Assessment of the

Critically ill Patients

Frans JV Pangalila
UNTAR

The aim of assessment of critically

ill patients
is to :
identify the physiological
abnormalities
identify the most appropriate way
to correct
those abnormalities
diagnose the underlying problem

The ABCDE approach

Airway & oxygenation

A
Exposure
&
examinati
on

B
D

Disability due
to neurological
deterioration

Breathing &
ventilation

C
Circulation &
shock
management

The principles
Perform primary ABCDE survey (5
min)
Instigate treatment for life
threatening conditions as you find
them
Reassess when any treatment is
completed
Perform more detailed secondary
ABCDE survey including
investigations

The primary survey

ABCDE assessment looking for
immediately life threatening
conditions
Rapid intervention usually includes
max O2, IV access, fluid challenge +/specific treatment
Should take no longer than 5 min
Can be repeated as many times as
necessary
Get experienced help as soon as you

The secondary survey

Performed when patient more stable
More detailed examination of patient
(ABCDE)
Order investigations to aid diagnosis
IF PATIENT DETERIORATES RETURN
TO PRIMARY SURVEY
The ABCDE approach often to be carried
out in parallel with history taking,
examination and initial resuscitation often
occuring in simultaneously

Initial assessment
Key components of initial assessment are :
- assessment of airways patency , breathing
and circulation
Clinical features suggestive of imminent
severe deterioration
or warning sign of severe illness are :

Initial Approach to Patient Assessment

.... start with simple question and evaluate the response

a normal verbal response implies that the

patients has a
clear airway/ breathing and cerebral
perfusion
an inappropriate response an indicate that
the patient is
confused,..e.g : hypoglycemia
breathless patient who can only talk in
short sentences is
suggestive of respiratory distress
failure to respond is an indicator of serious
illness

Some of the clinical and laboratory

features suggestive of severe illness :

Once again :
Key Points in Approaching The
Critically Ill Patient :
Management of the airway, breathing and
circulation (ABC)
Assessment and treatment should occur
simultaneously
Do not move on until the previous system is
stable or being
stabilized
Continual reassessment of the ABC is vital

A Airway : assessment of airway

patency is vital

LOOK
LISTEN
FEEL

Key points : Common

Causes
Airway Compromise
altered level of
consciousness
foreign body
inflammation
infection

Airway interventions
(basic)

Head Tilt Chin

Lift

Jaw Thrust

Airway assessment
-Keeping the airway open, look, listen and feel for
normal
Look breathing
for chest movement
(tachypnea,
use of accessory muscle/tracheal
tug,
paradox thoraco-abdomino
respiration)
sweating
Listen for gurgling, snoring,
stridor
(note : stridor
maybe
absent
in severe
-Hypercapnea
and
tend to
decrease
in
case
and
conscious level
the presence
of a normal oxygenation
indicate
: the compensatory
mechanisms are
does
not
ex
haus
exclude a compromised airway)
ted
Feel for air
-Bradycardia
indicates
on your
impending
cheek
cardiorespiratory
Key point : a patient with signs of airway
arrest
should never be left alone

obstruction

Airway interventions
(basic)
Oropharyngeal airway
Manfaat :
- mencegah pangkal
lidah jatuh
kebelakang
- fasilitas suction
- mencegah tergigitnya
lidah
- Airway patency untuk
penderita

Airway interventions
(basic)

Nasopharyngeal Airway
Indikasi : pasien setengah sadar dengan napas
spontan

Airway interventions
(advanced)
GET HELP!!!
Nebulised
adrenaline for
stridor
LMA
Intubation
Cricothyroidoto
my
Needle or
surgical

Breathing assessment
B
Note : that marked tachypnoea is a useful marker of a
severely ill patient regardless of whether the patient has respiratory failure

Look : Rate (< 10 or > 20), symmetry, effort,

pulse oxymetri,
skin colour
Listen : Taking....sentences, phrase and words
; wheeze, silent
chest and other
sounds
Signs added
of Severe
Respiratory
Feel : central trachea,
Compromise

percusion-expansion
tachypnoea > 25 bpm
bradypnoea < 10 bpm
accessory muscles of respiration
unable to complete sentences
confusion
cyanosis
PaO2 < 8 kPa , PaCO2 > 6kPa

Breathing - interventions B

Consider ventilation with

AMBU bag if resp rate <
10
Position upright if
struggling to breath
Specific treatment
i.e.: agonist for
wheeze, chest drain for
pneumothorax

Circulation - assessment

Rapid initial assessment of

circulatory states
focus on tissue perfusion not just
blood pres
sure
hypotension is a late feature of
cardiovascular
Evidence of inadequate tissue
dysfunction and often premorbid
perfusi
sign in all
on indicate a severely ill
forms of shock
patients even
in the absence of hypotension
-

decreased conscious level

skin mottling
cold peripheries
poor capillary refill
serum lactate > 1.5 mMol/l
oligouria and metabolic acidosis

Skin
mottling

Circulation assessment
Look :
- sweating
- pallor
- tachypnoea / kussmaul

Feel :
2s
-

cold peripheries
capillary refill time >
tachycardia
narrow pulse pressure
hypotension

Act : iv access, fluid

therapy,
inotropes/vasodilators

Circulation - shock
Inadequate tissue
perfusion
Loss of volume
Hypovolaemia

Pump failure
Myocardial & nonmyocardial causes

Vasodilatation
Sepsis, anaphylaxis,
neurogenic

BP = HR x SV
x SVR

Circulation-interventions
Position supine with legs raised
Left lateral tilt in pregnancy
IV access - 16G or larger x2
+/- bloods if new cannula
Fluid challenge
colloid or crystalloid?
ECG Monitoring
Specific treatment
-- Inotrope/vasopresor, vasodilator,
antibiotik,steroid
surgical

Disability - causes
a marked reduction in conscious level
indicates either that :
compensatory hemostatic mechanisms have been
overhelmed or severe
neurological disease

common causes :

inadequate perfusion of the brain

sedative side effects of drugs
hypoglycemia
toxins and poisons
CVA
increase intracranial pressure

Disability - assessment

The AVPU ( or GCS ) scale combined with assessment of the

pupils

AVPU
-

A lert
responds to V oice
responds to P ain
U nresponsive
Assessment of the pupils
- equal, size and do they responds to
light?
- un equal : alert intracranial SOL
- pinpoint : opiate abuse or brain stem
stroke

Treatment of altered of
conscious level
Recovery position

Disability - interventions

Optimise airway, breathing & circulation

Treat underlying cause
i.e.: naloxone for opiate toxicity
Caution if reversing benzos
Treat Hypoglycemia
100ml of 10% dextrose (or 25ml of
40% dextrose)
Control seizures
Seek expert help for CVA or ICP

Exposure and Examination

E
Remove clothes and examine Head to Toe
Front and Back
Haemorrhage
Swelling
Rashes and Urticaria etc

Keep warm ( unless post cardiac

arrest )
History taking and Investigation
Maintain Dignity

Exposure - Assessment

Based on History : the critically ill patients fall into

three charactheristic group

Secondary survey
Repeat ABCDE in more detail
History
Order investigations
ABG, CXR, 12 lead ECG, Specific bloods
Management plan
Referral

Summary
at all times
Recognize the severity of ilnness and call for
apprppriate per
sonnel and equipment
Reassess ABC informally or formally
Monitor the patient
Do not leave the patient alone
Ensure ECG, pulse oxymetry, and non-invasive blood
pressure
as a minimum standard of monitoring
Do not get out of your depth : ask for the help !!