Anaesthesiology - Critically Ill patient Flashcards
Define critical illness
Life-threatening multisystem process that carries significant morbidity or mortality
Preceded by a period of physiological deterioration
Define top five early and late signs of physiological deterioration before critical illness
Function of early warning scoring system
Combine signs from routine physiological observations
Link to a pre-determined response (e.g. increase frequency of monitoring, or escalation of care)
Assessment by medical emergency team (MET) or Critical Care Outreach Service (CCOS)
Outline MEWS system and function
MEWS - Modified early warning score system
Function: early detectiuon of patients with physiological impairment
Combined assessment of SBP, HR, RR, Temp., and neurological state AVPU (Alert, Voice, Pain, Unresponsive)
Score of 5 or more is a/w increased likelihood of ICU admission or death
Outline ABCDE apporach to critical illness
□ Airway (A): look for features of airway obstruction → Mx to ensure airway patency
□ Breathing (B): look for adequacy of breathing
□ Circulation (C): look for features of shock or cardiac arrest
□ Disability (D): assess conscious level
□ Exposure (E): to allow complete examination of patient
Airway
- Look, Listen, Feel signs
Look:
- See-saw respirations: paradoxical chest and abdominal movements
- Use of accessory muscles of respiration
- Central cyanosis (late feature)
Listen:
Noisy breathing for partial obstruction
- Stertor (snoring): low-pitched inspiratory sound indicating turbulent flow above larynx
- Stridor: high pitched monophonic sound heard during breathing indicating obstruction of large airway
- Wheeze: high pitched expiratory monophonic or polyphonic sound indicating obstruction of small airways
- Other sounds: gurgling (fluid in mouth/upper airway), rattling (secretions in airway), crowing (laryngospasm)
Silence for complete obstruction or apnoea
Feel:
- expired air at mouth/nose
qSOFA score components
Causes of paradoxical breathing
Paradoxical breathing: Chest trauma, diaphragmatic dysfunction, upper airway blockage, severe electrolyte imbalances
Breathing assessment
Look, Listen, Feel signs
Look:
- Features of respiratory distress incl. use of accessory muscles, tracheal tug, abdominal breathing, sweating, central cyanosis
- Rate, depth, rhythm and symmetry of breathing
- Impedance to normal breathing incl chest deformity and abdominal distension
- Other relevant features: ↑JVP, chest drains
Listen for:
- Noisy breathing indicating airway abnormalities
- Auscultate breath sounds for any chest pathologies
Feel the chest for
- Tracheal deviation indicating tension pneumothorax or massive pleural effusion
- Symmetry of chest expansion
- Surgical emphysema or crepitus
- Percussion notes
Circulation assessment
Look, Listen, Feel signs
Look for
- Pale/cyanosed/mottled limbs indicating poor peripheral perfusion
- Collapsed central/peripheral veins indicating hypovolaemia
- Engorged central veins indicating ADHF, cardiac tamponade, tension pneumothorax or acute severe asthma
- Signs of ↓CO incl ↓GCS, oliguria
- Signs of blood/ECF loss, eg. bleeding
Listen for:
- S3/4 indicating ventricular dysfunction
- Heart murmur indicating valvular heart disease
- Pericardial rub indicating pericarditis
- Very quiet heart sound indicating severe emphysema or pericardial effusion
Disability assessment
Look, Listen, Feel signs
Pupil size and symmetry
□ Pinpoint reactive → opioid, pontine lesion
□ Mid-sized fixed → midbrain lesion
□ Dilated fixed → severe global ischaemia or hypoxia, hypoglycaemia and ↓CNS function
□ Unil dilated fixed → uncal herniation, CN3 palsy
GCS, APVU assessment (Alert, Voice, Pain, Unresponsive)
Haemstick for hypoglycaemia
Drug charts for drug- induced causes, drug toxicology
Neuroimaging for primary intra-cranial causes
