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The approach to the critically ill patient Nick Smith Clinical Skills.

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Presentation on theme: "The approach to the critically ill patient Nick Smith Clinical Skills."— Presentation transcript:

1 The approach to the critically ill patient Nick Smith Clinical Skills

2 Objectives The rational of ABCDE The process of primary & secondary survey Recognition of life threatening events Treatment of life-threatening conditions Handover

3 Traditional medical approach Treatment Diagnosis Investigations Differential Examination History

4 The ABCDE approach ABCDE Airway & oxygenation Breathing & ventilation Circulation & shock management Disability due to neurological deterioration Exposure & examination

5 The principles Perform primary ABCDE survey (5 min) Instigate treatment for life threatening conditions as you find them Reassess when any treatment is completed Perform more detailed secondary ABCDE survey including investigations If condition deteriorates repeat primary survey

6 The primary survey ABCDE assessment looking for immediately life threatening conditions Rapid intervention usually includes max O 2, 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 If you have a team delegate jobs

7 The secondary survey Performed when patient more stable Get a brief relevant HPC & Hx More detailed examination of patient (ABCDE) Order investigations to aid diagnosis IF PATIENT DETERIORATES RETURN TO PRIMARY SURVEY

8 Airway - causes GCS Body fluids Foreign body Inflammation Infection Trauma

9 Airway - assessment Unresponsive Added sounds – Snoring, gurgling, wheeze, stridor Tracheal tug Accessory muscles See-saw respiratory pattern

10 Airway – interventions (basic) Head tilt chin lift Jaw thrust Suction Oral airways Nasal airways

11 Airway – interventions (advanced) GET HELP!!! Nebulised adrenaline for stridor LMA Intubation Cricothyroidotomy – Needle or surgical

12 Once airway open... 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%

13 Breathing - causes GCS Resp depressions Muscle weakness Exhaustion Asthma COPD Infection Pulmonary oedema Pulmonary embolus ARDS Pneumothorax Haemothorax Open pneumothorax Flail chest

14 Breathing - assessment Look – Rate ( 20), symmetry, effort, SpO 2, colour Listen – Taking: sentences, phrases, words – Bilateral air entry, wheeze, silent chest other added sounds Feel – Central trachea, Percussion, expansion

15 Breathing - interventions 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

16 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

17 Circulation – shock Loss of volume – Hypovolaemia Pump failure – Myocardial & non- myocardial causes Vasodilatation – Sepsis, anaphylaxis, neurogenic BP = HR x SV x SVR Inadequate tissue perfusion

18 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

19 Disability - causes Inadequate perfusion of the brain Sedative side effects of drugs BM Toxins and poisons CVA ICP

20 Disability - assessment AVPU (or GCS) – Alert, responds to Voice, responds to Pain, Unresponsive Pupil size/response Posture BM Pain relief

21 Disability - interventions Optimise airway, breathing & circulation Treat underlying cause – i.e.: naloxone for opiate toxicity – Caution if reversing benzos Treat BM – 100ml of 10% dextrose (or 20ml of 50% dextrose) Control seizures Seek expert help for CVA or ICP

22 Exposure Remove clothes and examine head to toe front and back – Haemorrhage (inc concealed), rashes, swelling etc Keep warm (unless post cardiac arrest) Maintain dignity

23 Secondary survey Repeat ABCDE in more detail History Order investigations – ABG, CXR, 12 lead ECG, Specific bloods Management plan Referral Handover


25 Situation Check you are talking o the right person State your name & department I am calling about... (patient) The reason I am calling is...

26 Background Admission diagnosis and date of admission Relevant medical history Brief summary of treatment to date

27 Assessment The assessment of the patient using the ABCDE approach

28 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

29 Questions ?

30 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

31 Acute severe asthma Nebulised salbutamol (5mg) - O 2 driven – Repeat as needed Nebulised ipratropium (500mcg) - O 2 driven Hydrocortisone 100mg IV or Prednisolone 50 – 60mg po MgSO 4 IV 1.2 – 2g – Seek guidance first Any one of: PEF 33 – 50% of best or predicted RR> 24 HR> 110 Inability to complete sentences in 1 breath HR SVR

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

33 Sepsis 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 SSIs + suspicion of a new infection = SEPSIS HR SVR

34 Severe Sepsis 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 Bilirubin >34µmol/L Platelets <100 x 10 9 /L Lactate>2 mmol/L Coagulopathy – INR>1.5 or APTT>60sec SEPSIS + Organ dysfunction = SEVERE SEPSIS Fluids +++ Monitor lactate & Hb Urinary Catheter & hourly monitoring HR SVR

35 Anaphylaxis Get expert help quickly Oxygen IM adrenaline 500mcg – repeat every 5 min if needed Highly likely if… 1.Sudden onset and rapid progression 2.Life threatening problem to airway &/or breathing &/or circulation 3.Skin changes (rash or angioedema) +/- Exposure to known allergen Chlorphenamine 10mg IV Hydrocortisone 200mg IV +/- fluids +++ HR SVR

36 Hypovolaemia Haemorrhagic External Drains GI tract Abdomen Trauma On the floor and 4 more – Chest, abdo, pelvis, long bones Fluid loss D&V Polyuria Pancreatitis Iatrogenic Diuretics +++ Inadequate fluid prescription HR SVR

37 Hypovolaemia RespondersPartial or transient responders Non-responders Patient improve and remains improved. Patient improves but shows a gradual deterioration on-going loss or re- equilibration No improvement. Exsanguination though severe dehydration & sepsis should be considered No further boluses maybe needed but investigate cause Further boluses and investigations Further boluses and get help quickly Give fluid challenge 250ml over 2 min and reassess after 5 min

38 Haemorrhagic shock Class I < 15% <750ml Class II 15-30% 750 – 1500ml Class III 30 – 40% 1500 – 2000ml Class IV >40% >2000ml RR HR<100>100>120>140 BPNormal Decreased Pulse pressureNormalDecreased NeuroSlighty AnxiousMildly anxiousAnxious or confused Confused or lethargic Urine Output> 3020 – Bladder sweat Use patients obs to estimate the blood loss then replace with crystalloid at 1.5 to 3ml for every 1ml of estimated blood loss Figures based on a young healthy adult with a compressible haemorrhage

39 Bradycardia Adverse signs BP HR < 40 Heart failure Ventricular arrhythmias compromising BP No adverse signs with a risk of asystole? Recent asystole Mobitz II AV block 3 rd degree HB w QRS QRS pauses > 3 sec Get expert help quickly! Atropine 500 mcg IV –Repeat to a max total dose of 3mg External cardiac pacing HR SVR

40 Tachyarrhythmia Get expert help quickly Unstable* – Sedate and synchronised cardiovertion Stable VT – Amiodarone 300mg 20 – 60 min Stable SVT – Vagal manoeuvers – Adenosine 6mg, 12mg, 12mg Stable tachy AF – Amiodarone 300mg 20 – 60 min if onset < 48hrs – Β-blocker IV or digoxin IV (*rate related symptoms are uncommon at less than 150 beats min -1 ) HR SVR

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