Initial Assessment of Critically Ill Patients

INITIAL ASSESSMENT OF THE CRITICALLY ILL PATIENT: 

INITIAL ASSESSMENT OF THE CRITICALLY ILL PATIENT

PowerPoint Presentation: 

A critically ill patient is one at imminent risk of death; the severity of illness must be recognized early and appropriate measures taken promptly to assess, diagnose and manage the illness.

PHILOSOPHY OF MANAGEMENT: 

PHILOSOPHY OF MANAGEMENT The approach required in managing the critically ill patient differs from that required in less severely ill patients with immediate resuscitation and stabilization of the patient’s condition taking precedence:

PRIORITIES: 

PRIORITIES Prompt resuscitation & adhering to advanced life support guidelines Urgent treatment of life-threatening emergencies such as hypotension, hypoxaemia, hyperkalaemia, hypoglycaemia and dysrhythmias

PRIORITIES cont.;: 

PRIORITIES cont.; 3. Analysis of the deranged physiology 4. Establish a complete diagnosis as history & further diagnostic results are available 5. Careful monitoring of the patient’s condition and response to treatment

How To Recognize?: 

How To Recognize? CARDIOVASCULAR SIGNS HR BP PERFUSION OLIGURIA ARREST

RESPIRATOY SIGNS: 

RESPIRATOY SIGNS RATE DISTRESS THREATENED OBSTRUCTION/OBSTRUCTION RISING PaCO2 DECREASING SPO2 ARREST

NEUROLOGICAL SIGNS: 

NEUROLOGICAL SIGNS THREATENED AIRWAY OBSTRUCTION/OBSTRUCTION SUDDEN DETERIORATION IN CONSCIOUSNESS GCS ABSENT GAG/COUGH FAILURE TO OBEY COMMANDS REPEATED SEIZURES

What are the steps to be followed?: 

What are the steps to be followed? Initial assessment Immediate management Monitoring Initial investigations

MONITORING: 

MONITORING Basic hemodynamic monitoring ECG, BP, CVP, PAP, CO ABGs, lactate, H ion Urine output Fluid balance Lung mechanics, capnography Peripheral skin temp O2 transport

FLUID MANAGEMENT: 

FLUID MANAGEMENT

SHOCK & LOW CO: 

SHOCK & LOW CO Failure to supply sufficient oxygen to meet the metabolic requirements of the tissues is the cardinal feature of circulatory failure or ‘shock’.

ALGORITH OF SHOCK: 

ALGORITH OF SHOCK

Initial management of circulatory failure: 

Initial management of circulatory failure

SEPSIS IN THE ICU: 

SEPSIS IN THE ICU

Magnitude Of the Problem : 

Magnitude Of the Problem Incidence and mortality rates underestimated since sepsis is not generally reported as a primary diagnosis Estimated > 750,000 new cases of severe sepsis/year in the United States

PowerPoint Presentation: 

Severe sepsis mortality rates range from 28% to 50% Approximately 500 up to 1,000 Americans die daily of severe sepsis

PowerPoint Presentation: 

More than 18 million cases of sepsis worldwide every year. Sepsis is the leading cause of death in non-coronary ICUS

Principles of Diagnosis – Sepsis: 

Principles of Diagnosis – Sepsis Suspicion based on susceptibility Systemic and organ-specific signs and symptoms Laboratory evidence Additional studies – focused by signs, symptoms and supportive data

Sepsis: What is it?: 

Sepsis: What is it? SCCM/ESICM survey 2001 1000 North American and European Critical Care Physicians 71%: No common definition of sepsis 36%: Sepsis would be defined differently by colleagues-in the same subspecialty 81%: Sepsis is misdiagnosed because of lack of clear definition

SCCM/ESICM: Key Findings: 

SCCM/ESICM: Key Findings 97%: sepsis is among the most challenging conditions a doctor can treat. 93%: sepsis symptoms can be easily, but incorrectly attributed to other conditions. 93% of American physicians surveyed agreed that the pathenogenisis of sepsis is not completely understood. 79%: sepsis treatment is one of the largest unmet needs in critical care medicine today.

Sepsis: ACCP/SCCM Definitions: 

Sepsis: ACCP/SCCM Definitions Infection Inflammatory response to microorganisms, or Invasion of normally sterile tissues Systemic Inflammatory Response Syndrome (SIRS) Systemic inflammatory response to a variety of insults Sepsis Confirmed or suspected infection, plus ≥ 2 SIRS criteria

Sepsis: ACCP/SCCM Criteria: 

Sepsis: ACCP/SCCM Criteria SIRS: A clinical response arising from a nonspecific insult manifested by ≥ 2 of the following: Temperature ≥38°C or ≤ 36°C HR ≥ 90 beats/min Respirations ≥ 20/min WBC count ≥ 12,000/μL or ≤ 4,000/μL or > 10% Immature neutrophils

Sepsis: ACCP/SCCM Definitions (cont): 

Sepsis: ACCP/SCCM Definitions (cont) Severe sepsis Sepsis ≥ 1 organ dysfunction

Septic Shock : 

Septic Shock Sepsis Hypotension despite fluid resuscitation Perfusion abnormalities

Multiple Organ Dysfunction Syndrome (MODS) : 

Multiple Organ Dysfunction Syndrome (MODS ) Altered function of more than one organ in an acutely ill patient Homeostasis cannot be maintained without intervention

Signs and Symptoms of Sepsis: 

Signs and Symptoms of Sepsis Chills Tachypnea Unexplained alterations in mental status Tachycardia Altered WBC Decrease platelets Elevated immature neutrophils Decrease skin perfusion Decreased urine output Skin mottling Poor capillary refill Hypoglycemia Petichae/purpura

2001 SCCM/ ESICM/ACCP/ATS : 

2001 SCCM/ ESICM/ACCP/ATS Sepsis Definitions The host response (sepsis) Is a progression from early, adverse consequences of this response to organ failure (severe sepsis) to shock (septic shock) Until more evidence-based data are available to inform a more precise definition, the current definitions will stand as before Sepsis, severe sepsis, septic shock

Mechanical Ventilation: 

Mechanical Ventilation Over 60% of appropriately admitted patients to the ICU require ventilatory support.

Indications of Mechanical Ventilation: 

Indications of Mechanical Ventilation Airway protection Hypoxia Hypercapnoea Hypoventilation Shock Resp. muscle fatigue Poor neurological status ( GCS <7 ) Arrest

MECHANICAL VENTILATION: 

MECHANICAL VENTILATION

ELDRLY POPULATION IN THE ICU: 

ELDRLY POPULATION IN THE ICU

Other Important Issues: 

Other Important Issues End of life care Renal replacement therapy ARDS Brain Death Etc.

THANK YOU: 

THANK YOU