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Information ⬇

Author(s): Marlies Ostermann and David Sprigings

Key features of the critically ill patient are severe respiratory, cardiovascular or neurological derangement, often in combination, reflected in abnormal physiological observations (Tables 1.1 and 1.2). Principles of management are summarised in Box 1.1 and Figure 1.1.

Priorities ⬆ ⬇

Outline

Make a rapid but systematic assessment using the ABCDE approach.

While doing this, collect information about the patient, the current problem, the context and comorbidities. Attach monitoring (ECG and oxygen saturation) and secure venous access.

Airway and Breathing!!navigator!!

  • Ensure the airway is clear. If the patient is unconscious, remove dentures if loose and aspirate the pharynx, larynx and trachea with a suction catheter. See Chapter 112 for detailed advice on airway management.
  • If there is no reflex response (gagging or coughing) to the suction catheter or the respiratory rate is <8/min, a cuffed endotracheal tube should be inserted, preferably by an anaesthetist. Before this is done, ventilate the patient using a bag-mask system with 100% oxygen.
  • What is the respiratory rate? Rates<8 or >30/min signify potential critical illness. Is there respiratory distress, shown by dyspnoea, tachypnoea, ability to speak only in short sentences or single words, agitation and sweating? Is arterial oxygen saturation <90% despite breathing 40% oxygen? This indicates severe impairment of gas exchange. See Chapter 11 for management of respiratory failure.

Circulation!!navigator!!

  • Remember that a ‘normal’ blood pressure may be maintained by vasoconstriction and does not mean that organ perfusion is adequate. Signs of low cardiac output include confusion and agitation, cold extremities, sweating, oliguria and metabolic acidosis.
  • Heart rates <40 or >130/min with signs of low cardiac output require urgent correction: see Chapters 39, 40, 41, 42, 43, 44 for management of arrhythmias.
  • If systolic BP is <80 mmHg, or has fallen by more than 40 mmHg and there are signs of low cardiac output, urgent correction is needed. Look carefully at the JVP, which may provide an important clue to the diagnosis. If there are no signs of pulmonary oedema, give IV fluid (500 mL crystalloid over 15 min). If hypovolaemia or vasodilatation is likely (suspect vasodilatation if the pulses are bounding), lay the patient flat and elevate the foot of the bed. See Chapter 2 for further management of hypotension and shock.

Neurological Status (‘disability’ – ‘da Brain’)!!navigator!!

  • What is the conscious level (assessed using the Glasgow coma scale score (GCS) (p. 20))? If the GCS is <9, contact an anaesthetist immediately, as the patient may need urgent endotracheal intubation.
  • If the conscious level is reduced, you must exclude hypoglycaemia by immediate stick test. If blood glucose is <4.0 mmol/L, give 100 mL of 20% glucose or 200 mL of 10% glucose over 15–30 min IV, or glucagon 1 mg IV/IM/SC. Recheck blood glucose after 10 min, if still below 4.0 mmol/L, repeat the above IV glucose treatment. In patients with malnourishment or alcohol use disorder, there is a remote risk of precipitating Wernicke encephalopathy by a glucose load: prevent this by giving thiamine 100 mg IV before or shortly after glucose administration. See Chapter 81 for further management of hypoglycaemia.
  • If the respiratory rate is <12/min or the pupils are pinpoint, or there is other reason to suspect opioid poisoning, give naloxone. Give up to 4 doses of 800 μgm IV every 2–3 min until the respiratory rate is around 15/min. Further doses may be needed (see p. 233).
  • If you suspect benzodiazepine overdose may be the cause, give flumazenil, 200 μgm IV over 15 s; if needed, further doses of 100 μgm can be given at 1-min intervals up to a total dose of 2 mg.
  • If there are recurrent or prolonged major seizures, treat with diazepam 10–20 mg IV or lorazepam 2–4 mg IV: see Chapter 16 for management of seizures.
  • Examine the eyes and pupils, and check for neck stiffness.
  • Make a rapid assessment of limb tone and power: is there lateralized weakness?

Exposure (Entire Examination)!!navigator!!

  • Check for abdominal tenderness and guarding. If the patient has severe abdominal pain or generalized abdominal tenderness, and is shocked (systolic BP <90 mmHg with cold skin), the likely diagnosis is generalized peritonitis, mesenteric infarction, severe pancreatitis or ruptured abdominal aortic aneurysm (Table 21.1).
  • Examine the limbs, spine and perineum for evidence of ischaemia or a septic focus.

Further Management ⬆ ⬇

Investigation of the critically ill patient is given in Table 1.4. Further management is directed by the dominant clinical problem or working diagnosis.

Further Reading ⬆

Capana M, Ivya J, Rohlederb T, Hickman J, Huddleston JM. (2015) Individualizing and optimizing the use of early warning scores in acute medical care for deteriorating hospitalized patients. Resuscitation93, 107–112.

Royal College of Physicians (2012) National Early Warning Score (NEWS): Standardising the assessment of acute illness severity in the NHS. Report of a working party. London: RCP. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news.