initial assessment of critically ill patients(presented at ima house,cuttack)
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initial assessment of critically ill patientsTRANSCRIPT
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INITIAL ASSESSMENT OF CRITICALLY ILL
PATIENTS
PROF.DR.NIBEDITA PANI
HOD,DEPT.OFANAESTHESIOLOGY
AND CRITICAL CARE,SCBMCH
AND
DR.PRERNA BISWAL,SCBMCH
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audio
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OUR CASE
52 years old male was admitted in our CICU with
C/C- severe breathlessness and sweating for last 5 hours.
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DEFINITION OF CRITICALLY ILLCritical 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.
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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.
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Clinical observationsAppearance Neurological Respiratory Cardiovascular
Normal AlertCooperative
NormalRR >8 <20 b/min pattern
HR 60–100b/minSBP > 90 mmHgUO > 0.5 ml/kg/hr
SweatyPaleAnxious
AgitationConfusionEyes open to voice only
Accessory muscle use RR < 8 b/min RR 20–30 b/min
HR > 100 b/minSBP < 90mmHgUO < 0.5 ml/kg/hr
GreyBlueMottled skin
Unresponsive or eyesopen to pain onlyFitting
Silent chestRR < 8 > 30 b/minAgonal respirations
HR < 50 b/minHR > 150 b/minSBP < 60 mmHg
Cardiac arrest or death
Patientcategory
Not critically ill
Potential criticalillness
Critically ill
SWEATY CONFUSEDACCESSORY MUSCLE USE
RR-30/MIN HR>120/MIN
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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.
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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
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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
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What are the steps to be followed?
1. Initial assessment 2. Immediate management 3. Monitoring 4. Initial investigations
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OUR CASE – ON EXAMINATION52-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, orientedOn auscultation, breath sound was diminished
bilaterally, Ronchi throughout bilateral lung fields, on percussion hyper resonant lung field.
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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.
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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”
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LOOK LISTEN AND FEEL
INTUBATE
BRONCHODILATORS
REMOVE FB/ INTUBATE
SUCTIONING
INSERT ORAL / NASOPHARYNGEALAIRWAY
SNORING – UPPER AIRWAY OBSTRUCTION BY TONGUE OR SOFT TISSUE
GURGLING- UPPER AIRWAY OBSTRUCTION BY LIQUID STRIDOR- OBSTRUCTION BY FOREIGNBODY 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 ORSURGICAL AIRWAY SHOULD BE BASED ON CLINICAL ASSESSMENT
“A”- AIRWAY
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“B”- BREATHING Clinical assessment of ventilation and oxygenation (with adjuncts)
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.
C/F of Respiratory Distress:1. Breathlessness2. Tachypnea3. Inability to talk4. Open mouth breathing5. Flaring of alae nassi6. Paradoxical breathing7. Use of accessory muscles
Respiration
C/F of Inadequate oxygenation:1. Restlessness2. Delirium3. Drowsiness4. Cool extremities5. Cyanosis6. Tachycardia7. Arrhythmia8. Hypotension
Adjuncts- Pulse Oximetry, ABG
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“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
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“C”- CIRCULATIONAssessment 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.
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JUDICIOUS USE OF VOLUME,IONOTROPES AND VASOPRESSORS
TREAT ACCORDING TOCAUSE
BROAD SPECTRUM ANTI-BIOTICS AND RESUSCITATION
URGENT CONTROL OF HYPERTENSION AND HEART RATE
URGENT ANTI-COAGULATION THEN INVESTIGATION
IMMEDIATE PERICARDIOCENTESISPERICARDIAL TAMPONADE-
HEMODYNAMIC INSTABILITY
PULMONARY EMBOLISM-
AORTIC DISSECTION-
SEPSIS AND SEPTIC SHOCK
SHOCK- HYPOVOLEMIC, CARDIOGENIC, SPINAL
MANAGEMENT OF CIRCULATION
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“D”- DISABILITY
TREAT ACCORDING TOCAUSE AFTER APPROPRIATE CONTROL
URGENTANTI-BIOTICS
URGENT CONTROL
SYSTEMIC DISEASE
S/O NEUROLOGICAL DISEASE
LATERALISING SIGNS LIKE HEMIPLEGIA
DEPRESSED CONCSCIOUS LEVELIN ABSENCE OF PRIMARY NEUROLOGICAL DISEASE
HYPOGLYCEMIA
BACTERIAL MENINGITIS
SEIZURES
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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 HISTORYPATIENTS RESUSCITATION STATUS AS PER
FAMILY’S WISH
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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.
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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
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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 HGGCS<12PR>150 OR <50 BPMRR >30 OR<8/MINUO<0.5 ML/KG/HR
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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 ECGAppropriate microbiology culturesFurther investigations as per history and
examination
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STEP 5 FOR OUR CASEA 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/lNormal ECG
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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
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STEP 6-RECOGNISE THE PATIENT AT RISK
Special precautions in following groupsElderly and immuno-compromised(may not
show features of decompensation)Polytrauma patients(multiple injuries,
distracting pain)Young adults(decompensation is late due to
physiological reserve)
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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.
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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
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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.
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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.
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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.
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MALARIA
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DENGUE
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ORGANO-PHOSPHOROUS POISONING
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SNAKE BITE
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COPD
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CVA
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POLYTRAUMA
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INTENSIVE-DIAGNOSTICIAN
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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.
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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.
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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.
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Patient dischaged from CICU ON DAY 5…
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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
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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
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THANK YOU….