Assessment of Seriously Ill Patients

Document Information

• Ministry of Higher Education and Scientific Research
• Middle Technical University, College of Health and Medical Technique, Anaesthesia Technique Department
• Fourth stage
• Teaching package for ICU technique
• By Dr. Hussam Kareem
• 2023-2024

Assessment of Seriously Ill Patients

• Aims of assessment:
  • Identifying physiological abnormalities
  • Identifying the correct way to correct those abnormalities
  • Diagnosing the underlying problem
• Process:
  • Full history and thorough examination are different in seriously ill patients due to urgency
  • Full history and detailed examination are often done simultaneously with initial resuscitation
  • Information is restricted to what is needed to direct the next treatment decision
  • Working diagnosis is reassessed as more information becomes available and based on response to treatment

Warning Signs of a Severely Ill Patient

• Parameter | Values
• ---|---|
• Blood Pressure | Systolic <90 or mean <70mmHg
• Heart Rate | >150 or <50 bpm
• Respiratory Rate | >30 or <8 breaths/min
• Consciousness Level | GCS<12
• Oliguria | <0.5 ml/kg/h
• Sodium | <120 mmol/l or >150 mmol/l
• Potassium | <2.5 mmol/l or >6 mmol/l
• pH | >7.2
• Bicarbonate | <18 mmol/l
• Worried nurse | Concerned experienced nurse

Initial Assessment Components

• Key components: Airway patency, Breathing, Circulation
• Absence of any prompts immediate resuscitation
• Severity of illness is judged from compensatory response to the primary abnormality
• Pre-terminal patient's compensatory response may be exhausted and present with bradycardia and bradypnea
• Patient's intensity of supportive therapy is important, e.g., oxygen saturation on a nasal cannula

Intensity of Support

• Inspired oxygen fraction needed to maintain saturation above 90%
• Intensity of ventilatory support: positive end-expiratory pressure, minute ventilation

Specific Problems Requiring Help

• Cardiologist: complete heart block, acute coronary syndrome, cardiogenic shock, intra-aortic balloon pump insertion, pericardial tamponade, massive pulmonary embolism
• Nephrologist: dialysis
• Neurologist: acute stroke, undiagnosed depressed conscious level
• Neurosurgeon: intracranial hemorrhage, head injury, severe cerebral edema
• Trauma surgeon: polytrauma, abdominal trauma, thoracic trauma, compartment syndrome
• Obstetrician: ruptured ectopic pregnancy, postpartum hemorrhage

Working Diagnosis and Further Management

• A differential diagnosis is arrived at after initial resuscitation, assessment, investigation, and response
• Frequent reassessment of the patient to modify the initial plan is needed
• Family briefing post-resuscitation: likely diagnosis, treatment plan, prognostication, approximate duration of stay, consent for invasive procedures

Airway Assessment

• Vital step in initial assessment
• Thorough evaluation using look, listen, and feel for airway obstruction

Breathing Assessment

• Look for: tachycardia, tachypnea, sweating, use of accessory muscles, drooling, epiglottitis, see-saw rib movement.
• Listen for: gurgling, stridor.
• Note: hypercarbia, decrease in conscious level, bradycardia indicate impending respiratory arrest
• Note: Inspiratory stridor is a rasping sound during inspiration
• Note: Wheezing occurs when secretion or liquid is present in the upper airways.
• Note: snoring occurs during partial occlusion of the oropharynx due to relaxation of the oropharyngeal muscles and tongue.
• Assess breath effectiveness and work of breathing

Circulation Assessment

• Assess for: cyanosis, hypoxia; rate, depth, and symmetry of chest movements; accessory muscles use.
• Palpate chest wall for structural integrity Evaluate: oxygen therapy, assisted ventilation, trauma management.
• Note: Marked tachypnea, regardless of respiratory failure, is a useful marker for a severely ill patient.
• Note: Pulse oximetry is important to assess oxygenation, significant desaturation is a late sign.
• Note: search for metabolic acidosis and sepsis if there is no defect detected in blood oxygenation.

Conscious State

• Assess for: a marked reduction in conscious level (indicates either that compensatory mechanisms have been overwhelmed or severe neurological disease).
• Assess pupils and response

Investigations

• Useful initial screening tests include:
  • Pulse oximetry
  • Arterial blood gases
  • Electrolytes
  • Renal function
  • Full blood count
  • Clotting
• Advanced imaging like ultrasound scanning to minimize need for transport to radiology department. Evaluate liver function, calcium/phosphate/magnesium estimation, and chest X-ray

Subsequent Assessment

• Part or all of the assessment may be done before initiating any treatment in less severely ill patients
• History, including medical records, nursing notes, ambulance reports, and family members
• Rate of deterioration is revealed from the history and notes
• Important to identify difficult groups to be assessed: young adults, elderly/immunocompromised, trauma patients

Groups of Patients Difficult to Assess

• Important to assess the physiological reserve, including exercise tolerance
• Assess the compensatory mechanisms in young adults, inflammatory response and physiological reserve in elderly and immunocompromised patients
• History of injury is vital in trauma cases for localized injury

Examination Subheadings

• Aims to detect life-threatening physiological abnormalities and determine appropriate supportive therapy
• Different focus in sub-groups: young adults, elderly or immunocompromised patients, and trauma patients

Investigations Subheadings

• Additional investigations should be ordered based on history and clinical findings
• Consider ultrasound scanning if advanced radiological imaging is indicated, to minimize transportation to radiology for the patient

Clinical and Lab Suggestive of Severely Ill Patients

• Cardiovascular: tachycardia, hypotension, cold peripheries, skin mottling, bradycardia
• Respiratory: tachypnea, recession, accessory muscle use of respiration, low oxygen saturation, low respiratory rate
• Renal: oliguria
• Nervous system: decreased consciousness, confusion, agitation, aggressive behaviour
• Metabolic: acidosis, severe electrolyte abnormalities, severe hyperkalemia, severe hyponatremia, severe anemia, thrombocytopenia, coagulopathy, elevated lactate
• Miscellaneous: sweating

Review

• Post primary assessment and full assessment, a working diagnosis and plan for management should be developed.
• The plan should include ongoing review of the treatment response and appropriate placement, possibly in intensive care or other high-care area.

ICU Admission Criteria

• Life support technology is used for temporary support in potentially reversible organ failure cases; not for advanced or terminally ill cases
• Assessment approach: Airway, respiratory failure (if resistant to conservative measures).

ICU Discharge Criteria

• Stable respiratory status
• Minimal or no oxygen support
• Stable hemodynamic parameters
• No need for inotropic support, vasodilators, and antiarrhythmic drugs; intracranial pressure monitoring no longer required
• Neurologic stability with seizure control
• Close monitoring no longer needed

MCQ Test Questions and Answers

• (Multiple choice questions, answers supplied)
• Focus on warning signs, airway assessment, and specific pathophysiological features

Monitoring definition, goals, guidelines

• Interpreting clinical data to identify present or future, unfavorable conditions
• Enhancing, but not replacing, the intensivist's vigilance
• Assessing physiological function and improving patient safety.
• Personnel presence is vital
• Thorough physical examination and diagnosis important tools.

Basic Monitoring Categories

• Oxygenation: Clinical assessment of colour, respiratory pattern (rate, rhythm, depth, equal air entry, wheezing, crackles). Use of an oxygen analyzer to measure delivered gas concentration. Blood oxygenation measured quantitatively using pulse oximetry
• Ventilation: Assessment of chest movement and breath sounds. Use of ABGs to show PaCO2. Continual end-tidal carbon dioxide analysis. Monitoring of expired gas volume is strongly encouraged in mechanically ventilated patients. Continuous use of a device to detect disconnections is vital.
• Circulation: Continuous ECG, BP, and HR measurement. Assessment by palpating pulse, auscultating heart sounds, oximetry.
• Temperature: Measurement is critical.

Other Monitors

• Temperature (pharyngeal, axillary, esophageal)
• Urine output
• Central venous pressure (CVP)
• Arterial line
• Continuous BP monitoring
• Swan-Ganz catheter, PCWP: pulmonary artery pressures, cardiac output
• ICP monitoring
• EEG
• Transesophageal echocardiography (TEE)

Central Venous Pressure (CVP)

• Pressure recorded from the right atrium or superior vena cava
• Represents filling pressure of the right side of the heart
• Measurements normal is 0-6mmHg in a spontaneously breathing non-ventilated patient
• Measurement is recorded at the end of expiration.
• Zeroed at the level of the right atrium (RA).

Causes of Increased CVP

• Right ventricular failure.
• Tricuspid stenosis or regurgitation.
• Pericardial effusion or constrictive pericarditis.
• Superior vena caval obstruction.
• Fluid overload.
• Hyperdynamic circulation.
• High PEEP settings

Low Central Venous Pressure

• Factors: Hypovolemia, vasodilation.
• Decreased venous return, blood loss
• Note the different factors like blood loss or shift of blood volumes, inspiratory pressure (leading to vena cava collapse) leading to decreased venous return and low central venous pressure.

CVP Waveform Analysis

• Dominant a wave: pulmonary hypertension, tricuspid stenosis, pulmonary stenosis
• Cannon a wave: complete heart block, ventricular tachycardia with atrioventricular dissociation
• Dominant v wave: tricuspid regurgitation
• Absent x descent: atrial fibrillation
• Exaggerated x descent: pericardial tamponade

Airway/Respiratory Axis

• Oxygenation
• Ventilation
• Correct ETT placement.
• ETT cuff pressure
• Airway pressure

Respiratory Monitoring

• Assessment of airway pressure, leakage, disconnections, kinks, blocked tubes, bronchospasms and low expired tidal volumes
• Monitoring for apnea, O2 sensor failure, and flow sensor failure
• (Alert for alarms and never ignore an alarm)

Cardiac Monitoring

• Arterial blood pressure (ABP)
• Electrocardiography (ECG)
• Central venous catheterization (CVC)
• Pulmonary artery catheterization (PAC)
• Cardiac output (CO) measurement methods: thermodilution, dye dilution, pulse contour devices, esophageal Doppler, Fick principle, echocardiography, thoracic bioimpedance

Electrolyte/Metabolic Axis

• Fluid balance
• Electrolytes
• Sugar
• Acid-base balance

Visual Monitoring

• Respiratory: patient colour, respiratory pattern (accessory muscle use)
• Patient monitor numbers and waveforms
• Bleeding/coagulation
• Diaphoresis/movements
• Line quality
• Positioning safety review

High Tech Monitoring

• Examples include multiparameter patient monitors displaying various waveforms showing vital signs.

ECG Fundamentals

• Rate analysis
• Rhythm analysis (supraventricular, ventricular, conduction problems).
• Axis assessment.

ECG Details

• P wave, PR intervals, Q wave, QRS complex, ST segment, T wave, QT intervals, and U wave analysis.

Heart Rate Calculation

• Method 1: Count large boxes between R waves (divide 300 by the count).
• Method 2: Count small boxes between R waves (divide 1500 by the count).
• Method 3: Six-second ECG rhythm strip (count R waves in 6 seconds and multiply by 10).

Heart Rate Interpretation

• Normal range: 60-100 bpm.
• Bradycardia: Below 60 bpm.
• Tachycardia: Above 100 bpm.

Bradycardia Assessment

• Consider possible causes (drugs, ischemia, hypothyroidism, electrolyte abnormalities, raised intracranial pressure, sick sinus syndrome).

Tachycardia Assessment

• Consider possible causes (drugs, caffeine, ischemia, acute myocardial infarction, heart failure, pulmonary embolism, fluid loss, anemia, hyperthyroidism)

Atrial Flutter

• Atrial rate of 250-350 bpm (often around 300 bpm)
• AV block is common, leading to lower ventricular rates (sometimes a 2:1 block) - Regular rhythm, 'sawtooth' appearance on ECG from flutter waves.
• Assessment: history, possible causes, and ECG analysis.

Atrial Fibrillation

• Rapid, irregular ventricular rate.
• ECG: Absence of distinct P waves, irregular rhythm
• Risk of thromboembolism
• (Assess for anticoagulant therapy as needed)

Ventricular Fibrillation

• Irregular waves, varying morphology and amplitude
• Causes: IHD, anti-arrhythmic drugs, severe hypoxia
• Treatment: immediate non-synchronized DC shock (200-360J): If ineffective, repeat, proceed to basic and advanced life support; Amiodarone is the preferred drug, lidocaine procainamide as alternatives

Defibrillation

• Technique depends on the device.
• Manual defibrillators: electrodes applied to the chest, practitioner delivers the shock.
• Automated external defibrillators (AEDs): provide automated analysis and shock deliver when indicated.
• Cardioverter-defibrillators (ICDs): Implanted devices for continuous monitoring and delivery of shocks when needed

Specific Precautions During Defibrillation

• (Focus on minimizing interruption and risk of fire/combustion during the procedure.)
• Importance of removing oxygen sources, securing bag-valve devices, and appropriate electrode placement (avoiding arcing)

Clinical aspects of defibrillation

• Key aspects of survival from cardiac arrest include: recognition, early CPR, early defibrillation, post resuscitation care, and prevention of future cardiac arrest events.
• Public access defibrillators and trained community responders are vital, particularly in high-density urban areas and some rural areas.

ECG Recording and Reporting

• Constant speed is key for accurate ECG recordings
• Data that must be recorded includes patient details (name, date, ID number, reason for the request, relevant medical history, medication history).

This quiz focuses on the critical aspects of assessing seriously ill patients. It covers the importance of initial assessments, scenarios where detailed examinations may be postponed, and the management of severe illness. Test your knowledge on effective strategies for evaluating and diagnosing patients in critical conditions.