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Uploaded byAhmed Abdelazeem
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Approach to the critically ill patient

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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Related topics:
Critical Care Overview•
Approach To The Critically Ill Patient Ahmed Mohamed Abdelazeem Critical Care Medicine Department Benha University 2019
PRIMARY SURVEY 1. Airway and cervical spine control 2. Breathing and ventilation 3. Circulation with hemorrhage control 4. Disability 5. Exposure/Environmental control
Airway and Cervical Spine Control
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
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”
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.
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
Breathing and Ventilation
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
2. Monitoring • pulse oximeter, end-tidal CO2 monitor 3. Diagnostics • arterial blood gas, portable chest radiograph (+ pelvic and cervical spine views in multiply injured).
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
2. Treatment Of The Cause • Needle thoracostomy • Chest tube thoracostomy • Thoracocentesis • Furosemide
Circulation with Hemorrhage Control
Assessment 1. Physical Examination • Pulse palpable carotid, femoral, radial, dorsalis pedis pulse = SBP > 60, 70, 80, 90 mm hg • Neck veins • Level of consciousness • Skin temperature and color • Capillary refill time • Heart sounds • Blood pressure • Urine output
2. Monitoring • Continuous electrocardiographic monitoring and noninvasive blood pressure monitoring 3. Diagnostics • ECG, POCUS
Interventions 1. Establishing Intravenous Access 2. Take Initial Blood Samples For Blood Grouping, Full Blood Count, Coagulation Studies, Electrolytes, Kidney Functions, Liver Functions 3. Fluid Resuscitation, Blood Products, Vasopressors, Inotropes 4. Treatment Of The Cause • needle decompression followed by tube thoracostomy for tension pneumothorax • needle pericardiocentesis for cardiac tamponade • thrombolytics for pulmonary embolism • Cardioversion • pacing
Disability
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
Interventions 1. Anticonvulsants For Seizures 2. Dextrose For Hypoglycemia 3. Antidote For Drug Overdose
Exposure/ Environmental Control
Assessment • Fully Undress The Patient To Examine The Patient’s Skin Surface
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
SECONDARY SURVEY 1. Subjective 2. Objective 3. Assessment and plans
Subjective
1. Chief Complaints • Demographics • Name • Age • Gender • Admission date • Source of referral • Relevant comorbidities • Complaining of
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
3. Systems Review • Neurological • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Infectious Diseases • Hematological • Endocrinal • Musculoskeletal
4. Past History • Medical • Surgical • Ob/Gyn 5. Personal And Social History • Occupation • Marital status • Living conditions • Habits “Tobacco, Alcohol, Illicit drugs”
6. Family History 7. Allergies 8. Medications • Indication • Dose • Duration • Side effects
Objective
1. Physical Exam • General • Vitals (Height, Weight, Temperature, Heart Rate, Blood Pressure, Central Venous Pressure, Respiratory Rate, Oxygen Saturation, 24 hr Urine Output, Net Fluid Balance) • HEENT “Head, Eyes, Ears, Nose and sinuses, Throat” • Neck • Cardiovascular • Respiratory • Abdominal • Neurological • Extremeties • Skin
2. Laboratory Data • ABG, CBC, Coagulation studies, electrolytes “Na, K, Ca, Mg, Ph”, Kidney functions, Liver functions, Thyroid function, Adrenal function, CRP, PCT, Cultures, Antibiotic levels, Troponins, Ck-Mb, others 3. Imaging Data • X Ray, CT, MRI, US, ECG, ECHO, others
Assessment and Plans
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)
Problem list Disease Syndrome Symptom, Sign, Lab Finding, Imaging Finding
Daily Presentation 1. Summary Statement with Synthesized Problem List 2. Major events during the last 24 h 3. System - Based Assessment and Plans (Diagnostic, Therapeutic): • Neurological (SOAP) • Cardiovascular (SOAP) • Respiratory (SOAP) • Renal (24 hr Urine Output, Dialysis, Urea, Creatinine), Fluids (Net Fluid Balance, Cumulative Fluid Balance), Electrolytes (Na, K, Ca, Mg, Ph) • Gastrointestinal (SOAP), Nutrition (Albumin, Tolerance) • Genitourinary (SOAP) • Infectious diseases (Temperature, TLC, CRP, PCT, Cultures, Antibiotic levels) • Hematological (CBC, PT, PTT, Fibrinogen, FDPs, D-dimer, Peripheral blood smear, Blood products transfusion) • Endocrinal (Glycemic control, Thyroid function, Adrenal function) • FAST HUGS SLR: Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of bed elevation, Ulcer prevention, Glycemic control, Skin breakdown ”Wounds, Bedsores”, Stool, Lines/catheters/drains, Readiness to wean • Physical Therapy • Discharge Planning
Summary • Primary Survey  Airway and cervical spine control  Breathing and ventilation  Circulation with hemorrhage control  Disability  Exposure/Environmental control • Secondary Survey  Subjective  Objective  Assessment and plans
THANKS