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 the community, 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 whatever the 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/her Five seconds critically looking at a patient is worth twenty minutes talking about them on the phone Oxygen is good for you and your patient: the vast majority of sick patients will benefit from high concentration oxygen so give them it ! The correct amount is enough In parallel with the patient being resuscitated and stabilised, someone should be getting a full history eg from relatives, paramedics, GP, ward staff. Delay in doing this can result in serious morbidity and occasionally mortality as delay in definitive treatment may result. 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 resort Do a blood gas, Hb, K+, glucose and lactate on any sick patient. Base deficit may alert you to how sick they are If you're not sure what is wrong with the patient could they have sepsis? Obtain cultures including 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 for ICU referral 4. Is there something else going on? ie a second diagnosis or a complication of the original diagnosis or its therapy.

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 "how are you doing ? " Immediately (ie within 5 seconds) you will have assessed airway (they can/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 time you should be thinking " can I take some time to assess or should I ?" a) start treatment b) call for help c) both a and b A & B for Airway and Breathing y y The earliest, most sensitive feature of developing severe illness is an increased respiratory rate: look, count, respond. Increased work of breathing due to increased respiratory rate and excessive respiratory muscle activity causes oxygen consumption to increase (often ten fold) at the same time as oxygen delivery is compromised . Give supplemental oxygen and consider how we can reduce the effort of breathing eg salbutamol for wheeze, nitrates for LVF). Sometimes the work of breathing is so high that the patient requires intubation and ventilation to reduce this work and divert oxygen delivery to vital organs.

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

The need for invasive blood pressure monitoring (reliable, real time, accurate) should precipitate early Intensive Care transfer. Secure or ensure vascular access. Any working cannula is worthwhile. If you are giving drugs or slow IV fluids an 18 gauge cannula is fine. If you need to rapidly infuse fluid or blood larger cannulae are needed. If the patient is shut down this may be difficult to achieve. This is another reason for early Intensive Care referral. Insert any size of cannula and call for help. An 8 F line inserted in the femoral vein can be achieved quickly by a skilled operator and is excellent for rapid volume resuscitation in many cases. Insertion of a central venous cannula at this stage is not usually a priority; get good big peripheral access and an arterial line in first. 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. 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 and the development of hypothermia. As you infuse fluids the haemoglobin will fall due to haemodilution (even if the patient is not bleeding). The optimisation of tissue oxygen delivery is pivotal to management (this will be explained further under the heading "equations of life").

Immediate investigations Arterial blood gases: O2, CO2, acid-base Potassium Glucose Haemoglobin Lactate* 12 lead ECG CXR Blood cultures, if sepsis is suspected Specific targeted tests Abnormalities in the investigations in bold destabilise the patient and are all amenable to direct intervention. *Elevated lactate and base deficit worse than -4 correlates with severe illness

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

AVPU Score A Alert V Responds to verbal stimulus P Responds to painful stimulus U Unresponsive A letter is assigned based on the patient's best response. E.g. AVPU score of V means the patient responds to verbal stimulus such as calling his name. DEFG: in any confused patient or patient with reduced conscious level Don't Ever ForgetGlucose. Hypoglycaemia is a common cause of reduced level of consciousness (usually insulin or drug induced) . Hypoglycemia can be caused by severe sepsis; this is a poor prognositic indicator. y If the patient is hypoglycaemic but hasn't taken exogenous insulin or oral hypoglycaemic agents consider: o liver failure (check prothrombin ratio, another dynamic monitor of hepatic synthetic 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 is exposure to look for important injuries. Although this is relevant in that context we would suggest that E is for targeted secondary Examination, review of Evidence (notes, drug/ fluid/observation charts) and Environment (what is the patient attached to ? eg iv infusions such as GTN in the hypotensive patient, epidural infusions 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 severity of illness (is the patient improving or getting worse?). Use of appropriate noninvasive or invasive monitors should be considered. A central line, for example, will allow us to assess the circulation's response to a fluid challenge. Worsening of the patient's condition despite appropriate treatment might be an indication for early transfer to ICU.

Important y At the same time as ABCDEF assessment and treatment are proceeding immediate monitoring with ECG and pulse oximetry should be established and consideration should be given to whether invasive monitoring is required. Think about 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 and this will be considered in more detail throughout the specific modules. However it is appropriate to introduce them here.

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 on preload (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 of oxygen in the blood. In most situations this depends on the amount of haemoglobin and the level of oxygen linked to it (Oxy-haemoglobin concentration). In shock and other acute conditions this system is disrupted eg in sepsis oxygenated blood is maldistributed 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) and reflects the amount of oxygen utilised throughout the body (the oxygen content difference 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 optimising oxygen delivery and this will be covered in detail in the appropriate modules.