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initial assessment of critically ill patients(PRESENTED AT IMA HOUSE,CUTTACK)

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initial assessment of critically ill patients(PRESENTED AT IMA HOUSE,CUTTACK)

  1. 1. INITIAL ASSESSMENT OF CRITICALLY ILL PATIENTS PROF.DR.NIBEDITA PANI HOD,DEPT.OFANAESTHESIOLOGY AND CRITICAL CARE,SCBMCH AND DR.PRERNA BISWAL,SCBMCH
  2. 2. audio
  3. 3. OUR CASE  52 years old male was admitted in our CICU with  C/C- severe breathlessness and sweating for last 5 hours.
  4. 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. 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. 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. 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. 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. 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. 10. What are the steps to be followed?  1. Initial assessment  2. Immediate management  3. Monitoring  4. Initial investigations
  11. 11. 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.
  12. 12. 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.
  13. 13. 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”
  14. 14. “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
  15. 15. “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
  16. 16. “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
  17. 17. “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.
  18. 18. 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
  19. 19. “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
  20. 20. 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
  21. 21. 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.
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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)
  28. 28. 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.
  29. 29. 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
  30. 30. 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.
  31. 31. 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.
  32. 32. 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.
  33. 33. MALARIA
  34. 34. DENGUE
  35. 35. ORGANO-PHOSPHOROUS POISONING
  36. 36. SNAKE BITE
  37. 37. COPD
  38. 38. CVA
  39. 39. POLYTRAUMA
  40. 40. INTENSIVE-DIAGNOSTICIAN
  41. 41. 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.
  42. 42. 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.
  43. 43.  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.
  44. 44. Patient dischaged from CICU ON DAY 5…
  45. 45. 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
  46. 46. 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
  47. 47. THANK YOU….

Notas del editor

  • Although the criteria for admission to an ICU are somewhat controversial—excluding patients who are either too well or too sick to benefit from intensive care—there are four recommended priorities that intensivists (specialists in critical care medicine) use to decide this question. These priorities include:
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