print Recognition and Assessment of the Seriously Ill Patient- dr. suparto.ppt

8/14/2019 print Recognition and Assessment of the Seriously Ill Patient- dr. suparto.ppt

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RECOGNITIONAND

ASSESSMENTOF

THESERIOUSLYILLPATIENT

Suparto

Anesthesiology Departement

UKRIDA


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INTRODUCTION

An ounce of prevention is worth a pound of cure

Early identification of patients at risk for life-threatening

illness makes it easier to manage them appropriately

and prevent further deterioration.

The longer the interval between the onset of an acuteillness and the appropriate intervention, the more likely

it is that the patientscondition will deteriorate, even to

cardiopulmonary arrest.

Critical illness is often associated with Inadequate cardiac output

Respiratory compromise

Depressed level of consciousness


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Recognizing seriously ill patient usually is not difficult

Young and otherwise fit patients may be much slower to

exhibit the signs and symptoms of an acute illness thanmay elderly patients with impaired cardiopulmonary

function.

Patients seldom deteriorate

abruptly, even though

clinicians may recognize the

deterioration suddenly


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ASSESSINGSEVERITY

How sick is this patient?

What physiological problem needs to be corrected

now to prevent further deterioration of the patients

condition?

Vital signs: pulse rate, RR, oxygenation, temperature,

urine output

Other spesific physiological variables

ex: bacterial infection

The goal is to recognize that a

problem exists and to maintainphysiological stability while

pursuing the cause and initiating

treatment


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INITIALASSESSMENTOFTHE

CRITICALILLPATIENTPhase I

Initial Contact-First minutes

(Primary Survey)

What is the main physiological

problem?

Phase II

Subsequent Reviews(Secondary Survey)

What is the underlying

cause?

Examination Look, listen, feel

(Basic elements)

Structured examination of

organ systems

Airway Resp system

Breathing & Oxygenation CVS system

Circulation Abdomen & genitourinary

tract

Level of consciousness CNS & musculoskeletal

system

Endocrine & hematological

system


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(Primary Survey)


problem?

Phase II


What is the underlying cause?

History Main features of

circumstances & environment

More detailed information

Witnesses, relatives present complaint

Main symptoms: pain,

dyspnea, weakness

past history, chronic disease

Trauma or no trauma medication & allergies

operative or nonoperative Family history

Medication or toxins systems review


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(Primary Survey)


problem?

Phase II



cause?

Chart review,

documentation

Essential physiology, Vital

Signs

Case record and note

keeping

Heart rate, rhythm Examine medical record

Blood pressure Formulate spesific

diagnosis or DD

RR & pulse oximetry Document current events

Level of consciousness


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(Primary Survey)


problem?

Phase II



cause?

Investigations ABGs Laboratory blood tests

Blood glucose Radiology

ECG

Microbiology


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(Primary Survey)


problem?

Phase II


What is the underlying cause?

Treatment Proceed in parallel with the

above

Refine treatment, assess

responses, review trends

Ensure adeq airway &

oxygen

Provide support for spesific

organ systems as required

Provide IV access, fluid Choose most appropriate site

for care

Assess response to

immediate resuscitation

Obtain specialist advice and

assistance

Call for more expirienced

advice and assistance


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ASSESSMENTOFAIRWAY

Causes of Obstruction

Direct trauma, blood, vomitus, foreign body, CNSdepression, laryngospasm, inflamation

Look for Cyanosis, altered respiratory pattern and rate, tracheal

tug, altered level of consciousness Listen for

Noisy breathing (stridor, wheezing, gurgling); complete

obstruction results in silence

Feel for Decreased or absent airflow


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ASSESSMENTOFBREATHING

Causes of inadequate breathing or oxygenation

CNS depressionDepressed respiratory drive

respiratory effortmuscle weakness, spinal cord

damage, pain, chest wall abnormalities

Pulmonary disorders: pneumothorax, hemothorax, COPD,

asthma, pulmonary edema Look for

Cyanosis, altered RR and respiratory pattern, O2sat

Listen for

Dyspnea, inability to talk, auscultation breath sounds Feel for

Symmetry and extent of chest movements, position of

trachea, abdominal distension


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ASSESSMENTOFCIRCULATION

Causes of Circulatory inadequacy Primary (directly involving the heart): ischemia, arrhythmias,

valvular disorders, cardiomyopathy, tamponade

Secondary (pathology originating elsewhere): drugs, hypoxia,

electrolyte disturbance, sepsis, blood loss

Look for Coolness, pallor, hemorrhage, altered level of consciousness,

dyspnea, urine output

Listen for

Altered heart sounds

Feel for

Pulses (assessing rate, quality, regularity, symmetry


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RESPIRATORYSIGNS

Respiratory arrest

Threatened or obstructed airway

Stridor, Intercostal recession, paradoxical breathing

RR 35x/min

Respiratory distress: use of accessory muscles SpO2 < 90% on high concentration oxygen

PaCO2 >52.5mmHg


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CARDIOVASCULARSIGNS

Cardiac arrest

Pulse rate < 40 or >140x/min

Systolic BP


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NEUROLOGICALSIGNS

Threatened or obstructed airway

Absent gag or cough reflex

Failure to maintain normal PaO2 and PaCO2

Failure to obey commands

GCS 2

point)

Repeated or prolonged seizures


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Even normal vital signs may be early indicators of

impending deterioration if they are changed from

prior measurements

Tachypnea is the single most important indicator of

critical illness

The presence of a metabolic acidosis is one of themost important indicators of critical illness


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KEYPOINT

The basic principles are summarized as the ABCs

of resuscitating the severely ill patient- shouldproceed regardless of the situation

The clinical history, physical examination and

laboratory tests should aid in clarifying the

diagnosis and determining the patients degree of

physiological reserve

It is particularly important to assess trends in

patients vital sign and physiological parameters as

they undergo treatment


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KEYPOINT

Early identification of a patient at risk is essential for

preventing or minimizing critical illness The clinical manifestation of impending critical

illness are often nonspesific. Tachypnea is one of

the most imporatnt predictors of risk and signals the

need for more detailed monitoring and investigation Resuscitation and physiological stabilization will

often precede definitive diagnosis and treatment of

the underlying cause


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A detailed history is essential for making an

accurate diagnosis, determining a patients

physiological reserve, and establishing a patients

treatment preferences

Clinical and laboratory monitoring of a patients

response to treatment is essential

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