Assessment of the Critically Ill Patients

8/10/2019 Assessment of the Critically Ill Patients

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Assessment of the

Critically ill Patients

Frans JV PangalilaUNTAR


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The aim of assessment of criticallyill patientsis to :

identify the physiological

abnormalitiesidentify the most appropriate wayto correct those abnormalities

diagnose the nderlying problem


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The A!C"# approach

Airway & oxygenation

Breathing &ventilation

Circulation &shock

management

Disability dueto neurological

deterioration

Exposure&

examination

E

D C

A

B


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The principles

Perform primary ABCDE survey (5min)

Instigate treatment for lifethreatening conditions as you ndthem

eassess !hen any treatment iscompleted

Perform more detailed secondaryABCDE survey including

investigations


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The primary sr$ey

ABCDE assessment loo"ing forimmediately life threateningconditions

apid intervention usually includesma# $%& I' access& uid challenge *+

specic treatment

,hould ta"e no longer than 5 min

Can -e repeated as many times asnecessary

.et e# erienced hel as soon as ou


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The secondary sr$ey

Performed !hen patient more sta-le

0ore detailed e#amination of patient(ABCDE)

$rder investigations to aid diagnosis

I1 PA2IE32 DE2EI$A2E, E2432$ PI0A ,4'E

The A!C"# approach often to be carriedot in parallel with history ta%ing&e'amination and initial resscitation often

occring in simltaneosly


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Initial Approach to Patient Assessment

.... start with simple question and evaluate the response

a normal $erbal response implies that thepatients has a clearairway* breathing and cerebral

perfsionan inappropriate response an indicate thatthe patient is

confsed&++e+g : hypoglycemia

breathless patient who can only tal% inshort sentences is sggesti$e of respiratory distressfailre to respond is an indicator of seriosillness


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Some of the clinical and laboratoryfeatures suggestive of severe illness


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)ey Points in Approaching TheCritically (ll Patient :,anagement of the airway& breathing and

circlation -A!C.Assessment and treatment shold occrsimltaneosly"o not mo$e on ntil the pre$ios system isstable or being

stabili/edContinal reassessment of the A!C is $ital

Once again :


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Airway :assessment of airwaypatency is vital

Key points : CommonCauses

Airway Compromisealtered level ofconsciousnessforeign bodyinammationinfection

!""#

!$S%E'EE!

A


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Airway interventions(basic) A

*ead %ilt + Chin!ift ,aw %hrust


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Airway assessment A-#eeping the airway open- look, listen and feel fornormal breathingLook for chest movement(tachypnea, use of accessory muscle/trachealtug, paradox thoraco-abdominorespiration sweatingListen for gurgling- snoring-stridor

(note : stridor maybe absent in severecase and the presence of a normal oxygenationdoes not exclude a compromised air!ay

"eel for air on your cheek

-*ypercapnea and tend to decrease inconscious levelindicate the compensatory mechanisms areex hausted.Bradycardia indicates impending

cardiorespiratoryarrestKey point : a patient with signs of airway obstrctionshold ne$er be left alone


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Airway interventions(basic) A

,anfaat :0 mencegah pang%al

lidah 1ath

%ebela%ang

0 fasilitas sction

0 mencegah tergigitnya

lidah

- Airway patency nt%penderita

/"ropharyngeal airway0


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Airway + interventions(basic) A

/ asopharyngeal Airway /

(ndi%asi :pasien setengah sadar dengan napasspontan


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Airway interventions(advanced)

.E2 6E7P888

3e-ulisedadrenaline forstridor

70A

Intu-ation

Cricothyroidotomy 3eedle or

surgical

A


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Breathing assessmentB

Note : that mar%ed tachypnoeais a sefl mar%er of ase$erely ill patient re0gardless of whether the patient has respiratory failreLook : Rate -2 34 or 5 64.& symmetry& e7ort&pulse oymetri,

s%in colorListen : Ta%ing++++sentences& phrase and words8 whee/e& silent chest and other added sonds

!eel : central trachea& percsion0e'pansion

/ Signs of Severe 1espiratory

Compromise / tachypnoea # $% bpm bradypnoea & ' bpm

accessory muscles of respiration unable to complete sentences

confusion

cyanosis )a*$ & + k)a , )a*$ # k)a


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Breathing . interventions

Consider ventilation withA2B34 bag if resp rate 567

8osition upright ifstruggling to breath

Speci9c treatment i:e: ; agonist for

whee


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Circulation . assessment C

Rapid initial assessment ofcirclatory states focs on tissue perfusion not "ustblood pres surehypotension is a late featre ofcardio$asclar dysfnction and often premorbidsign in all forms of shoc%

/ Evidence of inade=uate tissueperfusi on indicate a severely ill

patients even in the absence of hypotension / . decreased conscious level - skin mottling - cold peripheries - poor capillary re.ll

- serum lactate # '% m0ol/l - oli ouria and metabolic acidosis

Skinmottling


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Circulation assessment C

!ook - s!eating

- pallor - tachypnoea / kussmaul

'eel - cold peripheries - capillary re.ll time #$s

- tachycardia - narro! pulse pressure - hypotension

Act iv access, uid

therapy, inotropes/vasodilators


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Circulation . shock

Loss of volume *ypovolaemia

)ump failure 2yocardial & non.

myocardial causes

1asodilatation

Sepsis- anaphylaxis-neurogenic

C

B8 > *1 x S?x S?1

$nade=uate tissueperfusion


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Circulation.interventions

8osition supine with legs raised

!eft lateral tilt in pregnancy

$? access . 6@ or larger x

. bloods if new cannula 'luid challenge

colloid or crystalloid

EC 2onitoring

Speci9c treatment.. $notropevasopresor- vasodilator-

antibiotik-steroid

surgical

C


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Disability . causes D

a mar%ed redction in conscios le$elindicates either that : compensatory hemostatic mechanisms have beenoverhelmed or severe neurological disease

common cases : inade#uate perfusion of the brain sedative side e$ects of drugs hypoglycemia toins and poisons %&A increase intracranial pressure


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Disability - assessment D2he31)4 ( or 56 scale combined !ith assessment of the

pupils

7 3 1 ) 4 7.3 lert. responds to 1 oice. responds to ) ain. 4 nresponsive

7 3ssessment of the pupils 7-e=ual- si


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Treatment of altered ofconscios le$el

' (ecovery position '


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Disability . interventions

"ptimise airway- breathing & circulation

%reat underlying cause

i:e: naloxone for opiate toxicity

Caution if reversing ben


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Exposure and ExaminationE

Remo$e clothes and e'amine 9ead to ToeFront and !ac%

9aemorrhage welling Rashes and Urticaria etc

)eep warm - nless post cardiac arrest .9istory ta%ing and (n$estigation

,aintain "ignity


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Exposure .3ssessment E

Based on *istory the critically ill patients fall intothree charactheristic group


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Secondary survey

1epeat ABCDE in more detail

*istory

"rder investigations AB- CJ1- 6 lead EC- Speci9c bloods

2anagement plan

1eferral


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Summary

7 at all times 71ecogni

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Assessment of the Critically Ill Patients