tofacilitate urgent medical review


10/18


11/18

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


12/18

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


13/18

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


14/18

Specific Criteria For ICU Referral(contd)

Neurological Repeated or prolonged seizures

Decreasing conscious level sufficient to compromise theairway 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


15/18

Respiratory Support in ICU

Patients may be referred with

Hypoxemia

Ventilatory failureTreatment 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


16/18

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)


17/18

Support of Other Organ Systems

Renal

May require haemofiltration to deal with fluid and electrolyteimbalance

Neurological

Treat fits, reduce intracranial pressure

Haematological

Correct coagulation defects with platelets, FFP

Nutritional

Total parenteral nutrition

Enteral feeding


18/18

The Postoperative Patient in ICU

Surgery produces a temporary but predictablephysiological stress on the cardiovascular &

respiratory system which may need to besupported 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

Documents

Assessment and Stabilisation Critically Ill Patient