Identifying critical illness

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IDENTIFYING CRITICAL ILLNESS Arun Radhakrishnan

Transcript of Identifying critical illness

Page 1: Identifying critical illness

IDENTIFYING CRITICAL ILLNESSArun Radhakrishnan

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DEFINITION Critical illness: Difficult to define!

Insurers have definitions! A constellation of acute severe biochemical and physiologic derangements

associated with dysfunction of one or more organ systems that are life-threatening and need increased levels of medical and nursing care and specialized interventions and monitoring for optimization and treatment, and which may lead to a variety of outcomes including death, disability and chronic critical illness(this is an own definition, by the way!).

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INTRODUCTION Generally recognition and management (pre-ICU) are still suboptimal –

although much improved. Lack of a systematic approach Deficiencies in medical and/or nursing training Logistics and workload

Cardiac arrests in the ward are often preceded by hours of untreated (and unrecognized) physiological deterioration (Franklin and Matthew 1994)

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NEED TO RECOGNIZE EARLY Early recognition affords best chance of optimization and survival. Prevents further physiologic deterioration Time for prognostication, end of life discussions

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WHAT CAN GO WRONG WITH THE PATIENT? Anticipated deterioration of primary pathology (e.g. progressive worsening

of hypoxemia due to pneumonia) Deterioration due to entirely different (or previously unrecognized) issue

(e.g. AMI in a patient admitted with Cellulitis) Iatrogenic causes: medication errors, drug reactions, contrast-induced

nephropathy etc.

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WHAT HAVE WE LEARNT OVER THE YEARS? Recording (and interpretation of deviations) of vital signs can reliably

predict physiologic deterioration. Vital signs:

HR BP Respiratory rate SpO2 Level of consciousness (GCS) Urine output Temperature

Various scoring systems in place: MEWS, ADDS etc.

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EVALUATING FOR CRITICAL ILLNESS Reason for hospital admission Course of events in last few hours to days Trigger for deterioration History Physical examination Evidence of organ dysfunction(s) Investigations Ward Obs chart Discussion with treating team(s) and nursing staff

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CONSIDERATIONS Reason for referral? Urgency of the situation? Degree of physiologic instability? Pre-existing co-morbidities? Functional status, and Resuscitation status Prognosis?

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CATEGORIZATION

Frost P and Wise M; BJHM 2007; 68: 10

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BASIC EVALUATION - THE ABCDE APPROACH Airway Breathing Circulation Disability Exposure

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AIRWAY WITH O2 SUPPLEMENTATION AND C-SPINE CONSIDERATIONS

Needs to be patent! Can be impaired by neurologic states, head and neck pathologies, or upper

airway issues. Needs to be assessed in every patient!

Look for: Stridor Snoring Silent airway! (Breathing pattern, chest-abdominal dissynchrony, Pt usually

cyanosed) Video

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BREATHINGMONITORING OF PULSE OXIMETRY Respiratory rate Pattern of breathing Work of breathing SpO2

FiO2 requirements Course of respiration over last few hours

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CIRCULATIONSECURE IV ACCESS Signs of inadequate circulation/low Cardiac output/shock

Altered mentation Poor capillary refill Cool, clammy extremities Low BP (Note: BP is not always a good indicator of cardiac output) Decreased urine output Metabolic acidosis, raised Lactate in blood gas, decreased Central venous O2

saturations Global picture (more than one sign in tandem) more predictive of actual

clinical suspicion

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DISABILITY-ASSESSING THE LEVEL OF CONSCIOUSNESS Decreased level of consciousness

Airway- maintained? Focal neurology Pupillary signs Reflexes and tone Meningeal signs

Don’t ever forget Glucose

Use GCS (validated only for trauma) or the AVPU scale

More resources

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EXPOSURE (AND ENVIRONMENT) Facilitates rapid identification of cause of deterioration (e.g. trauma, needle

tracks, bite/sting marks) or complications (e.g. pressure areas) Avoid hypothermia, especially in trauma

Very important to conduct a comprehensive clinical examination

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DON’T FORGET-LOOK, LISTEN, AND EXAMINE Look at the patient Look at the observation charts- this is a goldmine of information Input-output charts as well Listen to the patient, relatives and ward staff (and home team) Focussed yet comprehensive physical examination (tailored to time and

situational constraints) Bedside information: e.g. Sugar levels, ECG, charts Basic labs: Blood gas (Arterial Vs Venous), EUC, CMP, FBC, cultures, coags,

LFTs etc.

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CATEGORIZATION

Frost P and Wise M; BJHM 2007; 68: 10

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PATHWAYS TO MANAGEMENT

Frost P and Wise M; BJHM 2007; 68: 10

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RAPID ASSESSMENT Airway- patent/compromised? Breathing: rate, rhythm, effort (WOB), use of accessories, pattern

(obstructed?). Tracheal position, percussion, Chest auscultation. SPO2

Circulation: HR, rhythm, capillary refill, pulse volume and equality, skin temperature, postural hypotension, BP. Lactate, Central venous Oxygen saturations. Level of consciousness, urine output

CVP or JVP not a reliable indicator of hypovolemia Low urine output by itself not very specific- in the absence of other signs of

low cardiac output Disability: Level of consciousness, Focal neurology, Meningeal signs Exposure and environmental control

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NEVER FORGET THE REASON FOR ADMISSION/REFERRAL Helps focus and prioritize Need to make a problem list or an issue list Think around the problem for other equally important aspects: for example,

K+ levels in a patient with acute kidney injury Resuscitation is the first priority Call for help ASAP – never hesitate (Use the ISBAR technique if time

permits) If the patient is deemed safe to remain on the wards, do review the patient

again, to make sure they are safe

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RESUSCITATION Maintain airway patency O2 supplementation (aim for safety, not normalcy) IV access and bloods Recovery position if unconscious (unless contraindicated) History, history, history…. Focussed and gentle examination Relevant investigations (bedside tests preferred) – avoid transport for

investigations unless absolutely necessary

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Always think about what category the patient fits into Disposition and Resuscitation status Communication of plans to patient and their family, all teams involved Intensive care is a team game!

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KEEP IT SIMPLE! A structured approach to identifying deterioration is easy if you remember

the alphabet!

Remember the reason for hospital admission, the history and examination findings- these are as important as the investigations

Maintain airway patency, give (adequate) O2 supplementation, secure IV access (large bore preferred), evaluate level of consciousness and examine properly

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KEEP IT SIMPLE! Time is crucial- identify and treat the most life-threatening issue first Call for help early- use the ISBAR technique preferably The critically-ill patient is at imminent risk of death: early and rapid

identification of pathology and institution of treatment measures to prevent irreversible organ dysfunction is paramount

Key Reference

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THANK YOU Disclaimer: Every effort has been made to give due credit to sources of information. The views and opinions in the slides and the podcasts are my own, and do

not represent the policies and protocols of the institutions I work in. Please email me at: [email protected] if anything has been

missed, or for feedback You are welcome to use this file and the associated podcast under the

Creative Commons Licence