Download The clinical setting

Clinical examination
INTRODUCTION
The initial assessment and management of an acutely ill patient is one of the most challenging tasks
that a clinician can undertake. Decisions must be made and actions performed rapidly in conditions of
uncertainty. There can be uncertainty about the disease process, the correct interventions, the likely
outcome, and one's own abilities to manage the situation appropriately. In this environment, a
structured approach to providing safe care is essential.
Elective medical care follows the traditional, comparatively leisurely,
pathway of taking a history, performing an examination, arranging
laboratory investigations to confirm or refute a diagnosis, starting
treatment, and evaluating outcomes (see traditional linear approach,
below). Emergency care is less predictable, but within this arena
some clinical activities, trauma care and cardiopulmonary
resuscitation for example, have developed management strategies
which reduce the clinical problems to their basic elements using wellestablished algorithms.
'Patients do not die of their
disease. They die of the
physiologic abnormalities
of their disease'
Sir William Osler
Between these two extremes however, is the complex and non-linear problem of the acutely ill or
deteriorating patient. For management of these patients, there is no standardised management
protocol or comforting algorithm to follow.
In this module we present a new 'iterative' structure and method for assessing and managing the
acutely ill patient. This iterative approach involves initial identification of physiological abnormality,
initiation of treatment and repetitive review while conducting other tasks to define the diagnosis and
treatment. This partial inversion of traditional practice (see new iterative approach, below) is one of the
more difficult tasks for a clinician to master. Traditional teaching is that outlined in the linear approach.
The new model requires that initial treatment precedes diagnosis. Using this approach to managing the
acutely ill patient, a clinician must be able to prioritise issues in relation to clinical care. Neither a
patient with a known diagnosis who dies from inadequately treated physiological abnormalities, nor a
patient who is made physiologically stable but then subsequently dies due to lack of specific treatment
for the underlying disease process is a satisfactory clinical outcome. The central point is the
importance of establishing and maintaining a safe environment for the patient through immediate
evaluation and manipulation of physiology to optimise tissue oxygen delivery.
This approach has several important merits. First, it makes clinicians attend to the essential task of
optimising tissue oxygen supply. Second, unlike the traditional method, the requirement to'fix the
physiology' reduces the number of possible problems and interventions to manageable proportions.
This simplifies initial management and reduces opportunities for error. Diagnostic possibilities begin to
open up with the process of iterative review, and then close down as information is obtained from the
history, laboratory tests, and from monitoring the response to treatment. The third advantage is that it
makes clinicians focus on global aspects of patient safety as a primary goal, rather than on the
diagnosis as an end in itself.
Why is this important?
Error in healthcare processes is a common problem and a substantial proportion cause avoidable
harm to patients. Acutely ill patients are most at risk of adverse events and system errors. A significant
proportion of errors are attributable to failure to identify patients at risk of critical illness, and to provide
safe care to minimise further deterioration. An important aim of this module therefore is to improve the
ability of clinicians to identify, assess, and manage acutely ill patients at risk of critical illness at all
stages in the patient journey from admission to discharge. In the following article you can read further
about patients' safety in the acute hospital and a framework for improvement and better integration of
care.
The module is based on four key tasks, which we present as phases
in patient care. The first three correspond to primary, secondary and
tertiary surveys, and the fourth focuses on team management. We
have summarised these tasks and the content of the module as a
whole in the overview - pdf.
Principles in patient care
summarised in the
overview - pdf
Although these four phases are presented as though they were part of a linear process, the content is
iterative. Activities will be performed partially and repetitively, and some will be accomplished at
different stages in the process of care. Although the system is not 'tightly coupled', and so allows for
considerable flexibility in application, the framework is intended to be followed in sequence, one stage
leading to another, but with frequent revisiting of earlier stages.
If you are interested in concepts of safety in relation to systems complexity, read following reference.
1/ THE PRIMARY SURVEY: ENSURING SAFE CARE
The table below gives an overview of the principles outlined in this Task. The material in the blue
column summarises the pragmatic themes of this first phase, whereas the material in the green
column indicates what you need to think about.
A NECDOTE
It is a Saturday evening in a busy University Teaching Hospital with a large accident
and emergency department and many regional specialities on site. A 58-year-old man
has been brought to the A&E department by his son: read the details in the Patient
Challenges
. Around the same time, there are three other in-patients who are
causing concern:
Case 1 A 65-year-old diabetic man who has become acutely hypotensive and
confused in the coronary care unit. Twelve hours earlier he had received thrombolysis
for vague lower chest pain, left bundle branch block on the ECG and an enzyme rise.
Case 2 A 60-year-old woman in a surgical ward. She has collapsed while being
mobilised four days after an abdominal hysterectomy
Case 3 A 48-year-old asthmatic woman who is undergoing pressure-regulated
volume-controlled mechanical ventilation in the intensive care unit. The nurses have
called the junior resident doctor because her central venous pressures and heart rate
have risen, oxygen saturation and blood pressure have fallen, and the ventilator has
started to alarm.
How do you prioritise your actions if asked for help?
Context – The clinical setting
Context makes a difference. Indeed, initially it may be the only accurate item of information available:
that someone has collapsed in the street, has been admitted to the emergency department, or is in a
surgical or medical ward. Additional contextual information might include gender and age, and
proximate events. Alternatively, you may be conducting a routine ward round in the coronary care unit,
or intensive care unit, reviewing patients who were admitted several days before. The general
principles are the same, but the boundary of the problem, the volume of information, and the degree of
urgency and uncertainty will vary.
A NECDOTE
A senior consultant described being called as a Senior House Officer to a patient with
a tracheostomy following ENT surgery who had suffered a respiratory arrest. At
laryngoscopy he was unable to see the epiglottis or vocal cords and several attempts
to intubate the patient were unsuccessful. The ENT consultant then arrived to the ward
and asked why he was trying to intubate a patient with no larynx following a total
laryngectomy for malignant disease. The ENT surgeon removed the blocked
tracheostomy and established a surgical airway and the patient survived. Since then
when called to an ENT patient, he asks if the patient has had a laryngectomy.
How can knowledge of context influence clinical assessment?
Setting
As you approach the patient, make a brief observation of the setting – the position the patient is in,
availability of monitoring, oxygen or other equipment, and documentation such as vital signs charts.
Within seconds of observation, using the ABC based approach, you will have made a rough
assessment of the patient's respiratory pattern, whether oxygen is being provided, if venous access
has been established, his level of consciousness and whether basic monitoring is available. Who is
with the patient?
A relative is an essential source of prior information. Remember their emotional needs too.
For the next ten patients you are called to see, try to predict what problems you
might have to address from the limited history you are given when you are
called. Does this help you manage an acutely ill patient?
Physiology 'Fix the physiology first'
N OTE
Although assessment and action are described separately, it is important to
emphasise that as each physiological abnormality is recognised it must be
corrected.
Assessment
Each of the eight steps below should take less than one minute to
perform. Overall, the entire assessment and initiation of treatment
should be complete within about five minutes. Try applying this
during your clinical care of patients.
Keep it simple and make it
quick
Airway
Look for signs of airway obstruction, and relieve if present (see the PACT Module on Airway
management ). If the patient is not fully conscious, the airway may not be adequately protected.
Breathing and oxygenation
During this assessment make sure that the patient is receiving high flow
oxygen (10-15 l/min). Observe the respiratory pattern, look for cyanosis,
percuss and auscultate the chest, and measure and record the respiratory
rate.
Don't delay giving oxygen!
A respiratory rate in excess of 25 b/min is a good 'predictor' of critical
illness. No patient who is tachypnoeic should be left unmonitored and
without regular clinical review.
Tachypnoea indicates critical
illness
Why is tachypnoea a good indicator of critical illness?
Circulation
The question we really need to ask is 'Are cardiac output and oxygen delivery adequate to meet
current systemic oxygen demand?' Clinical examination at this point can only provide a very partial
answer. We must use those variables which are available to us.
Examine the patient's capillary refill, pulse rate and volume, and blood pressure. Are they normal or
abnormal? What is this patient's normal blood pressure? A safe initial target blood pressure is 90-150
mmHg systolic, or 65-90 mmHg mean. A low diastolic blood pressure could indicate vasodilatation
from sepsis. Clinical assessment of jugular venous pressure is unreliable.
Hypovolaemia, relative or absolute, is an important precipitant of organ
dysfunction and critical illness, since it reduces cardiac output and systemic
oxygen delivery. Hypovolaemia must be identified and corrected promptly.
Clinical assessment of hypovolaemia includes assessing jugular venous
pressure, thirst, elevation of the legs and core temperature. Is there a coreperipheral temperature gradient which would suggest hypovolaemia? Is the
patient thirsty? Does elevating the patient's legs to increase venous return
improve level of consciousness, heart rate or blood pressure?
N OTE
Is the patient hypovolaemic?
Clinical assessment of hypovolaemia can be unreliable.
Delayed recognition and inadequate resuscitation of shock contributes to multiple organ
failure and mortality from sepsis.
T HINK
Tachycardia is an appropriate cardiovascular response to the increased metabolic rate of critical
illness (similar to tachypnoea). Think of several factors which could interfere with this
response.
BP = CO x SVR, and CO = HR x SV
So,
BP = HR x SV x SVR
These are elementary physiological formulae. Blood pressure (BP) is the product of cardiac output
(CO) and systemic vascular resistance (SVR). Cardiac output is the product of heart rate (HR) and
stroke volume (SV).
What factors determine stroke volume?
Oxygen delivery (DO2) is the product of cardiac output and arterial oxygen content (plus a small
amount of dissolved oxygen in plasma which we will ignore for simplicity).
DO2 = CO x CaO2 and CaO2 = Hb x SaO2
So, combining the two, we arrive at...
DO2 = (HR x SV) x (Hb x SaO2)
We will see how to apply these principles in the next section. At this point you should identify the main
physiological abnormalities in those variables which you can measure, and consider how they might
need to be modified to improve oxygen delivery to the tissues. We will try to answer the more complex
question 'Is oxygen supply adequate for metabolic demand?' at a later stage.
T HINK
Undergoing major surgery or suffering critical illness is analogous to continuous moderate
exercise. What do you think would happen if an elderly patient was forced to undertake
prolonged continuous moderate exercise?
Consciousness
Next, assess level Check the blood glucose
of consciousness.
Is the patient
confused or
obtunded? If he
can respond, what
is the
predominant
symptom? Is it
pain,
breathlessness or
another
symptom? If
consciousness is
impaired, is this a
primary
neurological
problem, a drug
effect, or
secondary to a
systemic
disturbance?
Look for signs of
neck stiffness
(infection,
haemorrhage) and
remember to
check the patient's
blood glucose
level
(hyperglycaemia
or
hypoglycaemia).
For further
information on
altered
consciousness,
see the PACT
module on
Altered
consciousness
.
N OTE
Impaired consciousness is a common but non-specific sign in critical
illness. You can document it using the Glasgow coma scale (GCS), but
remember that this was designed as a descriptor for neuro trauma, not
systemic illness. Impaired consciousness can be rapidly documented
using the AVPU (Alert, responsive toVerbal or Painful stimuli
or Unresponsive) scale. Neurological assessment in the presence of
disordered systemic physiology is unreliable, and detailed examination
should be deferred while basic resuscitation is being performed.
Drugs
What routine drugs are prescribed? Has anything been administered or
changed which might account for the deterioration? Focus in particular on:
 Opioids (particularly in renal impairment)
 Nephrotoxic combinations, for example, non-steroidal antiinflammatory analgesic drugs (NSAIDs), angiotensinconverting enzyme (ACE) inhibitors and radiocontrast
media
 Benzodiazepines, particularly in the elderly and patients
with chronic lung disease
 Hypoglycaemic agents
 Drug allergies
Review the drug chart
Errors in prescribing and in patient compliance are a major cause of adverse events
affecting patients. Errors include wrong drug, wrong dose, wrong route, wrong patient,
interactions, allergies, illegible handwriting, and failure to review continued need.
T HINK
of the last time you made a mistake in prescribing or administering a drug, or witnessed an
error by a colleague. Why did it happen? How could these errors be prevented?
Review the drug chart of the next ten patients requiring renal replacement therapy on
your intensive care unit and consider if there is any drug-induced nephrotoxicity which
could be avoided.
Excretion
Urine output or other fluid losses? When did the patient last pass urine? Is the urinary bladder
palpable? Is he catheterised, and is the catheter patent? Is the urine clear or cloudy? What is the most
recent serum creatinine level? Is the patient hypotensive or hypovolaemic, or receiving potentially
nephrotoxic drugs? Are there other sources of fluid loss, such as abdominal drains, diarrhoea, or
'occult' losses such as bleeding into a body cavity?
N OTE
The kidney is the only organ in the body which is required to increase
work (sodium and water retention) when oxygen supply (blood flow) is reduced.
Oliguria is difficult to detect in the absence of accurate input-output charts, and
its significance requires interpretation and evaluation of trends. Maintaining
cardiac output and arterial blood pressure by preventing hypovolaemia is
essential for minimising the risk of acute tubular necrosis. Urinary catheters are
a common cause of nosocomial urinary infection. See the PACT modules on
Acute renal failure
and Oliguria and anuria
.
Fluid and electrolyte intake
What fluids, by which route, and how much has the patient received in the last 24 hours and the last
few hours? Are potassium, magnesium and phosphate supplements required?
Hypovolaemia must be identified and treated promptly. Water losses can be met with 5% dextrose, but
volume expansion requires sodium-containing fluids. Dehydration will obscure anaemia. A
haemoglobin concentration of 8-9 g/dl is sufficient for oxygen carriage provided the patient is not
hypovolaemic. Patients with a systemic inflammatory response have increased vascular endothelial
permeability and are more susceptible to tissue oedema.
Electrolyte disorders, particularly hypokalaemia, are common in critically ill patients,
and are frequently ignored and under-treated. Unsafe intravenous potassium
supplementation causes avoidable morbidity and mortality. However, it is likely that an
even greater number of patients come to harm each year from inadequately treated
hypokalaemia causing arrhythmias and impaired myocardial function, which in turn
contribute to generalised organ-system dysfunction and critical illness.
Potassium is an intracellular cation, and serum levels only fall when there is already an established
deficit in total body potassium. Acutely ill patients, particularly the elderly with infections, should have
their serum potassium levels maintained around 4-5 mmol/l. Rapid correction of serum potassium
requires central venous access and close monitoring. In the setting of life-threatening hypokalaemia,
up to 60 mmol of potassium chloride at a maximum rate of 30 mmol/hr can be administered.
Anticipating and preventing hypokalaemia is better than trying to correct it in an unstable patient. See
the PACT module on Homeostasis
.
General examination
Keep it simple, and make it quick. What is the patient's age? Young people without prior chronic
disease will often disguise how ill they are – do not be mislead. What is the patient's body
temperature – febrile, hypothermic, or normal? Is the patient warm suggesting sepsis or cold and
clammy suggesting hypovolaemia or cardiac disease? Is the patient pale or anaemic, jaundiced, or
oedematous? Is there a skin rash? Examine sites of pain, and inspect the abdomen briefly for
distension, tenderness or obvious masses. Is the patient instrumented? Central venous catheters or
urinary catheters, in particular, could act as sources of infection.
Act to correct physiological abnormality
While you are undertaking the primary survey, you will also provide simple interventions to support or
improve organ system function as required, including clearing and supporting the airway, providing
high-flow oxygen, and giving a fluid challenge if the patient is hypotensive. The range of additional
interventions available to you at this stage is limited. This is an advantage, since complexity combined
with uncertainty will add to the risk of error.
Airway
Is the airway patent and are the patient's protective reflexes intact? An obtunded patient is at risk of
airway obstruction and aspiration of gastric contents. Airway adjuncts such as a nasopharyngeal
airway or oropharyngeal airway should be considered. Intubation is required for definitive airway
protection. See the PACT module on Airway management
Breathing and oxygenation
Oxygen saves lives – use it early, and use it in high flow. Medical students always remember that
oxygen can decrease respiratory drive in patients with severe chronic obstructive pulmonary disease
(COPD). Only in the rare circumstance of known or suspected severe COPD with CO 2 retention may
oxygen therapy be delayed for arterial blood gas measurement and minimisation of oxygen flow rates.
Consider bronchodilators, humidification, or analgesia to facilitate sputum clearance as appropriate.
Breathlessness means increased respiratory work. Ask yourself whether the patient may benefit from
ventilatory assistance, and whether this should be constant positive airway pressure (CPAP), noninvasive ventilation (NIV), or endotracheal intubation and invasive ventilation. The decision to provide
ventilatory support will usually be made on clinical grounds. Arterial blood gas analysis may provide
evidence to support that decision, but do not wait for blood gases to deteriorate in order to justify
intervention. See the PACT module on Respiratory failure
.
Circulation
Is venous access available? If not you will need to insert a venous cannula. This simple procedure is
often poorly performed, with inadequate attention paid to aseptic technique and patient comfort.
Choose a vein you can see, prepare the skin with antiseptic solution, infiltrate the dermis with
lignocaine (lidocaine in the USA), and use the largest bore cannula which you can insert safely. You
cannot provide rapid fluid resuscitation through an 18G cannula or smaller. Confirm proper placement
with an injection of normal saline, and secure the cannula, preferably with a transparent dressing.
Peripheral venous cannulation can be difficult in hypovolaemia and shock. Central venous access may
be preferable as the primary method for venous access. However it is important to remember rapid
fluid resuscitation can be achieved more effectively with a large bore peripheral cannula. Central
venous access must not be performed by inadequately trained and unsupervised doctors.
Let us return now to our simple formulae: BP = HR x SV x SVR
We have made a brief assessment of the patient's circulatory status. Perhaps we find that the heart
rate is 110/min and regular, and the blood pressure is 85/40 mmHg. Either the stroke volume, or the
systemic vascular resistance, or both, must be low. You do not yet know which, or why, and it does not
matter, because unless you have strong prior evidence that this patient is suffering from volume
overload and acute cardiac failure, you will give the patient a fluid challenge on the basis that this
patient has absolute, or relative, hypovolaemia.
Administer a fluid challenge safely




Choose a suitable intravenous fluid, which may be either a crystalloid (normal salinecontaining) or colloid.
Infuse 200 ml rapidly – use a pressure bag if required.
Check that the cannula remains intravascular.
The bolus of fluid should be given over a few minutes while you observe the patient's level
of consciousness, pulse rate and blood pressure, respiratory pattern and rate, and pulse
oximeter saturations (SpO2).
If none of these deteriorates, give the remaining 300 ml, again over a few minutes.
You may expect to see the patient become more rousable (but possibly more confused and difficult to
manage as cerebral perfusion improves), and an increase in blood pressure and SpO 2. These are
strong indications that hypovolaemia is part of the clinical problem, and that more fluid is required,
again using the same approach of rapidly administered boluses while observing the response. In the
majority of instances, volume resuscitation using repeated fluid boluses will improve the patient's
condition.
Survival from sepsis is improved by using a central
venous saturation over 70% as a therapeutic goal as
part of the fluid resuscitation regimen in the first six
hours after the onset of sepsis in the emergency
department. Consider how you might identify patients
with sepsis earlier and apply this in your own hospital.
Repeated fluid challenges delivered while monitoring the patient's response will usually result in a
clinical improvement. If the patient deteriorates however, for example, more laboured breathing, no
improvement in blood pressure, a fall in SpO2, the problem is more complex than 'simple'
hypovolaemia. Other, or additional, causes include:





Continued fluid loss – haemorrhage
Sepsis – infection causing a systemic inflammatory response and vasodilatation
Impaired myocardial contractility – severe sepsis, ischaemia, volume overload
Altered heart rhythm, e.g. atrial tachycardia or fibrillation
Obstruction to the circulation – embolism, tamponade or valve disease.
Several causes may operate simultaneously, and you may not be able to identify them. All you know is
that the patient has a low blood pressure, looks ill, and is not responding to your treatment. Think of
sepsis first – infection and a systemic inflammatory response causing vasodilation. Sepsis also impairs
myocardial contractility which may impair the compensatory increase in cardiac output. This is
calledseptic shock when hypotension has not responded to fluid resuscitation. Vasoactive drugs are
required, usually a combination of inotropic agents and vasoconstrictors. See the reference below for
further information on managing sepsis and septic shock. See also the PACT modules on Hypotension
and Sepsis and MODS
.
There are several vasoactive drugs which may be given by the peripheral intravenous route in the
emergency setting of fluid-unresponsive hypotension outside the ICU. These drugs (and the doses
proposed) are short-term options only in this situation, while you are preparing to move the patient for
more advanced monitoring and physiological support in an intensive care or high dependency unit.
They include:





Metaraminol (alpha-agonist vasoconstrictor): 10 mg diluted to 20 ml, in 1 ml boluses.
Atropine (anticholinergic vagolytic): 0.6 mg bolus in the setting of a sinus bradycardia
impairing cardiac output.
Dopamine (dose-dependent adrenergic agonist) by continuous infusion, maximum 10
µg/kg/min – but metabolised peripherally, unreliable by this route though commonly used
this way outside ICUs.
Noradrenaline (norepinephrine; alpha-agonist vasoconstrictor): 4 mg diluted to 100 ml, by
continuous infusion, titrated against response. This should only be considered as a shortterm measure in critically ill patients until central venous access is achieved.
Dobutamine (inotrope, chronotrope, vasodilator) by continuous infusion, maximum 10
µg/kg/min. With all peripheral infusions of vasoactive drugs, there is potential for local
complications. Therefore, there is a need for close observation of these peripheral infusions.
Complications include irregular administration and effect due to flexed (and unflexing) of
elbows, inflation of BP cuffs on same side, and, most importantly of all, extravascation
which could have severe local adverse necrotic consequences especially if recognition is
delayed.
The use of vasoactive drugs delivered peripherally carries a risk of serious adverse events
and should only be considered as a short-term emergency measure to establish
physiological safety. If there is likely to be delay pending ICU admission then insertion of
a CVC and central administration may be more appropriate.
Septic patients with overt or covert ischaemic heart disease (including the elderly) may require a
higher diastolic blood pressure to improve subendocardial perfusion, hence the proposed use of
metaraminol. A tachycardia is the main way in which sick patients can increase cardiac output and
systemic oxygen supply; consider using atropine, dopamine or dobutamine if the heart rate is <70/min
and you suspect cardiac output is inadequate.
Each time you see a vasoactive drug used, consider how it works and why it is useful for
the cause of shock in which it has been used.
Acute hypertension should make you consider reversible causes (pain, stress responses), and
requires treatment if vasoconstriction is impairing cardiac output, for example, in the setting of left
ventricular failure. Sublingual or intravenous nitrates or calcium channel blockers are effective first-line
therapies. Critically ill patients with chronic hypertension may present with a 'normal' blood pressure
which for them is suboptimal. See the PACT module on Hypertension
.
Conscious level
If an obtunded patient has received opioids or benzodiazepines, consider specific reversal agents.
Exclude hypoglycaemia. See the PACT module on Altered consciousness
.
Review response – To initial actions
Monitor trends – Better or worse?
We are now approximately 15-30 minutes from the point at which we
first met this patient, and the time has come to review the response
to our initial actions. Note at this stage that we have not really
concerned ourselves with the underlying diagnosis, not because this
is unimportant, but because we must deal with what we know (the
main physiological abnormalities), not with what we may hypothesise
to be the cause. Hypotheses need to be based on fact, otherwise
they will distract you.
No change after treatment
means the patient has
deteriorated
If you can (even partially) 'fix the physiology' using the simple interventions described above, then you
have purchased more time for the later stages in your clinical review of the patient.
Review the patient's level of consciousness and vital signs, and measure arterial blood gases (see
below). Have you been able to normalise physiology? If simple interventions have not worked, then the
problem is more complex, and you will need to use more complex interventions. Looking after an
acutely ill patient is time consuming and requires help from senior colleagues. You should not leave an
acutely ill patient unaccompanied.
Summary of the primary survey
We have focused on rapidly identifying and correcting abnormal physiology – aimed at ensuring
adequate tissue oxygenation – during our primary survey, and we have made an assessment of the
patient’s response to our initial actions. We will also have a better idea of how sick the patient is,
whether this is a problem which is easy to fix, or complicated, and whether we need help.
We now need more information to identify and treat the underlying problem. We will obtain this during
the secondary survey.
2/ THE SECONDARY SURVEY: IDENTIFYING THE UNDERLYING PROBLEM
The table below gives an overview of the principles outlined in this second Task. The material in the
blue column summarises the pragmatic themes of the second phase, whereas the material in the
green column indicates what you need to think about.
History – Building an hypothesis
Taking an accurate history is a fundamental skill of a clinician: the
history provides most of the data required to make a diagnosis.
However, when dealing with an acutely ill patient, history taking
comes after the immediate and primary task of correcting
physiological derangement. Gather information in stages, major items
early, details later. Important information relating to the acute illness
includes speed of onset and duration of symptoms and associated
symptoms.
Bernardino Ramazzini (16331717, Modena & Padua,
author of 'De Morbis
Artificium') recognised the
importance of an accurate
occupational history in
making a diagnosis. Many
famous physicians built their
reputations on accurate
observation: the greatest,
such as William Harvey and
Louis Pasteur, linked their
observations to hypothesistesting and scientific method
to determine mechanisms of
disease
How does the speed of onset of dyspnoea modify the likely differential diagnosis?
Details of psychosocial independence are often poorly documented, but are of considerable
importance in determining recovery from critical illness: intensive care rarely makes people better than
they were before the acute illness which precipitated their admission. The patient's prior health status
is therefore an important 'rate-limiting' factor for recovery.
T HINK
of a patient you have cared for whose previous health was very poor. How did this
affect his or her management and outcome?
If the patient is unable to provide an accurate history because of disease, drugs or medical
interventions, alternative sources of information must be sought: family, neighbours, or general
practitioner (family doctor).
For secondary referrals, information will already be available from the
primary clinician and in the case record. The later your involvement
with the patient, the more data there will be, often from multiple
clinical teams in complex cases. The problem becomes one of data
overload and potential inaccuracies which can become embedded in
handovers between medical and nursing shifts. A careful review of
the history is invaluable in these cases. Review of old notes is
particularly valuable. Previous arterial blood gases or renal function
can be invaluable in determining 'acuteness' and severity of current
illness. This is commonly overlooked and takes time and effort, but is
usually worthwhile.
Trust no-one, believe nothing,
give oxygen
Examination
Now you should undertake a targeted physical examination to
supplement the cursory primary survey of Phase I. Although the
physical examination contributes considerably less than the history to
making a diagnosis, it is important for confirming prior hypotheses
and selecting and interpreting subsequent laboratory tests.
Follow a systems based
approach
Revise your
clinical
examination
skills
Focus on your physical examination technique at every opportunity. Develop a
sequence from general inspection of the patient through each organ system in
turn. Anticipate signs and complications of disease, and formally exclude
potential adverse effects of medical equipment.
N OTE
Remember to be considerate of the patient's feelings and cultural norms,
particularly so when the patient is rendered incompetent through disease or
medical interventions.
A patient's capacity to respond and communicate will be impaired by disease, drugs and equipment.
Critically ill patients who are conscious are vulnerable, often frightened, and concerned for the future of
their families should they die. Always treat patients with compassion and respect. Address them by
name and introduce yourself even if they are unconscious, and remember that relatives should be
considered an extension of the patient and entitled to consideration.
Examination of patients in the ICU requires particular skills. The daily assessment of the stable but
critically ill patient in the intensive care unit requires meticulous attention to detail. As well as clinical
examination, an essential part of the assessment includes review of the intensive care chart.
Physiological parameters must be interpreted in the setting of increasing organ support. For example,
although a patient's blood pressure may be stable, inotropic support may be increasing. You should
look for signs of complications of disease or treatment such as pressure sores, wounds and drains,
mouth hygiene in intubated patients, contractures or muscle wasting. As well as the conventional
organ systems such as the cardiovascular system, it is important to review microbiological issues as
sepsis is so common in the ICU. The drug chart, haematology and biochemical blood results, and the
chest X-ray should be reviewed.
What microbiological issues should be considered in the daily assessment of a critically ill patient
in the ICU?
Before you start your ward round, wash your hands (remove your watch and roll
up your sleeves as appropriate). Before and after you examine each patient, use
an alcohol-based hand disinfectant. Wear protective clothing to prevent contact
with your clothing. If you can't obey these simple rules – KEEP YOUR HANDS
OFF! See the PACT module on Infection control strategies
.
Laboratory tests
Arterial (or venous) blood gases
One of the most important diagnostic and monitoring tasks you will undertake is measurement of
arterial (or venous) blood gases (ABGs). If you cannot obtain an arterial sample, use a venous sample
from a large vein (e.g. femoral) instead, but not from a site proximal to an intravenous infusion. This
will provide nearly as much information; venous PCO2 will be slightly higher than PaCO2; and the other
variables will be similar to arterial values. Adequacy of oxygenation can be assessed using pulse
oximetry. ABG analysis should be thought of as part of the basic initial clinical assessment of any
acutely ill patient.
ABG results will help us begin to answer the question about the
Plan to repeat the ABG soon
adequacy of oxygen supply in relation to tissue oxygen demands. It is
more useful when combined with central venous saturations, since
values for ScvO2 <70% mean sub-optimal oxygen delivery. A lactic
acidosis (base deficit worse than –5 and serum lactate more than 2
mmol/l or the laboratory normal range) is a strong indicator of a
tissue oxygen debt and critical illness. Use these measurements to
guide your resuscitation.
Interpreting the results of blood gas analysis
Develop a systematic approach to ABG analysis. Here are ten steps to follow:
Step 1: If you did not process the sample yourself, make sure you have been given the correct printout
(for example, check patient identifiers, time and date).
Step 2: pH or H+ – Does the patient have an acidosis, or alkalosis?
Step 3: PaCO2 – Is there a respiratory component? Think through the causes and consequences of
high or low PaCO2 tensions.
Step 4: Base Excess (BE) – Is there a metabolic component? This derived variable (which parallels
changes in bicarbonate) quantifies the metabolic component of acid-base disturbances. A 'negative
base excess' is the same thing as a 'base deficit'. A base deficit may indicate bicarbonate loss,
compensation for a respiratory alkalosis, or accumulation of metabolic acid. It is this last component
which concerns us most when dealing with an acutely ill patient, since it is likely to indicate a tissue
oxygen debt related to sepsis or other forms of shock and inadequate perfusion.
Step 5: Lactate (if available) – An important indicator of inadequate tissue perfusion and shock.
Step 6: PaO2 – Interpretation must be based on the approximate inspired oxygen concentration. You
will already have made an estimate of adequacy of oxygenation from the patient's colour and from
pulse oximetry (SpO2).
Step 7: SaO2 – Check this against the SpO2. A common cause for an apparently low SpO2 but normal
PaO2 or SaO2 is hypovolaemia.
Step 8: Haemoglobin concentration – Only accurate to 1 g either way.
Step 9: Electrolytes:




K+: keep serum potassium 4-5 mmol/l
Na+: exercise care if correcting extreme values
Cl-: hyperchloraemia may produce a base deficit (for example, prolonged saline
administration) or reflect a bicarbonate losing state e.g. renal tubular acidosis or a surgical
ileal conduit)
Ca+: can be acutely lowered if citrated plasma is being infused rapidly
Step 10: Blood glucose – Always exclude hypoglycaemia in patients with impaired consciousness.
Hyperglycaemia may also contribute less obviously to poor outcomes from critical illness; it requires
control.
For further information, see the PACT module on Homeostasis
T HINK
how the management of the patient in the Patient Challenges might have been different with
appropriate use and interpretation of the ABG results.
Automation has increased the availability of clinical chemistry and haematology tests, many of which
are now performed as a routine and to obtain a 'baseline' for analysis of trends. Similar considerations
apply to routine electrocardiography, chest X-rays and standard microbiology analyses. This does not
absolve the clinician from responsibility for justifying the need for these investigations, nor from
reviewing the results promptly. Remember too that technical staff are often hard-pressed and rarely
thanked for their efforts.
Special investigations will usually require particular liaison with the relevant laboratory service, most
obviously for radiology, microbiology and pathology. Interpretation of results requires an understanding
of the clinical situation.
Patient-related procedures
Practical procedures at this stage of patient management fall into two categories: monitoring to acquire
clinical data; and for therapy and organ support, for example, an intra-aortic balloon pump. Invasive
procedures all carry risks and therefore require justification. They should also be performed, or the
procedure supervised by, competent clinicians, since acutely ill patients do not need the added burden
of complications. The environment must also be safe for the planned interventions, with adequately
skilled nursing staff.
All practical procedures should be performed with regard for patient comfort, infection control, and a
favourable risk-benefit ratio. There is a large gap between theory and practice however. Learn to
cultivate a meticulous approach to all practical procedures. The less experienced you are, the more
help you will need. Use this simple six-point check list.
Apply these principles to central venous catheterisation when you next have
the opportunity.
Prior planning
Explain to the patient what you wish to do and ensure you have his/her consent if competent to give it.
Consider route of insertion, prepare necessary equipment, and ensure there is someone to assist you
who understands the procedure and can also care for the patient.
Indications and utility
A central venous catheter is required to monitor CVP and ScvO2 and to deliver powerful vasoactive
drug infusions.
T HINK
How will a central venous catheter (CVC) help this patient? What action will you take based on
that information?
Contraindications, complications, minimising risk
Common complications of central venous catheter insertion include
Early



Arterial puncture
Pneumothorax and haemothorax
Arrhythmias


Catheter-related sepsis
Venous thrombosis
Late
T HINK
Does the patient have any problems which might increase the risk of complications? If they
were to occur during or after the procedure, how would you manage them?
Patient comfort
Prior explanation, adequate local anaesthesia, careful patient positioning. If the patient is too ill to
cooperate, should other interventions be taken first?
Asepsis
What factors influence the incidence of CVC-related sepsis?
Despite an extensive literature on preventing CVC infections, suboptimal sterile technique during
insertion and careless handling of connectors, taps or syringes during use is common, even in ICUs
and operating theatres. This results in avoidable infectious complications which may occur remotely in
time and place so that the link between error and outcome is not observed by the responsible
practitioner. If it were your catheter, would you accept this?
Continued safe care
Medical and nursing staff who may maintain and use the CVC should be competent to do so. Staff
should be aware of the risks and likely presentation of complications, for example, inadvertent
disconnection. It is important to regularly review the necessity for the CVC.
3/ THE TERTIARY SURVEY: INTEGRATION; TURNING DATA INTO EFFECTIVE ACTION
The table below gives an overview of the principles outlined in this third Task. The material in the blue
column summarises the pragmatic themes of the third phase, whereas the material in the green
column indicates what you need to think about.
Making a diagnosis
Making a diagnosis is an essential part of patient management, but in acute care it should usually
follow or accompany, and not precede, the primary task of physiological stabilisation. Anxiety to make
a diagnosis may interfere with the prompt delivery of physiological support, while the wrong diagnosis
will result in the wrong treatment and may distract attention from the fact that the patient is failing to
respond to current interventions.
However, during this tertiary survey we must now start to focus on diagnosis as the major task, while
continuing to provide physiological support. Diagnosis involves pattern recognition, and attaching
labels as succinct descriptors which encapsulate information about causation, process, treatment and
outcome. To do this we need to integrate the clinical and laboratory data obtained in the first two
phases of management, and to revise our diagnoses according to new information and the patient's
response to treatment. If the patient is not responding to treatment, either the diagnoses are wrong, or
the disease process is too severe for treatment to be effective.
N OTE
Diagnostic accuracy determines therapeutic specificity.
The UK's Intensive Care National Audit and Research Centre (ICNARC) has developed a hierarchical
diagnostic coding system. An example is given below, for bacterial pneumonia.
T HINK
how many data items do you need to make even this comparatively simple diagnosis
with reasonable certainty?
Try using this method for describing a patient with septic shock from peritonitis.
You will need more than one 'set' of descriptors. See if one of your colleagues
chooses similar terms. If not, what were the reasons for the differences?
Treatment – Planning, monitoring and reviewing the response
Treatment consists of four elements:
1. Organ-system support: homeostasis ('housekeeping and maintenance')
2. Definitive therapy targeted at the cause of the illness
3. Comfort care: relief of suffering
4. Social and ethical factors: family, community
Prompt physiological support is an essential component in initiating
and maintaining a safe environment, but it is rarely sufficient in itself
to achieve a cure. Indeed, protracted organ support in the absence of
a definitive diagnosis and specific treatment often merely delays
death. Thus, failure to respond to treatment (including those patients
who enter a state of chronic 'stability' in the ICU) should prompt a
search for alternative diagnoses or additional underlying conditions
which prevent recovery. Think of every treatment as a therapeutic
trial targeted at a specific working diagnosis and which entails
objectives which need to be achieved by a specific time.
Is the patient getting better,
and if not, why not?
Treatment plans should include the following elements:


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


Problem-oriented analysis – What are the main problems that I need to fix?
Causation – Have I identified and adequately treated the underlying
disease(s)?
Therapeutic goals – What targets should be met, and how quickly?
Preventative measures – What are the main safety issues for this patient?
Site of care – Where is the most appropriate place for this patient to be treated?
Patient-centred outcomes – Am I doing the right things for this patient?
Communication tasks – With the patient, the family, and the multidisciplinary team.
Use the flow chart below to integrate the various processes we have described in Phases I to III.
Integration of
processes
Assessment of severity of illness
It is not always immediately obvious that a patient is critically ill. Less experienced doctors and nurses
may have difficulty in recognising the warning signs of impending critical illness. Sometimes they
realise that a patient is sick but do not feel 'empowered' to take the actions required to manage or
resolve the problem, including calling for senior or more experienced help. It is important to consider
the various factors which interact to create the clinical picture of illness and which also influence
outcomes. We have presented these graphically in the figure below. We will then review simple
methods for assessing severity of illness.
Factors influencing severity
& outcomes
Physiological reserve
The response to, and outcomes from, an illness are determined by:



The nature and magnitude of the disease process (stressor event)
The patient's physiological reserve
The timing and specificity of treatment
What factors influence physiological reserve?
Reduced reserve can make it more difficult for individuals to respond effectively to any given insult,
and may therefore put them at greater risk of critical illness. Reserve is the equivalent in physiological
terms of having sufficient financial credit to pay the bills. This is why young fit patients can disguise
how sick they are (and may therefore appear to deteriorate abruptly), whereas an elderly patient with,
for instance, impaired ventricular function will deteriorate earlier and more visibly.
Use this concept to identify the 'at-risk' patient earlier: patients with known limited reserve need to be
managed proactively. We often use chronological age as a surrogate measure for reserve, though
biological age would be more appropriate. Cardiac fitness is particularly important: patients with a low
anaerobic threshold (measured using cardiopulmonary exercise testing) have a much increased
cardiovascular morbidity and mortality after major elective surgery. However, there are no simple and
reliable tests of 'reserve' as a composite entity in the context of emergency medicine. Clinical
evaluation of general health and a history of physical and psychosocial independence may be the best
we can do in routine practice.
The mortality associated with major surgery can be substantially reduced by prior optimisation of
circulating volume and adjunctive inotropic agents to improve cardiac output and systemic oxygen
supply. Similar benefits have been obtained in patients presenting to an emergency department with
severe sepsis or septic shock. Benefits are more likely to be realised the earlier optimisation is applied,
and if the control group has a high mortality risk. However, not all research supports this approach.
The Canadian Critical Care Clinical Trials Group did not demonstrate improvements in outcome with
the use of pulmonary artery catheters in high risk surgical patients, and earlier work in patients with
established septic shock found no benefit from longer term use of high dose dobutamine infusions, see
references below for further details.
Discuss the possible reasons for the divergences noted above with your colleagues when
you next care for high-risk patients presenting for surgery or in the early phase of severe
sepsis.
Measures of severity
There are many ways of measuring severity of illness. Here, we will only consider general methods
and those which have been used in the non-ICU ward environment.
'Critical care outreach' scores
These simple descriptors of severity enable ward staff to identify that a patient is deteriorating and call
for more experienced help. These 'critical care outreach' systems generally use vital signs to alert staff
to take action. The table below lists some of the methods and the variables they employ.
Variables used for different
'outreach' scoring systems
The variables define calling
criteria or physiological
scoring to trigger referral to a
critical care service
Two of these, the Modified Early Warning Score and the Medical Emergency Team calling criteria, are
described in tables below. Individual references for the five scores are as follows:
The modified early warning
score
The further the deviation from the physiological normal, the higher the score and the sicker the patient.
Medical emergency team
calling criteria
All cardiac and respiratory
arrests and all conditions
listed in this table
ICU-based physiology scores: APACHE, SAPS, and Organ Failure Scores
Within the ICU, many scoring systems are available; they are all calibrated against mortality and
provide group estimates of mortality risk. The most widely used are the Acute Physiology and Chronic
Health Evaluation score II (APACHE II), (the more recent APACHE III system has proprietary
diagnostic weights for calculation of mortality risk) and the Simplified Acute Physiology Score III (SAPS
III). You can find out more about these scoring systems in the PACT module on Clinical outcome
.
What physiological parameters contribute to the APACHE II score?
T HINK
What other readily available physiological parameters might be useful in determining outcome?
An alternative approach to quantifying severity of illness is to use organ-system failures and the level
of therapeutic support that each system requires. In the UK, for example, appropriateness of
admission to, or discharge from, intensive care units has been defined in terms of requirements for
organ-system support. Admission would be expected for patients requiring acute invasive respiratory
support, or support of two or more non-respiratory systems, or of one acute and one chronic system
failure. The general principle is that the more organ failures (or the more organ systems requiring
support), the greater the need for advanced levels of care that can only be provided safely in a critical
care environment.
Thus, if a patient remains hypotensive despite fluid resuscitation and is tachypnoeic requiring high flow
oxygen to maintain saturations above 90%, this can be interpreted as two organ-system failures
sufficient to justify admission to intensive care.
4/ CONTINUING CARE: SYSTEMS MANAGEMENT
The table below gives an overview of the principles outlined in this fourth Task. The material in the
blue column summarises the pragmatic themes of the fourth phase, whereas the material in the green
column indicates what you need to think about.
Lack of continuity arises in the care of acutely ill and unstable patients. These gaps may result in poor
transfer of clinical information, and make it more difficult to detect changes in a patient's clinical
condition.
What factors contribute to
a) lack of continuity in the care of acutely ill patients and
b) to error in healthcare delivery?
Training in clinical examination must therefore include an understanding of the wider healthcare
system, focusing particularly on teamwork to optimise care of individual patients.
General principles
As a critical care physician you will be called to help in the care of acutely ill patients. Remember
.caring for the critically ill requires teamwork. It is easy to criticise with the benefit of hindsight
Teamwork involves respect for one's own skills as well as those of others, insight into personal
limitations, an attitude of mind which is supportive and anticipatory, and which seeks solutions to
problems. Teamwork occurs within an organisation which values all members and empowers local
.decision-making within a clear operational framework
Care of acutely ill patients in hospital will increasingly be delivered by multidisciplinary teams, and
healthcare systems will need to focus on teambuilding if they are even remotely to approach the
.reliability levels of these other organisations
!Attending to the 'ABCs' does not mean Arrive, Berate, Criticise
Think
of the qualities you would expect of a good team-player. What about the qualities of the team leader?
?Do you have these qualities
Anecdote
In Patrick O'Brian's 'Master and Commander' series of historical novels set in the Napoleonic Wars of
the late 18th century, Captain Jack Aubrey is an inspiring and much loved naval hero to his men. He
combines deep knowledge of the sea and ships with great personal courage, determination, a distaste
.'for gratuitous punishment and bullying, affection for his men, and leadership from 'in front
Observe how your senior colleagues lead the intensive care ward round. Who does it best? How could
it be better? Can you adopt the examples of good team leadership?
Team Work
General principles
As a critical care physician you will be called to help in the care of
acutely ill patients. Remember caring for the critically ill requires
teamwork. It is easy to criticise with the benefit of hindsight.
Teamwork involves respect for one's own skills as well as those of
others, insight into personal limitations, an attitude of mind which is
supportive and anticipatory, and which seeks solutions to problems.
Teamwork occurs within an organisation which values all members
and empowers local decision-making within a clear operational
framework.
Attending to the 'ABCs' does
not mean Arrive, Berate,
Criticise!
Care of acutely ill patients in hospital will increasingly be delivered by
multidisciplinary teams, and healthcare systems will need to focus on
teambuilding if they are even remotely to approach the reliability
levels of these other organisations.
T HINK
A NECDOTE
of the qualities you would expect of a good team-player. What about the qualities of
the team leader? Do you have these qualities?
In Patrick O'Brian's 'Master and Commander' series of historical novels set in the
Napoleonic Wars of the late 18th century, Captain Jack Aubrey is an inspiring and
much loved naval hero to his men. He combines deep knowledge of the sea and ships
with great personal courage, determination, a distaste for gratuitous punishment and
bullying, affection for his men, and leadership from 'in front'.
Observe how your senior colleagues lead the intensive care ward round. Who
does it best? How could it be better? Can you adopt the examples of good team
leadership?
Communication skills
Communication failures and problems with attitudes and behaviour, most
particularly 'failure to care', are amongst the most common causes for
complaints by patients and relatives. Communications skills, like any others,
are possessed by some individuals to a greater extent than others, but they
can also be acquired through training and reflective practice.
Kindness and courtesy to
patient and family are
essential attributes of a good
clinician
Communication is a two-way process. It includes the capacity to listen, as
well as to convey information in a manner suited to the recipient.
When conducting hand-overs between shifts or on ward rounds, listen to the way
your colleagues convey information. Who does it best? How could it be better? How
do you yourself measure up? What additional tools are useful for transmitting
information about multiple patients? For more information, see the following
reference and the PACT modules on Communication skills
management
.
and Organisation and
Documentation and Protocols:
Case records and electronic methods of information management
Although handwritten or typed clinical case records are still the mainstay of most healthcare systems,
the electronic patient record will eventually become an increasingly important facilitator of information
transfer, together with computerized physician order entry (prescribing systems). Indeed, electronic
prescribing systems are probably the best way of establishing the electronic patient record, since they
provide immediate advantages to the physician, and permit incorporation of decision support and
knowledge resources to promote best practice. They improve patient safety by reducing the burden of
documentation and warning of potential drug interactions, contraindications, dosing adjustments and
allergies.
Electronic patient records should improve availability of clinical information and the results of previous
investigations. The following references provide further information on improving patient safety in
hospitals.
The Leapfrog Safety Practices
Computerized provider order entry (CPOE) requirements for intensive care use and Computerized
provider order fulfilment (CPOF) system requirements for intensive care unit use. Both available as
pdfs under the Corporate resources/Coalition for Critical Care Excellence link on the website of the
Society of Critical Care Medicine (SCCM)
Protocols and guidelines
Acute hospital care needs the support of clinical pathways, protocols, practice guidelines, and decision
support tools to guide clinical decisions and avoid gaps in care. Integrated team approaches using
treatment algorithms result in more rapid weaning of ventilator-dependent patients as compared with
physician-dependent treatment models, for example. Clinical practice guidelines, when appropriately
adapted and implemented within the local clinical setting improve processes of care and increase the
likelihood of desired health care outcomes.
T HINK
Check your national or local hospital policy on the management of common medical
emergencies? If your hospital or unit does not have such policies, why not?
CONCLUSION
When dealing with an acutely ill patient focus on physiological safety first. Diagnosis comes second: a
process which is accomplished while maintaining a safe environment for the patient. Iterative and
frequent review is essential for effective and safe treatment. You are part of a system of care in which
teamwork and communication are essential elements.
Error in healthcare processes is a common problem, and frequently causes avoidable harm to
patients. The risk of error and adverse outcomes seems to be higher in the context of acute and
emergency care. Most healthcare systems report an increase in emergency admissions at a time when
they are trying to constrain costs, reduce length of stay, and reduce doctors' hours of work.
These problems require a systems approach for improving the safe care of the acutely ill hospitalised
patient. Australia has promoted the establishment of medical emergency teams led by doctors as an
alternative to cardiac arrest teams; the UK has established multidisciplinary outreach care, and in the
USA many hospitals are appointing 'specialist generalists' ('hospitalists') to provide in-patient care on
the wards. All these developments are based on the concept of earlier intervention by people with
appropriate knowledge and skills in managing acutely ill patients. An important aim of this module
therefore is to improve the ability of clinicians to identify, assess, and manage acutely ill patients at risk
of critical illness at all stages in the patient journey from admission to discharge.
PATIENT CHALLENGES
A 58-year-old man was brought to the Emergency Department at your University Teaching
Hospital on Saturday at 19.00 hrs after his son found him collapsed at home.
The ambulance crew had recorded the following vital signs: pulse 131/min, blood pressure 84/55
mmHg, and respiratory rate 27/min.
No history was available from the patient. His son said that he had last seen his father four days
previously when he appeared well. On visiting today there was no response and he had eventually
decided to break into the house. He had found his father lying on the floor in the bedroom, confused
and disorientated, but not complaining of any specific symptoms.
He was apparently previously fit and well, apart from recently complaining of a painful right knee. He
lives alone, takes no regular medications and smokes heavily. The son said that his father's alcohol
intake had increased markedly in the past three years. There is no history of diabetes, ischaemic heart
disease, hypertension or tuberculosis. There is no other significant history.
The emergency department doctor finds the patient to be drowsy, confused and afebrile. Pulse 120 per
minute and BP 83/60 mmHg. Jugular venous pressure is not elevated. Heart sounds are normal.
There is no peripheral oedema. Respiratory rate 25 breaths per minute, SpO 2 (room air) 90%. Chest
examination is unremarkable.
Abdomen is soft and non-tender with no organomegaly.
Neurological examination is hampered by lack of ability to cooperate; cranial nerves appear intact, and
power appears to be grade 5 in all muscle groups. Tone and reflexes are symmetrical with probable
flexor plantar responses. Coordination could not be assessed.
What would you have done if you were managing this patient initially?
Learning issues
Prioritise correction of abnormal physiology with detailed history taking
and examination (1)
Prioritise correction of abnormal physiology with detailed history taking
and examination (2)
New models for assessing and managing the acutely ill patient
N OTE
Fix physiology first
What approach to 'fixing the physiology' would you have used?
Learning issues
'Primary survey': ABC-DEF
N OTE
Simple things done well save lives
PACT module on Airway management
Learning issues
Assessing level of consciousness
What further information would you have needed at this stage?
Learning issues
'Secondary survey': Systems approach to identify underlying problem
Examination
Laboratory tests
Where would you have managed this patient?
N OTE
You need to stay with the patient until
physiologically safe
The patient was seen by the internal medicine resident who admitted him to the medical acute
admissions ward, where he was given 500 ml of normal saline over two hours. Oxygen was
administered at 2 l/min via nasal cannulae, which the patient partially dislodged.
On the vital signs chart the nurses documented the following observations at 21.00 hrs; afebrile, pulse
110 per minute, blood pressure 96/58 mmHg. The respiratory rate was not recorded.
At 21.00 hrs he was reviewed by the medical staff, and an arterial blood gas sample was taken while
breathing room air. The results documented in the notes were; pH 7.24, PaO 2 11.1 kPa, PaCO2 4.8
kPa, base excess –14.2, blood glucose 3.6 mmol/l (65 mg/dl).
It was felt he was dehydrated and maintenance fluids were continued at a rate of 500 ml/4 hrs with
normal saline alternating with 5% dextrose.
Learning issues
Recognition of the critically ill
Review response to treatment (1)
Review response to treatment (2)
What is the acid-base abnormality and what does it indicate?
Learning issues
Interpretation of acid-base abnormalities
N OTE
Metabolic acidosis is frequently unrecognised as a marker of severe illness
PACT module on Homeostasis
The following results were available at 23.15 hrs:
 Haemoglobin 12.5 g/dl, platelets 72 x 109/l, white cell count 9.4 x 109/l
 Sodium 137 mmol/l, potassium 4.3 mmol/l, urea 12.6 mmol/l, creatinine 155 µmol/l
 Bilirubin 28 µmol/l, aspartate transaminase 8554 U/l (normal <20)
 Prothrombin time 20 seconds (control <12 seconds)
 Repeat blood gas at 00:30 hrs on O2 2 l/min pH 7.19, PaO2 9.2 kPa, PaCO2 3.4 kPa, base
excess –16, lactate 15.1
The attending medical staff considered that the elevated aspartate transaminase and serum creatinine
were related to hypotension. As the patient had not passed urine, a urinary catheter was inserted,
producing 100 ml of dark urine. Frusemide (furosemide) 80 mg was given intravenously to 'treat' the
oliguria.
Learning issues
PACT module on Oliguria and anuria
How do you interpret these laboratory results and what additional information about organ
dysfunction do they provide? How would you have managed the patient differently?
No further specific action was taken overnight.
How often would you have reassessed this patient?
Learning issues
Regular assessment (1)
Regular assessment (2)
The patient was next evaluated at 10.00 the next morning and was noted to be more agitated. The
observation chart overnight showed a persistent tachycardia and a systolic blood pressure of around
100 mmHg. There was no urine output over the previous 12 hours. It was felt an urgent CT of the brain
was indicated and given the agitation he would require sedation. He was therefore referred to intensive
care for assistance.
When you are finally called by the ward staff to the ward, you find the patient's respiratory rate is
38/min, he has disconnected the nasal oxygen cannulae and he is only responding to painful stimuli.
The following repeat results are available:
Sodium 134 mmol/l, potassium 5.3 mmol/l, urea 18.9 mmol/l, creatinine 221 µmol/l, blood glucose 2.4
mmol/l (43 mg/dl).
Prothrombin time 38 seconds (control <12 seconds).
Arterial blood gas on room air pH 7.11, PaO2 8.2 kPa, PaO2 3.1 kPa, base excess –22, lactate 20.2.
How well do you think this patient has been managed so far?
Learning issues
Patient assessment (1)
Patient assessment (2)
System errors
What advice do you give the referring medical team?
Learning issues
Need for airway protection (1)
Need for airway protection (2)
PACT module on Airway management
The patient is transferred to intensive care. He requires immediate intubation and ventilation, two large
peripheral intravenous cannulae are inserted and rapid fluid resuscitation with repeated boluses of fluid
is commenced. Hypoglycaemia is treated with 50 ml of 50% dextrose and with a continuing infusion
pending the establishment of nutritional therapy. Coagulopathy is corrected with fresh frozen plasma.
A right internal jugular central line and a radial artery catheter are inserted.
Because of persistent hypotension despite fluid resuscitation, a noradrenaline (norepinephrine)
infusion is started. A haemocath is inserted in his right femoral vein to permit continuous veno-venous
haemofiltration (CVVH) using 2 l exchanges.
Following a one hour period of resuscitation the patient is reassessed and the following features
documented:
 Afebrile
 Sedated with midazolam and morphine
 Intubated and ventilated with SIMV tidal volume 550 ml. Respiratory rate 18/min with no
spontaneous effort.
PEEP 5 cmH2O. FiO2 0.6
 Breath sounds clear bilaterally
Learning issues
Safe transfer
PACT module on Transportation
Use of a fluid challenge and inotropic support
PACT module on Hypotension
PACT module on Acute renal failure
Assessment of the patient in the intensive care unit











Arterial blood gas pH 7.01, pO2 29.1 kPa, pCO2 3.8 kPa
Pulse 101/min, BP 110/68 mmHg, CVP +14, ScvO2 80%. Noradrenaline 0.5 µg/kg/min
No response to painful stimuli
Heart sounds normal, no oedema, peripheries warm
NG tube in situ but no nutrition
Abdominal examination normal
CVVH 2 l exchanges with equal balance
Base excess –19, lactate 18.8, blood glucose 3.1 mmol/l (55 mg/dl)
Right internal jugular line, no positive cultures, empirical benzylpenicillin and gentamicin
Peripheries and joints were normal
No other medications yet
How does this assessment process differ from the approach to a patient on a general ward?
Task
2
How are you going to manage this patient now?
Learning issues
Review history
Interpretation of clinical data
What differential diagnosis should you consider?
Task 3
PACT module on Sepsis and MODS
PACT module on Acute hepatic failure
Learning issues
Managing data and refining diagnosis
On further discussion, the patient's son said that when he had returned to his father's house he had
found several empty packets of paracetamol (acetaminophen) in a drawer, which he had assumed his
father had taken for his painful knee. On further questioning the son explained that his father had been
depressed since his other son had died three years ago and had been drinking alcohol heavily since
then. His son also commented that he had found his father in his dead son's bedroom.
A paracetamol level is found to be markedly elevated on the stored blood samples taken at hospital
admission, confirming the diagnosis of acute paracetamol-induced hepatic failure.
Treatment for acute hepatic failure is started. After review by the resident transplant team it is decided
that he fulfils the criteria for liver transplantation.
The patient's son is informed of the treatment plan. It is explained that he is critically ill and without a
liver transplant it is unlikely that he will survive. A complete summary of the patient's clinical history and
discussion with his son is documented in the notes.
The next day the man's son asks to speak to you and is clearly annoyed. He says his sister spoke to a
junior doctor last night who told her that his father had a good chance of survival even if he did not get
a liver transplant. He wants to know 'does anyone know what is going on?'
Learning issues
Criteria for liver transplantation
PACT module on Organ donation and transplantation
PACT module on Acute hepatic failure
What do you say to the man's son and why?
Learning issues
Record keeping
Effective communication
Why is it necessary to document the clinical history accurately?
Learning issues
PACT module on Communication skills
Following further discussion with the patient's son the misunderstanding is clarified. As part of the
patient's work up for liver transplantation a pulmonary artery catheter is inserted to measure cardiac
output. Unexpectedly a cardiac index of 2.1 l/min/m 2 is recorded. As one of the relative
contraindications to transplantation is a low cardiac output state, the resident proposes that the patient
may not be suitable for liver transplantation.
N OTE
Do not discuss patient details with a relative unless you are fully informed
How do you interpret this finding?
Learning issues
Integration of clinical assessment and technological monitoring (Phase 3 of the module overview)
N OTE
Always question monitoring measurements or investigation results which do not fit with
clinical assessment
You review the patient's history and reassess the patient. There is no history of cardiovascular
disease, the patient's peripheries are warm and the noradrenaline infusion is in place for a warm,
vasodilated state. You therefore feel the cardiac index may be wrong and review the monitoring
equipment. You find that the connection between the pulmonary artery catheter and the thermistor is
faulty. This is replaced with a correctly functioning cable and the repeat cardiac index measurement
was (5.1 l/min/m2).
The following day the patient has an initially uncomplicated liver transplant. The patient returns to the
ICU from theatre ventilated.
Learning issues
PACT module on Haemodynamic monitoring
How do you assess this patient?
Learning issues
Examination
N OTE
Problem prediction allows early identification and response to complications
The patient was extubated five days after the liver transplantation, and was initially well. The following
assessment is documented the morning after extubation.
 Febrile overnight, 38.9 °C this a.m.
 Drowsy, but awake and appropriate
 Pulse 111/min, BP 120/68 mmHg, CVP +6. No inotropes
 Heart sounds normal, no oedema, peripheries warm
 Spontaneous breathing FiO2 0.4 via face mask
 Respiratory rate 14/min, bronchial breathing at base of right lung
Learning issues
PACT module on Immunocompromised patients
PACT module on Organ donation and transplantation
PACT module on Acute hepatic failure






Arterial blood gas pH 7.41, pO2 12.3 kPa, pCO2 5.5 kPa
Tolerating NG feeding
Abdominal examination normal
CVVH 2 l exchanges with equal balance
Still anuric but creatinine and urea under control
Base excess +2, lactate 1.8, blood glucose 6.2 (112 mg/dl)
On ICU day six the right internal jugular venous catheter entry site is noted to be inflamed; there are no
positive cultures. The patient is still receiving empirical benzylpenicillin and gentamicin, with
prophylactic fluconazole and septrin since the transplant.
 White cell count increasing (15.2)
 Other medications: enoxaparin 40 mg od, pantoprazole 20 mg od
 Immunosuppression as per protocol
How would you manage this patient?
Learning issues
PACT module on Sepsis and MODS
The central line is removed. However the patient remains febrile over the next 24 hours. White cell
count continues to increase and repeat liver function tests showed increasing aspartate transaminase
and alkaline phosphatase. Cultures from the CVC tip are negative. Blood cultures produce a Gramnegative coliform in two bottles. Tracheal suction produces insignificant samples. A chest X-ray shows
some shadowing at the base of the right lung.
Learning issues
Revise diagnostic possibilities in light of response to intervention (1)
Revise diagnostic possibilities in light of response to intervention (2)
What do you conclude and what is your next step?
Learning issues
Patient genotype, treatment and environment may modify clinical presentation
Results obtained from investigations should be considered in light of clinical assessment (Phase 3 of
the module overview)
Repeat clinical assessment is unchanged. A portable abdominal ultrasound is performed which was
normal, including hepatic arterial and portal venous blood flow. Bronchoscopy and lavage are
performed and samples sent to microbiology. Benzylpenicillin and gentamicin are changed to a
carbapenem.
As the sensitivity of portable abdominal ultrasound is low in the critically ill, further abdominal imaging
is required.
Learning issues
PACT module on Clinical imaging
CT of the abdomen shows a modest amount of right-sided subphrenic fluid, and consolidation of the
right lower lobe. CT-guided aspiration of the subphrenic collection produces purulent fluid. The
aspirate cultured a gram-negative coliform sensitive to the carbapenem, which is continued; the
vancomycin is stopped. The bronchoalveolar lavage is sterile. The patient subsequently makes a slow
but otherwise uneventful recovery. He is discharged from the intensive care unit on ICU day ten, and
from hospital two weeks later to continue convalescence at his son's home with psychiatric and
transplant follow-up.
On reflection, clinical assessment of a critically ill patient can be seen to fall into distinct phases;
assessment and treatment of life-threatening conditions ('the primary survey'), systematic assessment
when physiologically more stable ('the secondary survey'), and integration of clinical information to
form a presumptive diagnosis leading to a specific management plan ('the tertiary survey'). Historytaking from critically ill patients can be difficult, takes time to obtain and frequently depends on
collateral sources. The fact that the majority of patients referred to intensive care come 'complete with
history' is not a reason for failing to confirm the clinical history and obtain additional details, since the
initial history may have been cursory, and have failed to identify important aspects of prior health and
social circumstances. In the 'high tech' environment of the intensive care unit it is relatively easy for the
basic clinical examination to become a cursory process. It is important to adapt the skills in clinical
examination to a critically ill patient. In addition information obtained by clinical assessment must be
integrated with that from complex monitoring and investigation
Self assessment:
Questions
Q1. Errors in healthcare
A. Occur in approximately 5% of hospitalised patients
True
False
B. Are more commonly associated with equipment failures rather than human error
True
False
C. The risk of healthcare error is higher in acutely ill patients
True
False
D. Hospitalised patients who suffer a cardiopulmonary arrest rarely demonstrate
clinical deterioration prior to the cardiac arrest
True
False
E. Continuity of care is an important factor in reducing errors in healthcare
True
False
A. It is more difficult to recognise in young patients
True
False
B. It is more difficult to recognise in immunosuppressed patients
True
False
C. Tachypnoea is the single most important indicator of critical illness
True
False
D. A base deficit is one of the most important indicators of critical illness
True
False
Q2. With regard to critical illness
E. A complete neurological examination is required immediately a reduced level of
True
consciousness is identified
Q3. In the care of the critically ill the following factors have been associated with poor outcome
False
A. Admission from accident and emergency department
True
False
B. Discharge from intensive care at night
True
False
C. Need for regular review
True
False
D. Increasing medical specialization
True
False
E. Regular input from intensive care physicians
True
False
A. A diagnosis based approach is appropriate
True
False
B. Physiological abnormality needs to be considered in the context of previous baseline
value
True
False
C. Treatment of physiological derangement should be commenced as it is identified
True
False
D. Hypovolaemia is common in the critically ill
True
False
E. In patients with acute respiratory failure O2 should be reduced if CO2 retention occurs
True
False
A. Haemoglobin concentration
True
False
B. Central venous oxygen saturation
True
False
C. Cardiac output
True
False
D. Arterial pO2
True
False
E. Serum lactate
True
False
Q4. In the initial care of the critically ill
Q5. Oxygen delivery depends on