Identifying critical illness

1. Arun Radhakrishnan

2.  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!).

3.  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)

4.  Early recognition affords best chance of optimization and survival.
 Prevents further physiologic deterioration
 Time for prognostication, end of life discussions

5.  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.

6.  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.

7.  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

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

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

10.  Airway
 Breathing
 Circulation
 Disability
 Exposure

11.  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

12. More

13.  Respiratory rate
 Pattern of breathing
 Work of breathing
 SpO2
 FiO2 requirements
 Course of respiration over last few hours

14.  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

15.  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

16.  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

17.  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.

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

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

20.  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

21.  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

22.  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

23.  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!

24.  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

25.  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

26.  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: arun@intensivisteducator.com if anything has been missed, or
for feedback
 You are welcome to use this file and the associated podcast under the Creative
Commons Licence