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Assessment of critically ill patients
1. Assessment of critically ill patients
Presenter : Dr. Krishna Dhakal
Moderator
Prof. Dr. Ravi Ram Shrestha
Assist. Prof. Dr. Nabin Pokhrel
1Department Of Anesthesiology And Critical Care, NAMS
2. Objectives :
• To define critical illness
• To enumerate principles of management of critically ill patients
• To know the ABCDE approach of assessment of critically ill patients
• To enumerate different Severity Of Illness (SOI) scoring system
2Department Of Anesthesiology And Critical Care, NAMS
3. Who Are Critically ill??
• Critical 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
British Journal of Hospital Medicine, 2007
Department Of Anesthesiology And Critical Care, NAMS 3
4. Who Needs ICU admission???
Department Of Anesthesiology And Critical Care, NAMS 4
Critical Care Medicine, 2016.
5. Who might need ICU admission??
Department Of Anesthesiology And Critical Care, NAMS 5
Critical Care Medicine, 2016.
6. Who doesn't need ICU??
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Critical Care Medicine, 2016.
7. Principles of management of critical ill patients
1. Assign responsibility
2. Initial assessment and resuscitation
3. Focused history
4. Perform focused examination
5. Basic investigations
6. Recognize patient at risk- elderly, immuno-compromised, polytrauma
7. Assess response to initial resuscitation
8. Assess intensity of support
9. Seek help for specific problems that might require expertise
10. Make a working diagnosis and plan for further management
11. Brief and counsel relatives
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8. • Outcome in ICU is predominantly determined by initial management
of patient at risk of life threatening illness.
• “TIME IS TISSUE”- a prompt and protocolized resuscitation regimen
helps salvaging these patients.
ASSESSMENT AND MANAGEMENT SHOULD GO HAND IN HAND
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9. 9Department Of Anesthesiology And Critical Care, NAMS
History
Examination
Investigation
Diagnosis
Treatment
Reassessment of
treatment
The classical medical model
13. History Examination
Probable diagnosis
Resuscitation
Immediate problem
History Examination
Probable diagnosisUnderlying problem Response
Definitive
treatment &
continued
resuscitation
History
Examination
Investigations
Revise diagnosis Response
1. Initial
Assessment
2. Initial
management
3. Monitoring
4. Initial
Investigation
14.
15. Initial assessment and monitoring
Goals
• Correcting physiological abnormalities should take precedence over
arriving at an accurate diagnosis.
Department Of Anesthesiology And Critical Care, NAMS 15
Acutely ill patients in Hospital Overview: NICE pathways September
2018
16. Initial assessment and monitoring
As a minimum, following physiological observation should be recorded at the
initial assessment and as a part of routine monitoring
1. Heart Rate
2. Respiratory rate
3. Systolic blood pressure
4. Level of consciousness
5. Oxygen saturation
6. Temperature
Acutely ill patients in Hospital Overview: NICE pathways September 2018
Department Of Anesthesiology And Critical Care, NAMS 16
17. In specific circumstances additional monitoring should be considered
• Hourly Urine Output
• Biochemical analysis such as lactate , blood glucose ,base deficit,
arterial PH
• Pain assessment
Acutely ill patients in hospital: NICE Pathways September 2018
Department Of Anesthesiology And Critical Care, NAMS 17
19. ABCDE approach
Has 4 interlinked phases :
1. Preparation before seeing the patient
2. Primary survey
3. Secondary survey
4. Definitive care intervention
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20. Preparation
1. Information gathering
• Key preliminary Data-
AMPLE(Allergy ,Medication, Past medical History, Last Meal , Events
Leading to presentation and environment)
• Previous primary care or hospital records
• Relatives
2. Managing resources
• Identification of available resources
• Staffs
• Identification of roles and responsibilities
• Communication properly (SBAR framework)
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21. Primary Survey
• Primary survey , investigations and intervention simultaneously
• Should take 5-10 minutes unless life saving intervention
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Parallel actions
23. Examination Sequence
• ABCDE
• A-Airway
• B-Breathing
• C-Circulation
• D-disability
• E-Environment and exposure
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24. Airway
Approach the patient
Speak slowly and assess response
If patient talks normally, airway is clear and there is perfusion of
brain
Give high inspired concentration by face mask and move on to
breathing
If no response to speech—more detailed airway assessment –LOOK ,
LISTEN AND FEEL
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25. A-airway
Look for the signs of airway obstruction:
• Secretion, blood vomit or Foreign Body- gentle suction under direct
vision
• Airway obstruction - paradoxical chest and abdominal movements
• Use of the accessory muscles of respiration.
• Central cyanosis -late sign of airway obstruction.
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The ABCDE approach: www.resus.org.uk
26. A- airway
Listen- airway noises
• Gurgling,Snoring,Grunting ,Hoarseness ,Wheeze ,stridor ,Silent airway
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27. Airway
• Untreated, airway obstruction leads to a
lowered -PaO2 and risks hypoxic damage
to the brain, kidneys and heart, cardiac
arrest, and even death.
Simple methods of airway clearance
• Airway opening maneuvers
• Airways suction
• Insertion of an oropharyngeal or
nasopharyngeal airway).
Department Of Anesthesiology And Critical Care, NAMS 27
The ABCDE approach: www.resus.org.uk
28. A-Airway
Principle indications for emergency advanced airway and ventilation
techniques
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29. B- Breathing
• Although airway evaluation always takes precedence, often the
airway and breathing are evaluated simultaneously
• Clinical assessment of ventilation and oxygenation
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30. Breathing
• Look- movement of chest (normal and abnormal) ,accessory muscles
and abdomen,
• Listen(Auscultate)- breath sound and added sound
• Position of trachea
• Adjunct – pulse oximetry , Capnography
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31. Breathing contd..
C/F of Respiratory Distress:
1. Breathlessness
2. Tachypnea
3. Inability to talk
4. Open mouth breathing
5. Flaring of alae nasi
6. Paradoxical breathing
7. Use of accessory muscles
Respiration
Department Of Anesthesiology And Critical Care, NAMS 31
C/F of Inadequate oxygenation:
1. Restlessness
2. Delirium
3. Drowsiness
4. Cool extremities
5. Cyanosis
6. Tachycardia
7. Arrhythmia
8. Hypotension
32. Breathing Contd..
• Worrying sign
• RR > 30/min (or < 8/min)
• Unable to speak 1/2 sentence
without pausing
• Agitated, confused or
comatose
• Cyanosed or SpO2 < 90%
• Deteriorating despite therapy
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33. Breathing contd..
Give oxygen at high concentration:
• Provide high-concentration oxygen using a mask with
oxygen reservoir.
• Ensure that the oxygen flow is sufficient (usually 15 L
min-1) to prevent collapse of the reservoir during
inspiration.
• If the patient’s trachea is intubated, give high
concentration oxygen with a self-inflating bag.
• In acute respiratory failure, aim to maintain an oxygen
saturation of 94–98%.
• In patients at risk of hypercapnic respiratory failure
aim for an oxygen saturation of 88–92%.
Department Of Anesthesiology And Critical Care, NAMS 33
The ABCDE approach: www.resus.org.uk
34. C- CIRCULATION
Assessment 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
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35. C- CIRCULATION
• Hypotension late feature of shock
• Assess tissue perfusion
• Conscious level
• Peripheries
• Urine output
• ABG-lactate
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36. Causes of circulatory problems
Primary
a. Acute coronary syndromes
b. Arrhythmias
c. Hypertensive heart disease
d. Valve disease
e. Hereditary cardiac diseases
f. Drugs
g. Electrolyte/acid base abnormalities
Secondary
a. Asphyxia
b. Hypoxaemia
c. Blood loss
d. Hypothermia
e. Septic shock
Department Of Anesthesiology And Critical Care, NAMS 36
37. C- CIRCULATION
• lowest acceptable BP depends on usual BP for each patient
• All non-pregnant, non-anaesthetised adults with systolic BP < 90 mm
Hg as seriously ill
• Few will have no other signs of shock, but still need to be treated with
great caution
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38. D- Disability
• Assessment of the patient’s conscious level using either the AVPU or
Glasgow Coma Scales.
• Pupils examination (size, equality and reaction to light).
• Plantar response
• Examination of limb for localizing sign
• Common causes of unconsciousness include profound hypoxaemia,
hypercapnia, cerebral hypoperfusion, or the recent administration of
sedatives or analgesic drugs.
Department Of Anesthesiology And Critical Care, NAMS 38
The ABCDE approach: www.resus.org.uk
39. D- Disability
• Patient’s drug chart checked for reversible drug-induced causes of
depressed consciousness- appropriate antagonist
• Measurement of the blood glucose using a rapid glucose meter or
stick method - exclude hypoglycaemia.
• If below 3 mmol/l, - 25-50 ml of 50% glucose solution intravenously.
• Monitoring of unconscious patients in the recovery position, where
possible.
Department Of Anesthesiology And Critical Care, NAMS 39
The ABCDE approach: www.resus.org.uk
40. Exposure and environment
• In order that patients are examined properly, and detail is not missed,
full exposure of the body may be necessary
• Dignity of the patient
• Trauma patient – log rolled and lift
• Rectal examination ,assessment of anal tone ,perineal sensation,
temperature
• Prevention of heat loss.
• Sheet to cover patient
Department Of Anesthesiology And Critical Care, NAMS 40
The ABCDE approach: www.resus.org.uk
41. Secondary Survey
• After primary survey
completed
• Systemic detailed
examination
• Started once there is no
need for resuscitation and
patient doesn’t require
immediate transfer for
definitive care
• Revaluation of response
to treatment
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42. Definitive treatment
• Once stable- moved to a critical area, operation theatre ,scanning
room or another hospital
• Needs to be adequately monitored
• Relevant documentation and investigation results and clear lines of
communications between clinicians
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43. • For terminally ill patient-recognition and preparation of patient death
is essential
• Communication with family , clinician involved in patient’s care
• Care for patient in dignified manner with emphasis on analgesia,
relief of distressing symptoms and highest quality of nursing care
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45. Severity of illness (SOI)scoring system
• In ICU, illness categorized by degree of severity
• Scoring system are measures of disease severity –used to predict
outcomes , typically mortality and morbidity of patient populations in
ICU
• SOI scoring system –useful in guiding hospital administrative policies,
directing the allocation of resources such as nursing and ancillary care
and assisting in assessment of quality of ICU care over time
• These tools – used as a source of important data to complement
clinical bedside decision making
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46. Severity score in Medical and Surgical ICU
Department Of Anesthesiology And Critical Care, NAMS
47. APACHE II Scoring system
• APACHE II ("Acute Physiology And Chronic Health Evaluation II") is a
severity-of-disease classification system (Knaus et al., 1985), one of
several ICU scoring systems
• Most commonly used SOI scoring system
• APACHE II was designed to measure the severity of disease for adult
patients admitted to intensive care units.
• It has not been validated for use in children or young people aged
under 16.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985).
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48. APACHE II Scoring system
• The score is not recalculated during the stay
• It is by definition an admission score and If a patient is discharged
from the ICU and readmitted, a new APACHE II score is calculated.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985)
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49. APACHE II Scoring system
Derivation of score
1. Age
2. Type of ICU admission ( after elective surgery vs Non surgical vs
after emergency surgery)
3. Chronic health problems (CLD, Heart failure-NYHA IV, Chronic lung
disease, Dialysis dependent, under immunosuppression))
4. 12 physiological variables (the worst values for each in 1st 24 hours
after ICU admission)
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52. Sequential Organ Failure Assessment (SOFA)
• The SOFA scoring system is useful in
predicting the clinical outcomes of
critically ill patients
• Developed in 1994 during a consensus
conference organized by European
society of intensive care and
emergency medicine
• Designed for patients with sepsis and
hence named initially as “Sepsis
related organ failure assessment”
53. Sequential Organ Failure Assessment (SOFA)
Takes into accounts 6 systems:
1. Neurology
2. Cardiovascular
3. Respiratory
4. Coagulation
5. Renal
6. Hepatic
• Scores of organ from 0-4
• 0-Normal
• 4- Extremely abnormal
• Presence of infection + >2 score
Sepsis
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56. Department Of Anesthesiology And Critical Care, NAMS 56
Sakr, Yasser & Lobo, Suzana & Moreno, Rui & Gerlach, Herwig & Ranieri, Marco & Michalopoulos, Argyris &
Vincent, Jean-Louis & Aykut, Güclü. Critical care (London, England). 2012
57. Quick SOFA score (qSOFA)
• Introduced by sepsis 3 group in February
2016 as simplified version of SOFA Score
• An initial way to identify patients at high risk
for poor outcome with infection
• Although less robust than a SOFA score
doesn’t require lab test and can be assessed
quickly and repeatedly
• Facilitate prompt identification of an
infection that posses greater threat to life, a
prolonged ICU course.
Department Of Anesthesiology And Critical Care, NAMS 57
JAMA ,2016
58. Quick SOFA (qSOFA)
Criteria
• low blood pressure (SBP≤100
mmHg) -1 point
• High respiratory rate (≥22 breaths
per min)-1 point
• Altered mentation (Glasgow coma
scale<15)- 1 point
• Score of 2 or more points – near
the onset of infection associated
with a greater risk of death or
prolonged ICU Stay
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JAMA ,2016
59. qSOFA
• qSOFA -derived from 1.3 million electronic
record encounters from 2010-2012 from 12
hospitals ICU in southeast Pennsylvania
• 24 % of infected patient with 2 or 3 score -70 %
death
• Outside ICU 3-14 fold increase in rate of in
hospital mortality
qSOFA.org
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61. Summary
• Critical illness is any disease process which causes physiological
instability leading to disability or death within minutes or hours.
• The severity of illness must be recognized as early as possible and
appropriate measures taken promptly to assess, diagnose and
manage the illness
• Severity of illness scoring system –useful in guiding hospital
administrative policies, directing the allocation of resources such as
nursing and ancillary care and assisting in assessment of quality of
ICU care over time
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62. References
• British Journal of Hospital Medicine, October 2007, Vol 68, No 10
• The ABCDE approach: www.resus.org.uk/resuscitation-
guidelines/abcde-approach
• Macleod’s Clinical Examination- 13th edition
• Critical Care Medicine 44(8):1553-1602, August 2016.
• Harrison’s Internal Medicine -20th edition
• Acutely ill patients in hospital: NICE Pathways September 2018
• Internet : www.qSOFA.org , Wikipedia
• JAMA.2016;315(8);762-774
• Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985). "APACHE
II: a severity of disease classification system". Critical Care
Medicine. 13 (10): 818–29
Department Of Anesthesiology And Critical Care, NAMS 62
the severity of illness must be recognized early and appropriate measures taken promptly to assess, diagnose and manage the illness
Focused HX-Seriously ill patients are often unable to give a history. Relatives and staff should be interviewed as well. Notes and charts are very useful sources of information
Ultimately a comprehensive history should be obtained. Initially history taking should concentrate on the immediate problem and on physiological reserve, especially cardiopulmonary reserve. This can be estimated from exercise tolerance and by asking about previous major illnesses
As with history taking a full examination should ultimately be performed but the initial focus is to rapidly determine how the patient should be resuscitated and the severity of the pathophysiological insult. The initial examination should therefore be a limited examination which should be carried out while simultaneously taking a history
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.
The classical medical model involves a sequential process involving a full history, thorough examination, investigations, diagnosis and then treatment. In this model treatment is only initiated when the diagnosis is firmly established
Unfortunately this model is only appropriate when there is sufficient time, which almost never occurs with seriously ill patients
Time is usually short
History and examination have to be carried out simultaneously
Aim is to determine the immediate life threatening problem and the probable cause of that problem
Resuscitation based on probable cause, rarely enough time to be certain of cause prior to starting resuscitation
During resuscitation further history taking and examination to determine underlying problem, probable underlying diagnosis and to assess response to resuscitation. Definitive therapy started and resuscitation continued
Further history, examination and investigations while treatment is on-going. Aim is to re-assess diagnosis and response to treatment
And to revise treatment accordingly
Important to realise that assessment of response to treatment needs to be made every few minutes not every few hours
Seek senior experienced..a team approach but the leader should ensure that all components are covered
In the critically ill patient, depressed consciousness often leads to airway obstruction.
In complete airway obstruction- no breath sounds at the mouth or nose. In partial obstruction, air entry is diminished and often noisy. Certain noises assist in localizing the level of the obstruction
Gurgling- fluids (secretions,vomit ,blood ) in oropharynx
Snoring-partial airway obstruction from soft tissue of mouth
Grunting – signs of resp fatigue
Hoarseness-partial laryngeal obstruction
Wheeze-musical noise ,signifies obstruction in small bronchi and bronchioles
stridor – harse noise , inspiration, partial obstruction around larynxor main bronchi, epiglottitis , retropharyngeal abscess
silent airway
Causes of airway obstruction
CNS depression
Blood
Vomit
Foreign body
Inflammation
Laryngospasm
Bronchospasm
Trauma
Compression
Appropriate size airway ,
Patient needs to be identified much earlier and appropriate management be instituted.
Give crystalloids …and start ionotropes if MAP <65 mm hg
Alert verbal stimuli painful stimuli and unresponsiveness
Review of the ABCs: exclusion of hypoxaemia and hypotension.
1 mg glucagon IM if no iv acess
Chronic alcohol???- iv Thiamine 100 mg to prevent Wernicke’s encephalopathy
Seizure management if present
Persisting of altered consciousnesseven after correction of hypoglycemia –suspect stroke or cerebral edema from hypoglycemia
Tumor herniated disk fracture
Spinal shock- combination of arreflexia and autonomic dysfunction that accompanies spinal cord injury…
Neurogenic-distributive shock triad hypotension brady and peripheral vasodilation (head reuma cervical cord trauma or high thoracic injur----unopposed vagal activity..t6 level….
Numerous SOI scoring system have been developed and validated over last three decades to assess populations of critically ill patients
Soi cant predict survival in individual patients
APACHE IV-129 variables…104 icu 110000 patients across USA
Simplified acute physiologic score
Mortality prediction model
ODIN-organ dysfunction and infectin system
Cellular injury score
Age<45 -0 45-54-2 55-64-3 65-74 5 >75 -6
Elective surgery-2
Emergency surgery-5
Nyha i- no limitation of physical activity
Nyha ii-slight limitation of physical activity.comfortable at rest
Nyha iii- marked limitation of physical activity.less than ordinary activity causes fatigue
Nyha iv- unable to carry any physical activity without discomfort
Life threatening organ dysfunction caused by dysregulated host response to infection
qsofa was derived from 1.3 million electronic heat record encounters from 2010-2012 @ 12 hospitals… they found 24 percent of infected pt wit 2 or 3 score accounted 70 percent death..outside icu there was 3-14 fold increase inrate of in hospital mortality
