Simple Way To Assess

Critically Ill Patients

Putu Andrika
JCCA
Introduction
• Unexpected in-hospital cardiac arrest is common and associated with
a high mortality rate.
• Previous studies have suggested that 66–84% of in hospital cardiac
arrests are preceded by at least one abnormal clinical observation.
• Traditionally, these observations are reported by nursing staff to
junior medical staff, leading to delays in evaluation and definitive
care.
• Early intervention may improve patient outcomes and failure to
recognised acute deterioration in patients may lead to increased
morbidity and mortality
R M Schein. Clinical antecedents to in-hospital cardiopulmonary arrest.
Chest. 1990 Dec;98(6):1388-92.

• We studied a group of consecutive general hospital ward patients developing

cardiopulmonary arrest.
• Sixty-four patients arrested 161±26 hours following hospital admission.
• Pathophysiologic alterations preceding arrest were classified as
respiratory in 24 patients (38 %),
metabolic in 7 (11 %),
cardiac in 6 (9 %),
neurologic in 4 (6 %),
multiple in 17 (27 %),
unclassified in 6 (9 %).
• Fifty-four patients (84% percent) had documented observations of clinical
deterioration or new complaints within eight hours of arrest.
• Michael Buist e al. Association between clinically abnormal observations and subsequent in-
hospital mortality: a prospective study. Resuscitation 62 (2004) 137–141
Who are Critically ill?
• Critical illness is any diseased process which cause physiological
instability leading to disability or death within minutes or hours.
• A critically ill patient is one at imminent risk of death
• The severity of illness must be recognized early and appropriate
measures taken promptly to assess, diagnose and manage the illness
• Timely recognition of warning signs from deteriorating patients and
proper treatment are important in improving patient safety.
• Identifying patients who are deteriorating or at risk of deterioration.
• The use of a physiological tracking and trigger systems to monitor all
patients in an acute hospital is recommended.
Using the ABCDE approach for all critically
unwell patients.

• Ian Peate. March 2021 Vol 15

No 2 British Journal of
Healthcare Assistants
• “Airway obstruction is an emergency:
get expert help immediately. If left
untreated, airway obstruction results in
hypoxia and can cause damage to the
brain, kidneys and heart, lead to cardiac
arrest and death can ensue”
You must look, listen and feel to
determine if the patient is
breathing.
● Is the patient diaphoretic (with
excessive, abnormal sweating)?
● Any signs of central cyanosis
(see Glossary)?
● Assess if the breathing is very
fast, very slow or very shallow
● Observe for increased work of
breathing: are the accessory
muscles of respiration being used?
● Is there nasal flaring?
● Observe chest wall movement: are
there any abnormalities?
● Listen and note abnormal breath
sounds (with severe wheeze,
there may
be no audible breath sounds
due to
severe airway narrowing)
● Listen to the chest: are the breath
sounds equal?
● Check for the absence of breath
sounds
on one side (unilaterally).
Look, listen and feel for signs of poor perfusion:
● Cool, moist extremities
● Delayed capillary refill
● Diaphoresis
● Low blood pressure
● Tachypnoea
● Tachycardia
● Absent pulses
● Oliguria (if a urinary catheter is in situ).
• There are a number of common causes of unconsciousness and these
include profound hypoxia, hypercapnia, cerebral hypoperfusion, or
the recent administration of sedatives or analgesic drugs.
• The ABCDE approach has been designed to ensure that life-
threatening conditions are identified and treated early, and that there
is an order of priority.
• If a problem is discovered as this stepwise approach is being
implemented, this problem must be addressed immediately, before
moving on to the next step.
The Early Warning Score (EWS)
• is a simple physiological scoring system suitable for bedside
application.
• The Early Warning Score (EWS) is a tool for bedside evaluation
based on five physiological parameters: systolic blood pressure,
pulse rate, respiratory rate, temperature and AVPU score.
The general scoring systems
• National Early Warning Score (NEWS),
• Modified Early Warning Score (MEWS),
• Between the Flags (BTF) criteria.
• The infection-targeted scoring systems were Quick Sequential Sepsis-
Related Organ Failure Assessment (qSOFA)
• Systemic Inflammatory Response Syndrome (SIRS) criteria.
• Vincent X e al. Comparison
of Early Warning Scoring
Systems for Hospitalized
Patients With and Without
Infection at Risk for In-
Hospital Mortality and
Transfer to the Intensive
Care Unit. JAMA Network
Open. 2020;3(5):e205191
Summary
• Critical illness is any disease process which causes physiological
instability leading to death within minutes or hours.
• Emergency warning score (EWS) systems are a simple, widely used
screening method for imminent patient deterioration, and are
becoming a standard of acute care.
• The severity of illness must be recognized as early as possible and
appropriate measures taken promptly to assess, diagnose and
manage the illness.