Critically ill patient

1. WEST AFRICAN COLLEGE OF SURGEONS
COLLEGE OUEST AFRICAN DES CHIRURGIENS
Diploma in Anaesthesia Update Course
March 2024
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

2. RECOGNITION AND TRANSFER OF THE CRITICALLY ILL PATIENT
DR A V ELUMELU
DA(WACS); FWACS
National Hospital Abuja.
Samtah General Hospital KSA
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

3. COURSE OUTLINE
• DEFINITION
• BASELINE CLINICAL EVALUATION
• CLINICAL FEATURES: SYSTEMIC
• SCORING SYSTEMS
• INITIAL MANAGEMENT
• PATIENT TRANSPORTION
• MODES
• HAZARDS
• CHECKLIST
• SUMMARY
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

4. CRITICAL ILLNESS
• Critical illness is a general state which may arise
from various medical conditions, surgical
pathologies or injury with the potential for
threatened or actual impairment of vital organ
function.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

5. CRITICAL ILLNESS
• Critical illness is any disease process which causes
physiological instability, potentially leading to
disability or death within minutes or hours.
• The medical condition in which a patient, because
of major surgery or severe illness, requires
immediate intensive medical support of vital organ
functions in order to survive.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

6. CRITICAL ILLNESS: DEFINITION
• A state of ill health with vital organ dysfunction, a high risk
of imminent death if care is not provided and the potential
for reversibility (R K Kayambankadzanja et al BMJ Open, 12,
9.)
• No defined consensus of an exact definition of a critically ill
patient.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

7. THE CRITICALLY ILL PATIENT
• We must remember that the critically ill state is defined
more by the patients condition or physio-pathological state
rather than the patients actual diagnosis.
• Though some medical diagnoses are critical illness states in
themselves
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

8. BASELINE CLINICAL EVALUATION OF PATIENTS
• To recognize critical illness or critical changes, one must have
a baseline knowledge of expected physiological parameters
or the actual clinical findings of patients for age, gender and
ethnicity.
• Careful clinical evaluation: History and physical examination
• Baseline vital signs at first visit must be checked and recorded
and thereafter recorded at regular intervals.
• Documentation is key
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

9. BASELINE CLINICAL EVALUATION OF
PATIENTS
• Level of consciousness,
demeanor.
• Motor activity
• Airway and Respiration
• Pulse
• Blood Pressure
• Temperature
• Urine output
• Multi-parameter monitoring
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

10. POINT OF CARE TESTING
• Blood glucose estimation
• Arterial Blood Gas analysis
• Hemocue, Estimation of Hemoglobin
• Portable ultrasonography
• Electrocardiography/Bedside Echocardiography
• Radiological tests: X rays , CT
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

11. ARTERIAL BLOOD GAS MACHINE AND
I-STAT
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

12. ULTRASONOGRAPHY
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

13. In the critically ill patient there is a marked deviation from the expected normal or from the baseline features.
There is an actual or impending compromise of the systems: airway, respiratory, neurological, cardiovascular or other systems.
Biochemical changes may be profound and equally life threatening.
Irrespective of the underlying diagnosis, there are clinical features that alert one to the critical state of the patient.
HOW TO RECOGNIZE THE CRITICALLY ILL PATIENT
• In the critically ill patient there is a marked deviation from
the expected normal or from the baseline features.
• There is an actual or impending compromise of the
systems: airway, respiratory, neurological, cardiovascular
or other systems.
• Biochemical changes may be profound and equally life
threatening.
• Irrespective of the underlying diagnosis, there are clinical
features that alert one to the critical state of the patient.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

14. HOW TO RECOGNIZE THE CRITICALLY ILL PATIENT:
Neurological Signs
▪Confusion, Failure to obey commands, agitation, mania
▪Reduced GCS <10/15. Sudden drop in GCS >2 points
▪Absent cough or Gag reflexes
▪Seizures - prolonged or repeated
▪Facial weakness, hemiparesis, hypotonia
▪Change in the size and light reflexes of the pupils
▪Delayed recovery from anaesthesia for the postoperative
patient
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

15. THE CRITICALLY ILL PATIENT: Neurological
❖AVPU: Alert, Response to Verbal, Pain stimulus or
Unresponsive
❖Glasgow Coma Scale: Eye opening-4, Best Verbal-5,
Best Motor -6. (15/15)
❖GCS: Best score is 15, lowest score is 3
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

16. .
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

17. HOW TO RECOGNIZE THE CRITICALLY ILL PATIENT:
Respiratory Signs
▪Any form of airway obstruction
▪Respiratory distress: Stridor/wheezing, Intercostal
recession, Abdominal seesawing, use of accessory muscles.
▪Inability to speak in complete sentences
▪RR <8 or >35cpm
▪Respiratory failure (type I or 2), respiratory arrest
▪Low SpO2, below 92% in room air
▪Pulmonary oedema, pneumothorax, thoracic trauma
▪ABG: PaCO2 >60mmHg (>8kPa), low PaO2, Respiratory Acidosis
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

18. HOW TO RECOGNIZE THE CRITICALLY ILL PATIENT:
Cardiovascular signs
▪Cardiac Arrest
▪Life threatening Cardiac Arrhythmias (SVT, VF, VT, AF,
bradycardia)
▪Pulse <50/>140 bpm
▪SBP <60/>200mmHg
▪Tissue Hypoxia: Metabolic acidosis, Raised serum Lactate,
Poor peripheral perfusion, mottling of the skin.
▪Muffled heart sounds
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

19. HOW TO RECOGNIZE THE CRITICALLY ILL PATIENT:
Cardiovascular signs
▪Poor response to volume resuscitation
▪Oliguria <0.5ml/kg/hr
▪Delayed capillary refill. Greater than 5 seconds
▪ECG changes: ST elevation, T wave abnormalities, heart
block with clinical deterioration
▪Haemorrhage from any source
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

20. HOW TO RECOGNIZE THE CRITICALLY ILL PATIENT:
Biochemical/Laboratory findings
• ABG Changes: severe acidosis/alkalosis
• Hyperglycaemia, Hypoglycaemia
• Electrolyte disorders: Hyper or Hyponatremia, Hypo or
hyperkalaemia, Hypocalcaemia
• Severe anemia
• Altered clotting profile
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

21. THE CRITICALLY ILL PATIENT:
• Any patient may present as critically ill.
• All age ranges: neonatal to geriatric
• In hospital or out of hospital
• Acute onset, acute deterioration or a slow decline in
constitution.
• Patient may have multiple pathologies /co-morbidities
• May be on medications, multiple meds or may have
missed doses
• May be part of a mass wave of patients – mass casualty
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

22. THE CRITICALLY ILL PATIENT: In Hospital
The critically ill patient may be identified from different
locations:
➢in the emergency department having presented from
home
➢or referred from another healthcare facility,
➢ may be identified on the ward,
➢ in the operating theatre,
➢ Labour ward or
➢ other patient care areas within the hospital.
➢At the scene of disaster : patient retrieval team
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

23. THE CRITICALLY ILL PATIENT
➢The critically ill patient is vulnerable, unstable and
complex.
➢Single or multiple organs may be failing or at risk of
failure.
➢Significant morbidity and high risk of mortality
➢A systematic approach is needed to recognize
clinical deterioration and escalate care
➢Sadly these may be missed
➢Team based care approach is needed
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

24. THE CRITICALLY ILL PATIENT
The proper management of a critically ill patient
requires:
✓Early identification of the critically ill patient
✓Identification of the immediate life threatening
problems
✓Prompt intervention to save the life of the patient.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

25. SOME CRITICAL CLINICAL CONDITIONS
▪Neurological- Coma, Seizures, SOLs, CVA, neuromuscular disorders
▪Cardiovascular – Arrhythmias, MI, Failure, Arrest
▪Airway and Respiratory –Actual or potential Airway compromise,
Respiratory Embarrassment or failure
▪Metabolic disorders – Diabetic comas, hormone disorders,
electrolyte imbalances
▪Poisonings and Envenomation – Accidental/Intentional: Self,
Homicide, Iatrogenic. Snake bites
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

26. SOME CRITICAL CLINICAL CONDITIONS
▪Trauma: RTA, Assault, Falls, Drowning, Burns, Electrocution
▪Sepsis and Inflammatory disorders
▪Hypersensitivity reactions, Allergies
▪Acute abdomen
▪Abdominal or pelvic disorders
▪Disorders of pregnancy
▪Haemorrhage from any cause
▪Extensive, Highly invasive or prolonged surgery
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

27. THE CRITICALLY ILL PATIENT: Initial Management
IN THE CRITICALLY ILL PATIENT:
➢ The pace of assessment and therapy is quicker
➢ Simultaneous evaluation and therapy are carried out to
arrest the situation
➢ Expeditious transportation may be needed to the
Operating Theatre, ICU, Radiology suite or another
hospital for investigations, interventions and definitive
care.
➢ Escalate and call for help or assistance as early as
possible.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

28. THE CRITICALLY ILL PATIENT: Initial Management
1. SAFETY: Scene safety, Basic PPE
2. FIRST GLANCE: Initial Impression, Demeanor of pt/caregivers. Pt
responsiveness
3. INITIAL ASSESMENT (Primary Survey):
A- Airway. B- Breathing, C-Circulation, D-Disability, E- Exposure
Maintain patients dignity
4. IMMEDIATE MANAGEMENT:
Also following the A B C format
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

29. THE CRITICALLY ILL PATIENT: Safety
and PPE
the new normal!
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

30. A: Airway
▪ Look, feel and listen.
▪ Head tilt, Chin lift, jaw thrust. Suction the airway.
▪ Oropharyngeal airway, nasopharyngeal airway
▪ Left lateral positioning if the situation and clinical
condition permits
▪ Pulse Oximetry
▪ Attach all monitors
▪ Call for the Crash cart if needed
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

31. A: Airway
Commence Oxygen:
✓ by nasal prongs (4 – 6 LPM; 24 – 44%)
✓simple face mask (6 – 10 LPM; 35-50%) or a
✓Non-rebreather face mask with a reservoir bag ( 10-
15LPM; 60-80%)
✓Venturi mask: FIO2 can be more precisely titrated
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

32. OXYGEN THERAPY:
Nasal Prongs/Simple Face Mask
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

33. OXYGEN THERAPY: Non- rebreathing
Face Mask with a reservoir bag. Venturi
Mask
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

34. OXYGEN THERAPY:
Venturi Mask and Valves
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

35. AIRWAY
• Where the airway is compromised:
• Secure the airway: Supraglottic device
• Definitive control of the airway by tracheal intubation.
• The critically ill patient is not as robust as the ASA I patient
coming for elective surgery!
• All precautions must be taken to prevent profound
hypotension, bradycardia or cardiac arrest after
intubation.
• Volume loading, judicious use of sedative medication or
muscle relaxant and always prepare for difficult intubation
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

36. B:
BREATHING
• Assessment of the Airway and Breathing go hand in
hand/overlap.
• Check if the respiratory effort is adequate.
• Check for chest expansion. Auscultate and percuss the lung
fields
• If respiratory effort is inadequate or ineffective, ventilations
may be commenced using a Bag-valve-mask device.
• Non invasive Ventilation using a BIPAP machine may be used
–conscious patient.
• Intubation and IPPV as the situation may demand.
• Appropriate sedation must be given for IPPV
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

37. B: BREATHING
Bag – Valve-mask device (Ambubag)
BIPAP Ventilation
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

38. B: BREATHING
High flow nasal oxygenation/Tracheal
Intubation
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

39. C - CIRCULATION
• Check for pulse: rate, pattern, volume. Pallor, cyanosis, capillary refill.
• If no palpable carotid pulse in an unresponsive patient, call a code,
Cardiac arrest team to respond. Commence CPR .
• Blood pressure, ECG
• Secure good large bore vascular access.
• Blood samples: VBG/ABG, CBC, LFT, RFT, serum electrolytes, Troponin
• Commence IV fluids: crystalloids, colloid or blood products
• Inotropic support may be commenced as needed. MAP > 65mmHg
• Control bleeding. Call the appropriate specialty. Team work!
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

40. D - DISABILITY
• Check the neurological status: AVPU, GCS, Pupils
• Check glucose
• Examine muscle tone and reflexes
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

41. E - EXPOSURE
• The patient should be exposed and thoroughly examined
for any other clinical features or injuries, including an
inspection of the back and the perineum.
• Patients dignity must be maintained
• Appropriate covering thereafter to prevent hypothermia
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

42. MANAGEMENT..
➢ Secondary Survey: REEVALUATE patient, again using the
ABCDE format. Focused history.
➢ SAMPLE HISTORY:
• Signs and Symptoms
• Allergies. Age
• Medication
• Past Medical History
• Last meal
• Events leading to presentation

43. NEXT STEPS..
• Specific investigations and therapies should be
commenced depending on the likely pathology
• For instance: radiological interventions
• Emperical antimicrobials commenced after culture samples
• Decision is made as to the appropriate place for the
patient: ICU, OT, Interventional radiology, CATH lab, higher
center
• There will be a constant and continuing assessment and
definitive management of the patient
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

44. THE CRITICALLY ILL PATIENT: THE SICK IN-PATIENT
• 50% of in-hospital cardiac arrests are said to occur in the
wards.
• Slow deterioration of the in patient is not easily picked up
and the signs may be subtle.
• Why? High patient to nurse ratio, Inexperience, voice not
listened to, not knowing what to do.
• Conversely, alarm may be raised but more experienced
senior staff may not react in a timely fashion.
• Early Warning schemes have been introduced in some
systems and countries to help
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

45. CARDIAC ARREST (Reversible Causes)
▪ Hypovolaemia Toxins
▪ Hypoxia Tamponad(cardiac)
▪ Hydrogen ion (acidosis) TensionPneumothorax
▪ Hypo/Hyperkalaemia Thrombosis(coronary)
▪ Hypothermia Thrombosis(pulmonary)
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

46. EARLY WARNING SCORES (EWS)
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

47. SOFA SCOREs
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

48. THE CRITICALLY ILL IN-PATIENT
• Acute event or a subtle deterioration
• Early warning Scores were developed to pick important changes
• There should be a clear chain of reporting when deterioration of
the patient is noted and documented.
• For In patients, there is the advantage of a clear diagnosis and
treatment plan as well as documentation to help out.
• ABCDE approach is still to be undertaken, with activation of the
available team and decision made to escalate care as needed.
• Rapid response teams, Cardiac Arrest teams, Medical Emergency
teams have all been developed in different health care systems
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

49. THE CRITICALLY ILL PAEDIATRIC PATIENT
• We may be called upon to assist with the care of a critically ill
paediatric patient, usually for intubation and ventilatory support.
• Hypoxia is the commonest cause of Cardiac arrest in children.
• The patient may range in size from the underweight poorly
nourished 2 year old to the overweight school age child.
• Congenital abnormalities and inborn errors of metabolism occur. Be
mindful of the likely clinical situations that occur in this age group.
• A careful stepwise approach using the ABCDE format and teamwork
is also necessary here.
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

50. TRANSFER OF THE CRITICALLY
ILL PATIENT
• .
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

51. PATIENT TRANSFERS:
• Patients are transported from one location to another for:
• Investigations to make a proper diagnosis,
• For Therapeutic purposes or for Definitive intervention
• To a specific ward/ICU/hospital for continued management
• To a higher medical facility for specific care or if there is
clinical deterioration.
• Elective and planned OR Emergent
• Stable patient or an unstable critically ill patient
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

52. PATIENT TRANSFER
• Intra-hospital
• Inter-hospital
• In between regions/countries- Medical evacuation
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

53. BEFORE THE PATIENT TRANSFER
• Determine the reason for the transfer
• Inform and confirm from the receiving department
or facility.
• Inform and explain situation to the patient or
caregivers
• Informed Consent, if applicable
• Logistics, payment, insurance should be worked out
by the relevant authorities/personnel
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

54. MODES OF TRANSPORTATION
oHospital Trolley
oHospital bed
oAmbulance (50miles/80km/2hr)
oRotary wing Aircraft (50-150miles/80-240km)
oFixed Wing Aircraft (>150miles/240km)
oWatercraft
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

55. PATIENT PREPARATION: Patient trolley/bed
▪The patient trolley should have side rails and be tiltable
head up
▪There should be a head rail, a foot rail and wheels with
foot operated brakes
▪There should be ports for IV poles to be attached
▪It should have straps to secure the patient in firmly.
▪Proper coverage for the patient with hospital bedsheets,
blanket or reflective space blanket as needed
▪The pathway for the trolley should be as smooth as
possible
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

56. MODES OF TRANSPORTATION
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

57. MEDICAL TRANSPORT VEHICLES..
Aircraft
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

58. MODES OF TRANSPORTATION:
By Helicopter or by Water Ambulance
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

59. MODES OF TRANSPORTATION:
In more resource challenged
locations
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

60. REQUIREMENTS FOR TRANSPORTING
THE CRITICALLY ILL PATIENT
➢Experienced Staff – properly trained
➢Appropriate equipment for Transfer
➢Full assessment and Investigation of the Patient
➢Extensive Monitoring
➢Careful Stabilization of Patient
➢Reassessment
➢Continuing Care during Transport
➢Direct handover
➢Documentation and Audit
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

61. STAFFING
➢ For a Critically ill patient, a doctor competent in
resuscitation, Airway care, ventilation and organ support
should accompany the patient.
➢ Ideally an Intensivist/ Anaesthetist/Emergency Physician
not less than an SR in rank
➢ This is not always the situation.
➢ Accompanied by a competent Nurse and/or a Paramedical
Staff or Technician.
➢ Good rapport within the staff
➢ Insurance Cover for disability or death during transfer
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

62. VEHICLE
❑The Transport Vehicle should be road/air/seaworthy –
adequate fuel.
❑Vehicles papers should be up to date.
❑It should have good trolley Access and Fixing systems –
Trolley, Patient & Equipment
❑Good Lighting
❑Temperature Controls
❑Adequate space for the medical Attendants and Equipment
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

63. EQUIPMENT
➢ Robust, Lightweight, Battery powered. Well secured.
➢ Sufficient oxygen for the duration of transfer + reserve for
1-2 hrs.
➢ Portable ventilator with disconnection alarms
➢ Portable multi-parameter monitor with illuminated display
(displaying HR, SPO2, RR, ECG, Capnography)
➢ Syringe drivers, Infusion pumps
➢ Suction machine
➢ Defibrillator
➢ Warming Blanket
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

64. ROBUST AND PORTABLE EQUIPMENT
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

65. EQUIPMENT PATIENT MONITOR
/PREFILLED MEDICATION SYRINGES
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

66. PATIENT PREPARATION
▪Ensure the airway is secure. Intubate if necessary. Secure ETT with
ties
▪Breathing –Check ventilator (Back up Bag-valve device)
▪IV Access -2 lines, Central access if possible, all well secured
▪Meds- Sedation, Analgesics, Neuromuscular Blockade, emergency
meds.
▪All should be drawn up and labelled.
▪Chest tubes – secured properly below the level of the thorax. Clamps
available
▪Urethral catheters – strapped to the inner thigh with tape
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

67. CHECKLIST
➢Ensure the patient is resuscitated and stable
➢All lines and tubings should not be tangled and should
be firmly secured
➢Referring Hospital notified and ready to accept
patient
➢Documents: Referral note, Med records, X-rays,
Transport checklist and records
➢Relatives informed and Consent forms duly signed
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

68. CHECKLIST
➢Adequate Oxygen. Have back up oxygen cylinders
➢Equipment –Functional with extra batteries for back
up
➢Cash, ATM/Phone cards, a Charged phone and a list
of numbers to call.
➢Clear return arrangements
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

69. HAZARDS OF PATIENT TRANSPORT: To the patient
PHYSIOLOGICAL:
Acceleration and deceleration forces have effects on the patient:
❖Cardiovascular Instability, Cardiac arrest
❖Raised Intracranial pressure
❖Change in respiratory rate, Hypoxaemia, Hypo/Hypercapnia
PHYSICAL:
❖Entanglement and Displacement of IV lines, Airway devices,
drains and Catheters
❖Expansion of air filled spaces at high altitudes: Inflate ETT cuff
with saline
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

70. HAZARDS OF TRANSPORTATION
MECHANICAL:
❖Equipment Failure
❖Exhaustion of oxygen
❖Battery failure for medical devices
❖Cramped, noisy, Vibrating space
❖Vehicular accidents (injury/death)
❖ OTHER: Motion sickness,
❖ Misunderstanding/disputes with personnel
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

71. HAZARDS: ACCIDENTS
Five dead as medical transport plane crashes in
Nevada US
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

72. DURING TRANSPORT
• Constant vigilance of clinical condition/vital signs
• Medications and fluids should be continued as prescribed
(Never let the IV get blocked with blood clot or to get
tissued)
• Pace of transport should be timely but not high risk driving
• The patient should be assessed constantly
• Vasopressors and other emergency medication should be
available. CPR may even need to be carried out.
• Proper documentation is also mandatory
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

73. ARRIVAL
• Upon arrival, information should be handed over
to the receiving facility with clear
communication.
• The patient should again be assessed. He may
need further intervention.
• Proper documentation is also mandatory
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

74. DOCUMENTATION
• A very important medical and legal requirement. Medical
records/report
• A report documenting the patients condition prior to transfer,
during the transfer and upon arrival. Interventions and
medications given during transfer must be documented,
• All handed over to the receiving team/facility. A copy kept
with the transfer team/referring facility
• Pre return checklist (Personnel, equipment, Patient
information)
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

75. SUMMARY
• The critically ill patient, of any age, is at constant risk of death or
serious disability with grave consequences for the patient, family,
the health care system and the greater community
• Proper recognition, assessment and timely interventions may
possibly reverse the clinical state with a good outcome.
• Proper recognition for the need, the plan and flawless execution of
patient transport is invaluable
• A systematic team based approach yields the best outcomes
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

76. READ
• Early warning scores (EWS)
• SOFA/qSOFA
• APACHE scores
• AAGBI guidelines on Interhospital
transfer
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

77. RELEVANT
TRAININGS/CERTIFICATIONS
• AHA Basic Life Support (BLS)
• AHA Advanced Cardiac Life Support (ACLS)
• Paediatric Advanced Life Support (PALS)
• Advanced Trauma Life Support (ATLS)
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

78. REFERENCES
• Critical Illness. Newton L E, Heimburger D C. Handbook of Clinical
neurology 2014
• Towards definitions of critical illness and critical care using concept
analysis. Kayambankadzanja, Schell C O, Warnberg M G et al BMJ
Open, vol 12,issue 9.
• ABCDE Assessment oxfordmedicaleducation.com
• Case files Critical Care. Second edition. Toy, Liu, Suarez
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

79. THE CRITICALLY ILL PATIENT
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

80. QUESTIONS?
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024

81. THE CRITICALLY ILL PATIENT
DR AFFIONG V ELUMELU. WACS DIPLOMA IN ANAESTHESIA
UPDATE; MARCH 2024