RECOGNITION AND ASSESSMENT OF THE SERIOUSLY ILL PATIENT

Suparto
Anesthesiology Departement UKRIDA

INTRODUCTION

“An ounce of prevention is worth a pound of cure”

Early identification of patients at risk for life-threatening illness makes it easier to manage them appropriately and prevent further deterioration.  The longer the interval between the onset of an acute illness and the appropriate intervention, the more likely it is that the patient’s condition will deteriorate, even to cardiopulmonary arrest.  Critical illness is often associated with


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Inadequate cardiac output Respiratory compromise Depressed level of consciousness

 Recognizing seriously ill patient usually is not difficult  Young and otherwise fit patients may be much slower to exhibit the signs and symptoms of an acute illness than may elderly patients with impaired cardiopulmonary function. “Patients seldom deteriorate abruptly. even though clinicians may recognize the deterioration suddenly” .

temperature. oxygenation. urine output Other spesific physiological variables ex: bacterial infection The goal is to recognize that a problem exists and to maintain physiological stability while pursuing the cause and initiating treatment . RR.ASSESSING SEVERITY  “How sick is this patient?”  “What physiological problem needs to be corrected now to prevent further deterioration of the patient’s condition?”   Vital signs: pulse rate.

listen.INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT Phase I Initial ContactFirst minutes (Primary Survey) What is the main physiological problem? Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Structured examination of organ systems • Resp system Examination Look. feel (Basic elements) • Airway • Breathing & Oxygenation • Circulation • CVS system • Abdomen & genitourinary tract • Level of consciousness • CNS & musculoskeletal system • Endocrine & hematological system .

weakness • Trauma or no trauma • operative or nonoperative Medication or toxins • present complaint • past history. relatives • Main symptoms: pain. chronic disease • medication & allergies • Family history • systems review .INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT Phase I Initial ContactFirst minutes (Primary Survey) What is the main physiological problem? Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? More detailed information History Main features of circumstances & environment • Witnesses. dyspnea.

rhythm • Blood pressure • RR & pulse oximetry • Level of consciousness .INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT Phase I Initial ContactFirst minutes (Primary Survey) What is the main physiological problem? Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Case record and note keeping • Examine medical record • Formulate spesific diagnosis or DD • Document current events Chart review. Vital Signs • Heart rate. documentation Essential physiology.

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT Phase I Initial ContactFirst minutes (Primary Survey) What is the main physiological problem? Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? • Laboratory blood tests Investigations • ABG’s • Blood glucose • Radiology • ECG • Microbiology .

INITIAL ASSESSMENT OF THE CRITICAL ILL PATIENT Phase I Initial ContactFirst minutes (Primary Survey) What is the main physiological problem? Phase II Subsequent Reviews (Secondary Survey) What is the underlying cause? Refine treatment. fluid • Assess response to immediate resuscitation • Call for more expirienced advice and assistance • Provide support for spesific organ systems as required • Choose most appropriate site for care • Obtain specialist advice and assistance . review trends Treatment Proceed in parallel with the above • Ensure adeq airway & oxygen • Provide IV access. assess responses.

complete obstruction results in silence Listen for   Feel for  Decreased or absent airflow . altered respiratory pattern and rate. CNS depression. altered level of consciousness Noisy breathing (stridor. tracheal tug. blood. foreign body. gurgling).ASSESSMENT OF AIRWAY  Causes of Obstruction  Direct trauma. wheezing. vomitus. laryngospasm. inflamation  Look   for Cyanosis.

pulmonary edema   Look for  Cyanosis. altered RR and respiratory pattern. pain. chest wall abnormalities  Pulmonary disorders: pneumothorax. abdominal distension  Listen for   Feel for  . COPD.ASSESSMENT OF BREATHING  Causes of inadequate breathing or oxygenation CNS depression  Depressed respiratory drive  ↓ respiratory effort  muscle weakness. O2sat Dyspnea. position of trachea. spinal cord damage. asthma. inability to talk. auscultation breath sounds Symmetry and extent of chest movements. hemothorax.

dyspnea. arrhythmias. pallor. cardiomyopathy. symmetry  Listen for   Feel for  . blood loss   Look for  Coolness. sepsis. electrolyte disturbance. hypoxia. tamponade  Secondary (pathology originating elsewhere): drugs. quality. regularity. ↓ urine output Altered heart sounds Pulses (assessing rate.ASSESSMENT OF CIRCULATION  Causes of Circulatory inadequacy Primary (directly involving the heart): ischemia. altered level of consciousness. hemorrhage. valvular disorders.

Intercostal recession. paradoxical breathing  RR <8 or > 35x/min  Respiratory distress: use of accessory muscles  SpO2 < 90% on high concentration oxygen  PaCO2 >52.5mmHg  .RESPIRATORY SIGNS Respiratory arrest  Threatened or obstructed airway  Stridor.

CARDIOVASCULAR SIGNS Cardiac arrest  Pulse rate < 40 or >140x/min  Systolic BP <100mmHg  Poor peripheral perfusion  Evidence of inadequate oxygen delivery  metabolic acidosis. Hyperlactate  Poor response to volume resuscitation  Oliguria < 0. creatinine. K+)  .5cc/kg/hr (check urea.

NEUROLOGICAL SIGNS Threatened or obstructed airway  Absent gag or cough reflex  Failure to maintain normal PaO2 and PaCO2  Failure to obey commands  GCS <10  Sudden fall in level of consciousness (GCS by > 2 point)  Repeated or prolonged seizures  .

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“Even normal vital signs may be early indicators of impending deterioration if they are changed from prior measurements” “Tachypnea is the single most important indicator of critical illness” “The presence of a metabolic acidosis is one of the most important indicators of critical illness” .

KEY POINT The basic principles are summarized as the ABC’s of resuscitating the severely ill patient.should proceed regardless of the situation  The clinical history. physical examination and laboratory tests should aid in clarifying the diagnosis and determining the patient’s degree of physiological reserve  It is particularly important to assess trends in patients vital sign and physiological parameters as they undergo treatment  .

KEY POINT Early identification of a patient at risk is essential for preventing or minimizing critical illness  The clinical manifestation of impending critical illness are often nonspesific. Tachypnea is one of the most imporatnt predictors of risk and signals the need for more detailed monitoring and investigation  Resuscitation and physiological stabilization will often precede definitive diagnosis and treatment of the underlying cause  .

and establishing a patient’s treatment preferences  Clinical and laboratory monitoring of a patient’s response to treatment is essential  . determining a patient’s physiological reserve.A detailed history is essential for making an accurate diagnosis.