The document provides guidelines for approaching critically ill patients, beginning with the primary survey of airway and cervical spine control, breathing and ventilation, circulation and hemorrhage control, disability, and exposure/environmental control. It then details assessments and interventions for each component. The secondary survey involves collecting subjective information from the patient, performing objective examinations, and creating a problem list and treatment plans. The approach emphasizes stabilizing life-threatening issues first before conducting full evaluations and treatments.
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Approach to the critically ill patient
1. Approach To The Critically
Ill Patient
Ahmed Mohamed Abdelazeem
Critical Care Medicine Department
Benha University
2019
2. PRIMARY SURVEY
1. Airway and cervical spine control
2. Breathing and ventilation
3. Circulation with hemorrhage control
4. Disability
5. Exposure/Environmental control
4. Assessment
1. Airway Patency
• Have the patient speak
If the patient talks to you normally, the airway is clear. If there is no response to speech,
perform a more detailed assessment of the airway
• Look, listen and feel
Look for secretions, blood, vomit, foreign bodies, facial, mandibular, or tracheolaryngeal
fractures
Listen for upper airway noises
Gurgling ” caused by fluids (secretions, blood or vomit) in the oropharynx”
Snoring “partial airway obstruction at the pharyngeal level”
Stridor ”high-pitched inspiratory sound, may be associated with partial airway obstruction
at the level of the larynx (inspiratory stridor) or the trachea (expiratory stridor)”
Hoarseness “caused by partial laryngeal obstruction associated with oedema”
Absent breath sounds indicates either complete airway obstruction or absence of
breathing
Feel air flow
5. 2. Airway Protection
• Testing the gag reflex or the ability to swallow
3. Assume Injury To The Cervical Spine In Any Patient With The
Following Findings:
• Multi-system or major trauma
• Altered level of consciousness
• Blunt injury above the clavicles
• Concerning mechanism of injury
• Neck pain, ecchymosis or deformity
• Neurologic deficits
“A normal neurologic exam does not exclude cervical spine injury”
6. Interventions
1. General Guidelines
• Protection of the cervical spine
All trauma victims should be placed in a protective cervical spine collar
• Prevention of aspiration
Suctioning of the lower pharynx and oropharynx
A vomiting patient should be rolled to the left lateral decubitus position and the entire
spine properly protected so that the airway can be cleared.
7. 2. Simple Maneuvers
• Head tilt/chin lift: contraindicated if neck injury is suspected
• Jaw thrust: the preferred method for patients with possible cervical spine injury
3. Airway Adjuncts
• Oropharyngeal airway (unconscious patient)
• Nasopharyngeal airway (semiconscious patient)
“Do not use a nasopharyngeal airway if you suspect a skull base fracture”
• Laryngeal mask airway
4. Tracheal Intubation
9. Assessment
1. Physical Examination
• Inspection: Observe the chest wall for symmetric rise as well as for
paradoxical movement suggestive of flail chest
• Palpation: position of the trachea in the suprasternal notch,
Subcutaneous Emphysema, for crepitus and rib tenderness
• Auscultation: provides clues to possible causes of respiratory arrest or
distress, including pneumothorax, congestive heart failure (CHF),
pulmonary edema, or pleural effusions
10. 2. Monitoring
• pulse oximeter, end-tidal CO2 monitor
3. Diagnostics
• arterial blood gas, portable chest radiograph (+ pelvic and cervical spine
views in multiply injured).
11. Interventions
1. Administration Of Supplemental Oxygen
• Nasal cannula: delivers oxygen at concentrations of 25%–45% at a flow rate of 1–6
L/min
• Simple face mask: delivers oxygen at concentrations of 40%–60% at a flow rate of 6–
10 L/min
• Venturi mask: delivers oxygen at concentrations of 65%–75% at a flow rate of 12–15
L/min
• Non rebreather mask: delivers oxygen at concentrations of 24%–60% at a flow rate
of 2–15 L/min
• Bag-mask: delivers oxygen at concentrations of 90%–97% at a flow rate of 12–15
L/min, while the previous methods require spontaneous respirations the BVM is used
for apneic patients
• Mechanical positive-pressure ventilation
12. 2. Treatment Of The Cause
• Needle thoracostomy
• Chest tube thoracostomy
• Thoracocentesis
• Furosemide
18. Assessment
1. Level Of Consciousness:
• AVPU/GCS
2. Pupillary Examination:
• Size, equality, reactivity to light
• In structural causes of coma the light reflex is usually absent, in metabolic
causes it is usually present
• A difference in pupil diameters >1 mm suggests A structural cause
3. Movement Of Extremities And Lateralization
4. Check The Blood Glucose
22. Interventions
1. Remove All Wet Or Contaminated Clothing
2. Keep The Patient Warm By
• Applying warm blankets
• Ventilating with warm humidified air
• Administering warmed IV fluids
25. 1. Chief Complaints
• Demographics
• Name
• Age
• Gender
• Admission date
• Source of referral
• Relevant comorbidities
• Complaining of
26. 2. History Of Present Illness
• Presenting scenario (A brief summary of significant data only
“subjective, objective, assessment, plan” in a chronological order, first
during Pre hospital course then during ED/floor hospital course and
finally during ICU course)
• Relevant Systems Review, Past History, Personal and Social
History, Family History, Allergies, Medications
28. 4. Past History
• Medical
• Surgical
• Ob/Gyn
5. Personal And Social History
• Occupation
• Marital status
• Living conditions
• Habits “Tobacco, Alcohol, Illicit drugs”
29. 6. Family History
7. Allergies
8. Medications
• Indication
• Dose
• Duration
• Side effects
34. 1. Summary Statement with Synthesized Problem List
• Demographics (Name, Age, Gender, Admission date, Source of referral),
Relevant comorbidities, Presented complaining of, Found to have “main
problems in descending order of importance”
2. System – Based/Problem - Based Assessment and
Plans (Diagnostic, Therapeutic)