Approach to critically
ill patients
By
Sameh Aziz
Assistant professor
Emergency Medicine
Objectives
To define critical illness
Toenumerate principles of management of critically ill
patients
To know the ABCDE approach of assessment of critically
ill patients
Toenumerate different Severity Of Illness (SOI) scoring
system
Who Are Critically ill??
Criticalillness 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
Manage the illness
Principles of management of critical ill patients
Assign responsibility
Initial assessment and resuscitation
Focused history
Perform focused examination
Basic investigations
Recognizepatient at risk- elderly, immuno-
compromised, polytrauma
Principles of management of critical ill patients
Assess response to initial resuscitation
Assess intensity of support
Seek help for specific problems that might require
expertise
Makea working diagnosis and plan for further
management
Brief and counsel relatives
Prognosis
Outcomeis predominantly determined by initial
management of patient at risk of life threatening
illness
“TIMEIS TISSUE”- a prompt and protocolized
resuscitation regimen helps salvaging these
patients.
Assessment and management should go
hand in hand
The classical medical model
The critically ill medical model
Initial assessment and monitoring
Goals
Correcting
physiological abnormalities should take
precedence over arriving at an accurate diagnosis
As a minimum, following physiological observation should
be recorded initially and as a part of routine monitoring
Heart Rate
Respiratory rate
Systolic blood pressure
Level of consciousness
Oxygen saturation
Temperature
Initial assessment and monitoring
Inspecific circumstances additional monitoring
should be considered
Hourly Urine Output
Biochemical analysis such as lactate , blood
glucose ,base deficit, arterial PH
Pain assessment
ABCDE approach
ABCDE approach Has 4 interlinked phases
Preparation before seeing the patient
Primary survey
Secondary survey
Definitive care intervention
Preparation
Information gathering
Keypreliminary Data (AMPLE :Allergy ,Medication, Past
medical History, Last Meal , Events)
Previous primary care or hospital records
Relatives
Managing resources
Identification of available resources
Staffs
Identification of roles and responsibilities
Communication properly
Primary Survey
Primarysurvey , investigations and intervention
simultaneously
Shouldtake 5-10 minutes unless life saving
intervention
Examination Sequence ABCDE
A-Airway
B-Breathing
C-Circulation
D-disability
E-Environment and exposure
Airway
Approach the patient
Speak slowly and assess response
Ifpatient talks normally, airway is clear and there is
perfusion of brain
Give high inspired concentration by face mask and
move on to breathing
Ifno response to speech—more detailed airway
assessment –LOOK , LISTEN AND FEEL
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.
Airway
Listen- airway noises
Gurgling,
Snoring, Grunting, Hoarseness,
Wheeze, Stridor ,Silent airway
Untreated, airway obstruction leads to a
lowered -PaO2 and risks hypoxic damage to the
brain, kidneys and heart, cardiac arrest, and
even death
Airway
Simple methods of airway clearance
Airway opening maneuvers
Airways suction
Insertion
of an oropharyngeal or
nasopharyngeal airway
Indicationsfor emergency advanced
airway and ventilation techniques
Breathing
Although airway evaluation always takes precedence,
often the airway and breathing are evaluated
simultaneously
Clinical assessment of ventilation and oxygenation
Look(inspection)-movement of chest (normal and
abnormal) ,accessory muscles and abdomen,
Listen(Auscultate)- breath sound and added sound
Position of trachea
Adjunct – pulse oximetry , Capnography
Breathing
Signs of Respiratory
Distress: Signsof Inadequate
Breathlessness oxygenation:
Tachypnea Restlessness
Inability to talk Drowsiness
Open mouth breathing Cool extremities
Flaring of alae nasi Cyanosis
Paradoxical breathing Tachycardia
Use of accessory muscles Arrhythmia
Hypotension
Breathing
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
Breathing
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)
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%.
Circulation
Assessment of adequacy of circulation
Peripheral and central pulse(rate, rhythm, volume, symmetry)
Skin temperature
Heart rate
Blood pressure
Capillary refill time
JVP
Urine output
Advanced monitoring- bedside ECHO, CVP , IBP
Circulation
Hypotension late feature of shock
Assess tissue perfusion
Conscious level
Peripheries
Urine output
ABG-lactate
Circulation
Causes of circulatory problems
Primary Secondary
Acute coronary syndromes Asphyxia
Arrhythmias Hypoxaemia
Hypertensive heart disease Blood loss
Valve disease Hypothermia
Hereditary cardiac diseases Septic shock
Drugs
Electrolyte/acid base
abnormalities
Circulation
Lowest acceptable BP depends on usual BP for each
patient
Allnon-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
Disability
Assessmentof 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 hypoxemia, hypercapnia, cerebral hypo
perfusion
Recent administration of sedatives or analgesic drugs
Disability
Patient’sdrug 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 hypoglycemia
Ifbelow 3 mmol/l, - 25-50 ml of 50% glucose solution
intravenously
Monitoring of unconscious patients in the recovery
position, where possible
Exposure and environment
Fullexposure of the body may be necessary in order that
patients are examined properly, and detail is not missed,
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
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
Summary
Criticalillness 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
Thank you
