Assessment of Critically Ill Patient

Embed Size (px)

Citation preview

  • 8/6/2019 Assessment of Critically Ill Patient

    1/5

    Paglinawan, Daryl O.

    BSN IV - 5

    Assessment and treatment of the acutely ill

    We may be confronted at any time with a sick patient. This may happen in thecommunity, in the Emergency Room, in a ward or a clinic, in the intensive care unit.This module aims to give you the bones of an approach which can be applied whateverthe situation, whatever the diagnosis.

    Some advice

    To paraphrase Captain Barbosa: "these are more rules than guidelines"

    General rules

    If you are responsible for a sick patient go and see him/herFive seconds critically looking at a patient is worth twenty minutes talking about them onthe phone

    Oxygen is good for you and your patient: the vast majority of sick patients will benefitfrom high concentration oxygen so give them it ! The correct amount is enough

    In parallel with the patient being resuscitated and stabilised, someone should be gettinga full history eg from relatives, paramedics, GP, ward staff. Delay in doing this can resultin serious morbidity and occasionally mortality as delay in definitive treatment mayresult. Most likely in vascular events (ie thrombosis or bleeds)

    Any IV access is better than none (for fluids and drugs)

    If there is a cannula already in place, make sure it works

    Avoid the ante-cubital fossa for iv access except as a last resortDo a blood gas, Hb, K+, glucose and lactate on any sick patient. Base deficit may alertyou to how sick they are

    If you're not sure what is wrong with the patient could they have sepsis? Obtain culturesincluding blood cultures. Identifying sepsis early

    If the patient isn't improving despite your treatment consider:

    1. Calling for help

    2. Is the diagnosis correct ?

    3. Is this patient sick enough to require Intensive Care transfer? common reasons forICU referral

    4. Is there something else going on? ie a second diagnosis or a complication of theoriginal diagnosis or its therapy.

  • 8/6/2019 Assessment of Critically Ill Patient

    2/5

    Initial approach

    'Advanced first aid'

    A = Airway assess and manage

    B = Breathing assess and manage + O2 therapy

    C = Circulation assess and manage + IV access & blood tests

    D = Disability assessment (what's the glucose ?)

    E = Evidence, environment, examination (targeted)

    F = Frequent re-assessment and establish monitoring

    As you walk up to the patient and introduce yourself shake hands and ask "howare you doing ? " Immediately (ie within 5 seconds) you will have assessed airway (theycan/can't talk, noises eg stridor, snoring/gurgling, none), breathing (rate, symmetry,work of breathing: accessory muscle use, paradoxical or see-saw pattern), circulation(warm/cold peripheries) and conscious level (their response to you). In this short timeyou should be thinking " can I take some time to assess or should I ?"

    a) start treatmentb) call for helpc) both a and b

    A & B for Airway and Breathing

    y The earliest, most sensitive feature of developing severe illness is an increasedrespiratory rate: look, count, respond.

    y Increased work of breathing due to increased respiratory rate and excessiverespiratory muscle activity causes oxygen consumption to increase (often tenfold) at the same time as oxygen delivery is compromised .

    y Give supplemental oxygen and consider how we can reduce the effort ofbreathing eg salbutamol for wheeze, nitrates for LVF). Sometimes the work ofbreathing is so high that the patient requires intubation and ventilation to reducethis work and divert oxygen delivery to vital organs.

    C forCirculation

    y If the patient is speaking to you they must have a carotid pulse. Feel for the radialand if it is thready or absent that gives qualitative information on the state of thecirculation. Blood pressure measured non-invasively by oscillotonometry mightbe inaccurate. Consider performing a manual BP with a sphygmomanometer.

  • 8/6/2019 Assessment of Critically Ill Patient

    3/5

    The need for invasive blood pressure monitoring (reliable, real time, accurate)should precipitate early Intensive Care transfer.

    y Secure or ensure vascular access. Any working cannula is worthwhile. If you aregiving drugs or slow IV fluids an 18 gauge cannula is fine. If you need to rapidlyinfuse fluid or blood larger cannulae are needed.

    y

    If the patient is shut down this may be difficult to achieve. This is another reasonfor early Intensive Care referral. Insert any size of cannula and call for help. An 8F line inserted in the femoral vein can be achieved quickly by a skilled operatorand is excellent for rapid volume resuscitation in many cases. Insertion of acentral venous cannula at this stage is not usually a priority; get good bigperipheral access and an arterial line in first.

    y If there is good flow from your iv cannula take blood for immediate investigations.If flow is sluggish don't compromise the cannula by trying to get blood samples,do a venepuncture. In any patient where volume resuscitation is a priority(hypovolaemia, haemorrhage, sepsis) send blood for cross matching.

    y Rapid infusion can be facilitated by the use of pressure infusors and in major fluid

    resuscitation the early application of a fluid warmer reduces coagulopathy andthe development of hypothermia.

    y As you infuse fluids the haemoglobin will fall due to haemodilution (even if thepatient is not bleeding). The optimisation of tissue oxygen delivery is pivotal tomanagement (this will be explained further under the heading "equations of life").

    Immediate investigationsArterial blood gases: O2, CO2, acid-base

    Potassium

    Glucose

    Haemoglobin

    Lactate*12 lead ECG

    CXR

    Blood cultures, if sepsis is suspected

    Specific targeted testsAbnormalities in the investigations in bold destabilise the patient and are all amenable

    to direct intervention. *Elevated lactate and base deficit worse than -4 correlates withsevere illness

    D for Disability

    y In the ABCDE system this is usually labelled 'disability'. This is a bit naff as itreally means 'central nervous system function'. Assess the GCS or AVPU score,check the pupils for symmetry, size and reactivity and quickly assess limbfunction.

  • 8/6/2019 Assessment of Critically Ill Patient

    4/5

    AVPU Score

    A V Responds to verbal stimulus

    P Responds to painful stimulusU Unresponsive

    A letter is assigned based on the patient's best response. E.g. AVPU score of V meansthe patient responds to verbal stimulus such as calling his name.

    DEFG: in any confused patient or patient with reduced consciouslevel Don't EverForgetGlucose. Hypoglycaemia is a common cause of reduced level ofconsciousness (usually insulin or drug induced) . Hypoglycemia can be caused bysevere sepsis; this is a poor prognositic indicator.

    y If the patient is hypoglycaemic but hasn't taken exogenous insulin or oralhypoglycaemic agents consider:

    o liver failure (check prothrombin ratio, another dynamic monitor of hepaticsynthetic function)

    o hypoadrenalism (Addison's disease).

    E for Exposure, Examination, and review of Evidence

    y In the standard scheme derived from Advanced Trauma Life Support this isexposure to look for important injuries. Although this is relevant in that context wewould suggest that E is for targeted secondary Examination, review of Evidence(notes, drug/ fluid/observation charts) and Environment (what is the patientattached to ? eg iv infusions such as GTN in the hypotensive patient, epiduralinfusions or PCA pumps in the post-operative patient and so on).

    F for Frequent examination and establish monitoring

    y It is often important to examine the patient more than once to assess the severityof illness (is the patient improving or getting worse?). Use of appropriate non-invasive or invasive monitors should be considered. A central line, for example,will allow us to assess the circulation's response to a fluid challenge.

    y Worsening of the patient's condition despite appropriate treatment might be anindication for early transfer to ICU.

    Important

    y At the same time as ABCDEF assessment and treatment are proceedingimmediate monitoring with ECG and pulse oximetry should be established andconsideration should be given to whether invasive monitoring is required. Thinkabout the definitive diagnosis and treatment.This ABCDE approach is grounded in what we might call 'the equations of life'.These delineate the physiology which keeps us alive from minute to minute andthis will be considered in more detail throughout the specific modules. However itis appropriate to introduce them here.

  • 8/6/2019 Assessment of Critically Ill Patient

    5/5

    The equations of life

    y MAP = CO x SVR

    Mean arterial pressure = cardiac output x systemic vascular resistance

    Blood pressure is the product of flow and peripheral resistance

    y CO = HR x SV

    Cardiac output is the product of heart rate and stroke volume. Stroke volume relies onpreload (mainly influenced by venous return and circulating blood volume), afterload(SVR) and cardiac muscle contractilty.

    y DO2 = CO x CaO2

    DO2 is oxygen delivery, the amount of oxygen leaving the left ventricle (and delivered to

    the respiring tissues in health) which is the product of blood flow and the amount ofoxygen in the blood. In most situations this depends on the amount of haemoglobin andthe level of oxygen linked to it (Oxy-haemoglobin concentration). In shock and otheracute conditions this system is disrupted eg in sepsis oxygenated blood is mal-distributed in the micro-circulation resulting in impaired oxygen consumption.

    y VO2 = CO x (CaO2 - CvO2)

    VO2 is oxygen consumption which is flow weighted (related to cardiac output) andreflects the amount of oxygen utilised throughout the body (the oxygen contentdifference in arterial and mixed venous ie pulmonary arterial blood). In the acutely ill

    patient we should be aiming to reduce oxygen consumption as well as optimisingoxygen delivery and this will be covered in detail in the appropriate modules.