initial assessment of critically ill patients

1. INITIAL ASSESSMENT
OF CRITICALLY ILL
PATIENTS
PROF.DR.NIBEDITA PANI
HOD,DEPT.OFANAESTHESIOLOGY
AND CRITICAL CARE,SCBMCH
AND
DR.PRERNA BISWAL,SCBMCH

2. audio

3. OUR CASE
 52 years old male was admitted in our
CICU with
 C/C- severe breathlessness and sweating for
last 5 hours.

4. DEFINITION OF
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.

5. 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.

6. Clinical observations
Appearance Neurological Respiratory Cardiovascular
Normal Alert
Cooperative
Normal
RR >8 <20
b/min pattern
HR 60–
100b/min
SBP > 90
mmHg
UO > 0.5
ml/kg/hr
Sweaty
Pale
Anxious
Agitation
Confusion
Eyes open to
voice only
Accessory
muscle use
RR < 8 b/min
RR 20–30
b/min
HR > 100 b/min
SBP < 90mmHg
UO < 0.5
ml/kg/hr
Grey
Blue
Mottled skin
Unresponsive
or eyesopen to
pain only
Fitting
Silent chest
RR < 8 > 30
b/min
Agonal
respirations
HR < 50 b/min
HR > 150 b/min
SBP < 60
mmHg
Cardiac arrest or death
Patient
category
Not critically ill
Potential critical
illness
Critically
ill
SWEATY CONFUSED
ACCESSORY
MUSCLE USE
RR-30/MIN HR>120/MIN

7. 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.

8. 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

9. 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

10. What are the steps to be
followed?
 1. Initial assessment
 2. Immediate management
 3. Monitoring
 4. Initial investigations

12. OUR CASE – ON EXAMINATION
 52-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, oriented
 On auscultation, breath sound was diminished
bilaterally, Ronchi throughout bilateral lung fields,
on percussion hyper resonant lung field.

13. 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.

14. 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”

15. “A”- AIRWAY
LOOK LISTEN AND FEEL
INSERT ORAL /
NASOPHARYNGEAL
AIRWAY
SUCTIONING
REMOVE FB
/ INTUBATE
BRONCHO
DILATORS
INTUBATE
SNORING – UPPER AIRWAY OBSTRUCTION
BY TONGUE OR SOFT TISSUE
GURGLING- UPPER AIRWAY
OBSTRUCTION BY LIQUID
STRIDOR- OBSTRUCTION BY FOREIGN
BODY 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 OR
SURGICAL AIRWAY SHOULD BE BASED ON CLINICAL ASSESSMENT

16. “B”- BREATHING
 Clinical assessment of ventilation and oxygenation (with adjuncts)
C/F of Respiratory Distress:
1. Breathlessness
2. Tachypnea
3. Inability to talk
4. Open mouth breathing
5. Flaring of alae nassi
6. Paradoxical breathing
7. Use of accessory muscles
Respiration
C/F of Inadequate oxygenation:
1. Restlessness
2. Delirium
3. Drowsiness
4. Cool extremities
5. Cyanosis
6. Tachycardia
7. Arrhythmia
8. Hypotension
 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.
Adjuncts- Pulse Oximetry, ABG

17. “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

18. “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,
Cardiac Output.

19. MANAGEMENT OF CIRCULATION
JUDICIOUS USE OF VOLUME,IONOTROPES AND VASOPRESSORS
IMMEDIATE
PERICARDIOCENTESIS PERICARDIAL TAMPONADE-HEMODYNAMIC
URGENT
ANTI-COAGULATION
THEN INVESTIGATION
URGENT CONTROL
OF HYPERTENSION AND
HEART RATE
BROAD SPECTRUM
ANTI-BIOTICS AND
RESUSCITATION
TREAT ACCORDING TO
CAUSE
INSTABILITY
PULMONARY EMBOLISM-AORTIC
DISSECTION-SEPSIS
AND SEPTIC SHOCK
SHOCK- HYPOVOLEMIC,
CARDIOGENIC, SPINAL

20. “D”- DISABILITY
S/O NEUROLOGICAL
DISEASE
SYSTEMIC DISEASE
URGENT CONTROL
URGENT
ANTI-BIOTICS
TREAT ACCORDING TO
CAUSE AFTER
APPROPRIATE CONTROL
LATERALISING SIGNS
LIKE HEMIPLEGIA
DEPRESSED CONCSCIOUS LEVEL
IN ABSENCE OF PRIMARY
NEUROLOGICAL DISEASE
HYPOGLYCEMIA
BACTERIAL MENINGITIS
SEIZURES

21. 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 HISTORY
 PATIENTS RESUSCITATION STATUS AS PER
FAMILY’S WISH

22. 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.

23. 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

24. 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 HG
GCS<12
PR>150 OR <50 BPM
RR >30 OR<8/MIN
UO<0.5 ML/KG/HR

25. 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 ECG
 Appropriate microbiology cultures
 Further investigations as per history and
examination

26. STEP 5 FOR OUR CASE
 A 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/l
 Normal ECG

27. 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

28. STEP 6-RECOGNISE THE
PATIENT AT RISK
Special precautions in following groups
 Elderly and immuno-compromised(may not
show features of decompensation)
 Polytrauma patients(multiple injuries,
distracting pain)
 Young adults(decompensation is late due to
physiological reserve)

29. 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.

30. 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

31. 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.

32. 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.

33. 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.

34. MALARIA

35. DENGUE

36. ORGANO-PHOSPHOROUS
POISONING

37. SNAKE BITE

38. COPD

39. CVA

40. POLYTRAUMA

41. INTENSIVE-DIAGNOSTICIAN

42. 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.

43. 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.

44.  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.

45. Patient dischaged from CICU ON
DAY 5…

48. 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

49. 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

50. THANK YOU….