Download Assessment of the Critically Ill Patient

Assessment of the Critically Ill
Patient
Dr Sattam Alenezi
ED consultant
Learning outcomes:
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Identify the correct sequence of priorities in
assessing the critically ill patient.
State why it is important to have a systematic
approach to assessment and care, with rational for
each step.
Identify clinical situations in which a patient’s
condition may become compromised.
Demonstrate safe and effective assessment and care
of the critically ill patient using a systematic
approach.
Introduction
Healthcare workers should be competent
in undertaking a systematic and
comprehensive approach to patient
assessment to enable early recognition of
potential or actual deterioration in the
patient’s condition.
(DOH, 2001)
Facts
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Patients admitted from the wards to ICU
when compared to those admitted from A&E
have a higher percentage mortality (Goldhill,
2001).
Nearly 80% of hospital inpatients who
experience a cardiorespiratory arrest have
documented observations of deterioration in
the 8hours before the arrest (Bristow et al
2000)
The 3 key stages of recognition and
treatment of a critically ill patient:
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Understanding that an emergency
exists
Identifying and prioritising
problems.
Action and evaluation
Underlying principles
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1. Use a systematic approach, based on
airway, breathing and circulation (i.e.,
the ABCDEs) to assess and treat the
acutely ill patient.
2. Undertake a complete initial
assessment and re-assess regularly.
3. Always assess the effects of
treatment or other interventions.
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4. Always correct life-threatening
abnormalities before moving on to the
next part of assessment.
5. Recognize the circumstances when
additional help is required and ask for it
early.
6. Use all members of the
multidisciplinary team.
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7.Communicate effectively.
8. The underlying aim of the initial
interventions should be seen as
a“holding measure” that keeps the
patient alive, and produces some
clinical improvement, in order that
definitive treatment may be initiated.
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9. Remember that it often takes a few
minutes for resuscitative measures to
have an effect.
Patient Assessment Systems
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Basic Life support (BLS)
Advanced cardiac Life Support (ACLS)
The Advanced Trauma Life Support
(ATLS) .
What about paediatric ( PALS) and
neonates (NRP)?
All of these assessment systems use a
systematic approach in a strict order:
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A: airway (with C-spine protection in trauma)
B: breathing
C: circulation
D: deficits in neurological status
E: environment (exposure)
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Ask the patient a simple question. In assessing any patient,
a simple question such as “How are you” can provide
valuable information.
A normal verbal response implies that the patient has a
patent airway, is breathing and has brain perfusion.
If the patient can only speak in short sentences, they may
have extreme respiratory distress.
Failure of the patient to respond is a clear marker of
serious illness.
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Use vital signs monitoring early.
Apply a pulse oximeter.
ECG monitor
Continuous non-invasive blood
pressure monitor to all critically ill
patients, as soon as is safely possible.
Airway
How do we assess airway and
why?
Airway (A)
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Treat airway obstruction as a medical
emergency and obtain expert help
immediately.
Untreated, airway obstruction leads to
a lowered PaO2 and risks hypoxic
damage to the brain, kidneys and heart,
cardiac arrest, and even death.
Look for the signs of airway obstruction.
 The use of the accessory muscles of
respiration.
 Central cyanosis is a late sign of airway
obstruction.
 In the critically ill patient, depressed
consciousness often leads to airway
obstruction.
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In the majority of cases, simple methods of
airway clearance are all that are required
(e.g., airway opening maneuvers, airways
suction, insertion of an oropharyngeal or
nasopharyngeal airway).
Tracheal intubation may be required, where
simple airway opening measures fail.
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Give oxygen at high concentration.
Breathing
Why do we assess breathing and how
do we carry out a comprehensive
respiratory assessment?
Breathing (B)
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During the immediate assessment of
breathing, it is vital to diagnose and treat
immediately life-threatening conditions as :
Acute severe asthma
Pulmonary oedema.
Tension pneumothorax.
Massive haemothorax.
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Look for the general signs of respiratory
distress:
Sweating.
Central cyanosis.
Use of the accessory muscles of
respiration.
Abdominal breathing.
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Count the respiratory rate. The normal
rate is between 12 and 20 breaths per
minute.
High rates, and especially increasing
rates, are markers of illness and a
warning that the patient may suddenly
deteriorate.
Assess the depth of each breath, the
pattern (rhythm) of respiration and
whether chest expansion is equal on both
sides.
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Note any chest deformity .
Look for a raised JVP (e.g., in acute
severe asthma or a tension
pneumothorax).
Note the presence and patency of any
chest drains;
Abdominal distension may limit
diaphragmatic movement, thereby
exacerbating respiratory distress.
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Listen to the patient’s breath sounds.
Percuss the chest; hyper-resonance
suggests a pneumothorax, dullness
suggests consolidation or pleural fluid.
Auscultate the chest:
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The quality of the breath sounds should
be evaluated.
Bronchial breathing indicates lung
consolidation.
Absent or reduced sounds suggest a
pneumothorax or pleural fluid.
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Check the position of the trachea in the
suprasternal notch.
Deviation to one side indicates
mediastinal shift (e.g., pneumothorax,
lung fibrosis or pleural fluid).
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Palpate the chest wall to detect surgical
emphysema or crepitus (suggesting a
pneumothorax until proven otherwise).
Circulation
What is the significance of circulation
and how do we assess the patient?
Circulation (C)
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Consider Hypovolaemia to be the
primary cause of shock, until proven
otherwise.
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Look at the colour of the hands and
digits: are they blue, pink, pale or
mottled?
Assess the limb temperature by feeling
the patient’s hands: are they cool or
warm?
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Measure the capillary refill time
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Count the patient’s pulse rate.
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Palpate all the peripheral and central
pulses, assessing for presence,rate,
quality, regularity and equality.
Low volume palpable pulses suggest a
poor cardiac output, whilst a bounding
pulse may indicate sepsis.
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Measure the patient’s blood pressure.
A low diastolic BP suggests arterial
vasodilatation (as in anaphylaxis or sepsis).
A narrowed pulse pressure (difference
between systolic and diastolic pressures;
normally ~ 35-45 mmHg) suggests arterial
vasoconstriction (cardiogenic shock or
hypovolaemia).
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Auscultate the heart.
Look for other signs of a poor cardiac
output, such as reduced level of
consciousness and, if the patient has a
urinary catheter, oliguria (urine volume
< 0.5 ml kg-1 hour-1).
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Examine the patient thoroughly for
external haemorrhage from wounds or
drains or evidence of concealed
haemorrhage (e.g., thoracic,
intraperitoneal or into gut).
Central Venous Pressure
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Involves insertion of a line to a major vein e.g.
subclavian, internal jugular under full aseptic technique.
It is a direct measurement of pressure within the right
atrium.
Readings should not be used in isolation, but as part of
full haemodynamic assessment.
Used as a guide in fluid replacement.
Used to establish deficits in blood volume.
Used for drug administration, maintaining nutrition
(TPN)
Deficits in neurological status &
environment (exposure)
How will you assess neurological status
and environment?
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Disability (D)
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Common causes of unconsciousness
include profound hypoxaemia,
hypercapnia, cerebral hypoperfusion, or
the recent administration of sedatives
or analgesic drugs.
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Examine the pupils (size, equality and
reaction to light).
Assess the patient’s conscious level
using either the AVPU or Glasgow Coma
Scales.
Measure the blood glucose.
Exposure / Examination (E)
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In order that patients are examined
properly, and detail is not missed, full
exposure of the body may be
necessary. Do this in a way that
respects the dignity of the patient and
prevents heat loss.
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Take a full clinical history from the
patient, his relatives or friends, and
other staff.
Review the patient notes and charts
Study both absolute and trended
values of vital signs.
Check that important routine
medications are prescribed and being
administered.
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Review the results of laboratory or
radiological investigations.
Consider which level of care is required
by the patient (e.g., ward, HDU, ICU).
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Consider definitive treatment of the
patient’s underlying condition.