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Assessment and Stabilisation of aCritically Ill Patient
Dr.S. VashishtDept.of Anaesthesia
Hillingdon Hospital
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Assessment
Traditional history taking & examination is
inappropriate
Assessment and stabilisation should proceed
simultaneously
Priority given to detection of potentially lifethreatening conditions
Life saving measures must be institutedrapidly
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What Should I Assess ?
A - Does this patient have a patent airway? Can this patient vocalise/phonate?
B - Is this patient breathing adequately?
Can this patient speak in sentences withoutgetting breathless?
C - Is the patient perfusing his brainadequately? Can this patient comprehend & respond
appropriately to questions?
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Assessing Airway Patency
Look for- Foreign bodies,secretions,blood in oropharynx
Obstruction of the pharynx by the tongue Use of accessory muscles of respiration
Chest expansion
Paradoxical breathing
Listen for-
Abnormal upper airway sounds (stridor,gurgling) If airway obstruction is complete, breath sounds will be
absent
Feel for- Expired air
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Assessing Breathing
Look for- Cyanosis
Respiratory rate, pattern and depth
Equality of chest expansion
SpO2 in the context of the FiO2
Listen for- Wheeze,crackles,bronchial breathing
Bilateral breath sounds
Feel for (palpate/percuss) Position of the trachea (central / deviated)
Chest wall for surgical emphysema,crepitus
Elicit dullness or hyper-resonance
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Assessing Circulation
Look for - Conscious level
Capillary refill (normally < 2 secs)
Colour and temperature of digits (cyanosed, pale, clammy, in shock)
Venous filling, including JVP
Urine output
Evidence of concealed or overt haemorrhage
Listen for Heart sounds Blood pressure
Feel for Presence, rate, quality, regularity of central & peripheral pulses
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Disability
Rapid assessment of the patients neurological statusinvolves
Examination of pupils (size,equality,reaction to light)
Level of consciousness (AVPU) Alert
Responds to vocal stimuli
Responds to painful stimuli Unresponsive
Common causes of unconsciousness include Profound hypoxemia
Hypercapnia
Cerebral hypoperfusion Hypoglycaemia
Recent administration of sedatives, anaesthetic drugs
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Monitoring the Critically Ill Patient
Institute the following Pulse oximetry SpO2
Capnograph - EtCO2
ECG rate, rhythm, ischaemia, conduction BP (intra-arterial)- accurate real time BP
CVP to guide fluid therapy and adminiterinotropes
Nasogastric tube
Urinary catheter to monitor hourly output
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Critical Illness Is Recognised By..
Prodromal signs which warn of impending
physiological catastrophe
Simple physiological signs basis of Early Warning
Score of which the RR (respiratory rate) is the mostsensitive
A score of > 3requires urgent medical review
Have been incorporated into a call out cascade tofacilitate urgent medical review
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EWS call out cascade
Score > 0 Inform a doctor
Score 1 3 Increase frequency of patient
observations to at least 4 hourly
Score is 3 in one category contact Registrar
for immediate patient review
Score total > 3 Senior medical review / liaise
with critical care team
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Early Management
Relieve airway obstruction Suction oropharynx
Insert nasal / oral airway
Administer supplemental O2 by mask
Intubate and mechanically ventilate
if spontaneous respiration is inadequate
Or if gag reflex absent- inability to protect airway against aspiration
Support circulation with
Intravenous fluids Inotropic agents & vasopressors
General Antibiotics
Correct acidosis, hypo / hyperglycemia
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Specific Criteria For ICU Referral
Airway
Actual or threatened airway obstruction
Impaired ability to protect airway
Breathing
RR < 8 or > 30
Respiratory arrest
Oxygen saturation < 90% on 50% oxygen or more
Worsening respiratory acidosis
Circulation
Pulse < 40 or > 140
Systolic BP
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Specific Criteria For ICU Referral(contd)
Neurological Repeated or prolonged seizures
Decreasing conscious level sufficient to compromise theairway and protective reflexes Head injury
Meningitis,encephalitis
Intracranial haemorrhage Hepatic encephalopathy
Drug overdose
Neuromuscular disease such as M.Gravis, Guillain -Barre
General
Any patient with an EWS score of 6 or above Any patient who is showing an adverse trend despite treatment
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Respiratory Support in ICU
Patients may be referred with
Hypoxemia
Ventilatory failureTreatment is mechanical ventilation for both the above
Decision to ventilate is based on following criteria
Patient is exhausted (unable to speak in complete sentences,using accessory muscles of respiration,confused)
Blood gas results (PaO2 < 8.5 on 60% O2,PaCO2 >6.5,
pH < 7.3 )
Failure to institute IPPV will result in respiratory arrest
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Circulatory Support in ICU
Circulatory failure can result from Impaired pump function of heart low cardiac output
Severe hypovolemia
Septic shock
Manifests as ( signs of impaired tissue perfusion)
Reduced conscious level Cool peripheries
Oliguria
Increasing metabolic acidosis
Treatment priorities
Rapid replacement of fluids / blood (CVP monitoring) Inotropic support (intra-arterial BP)
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Support of Other Organ Systems
Renal
May require haemofiltration to deal with fluid and electrolyteimbalance
Neurological
Treat fits, reduce intracranial pressure
Haematological
Correct coagulation defects with platelets, FFP
Nutritional
Total parenteral nutrition
Enteral feeding
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The Postoperative Patient in ICU
Surgery produces a temporary but predictablephysiological stress on the cardiovascular &
respiratory system which may need to besupported post-operatively
Following major complex surgery regardless of the
previous ASA status Following modest surgery in a patient with significant
cardio-respiratory disease
Do not admit patients to ICU
if the outcome is unlikely to be good
Irreversible end stage disease Further treatment is deemed to be futile
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