بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. The approach to the critically ill patient Assessment of the Critically Ill Patient Nick Smith Clinical Skills Khaled M.Hassan MD; 2011 A E B D C

3. Learning outcomes: • Identify the correct sequence of priorities in assessing the critically ill patient. • State why it is important to have a systematic approach to assessment and care, with rational for each step. • Identify clinical situations in which a patient’s condition may become compromised. • Demonstrate safe and effective assessment and care of the critically ill patient using a systematic approach. Khaled M.Hassan MD; 2011

4. ISIT IMPORTANT TO ASSESS? • Assessment is the first step in Caring for a patient, and assessing the critically ill patient is an essential part of their care. • Careful assessment is fundamental in order to recognise when a patient is becoming compromised. • The nurse acts as patient advocate, monitoring, anticipating potential problems, planning, implementing and constantly evaluating care, and communicating with other MDT; multidisciplinary team; staff involved in the patient care. • Khaled M.Hassan MD; 2011

5. The Multidisciplinary Team (MDT) • The MDT brings together people who are experts in different areas of medicine and care, and usually meet every week to discuss the diagnosis, treatment and care of individual patients. The Team is responsible for: • Working out your treatment plan • Deciding on further tests • Making appropriate referrals to specialist services • Making sure the team has all the necessary members • Collecting information and keeping good records. Khaled M. Hassan MD. 2011

6. Patient Assessment Systems • Basic Life support (BLS) • Advanced Life Support (ALS) • Acute Life-threatening Events, Recognition and Treatment (ALERT) • The Advanced Trauma Life Support (ATLS) Khaled M.Hassan MD; 2011

7. All of these assessment systems use a systematic approach in a strict order: • A: airway (with C-spine protection in trauma) • B: breathing • C: circulation • D: deficits in neurological status • E: environment (exposure) Khaled M.Hassan MD; 2011

8. Objectives • The rational of ABCDE • The process of primary & secondary survey • Recognition of life threatening events • Treatment of life-threatening conditions • Handover Khaled M. Hassan MD; 2011

9. Traditional medical approach

10. The ABCDE approach A E B Airway & oxygenation D C Exposure & examination Breathing & ventilation Disability due to neurological deterioration Circulation & shock management

11. The principles • Perform primary ABCDE survey (5 min) • Instigate treatment for life threatening conditions as you find them • Re-assess when any treatment is completed • Perform more detailed secondary ABCDE survey including investigations • If condition deteriorates repeat primary survey Khaled M. Hassan MD; 2011

12. The primary survey • ABCDE assessment looking for immediately life threatening conditions • Rapid intervention usually includes max O2, IV access, fluid challenge +/- specific treatment • Should take no longer than 5 min • Can be repeated as many times as necessary • Get experienced help as soon as you need it Khaled M. Hassan MD; 2011

13. The secondary survey • Performed when patient more stable • More detailed examination of patient (ABCDE) • Order investigations to aid diagnosis • IF PATIENT DETERIORATES RETURN TO PRIMARY SURVEY Khaled M.Hassan MD; 2011

14. Airway • How do we assess airway and why? Khaled M. Hassan MD; 2011

15. Airway - causes A •  GCS • Body fluids • Foreign body • Inflammation • Infection • Trauma Khaled M. Hassan MD; 2011

16. Airway - assessment A • Unresponsive • Added sounds • Snoring, gurgling, wheeze, stridor • Tracheal tug • Accessory muscles • See-saw respiratory pattern Khaled M. Hassan MD; 2011

17. Airway – interventions(basic) A • Head tilt chin lift • Jaw thrust • Suction • Oral airways • Nasal airways Khaled M. Hassan MD; 2011

18. Airway – interventions(advanced) A • GET HELP!!! • Nebulised adrenaline for stridor • LMA • Intubation • Cricothyroidotomy • Needle or surgical Khaled M.Hassan MD; 2011

19. Once airway open... A • Give 15 litres of oxygen to all patients via a non-rebreathing mask • For COPD patients re-assess after the primary survey has been complete & keep Sats 90-93% Khaled M. Hassan MD; 2011

20. Breathing • Why do we assess breathing and how do we carry out a comprehensive respiratory assessment? Khaled M. Hassan MD; 2011

21. Breathing - causes B •  GCS • Resp depressions • Muscle weakness • Exhaustion • Asthma • COPD • Infection Khaled M. Hassan MD; 2011 • Pulmonary oedema • Pulmonary embolus • ARDS • Pneumothorax • Haemothorax • Open pneumothorax • Flail chest

22. Breathing - assessment B • Look • Rate (<10 or >20), symmetry, effort, SpO2, colour • Listen • Taking: sentences, phrases, words • Bilateral air entry, wheeze, silent chest other added sounds • Feel • Central trachea, Percussion, expansion Khaled M. Hassan MD; 2011

23. Breathing - interventions B • Consider ventilation with AMBU™ bag if resp rate < 10 • Position upright if struggling to breath • Specific treatment • i.e.: β agonist for wheeze, chest drain for pneumothorax Khaled M. Hassan MD; 2011

24. Circulation • What is the significance of circulation and how do we assess the patient? Khaled M. Hassan MD; 2011

25. Circulation - assessment • Look at colour • Examine peripheries • Pulse, BP & CRT • Hypotension (late sign) • sBP< 100mmHg • sBP < 20mmHg below pts norm •  Urine output • Consider compensation mechanisms Khaled M. Hassan MD; 2011 C

26. Circulation – shock Inadequate tissue perfusion • Loss of volume • Hypovolaemia • Pump failure • Myocardial & non-myocardial causes • Vasodilatation • Sepsis, anaphylaxis, neurogenic C BP = HR x SV x SVR Khaled M.Hassan MD; 2011

27. Circulation - interventions • Position supine with legs raised • Left lateral tilt in pregnancy • IV access - 16G or larger x2 • +/- bloods if new cannula • Fluid challenge • colloid or crystalloid? • ECG Monitoring • Specific treatment Khaled M.Hassan MD; 2011 C

28. Central Venous Pressure • Involves insertion of a line to a major vein e.g. subclavian, internal jugular under full aseptic technique. • Patient is placed in supine or Trendelenburg position – promotes venous filling,aids catheter placement and reduces risk of air embolism. • Following insertion a check x-ray is required to confirm position and absence of pneumothorax. Khaled M. Hassan MD; 2011

29. CVP (contd.) • It is a direct measurement of pressure within the right atrium. • Readings should not be used in isolation, but as part of full haemodynamic assessment. • Used as a guide in fluid replacement. • Used to establish deficits in blood volume. • Used for drug administration, maintaining nutrition (TPN) Khaled M.Hassan MD; 2011

30. CVP (contd.) • What is the nursing management of CVP lines Khaled M.Hassan MD; 2011

31. Deficits in neurological status & environment (exposure) • How will you assess neurological status and environment? Khaled M. Hassan MD; 2011

32. Disability - causes • Inadequate perfusion of the brain • Sedative side effects of drugs •  BM • Toxins and poisons • CVA •  ICP Khaled M. Hassan MD; 2011 D

33. Disability - assessment • AVPU (or GCS) • Alert, responds to Voice, responds to Pain, Unresponsive • Pupil size/response • Posture • BM • Pain relief Khaled M. Hassan MD; 2011 D

34. Disability - interventions • Optimise airway, breathing & circulation • Treat underlying cause • i.e.: naloxone for opiate toxicity • Caution if reversing benzo’s • Treat  BM • 100ml of 10% dextrose (or 20ml of 50% dextrose) • Control seizures • Seek expert help for CVA or ICP Khaled M. Hassan MD; 2011 D

35. Exposure E • Remove clothes and examine head to toe front and back • Haemorrhage (inc concealed), rashes, swelling etc • Keep warm (unless post cardiac arrest) • Maintain dignity Khaled M. Hassan MD; 2011

36. Secondary survey • Repeat ABCDE in more detail • History • Order investigations • ABG, CXR, 12 lead ECG, Specific bloods • Management plan • Referral • Handover Khaled M. Hassan MD; 2011

37. Handover S ITUATION B ACKGROUND A SSESSMENT R ECCOMENDATION

38. S Situation • Check you are talking o the right person • State your name & department • I am calling about... (patient) • The reason I am calling is... Khaled M. Hassan MD; 2011

39. B Background • Admission diagnosis and date of admission • Relevant medical history • Brief summary of treatment to date Khaled M. Hassan MD; 2011

40. A Assessment • The assessment of the patient using the ABCDE approach Khaled M. Hassan MD; 2011

41. Current practice in critical care services • Development of outreach services from critical care specialists to support ward staff in managing patients at risk. • Improved patient monitoring through the use of early warning scores (EWS) or modified early warning scores (MEWS) Khaled M. Hassan MD; 2011

42. R Recommendation • I would like you to... • Determine the time scale • Is there anything else I should do? • Record the name and contact number of your contact Khaled M. Hassan MD; 2011

43. Questions ?

44. Summary • Assess ABCDE in turn • Instigate treatments for life-threatening problems as you find them • Reassess following treatment • If anything changes go back to A Khaled M.Hassan MD; 2011

45. Nebulised salbutamol (5mg) - O2 driven Repeat as needed Nebulised ipratropium (500mcg) - O2 driven Hydrocortisone 100mg IV or Prednisolone 50 – 60mg po MgSO4 IV 1.2 – 2g Seek guidance first Acute severe asthma HR SVR • Any one of: • PEF 33 – 50% of best or predicted • RR> 24 • HR> 110 • Inability to complete sentences in 1 breath

46. PEF <33% SpO2 <92% PaO2 <8 kPa Normal PaCO2 PaCO2 is a pre-terminal sign Silent chest Cyanosis Poor respiratory effort Arrhythmias Exhaustion / GCS Life threatening asthma HR SVR Severe asthma plus one of the following: Get expert help quickly and treat as for acute severe asthma

47. Sepsis HR SVR Signs and symptoms of infection (SSI) or Systemic Inflammatory Response (SIRs) • Temperature > 38.2°C or <36°C • HR>90 beats/min • Respiratory rate >20 breaths/min • WBC count > 12,000 or <4,000/mL • Hyperglycaemia (in absence or DM) 2 or more SSI’s + suspicion of a new infection = SEPSIS

48. Oxygen Blood cultures IV antibiotics (within 1 hour) BP < 90 systolic Acute alteration in mental status O2 sats < 90% UO < 0.5ml/kg/hr for 2 hours Severe Sepsis HR SVR SEPSIS + Organ dysfunction = SEVERE SEPSIS • Bilirubin >34µmol/L • Platelets <100 x 109/L • Lactate>2 mmol/L • Coagulopathy – INR>1.5 or APTT>60sec • Fluids +++ • Monitor lactate & Hb • Urinary Catheter & hourly monitoring

49. Get expert help quickly Oxygen IM adrenaline 500mcg repeat every 5 min if needed Highly likely if… Sudden onset and rapid progression Life threatening problem to airway &/or breathing &/or circulation Skin changes (rash or angioedema) +/- Exposure to known allergen Anaphylaxis HR SVR • Chlorphenamine 10mg IV • Hydrocortisone 200mg IV • +/- fluids +++

50. Patterns of Traumatic Injury • Penetrating injury – ongoing significant blood loss is expected • Blunt injury – blood loss may be occult or contained and significant or limited • Head injury – maintenance of cerebral perfusion pressure • Others: pediatric and obstetric trauma