Recognizing the critically illpatientLaura C Robertson

Mohammed Al-Haddad

correction of life-threatening problems by priority, provides

a standardized approach between professionals, aids communi-

cation and reduces the risk of missing important details. In the

initial stages primary assessment, resuscitation and life-saving

interventions should be performed concurrently.

A e Assessment of airway

Complete airway obstruction is silent but normally accompanied

by exaggerated respiratory effort (see-saw breathing) until the

point of cardio-respiratory collapse. Partial airway obstruction

results in noisy breathing (gurgling, snoring, etc). Stridor

suggests large airway obstruction and hoarseness implies

involvement of the vocal cords. Both are worrying signs and

INTENSIVE CARELaura C Robertson MBBS FRCA is an Anaesthetic Registrar in the West of

Scotland, Scotland. Conflicts of interest: none declared.

Mohammed Al-Haddad MBChB FRCA FFICM EDIC MSc Clinical Education is

a Consultant in Anaesthesia and Intensive Care at the Western Infirmary

of Glasgow, Scotland. Conflicts of interest: none declared.priority and provides a standardized approach between professionals.

Good outcomes rely on rapid identification, diagnosis and definitive treat-

ment and all doctors should possess the skills to recognize the critically ill

patient and instigate appropriate initial management.

Keywords Assessment; CCOS, critical care outreach services; critical

illness; early-warning systems; MET, medical emergency teams; outcomes;

prediction; signs

Royal College of Anaesthetists CPD Matrix: This article correlates with thefollowing competencies from the RCOA 2010 curriculum:

Basic level training

RC_BS_01

Basic ICM e 1.1, 2.1, 2.2, 2.7

MK_BK_01-06

Intermediate level training

Intermediate ICM e 1.4, 12.9

Critical illness is a life-threatening process that, in the absence of

medical intervention, is expected to result in mortality or signifi-

cant morbidity. It may be the product of one or more underlying

pathophysiological processes; however, the end result is a multi-

system progression that ultimately involves respiratory, cardio-

vascular and neurological compromise. Simple and preventative

critical care is the most effective approach, considering that up

to 40%of intensive care unit (ICU) admissionsmay be avoidable.1AbstractCritical illness is a life-threatening multisystem process that can result in

significant morbidity or mortality. In most patients, critical illness is

preceded by a period of physiological deterioration; but evidence

suggests that the early signs of this are frequently missed. All clinical

staff have an important role to play in implementing an effective Chain

of Response that includes accurate recording and documentation of

vital signs, recognition and interpretation of abnormal values, patient

assessment and appropriate intervention. Early-warning systems are an

important part of this and can help identify patients at risk of deteriora-

tion and serious adverse events. Assessment of the critically ill patient

should be undertaken by an appropriately trained clinician and follow

a structured ABCDE (airway, breathing, circulation, disability and expo-

sure) format. This facilitates correction of life-threatening problems byANAESTHESIA AND INTENSIVE CARE MEDICINE 14:1 11Ineffective management or failure to intervene in a timely fashion

can lead tomulti-organ failure andmortality rises as the number of

organ systems involved increases.2 Ideal management involves

prediction of at risk patients, proactive observation and timely

intervention to prevent deterioration. Simple, appropriate treat-

ment can improve outcomes, for example early administration of

antibiotics in patients with an infective cause of critical illness (e.g.

meningitis, pneumonia, septic shock) improves chances of

recovery.

Occasionally, the onset of life-threatening illness is acute and

catastrophic. More commonly, however, the onset is insidious.

Studies have shown that early indicators of critical illness are often

missed by healthcare professionals.3 Signs and symptoms can be

unreliable and patients may compensate for a long time for

abnormal changes in their physiology (Figure 1). Hence the

gradually deteriorating patient on a hospital ward may go unno-

ticed until severe organ failure is established. The Department of

Health has recently published guidance on recognizing critically ill

patients and recommends that all healthcare professionals are

aware of the Chain of Response and their role within it.4 The

Chain of Response requires accurate recording and documenta-

tion of vital signs, recognition and interpretation of abnormal

values and appropriate patient assessment and intervention. It

should be conducted in an effective, timely and seamless manner,

aiming to ensure the right patient receives the right treatment at

the right time. Use of early-warning scoring systems can highlight

subtle physiological derangement (Table 1). An abnormal score

should prompt assessment by an appropriately qualified profes-

sional or team, often called a medical emergency team (MET) or

critical care outreach service (CCOS).

Regardless of who assesses the patient, a systematic ABCDE

approach should be used. This facilitates assessment and

Learning objectives

After reading this article, you should be able to:

C recall the abnormal clinical signs associated with a critically ill

patient and common patterns of presentation

C describe a logical and systematic approach to the assessment

of an acutely unwell patient

C discuss the clinical importance of the Chain of Response and

early-warning systems in the recognition of the critically ill 2013 Elsevier Ltd. All rights reserved.

Early sign: OR (95% C.I.) Late sign: OR (95% C.I.)

Partial airway obstruction:38.7 (3.964.4)

Poor peripheral circulation:34.4 (6.8174.0)

Unresponsive to voice:34.8 (10.7113.0)

Base deficit 5 to 8 mmol/litre:40.2 (7.7208.8)

pH 7.3 but 7.2:29.0 (3.1268.3)

pH 7.2:116.1 (7.11906.1)

Base deficit 8 mmol/litre:29.0 (3.1268.3)

Top five early and late signs of physiological deterioration with the odds ratio (OR) for death

INTENSIVE CAREDrain fluid loss expected:30.1 (6.1148.9)warrant immediate action by an experienced anaesthetist and/or

ear, nose and throat surgeon.

A fast, simple way of assessing the airway is to ask the patient

a question, such as how are you? A clear, coherent answer

implies a patent airway, sufficient respiratory capacity to permit

speech and adequate cerebral perfusion for cognitive processing.

A more thorough airway assessment should use the look, listen,

Adapted from the SOCCER study

Figure 1

Example of an early-warning scoring system

The modified early-warning score (MEWS) system is employed in many UK

impairment. It is a five-component scoring system based on four bedside p

the AVPU (alert, voice, pain, unresponsive) score. A score of 5 or more is ass

care unit. Abnormal scores should prompt an escalating response, varying

appropriately qualified professional.

Score 3 2 1 0

Systolic blood pressure 38.5 d

lert Voice Pain Unresponsive

ical admissions. Quarterly Journal of Medicine 2001; 94; 521e6.

2013 Elsevier Ltd. All rights reserved.

be secured and a fluid challenge considered in all but those with

INTENSIVE CAREepiglottitis) and inflammatory (e.g. burns, anaphylaxis) causes of

airway obstruction are less common but can be rapidly

progressive and life-threatening. If conscious, the patient will

often adopt the best position to maintain their airway (usually

sitting upright and leaning forward). Do not attempt to lay such

a patient flat as this may precipitate complete obstruction.

Involve an experienced anaesthetist early.

B e Assessment of breathing

Adequate respiratory function requires an intact central respira-

tory drive, respiratory muscle activity, sufficient surface area for

alveolar gas exchange and adequate pulmonary circulation.

Impairment of any of these can cause respiratory embarrass-

ment. Clinical assessment using a look, listen, feel approach is

advocated. Tachypnoea can imply respiratory pathology but is

also a sensitive early indicator of acute illness, occurring as the

body attempts to correct metabolic acidosis secondary to poor

tissue perfusion. Peripheral oxygen saturations should be recor-

ded, but pulse oximetry can be unreliable, falsely reassuring and

does not indicate adequate ventilation. Arterial blood gas anal-

ysis should be performed if time allows.

Differentiating between the two types of respiratory failure

can aid diagnosis and management. Type I failure (PaO2

secondary survey, including thorough history, case note and

chart review, detailed clinical examination and targeted investi-

gation. Good outcomes rely on rapid identification of critical

illness, accurate diagnosis and definitive management. Simple

measures performed well can prevent irreversible deterioration

and save lives. A

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FURTHER READING

National Institute for Health and Clinical Excellence. Acutely ill patients in

hospital: recognition of and response to acute illness in adults in

hospital (NICE guideline no. 50). London: National Institute for Health

and Clinical Excellence, 2007.

National Patient Safety Agency. Recognising and responding appropri-

ately to early signs of deterioration in hospitalised patients. Ref no.

0683. London: National Patient Safety Agency, 2007.

Smith GB, Osgood VM, Crane S. ALERT e a multiprofessional trainingcourse in the care of the acutely ill adult patient. Resuscitation 2002;

52: 281e6.

INTENSIVE CAREANAESTHESIA AND INTENSIVE CARE MEDICINE 14:1 14 2013 Elsevier Ltd. All rights reserved.

Recognizing the critically ill patientA Assessment of airwayB Assessment of breathingC Assessment of circulationD and E Assessment of disability and exposureReferencesFurther reading