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Approach to a critically ill patient (PATIENT IS CONSCIOUS but IN DISTRESS): Rapid assessment via
the ABCDE approach then go on with History, Examination, Investigations and Management
a. If patient is breathing but appears acutely sick you can calculate the News score (or it is
usually calculated by the nurse) to assess the severity of your observations and decide for
how frequently you will monitor vital signs.
b. NEWS score equal or higher than 7 indicates a critically ill patient.
c. Monitor vital signs early: Place pulse oximeter – ECG monitor – Non-invasive BP monitoring
(e.g. BP cuff) and insert IV cannula (to administer drugs and take blood for investigations)
d. Call for help early if you need it if you want to be safe.
e. Airways - In a critically ill patient airway obstruction can be caused by loss of muscle tone
secondary to depressed level of consciousness or from physical obstruction
f. Airways is usually assessed simply by talking to the patient: if patient responds and is able
to talk it means airway is clear, otherwise a number of noises can be a sign of obstruction
g. Listen to patient’s breath sound close from his face. Look for signs of airway obstruction
such as snoring (relaxed tone in nose/pharynx), gurgling (secretions in airways) inspiratory
stridor (laryngeal damage), expiratory wheezes (airway obstruction to air outflow) or
hoarseness (damage-obstruction at level of trachea).
i. In partial obustruction air flow is noisy e.g. gurgling / snoring / stridor / wheezes vs
in complete obstruction there are no breath sounds at the nose or mouth.
ii. Other signs of obstruction are similar to those of respiratory distress: breathing
with adbomen and paradoxical chest breathing with chest (see saw breathing), the
use of accessory muscles of breathing and central cyanosis (late sign)

h. Management of airway obstruction:


i. If there is airway obstruction: call for expert help because it is a medical
emergency but start with the simple maneuvers such as head chin lift and jaw
thrust (if there is spinal injury)
ii. If there is visible obstruction try to remove it safely with forceps or suction of
vomit/blood/foreign body etc
iii. in most cases simple airway clearance methods are not enough: airway adjuncts
such as oropharyngeal or nasopharyngeal tube
1. Measure the size of the oropharyngeal airway from the incisors to angle of
mandible and remove if patient is gagging
2. Nasopharyngeal airway is measured from the nostrils to the earlobes and is
inserted in the right nostril
iv. If all these fail then tracheal intubation or crycothyroidotomy are required
v. All critically ill patients receive oxygen - give high concentration oxygen using
oxygen mask with non-rebreather reservoir bag (15 L min flow) and maintain high
O2 saturation (target levels are different according to condition but usually above
94% or 88-92% if pt is at high risk of hypercapnic respiratory failure
i. Breathing
i. IPPA: Inspection Percussion Palpation and Auscultation
ii. Inspection: Look for general signs or respiratory distress: abdominal breathing,
work of breathing, use of accessory muscles of breathing, flaring of nostrils,
labored difficult breathing, central cyanosis (late sign)
iii. Evaluate RR (normal 12-20), rhythm of breathing , depth of each breath (shallow or
deep) and whether chest expansion is equal on both sides
iv. Palpation: palpate for position of trachea in the suprasternal notch (is it central?
deviation can indicate pneumothorax or pleural effusion). Palpating the chest can
reveal crepitus (pneumothorax)
v. Percuss the chest: Dullness indicates consolidation (pneumonia) or pleural fluid
while hyper-resonance indicates a pneumothorax
vi. Auscultate chest: absent or reduced breath sounds suggests pneumothorax,
consolidation or pleural fluid. Bronchial breath sounds indicate consolidation of
lung (pneumonia).
j. Management of respiratory disorders depends on the cause. All patients receive oxygen to
maintain high oxygen saturation level. If patient breathing is inadequate (depth or rate) or
absent use bag mask or NIV to help with oxygen and ventilation and call for expert help
(e.g. if NIV not enough – tracheal intubation)
k. Circulation -
i. Assess for circulatory system collapse looking for causes of shock (hypovolemia–
hemorrhage or low pulses due to low cardiac output) or suspected ACS
ii. IPPA: Inspection Percussion Palpation and Auscultation
iii. Inspection: look at the patients hands and digits for signs of poor perfusion or
cyanosis: are they pink, pale, blue or mottled?
iv. Palpation: assess temperature of limbs and hands: cool (shock) or warm? Check
peripheral and central pulses to assess cardiac output and heart rate / rhythm
v. Measure capillary refill time (normal CRT is less than 2 sec). Longer CRT suggests
poor perfusion of periphery
vi. Auscultate heart for HR, rhythm and presence of murmurs or additional sounds
vii. Look for signs of external or internal haemorrhage from external wounds or
evidence of internal hemorraghe (e.g. from drains)
viii. Look for signs of low cardiac output such as weak central pulses, low urine output
ix. If patient has chest pain get a 12-lead ECG and look for typical changes
l. Management of cardiovascular collapse depends on the cause but is based on fluid
replacement, haemorrage control and restore tissue perfusion
i. Insert two large bore IV cannulae (14 or 16G) and take blood from routine blood
investigations (FBC U&E microbiological and cross matching investigations) before
IV fluids
ii. Fluid challenge test: if patient is hypotensive (MAP < 65 mmHg or clinical evidence)
- give a bolus of 500 ml crystalloid solution (Hartmann’s or 0.9 sodium chloride
solution) over 15 min and reassess the heart rate and BP regularly -> target MAP >
70 mmHg
iii. If patient does not improve repeat fluid challenge and seek expert help.
iv. Decrease or stop the fluids if you notice symptoms of heart failure (dyspnoea,
raised JVP, S3 and pulmonary crackles on auscultation). Find other means of
improving tissue perfusion (e.g. inotropes or vasopressors)
m. If patient has ACS emergency management is MANO:
i. IV Morphine
ii. Oxygen only if patient has <94% sat when breathing air
iii. Sublingual nitroglycerine (tablet or spray)
iv. Aspirin 300 mg, PO asap
n. Disability
i. Make a rapid assessment of patient’s level of consciousness using AVPU or GCS
score
ii. AVPU stands for alert, responsive to vocal stimuli, responsive to painful stimuli and
unresponsive to any stimulus (painful stimulus is supraorbital pressure)
iii. Check for pupils size, equality and reaction to light
iv. ABCDEFG: ABC Don’t Even Forget Glucose: Check blood glucose: hypoglycaemia
possible cause of unconscioussness and if present, treat the hypogglycemia ( IV 50
mL of 10% glucose solution then give same dose every 10 min until return of
consciousness )
o. Exposure: expose the patient properly to continue the exam while maintaining the dignity
and minimising heat loss (risk of hypothermia)
p. ABCDE assessment is over, patient is not at immediate risk of death: continue to history,
examination, investigations to define the diagnosis and management of the condition

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