INITIAL ASSESSMENT OF CRITICALLY ILL

PATIENTS

PROF.DR.NIBEDITA PANI

HOD,DEPT.OFANAESTHESIOLOGY

AND CRITICAL CARE,SCBMCH

AND

DR.PRERNA BISWAL,SCBMCH

audio

OUR CASE

52 years old male was admitted in our CICU with

C/C- severe breathlessness and sweating for last 5 hours.

DEFINITION OF CRITICALLY ILLCritical illness is any disease process which

causes 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.

NEED FOR ICU???

To provide appropriate care, specialized knowledge ,skills and the care delivery mechanisms needed to evolve to support the patients' needs for continuous monitoring and treatment.

Clinical observationsAppearance Neurological Respiratory Cardiovascular

Normal AlertCooperative

NormalRR >8 <20 b/min pattern

HR 60–100b/minSBP > 90 mmHgUO > 0.5 ml/kg/hr

SweatyPaleAnxious

AgitationConfusionEyes open to voice only

Accessory muscle use RR < 8 b/min RR 20–30 b/min

HR > 100 b/minSBP < 90mmHgUO < 0.5 ml/kg/hr

GreyBlueMottled skin

Unresponsive or eyesopen to pain onlyFitting

Silent chestRR < 8 > 30 b/minAgonal respirations

HR < 50 b/minHR > 150 b/minSBP < 60 mmHg

Cardiac arrest or death

Patientcategory

Not critically ill

Potential criticalillness

Critically ill

SWEATY CONFUSEDACCESSORY MUSCLE USE

RR-30/MIN HR>120/MIN

CRITERIA FOR ICU ADMISSION Critically ill patients in a medically unstable state

(monitoring and treatment). Patients requiring intensive monitoring who may also

require emergency interventions. Patients who are medically unstable or critically ill and

who do not have much chance for recovery due to the severity of their illness .

Patients who are generally not eligible for ICU admission because they are not expected to survive.

PHILOSOPHY OF MANAGEMENT

Outcome in ICU is predominantly determined by initial management of patient at risk of life threatening illness.

“TIME IS TISSUE”

So a prompt and protocolized resusucitation regimen helps in salvaging these patients.

ASSESSMENT AND MANAGEMENT SHOULD GO HAND IN HAND

PRIORITIES

1. Prompt resuscitation & adhering to advanced life support guidelines

2. Urgent treatment of life threatening emergencies such as hypotension, hypoxaemia , hyperkalaemia, hypoglycaemia and dysrhythmias

3. Analysis of the deranged physiology

4. Establish a complete diagnosis as history & further diagnostic results are available

5. Careful monitoring of the patient’s condition and response to treatment

What are the steps to be followed?

1. Initial assessment 2. Immediate management 3. Monitoring 4. Initial investigations

OUR CASE – ON EXAMINATION52-years-old male in acute respiratory distress Vitals : Temp. 98.8F, HR 120 bpm & regular, RR -

30pm, BP 140/90 mmhg. He had no cyanosis and clubbing, JVP-Not raised He was drowsy but easily arousable, orientedOn auscultation, breath sound was diminished

bilaterally, Ronchi throughout bilateral lung fields, on percussion hyper resonant lung field.

STEP 1:ASSIGN RESPONSIBILITIES

Quickly make a team and assign job responsibilities to every member clearly and appropriately.

Initially patient should be seen by a senior intensivist for initial resuscitation, management, planning and family briefing.

STEP 2: START INITIAL ASSESSMENT AND RESUSCITATION

Correcting physiological abnormalities should take precedence over arriving at an accurate diagnosis.

For patients in cardio-respiratory arrest follow ACLS protocol.

For hemodynamically unstable patients assessment and management should be simultaneous as per the clinical clusters “A B C”

LOOK LISTEN AND FEEL

INTUBATE

BRONCHODILATORS

REMOVE FB/ INTUBATE

SUCTIONING

INSERT ORAL / NASOPHARYNGEALAIRWAY

SNORING – UPPER AIRWAY OBSTRUCTION BY TONGUE OR SOFT TISSUE

GURGLING- UPPER AIRWAY OBSTRUCTION BY LIQUID STRIDOR- OBSTRUCTION BY FOREIGNBODY OR STENOSIS OF UPPER AIRWAY

WHEEZE- SPASM OF SMALL AIRWAYS

SILENT- COMPLETE AIRWAY OBSTRUCTION

NEED FOR DEFINITIVE AIRWAY BY ENDO-TRACHEAL INTUBATION OR ADJUNCTS LIKE- AIRWAY, SUPRA-LARYNGEAL DEVICES ORSURGICAL AIRWAY SHOULD BE BASED ON CLINICAL ASSESSMENT

“A”- AIRWAY

“B”- BREATHING Clinical assessment of ventilation and oxygenation (with adjuncts)

Clinical presentation of inadequate oxygenation is a late feature of respiratory failure and imply impending cardio-respiratory arrest. Patient needs to be identified much earlier and appropriate management be instituted.

C/F of Respiratory Distress:1. Breathlessness2. Tachypnea3. Inability to talk4. Open mouth breathing5. Flaring of alae nassi6. Paradoxical breathing7. Use of accessory muscles

Respiration

C/F of Inadequate oxygenation:1. Restlessness2. Delirium3. Drowsiness4. Cool extremities5. Cyanosis6. Tachycardia7. Arrhythmia8. Hypotension

Adjuncts- Pulse Oximetry, ABG

“B”- BREATHING(contd...)ETIOLOGIES TO BE KEPT IN MIND:-

– Tension Pneumothorax– Pleural Effusion or Hemothorax– Flail chest

Indications for intubation and mechanical ventilation:-– GCS < 8– Severe hemodynamic instability– Severe respiratory depression

Non invasive ventilation tried in relatively stable patients

“C”- CIRCULATIONAssessment of adequacy of circulation

– Peripheral and central pulse(rate, rhythm, volume, symmetry)

– Skin temperature– Heart rate– Blood pressure– Capillary refill– JVP– Urine output

Advanced monitoring- bedside ECHO, CVP , IBP, Cardiac Output.

JUDICIOUS USE OF VOLUME,IONOTROPES AND VASOPRESSORS

TREAT ACCORDING TOCAUSE

BROAD SPECTRUM ANTI-BIOTICS AND RESUSCITATION

URGENT CONTROL OF HYPERTENSION AND HEART RATE

URGENT ANTI-COAGULATION THEN INVESTIGATION

IMMEDIATE PERICARDIOCENTESISPERICARDIAL TAMPONADE-

HEMODYNAMIC INSTABILITY

PULMONARY EMBOLISM-

AORTIC DISSECTION-

SEPSIS AND SEPTIC SHOCK

SHOCK- HYPOVOLEMIC, CARDIOGENIC, SPINAL

MANAGEMENT OF CIRCULATION

“D”- DISABILITY

TREAT ACCORDING TOCAUSE AFTER APPROPRIATE CONTROL

URGENTANTI-BIOTICS

URGENT CONTROL

SYSTEMIC DISEASE

S/O NEUROLOGICAL DISEASE

LATERALISING SIGNS LIKE HEMIPLEGIA

DEPRESSED CONCSCIOUS LEVELIN ABSENCE OF PRIMARY NEUROLOGICAL DISEASE

HYPOGLYCEMIA

BACTERIAL MENINGITIS

SEIZURES

STEP-3 TAKE FOCUSED HISTORY INFORMANT- PATIENT OR RELATIVES

CHIEF COMPLAINS- CHRONOLOGICAL ORDER

HISTORY OF PRESENT ILLNESS- ELABORATION OF CHIEF COMPLAINS, ASSOCIATED PROBLEMS, INDICATION TOWARD A DIFFERENTIAL DIAGNOSIS.

PAST HISTORY- COMORBIDITIES, PREVIOUS SURGERY, HOSPITALIZATION

PERSONAL HISTORY- ADDICTION ALLERGY HISTORY

TREATMENT HISTORY & HANDOVER HISTORYPATIENTS RESUSCITATION STATUS AS PER

FAMILY’S WISH

HISTORY- OUR CASE

HOPI-Inability to do daily activities as he becomes short of breath for last one year.

PH-Stage 1 COPD 4 years back , is not diabetic or hypertensive but he suffered from bronchitis with upper respiratory infection for 3 times last year

T/T History-salmetarol+Fluticasone Personal History- He was a smoker and used to smoke 1

packet per day for 30years(30 pack year) and has quit for 1year.

STEP 4- PERFORM FOCUSED PHYSICAL EXAMINATION

VITALS-BP,PULSE,TEMP,RESPIRATION

EXAMINE FOR PALLOR,CYANOSIS,JAUNDICE,

CLUBBING,PEDAL EDEMA EXAMINE SKIN FOR

RASH,PETECHIAE,URTICARIA,ESCHAR. EXAMINE ALL ORGAN SYSTEMS SYSTEMATICALLY

REPEAT EXAMINATIONS FREQUENTLY FOR NEW FEATURES OR MISSED FINDINGS

IN NEUROLOGICAL PATIENTS,GCS NEEDS TO BE ASSESSED FREQUENTLY

STEP 4- PERFORM FOCUSED PHYSICAL EXAMINATION cont...

PATIENTS SHOULD BE FULLY EXPOSED WITH PRIVACY DURING INITIAL EXAMINATION.

WARNING FEATURES OF SEVERE ILLNESS

SBP<90 OR MAP<60 MM HGGCS<12PR>150 OR <50 BPMRR >30 OR<8/MINUO<0.5 ML/KG/HR

STEP 5-SEND BASIC INVESTIGATIONS

Send screening investigations during initial resuscitation

CBC, blood sugar ,electrolytes, urea, creatinine,

LFT, coagulation profile, ABG, Lactate Level in sepsis patients-initial investigations

Chest x-ray,12 lead ECGAppropriate microbiology culturesFurther investigations as per history and

examination

STEP 5 FOR OUR CASEA chest radiograph showed hyper inflated lung

field, low and almost flat diaphragm,tubular heart.ABG showed pH; 7.30, PO2; 62, mmhg PCO2:

64 mm hg HCO3: 29. mmol/lNormal ECG

STEP 5-SEND BASIC INVESTIGATIONS contd... In unstable patients investigations should be performed at

bedside as much as possible To transport outside ICU, patients should be accompanied

by qualified personnel. Red flag investigations that require immediate corrective

actions

•Blood sugar<80 mg/dl•Sodium <120 or >150 Meq/l•Potassium<2.5 or > 6 Meq/l•pH<7.2•sPo2<90%•Bicarbonate <18 mmol/l

STEP 6-RECOGNISE THE PATIENT AT RISK

Special precautions in following groupsElderly and immuno-compromised(may not

show features of decompensation)Polytrauma patients(multiple injuries,

distracting pain)Young adults(decompensation is late due to

physiological reserve)

STEP 7-ASSESS RESPONSE TO INITIAL RESUSCITATION

Assess changes in vital signs with initial resuscitation-pulse rate, rhythm, BP, oxygen saturation, urine output, mental state

Continuous assessment is mandatory……one needs to be vigilant and present at the bed side.

STEP 8-ASSESS INTENSITY OF SUPPORT

Inspired oxygen fraction needed to maintain saturation above 90%

Intensity of ventilatory support-MV,NIV dose of vasopressor and ionotrope needed to maintain

MAP >60mmHg need for volume support to keep adequate urine output need for BT to keep Hb >8 gm/dl Need for sedation in agitated patients Need for dialysis support

STEP 9-SEEK HELP FOR SPECIFIC PROBLEMS THAT MIGHT

REQUIRE EXPERTISE Cardiologist-complete heart block, acute coronary

syndrome, cardiogenic shock, pericardial tamponade, massive pulmonary embolism

Nephrologist-dialysis Neurologist-acute stroke, undiagnosed depressed

conscious level Neurosurgeon-ICH, head injury, cerebral edema Trauma surgeon-polytrauma, abdominal trauma, thoracic

trauma Obstetrician-ruptured ectopic,PPH.

STEP 10-CONSTRUCT A WORKING DIAGNOSIS AND PLAN FOR FURTHER

MANAGEMENT After initial resuscitation, assessment,and response, a

differential diagnosis should be arrived at. Reassess the patient frequently to modify initial plan if

needed.

STEP 11-BRIEF AND COUNSEL RELATIVES

After initial assessment, resuscitation,investigations and response the family and relatives should be briefed about the likely diagnosis, treatment plan, and approximate prognosis and duration of stay and consent should be taken for any invasive procedures.

Family briefing should be documented in clinical notes.

MALARIA

DENGUE

ORGANO-PHOSPHOROUS POISONING

SNAKE BITE

COPD

CVA

POLYTRAUMA

INTENSIVE-DIAGNOSTICIAN

OUR CASE MANAGEMENT Admitting diagnosis - Acute exacerbation of COPD T/T- O2 2L/min via nasal cannula Goal- O2 saturation 90-

91%, – Corticosteroid -Hydrocortisone 100 mg 6 hourly,– Inhaled bronchodilator: Ipratropium bromide and

Salbutamol 4hrly.– Later on we added aminophylline; initially 6

mg /kg bolus with in 20 min then 1 mg/kg/hr.– Antibiotics– ABGs q 8 hours, CXR.

On second day of admission his condition deteriorated: his distress became more pronounced,

his work of breathing increased significantly– he became confused– SpO2 went down 80 to 85% with 5L O2/min,– ABG showed pH; 7.27, PO2: 55, PCO2, 72,

Hco3: 30,

with the consent of patient's relatives NIV was added along with the conventional treatment.

Patient was kept in close monitoring with hourly recording of vital signs, conscious level.

Blood gas was measured after 2 hours of administration of NIV and every 6-hour interval. There was gradual improvement of patient's symptoms and blood gas parameter.

Patient was disconnected from ventilator for 10 mins in every 2 hour and only during feeding.

After 20 hours of NIV patient's clinical condition significantly improved.

Patient dischaged from CICU ON DAY 5…

Medicine is not the exact science,I shall use my experience, knowledge and judgement to its best,I may go wrong or anything with patient may go wrong anytime

I guarantee nothing but my honest effort and care for you,I am not God, but well-trained professional wanting to take care of patients

THANK YOU….