Assessment of the Seriously Ill Patient,Objectives,Early identification of patients at risk for life-threatening illness Recognize early signs of critical illness Review the initial assessment of critically ill patients,Why identify patients at risk?,Easier management with simpler interventions Prevent further deterioration Provide time for investigation and treatment,Challenging Patients,Young, fit patients Immunosuppressed patients Debilitated patients Patients with abrupt deterioration Patients with limited reserve,Risk Assessment,Background health Severity of acute physiology Vital signs Other clinical monitoring Trends and rate of deterioration Goals Recognition that problem exists Maintain stability,Risk Assessment,Making a diagnosis Often secondary to treatment of physiological abnormalities Investigate while stabilizing Requires disciplined approach,Assessment,Primary survey What is main physiological problem? First minutes of initial contact Secondary survey What is underlying cause? Subsequent reviews,Assessment of the Seriously Ill Patient,History Physical examination Chart review and documentation Investigations Treatment,Patient,54 year old diabetic with shortness of breath 3 days postoperative for laparoscopic cholecystectomy,What history would you obtain initially?,Initial Survey,History Main symptoms Physiological abnormalities Co-existing illness Major surgery Severe hemorrhage/transfusion Lack of improvement,Patient,54 year old diabetic with shortness of breath 3 days postoperative for laporoscopic cholecystectomy,What additional details would be helpful?,Secondary Survey,History Past history, chronic diseases Psychosocial issues Medications/allergies Family history Ethical/legal issues Systems review,Patient,54 year old diabetic with shortness of breath 3 days postoperative for laporoscopic cholecystectomy,What parts of the physical examination would you concentrate on initially?,Initial Survey,Examination Airway Breathing Circulation Level of consciousness,Secondary Survey,Examination Respiratory Cardiovascular Abdomen and genitourinary tract Central nervous system Musculoskeletal system Endocrine, hematologic systems,Patient,BP 100/40 P 96 RR 26 T 37.8 C Pulse oximetry 92% on 2 L cannula Appears anxious, slightly confused Bibasilar rales Decrease bowel sounds, distended abdomen Warm extremities,Which findings are most concerning?,Airway/Respiratory System,Observe mouth and chest Respiratory rate and pattern Tachypnea is the single most important indicator of critical illness Use of accessory muscles Level of consciousness Oxyhemoglobin saturation,Circulation,Peripheral pulses and blood pressure Evidence of decreased perfusion Most common cardiovascular disturbance in the seriously ill is hypotension caused by hypovolemia and/or sepsis,Patient,BP 100/40 P 96 RR 26 T 37.8 C Pulse oximetry 92% on 2 L cannula Appears anxious, slightly confused Bibasilar rales Decrease bowel sounds, distended abdomen Warm extremities,What information from the chart would be helpful?,Chart Review and Documentation,Initial survey Vital signs Fluid balance Inspired oxygen concentration Medications Invasive parameters,Chart Review and Documentation,Secondary survey Review medical records Document current events Document diagnosis and treatment rationale,Patient,BP 100/40 P 96 RR 26 T 37.8 C Pulse oximetry 92% on 2 L cannula Appears anxious, slightly confused Bibasilar rales Decrease bowel sounds, distended abdomen Warm extremities,What investigations should be ordered?,Investigations,Guided by history and physical examination Standard biochemistry, hematology, microbiology, radiographs Arterial or venous blood gas Lactate level,Metabolic acidosis is an important indicator of critical illness,Patient,BP 150/90, HR 70-80, RR 16, T 37.8 Pulse ox 97%(RA) Distended abdomen Warm extremities WBC 16,000/mm3 BUN/creatinine norm,BP 100/40, HR 96, RR 26, T 37.8 Pulse ox 92% on 2L Distended abdomen Warm extremities WBC 21,000/mm3 BUN/creatinine ABG 7.3/30/65,Previous exam Current exam,What now?,Information Action,Ensure physiological safety Oxygen Intravenous access Circulatory support Determine patients reserve Assess likely diagnosis and treatments,Information Action,Refine treatment Assess response to treatment Provide organ system support Determine best site for care Call for advice and assistance,Key Points,Identify patients at risk early Recognize signs of critical illness Stabilize first, then determine diagnosis Obtain detailed history Monitor response to treatment,