Intensive care Flashcards
Recognising the sick patient-on the wards or in A + E
A sick patient is one who is failing to deliver oxygen to their tissues where it is needed to form ATP.
Body responds to everything as if it were experiencing haemorrhagic shock.
If there is no oxygen delivery, then anaerobic metabolism occurs, producing lactate, acid and carbon dioxide as waste products. Therefore respiratory rate increases because you are trying to get more oxygen to the mitochondria, but also you have all this waste product to get rid off. This makes you acidotic and stimulates your respiratory senses, telling you to breathe harder. Heart rate also increases, to try and increase cardiac output and increase CO, so more flow to lungs and get carbon dioxide to lungs so it can be excreted. Respiratory rate increases as you are trying to breathe more. Urine output also increases.
Assess, intervene and then reassess.
High resp rate: also reflected in short sentences.
Delivery of oxygen
Determined by cardiac output, multiplied by the amount of oxygen bound to haemoglobin, plus the amount of oxygen dissolved in blood plasma. Therefore the only way to compensate when Hb and SaO2 are low is an increase in CO.
Severe sepsis
Conditions such as severe sepsis cause mitochondrial dysfunction so you can deliver as much oxygen as you like to the mitochondria, but the mitochondria will not use it and you are still shocked.
Approach to a sick patient
Airway and oxygenation Breathing and ventilation Circulation and management of shock Disability due to neurological deterioration Exposure and examination.
Analgesia –> morphine, after ABCDE.
Airway and oxygenation
Is the airway patent? Can the patient talk? can they answer you? if they can answer, you know that their airway, breathing, circulation and neurological exam are grossly normal.
Alternatively, if a patient can’t talk need to think, does the patient sound distressed? Are they using short sentances –> sign of high resp rate.
If airway seems to be impaired then give oxygen (15L via a nebuliser). You can reduce this in certain circumstances. This will allow them to maximally saturate their haemoglobin so you are maximally trying to deliver as much oxygen to them as possible. If airway is not patent: gurgling noises, snoring, then you need to open that airway.
Breathing and ventilation
Respiratory rate is one of the most important signs of clinical deterioration, so many things effect it.
Normal: 12-20 breaths per minute.
Could be low due to drugs, eg. morphine or neurotransmitters.
But being high, greater than 20, implies there is a high acid or carbon dioxide build up which the body is trying to get rid off. This implies that patient is shocked.
Assessing part will include a cursory physical examination: is the chest clear, is it bilateral or equal, cyanosis? SaO2,< 94% give some oxygen.
Management of Breathing:
-so having given oxygen.
-can give nebulisers for wheeze (Steroids, magnesium), if pneumothorax or haemothroax, you have to decompress that chamber. So a needle or a drain needs to go into that haemothorax. If patient has COPD and has developed hypercarbic respiratory failure, you may need to augment their ventilation, with non-invasive ventilation (NIV).
Circulation and management of shock
What is the normal HR and BP for that patient, and how far off baseline is the patient currently.
Capillary refill time (<2seconds is normal).
Temperature of limbs, heart sounds, urine output. Oedema? Look at JVP.
All of these are a cursory examination of the circulatory system.
IV access (large bore)
Bloods (FBC, VE, CRP, LFTS, Coag, BC, VBG). Then you will do intervention and give them some fluid.
We have alaready established that if our HB, saturation of oxygen are normal, then our oxygen content of our blood is okay. So the problem isn’t a breathing problem, if our patient is shocked it must be an oxygen delivery problem. So there is a problem with CO. or SV. Hypovolaemic problem: administer fluids. By adding fluid, your stroke volume goes up. Increase stroke volume, increases HR, which means you have increased CO.
Once have optimised preload, optimised HR, and you’ve optimised your oxygen content, then if those things don’t work, then you have to refer to ITU for management of either afterload or contractility.
Starlings curve shows, that if SV is low, and you add fluid, your stroke volume significantly increases. If SV already high, when you add fluid, it is unlikely to make a difference and can be harmful.
Need to assess after to see if intervention worked.
A positive response to IV fluid is a decrease in HR, mean arterial pressure increases, arterial pulse pressure increases, urine output increases (only 2-3 H later), lactate clearance increases (VBG would start to clear), cardiac output or stroke volume increases.
Disability due to neurological deterioration
Neurological consequences of metabolic derangement. If you are hypoglycaemic, that can cause a low GCS.
GCS: mainly used in patients suffering from neurological disease. Or can use the simplified version called the AVPU scale: alert, alert to voice, alert to pain, and unresponsive. Alert: respond to hello, voice: if they arent saying anything but respond to you shouting at them, p: if you have to stimulate them physically to speak. If none of that works they are unresponsive.
BM: basal metabolism: 4.4-6.1 mmol/L.
Glasgow coma scale
Mainly used in patients sufferring from neurological disease. Used in neurointensive units, to try and identify the exact components causing a problem and make a score for each row, then add them together. On the whole, your motor score is most predictive of neurological injury.
Exposure and examination
Temperature. Rest of the physical examination. Feel their abdomen, look at their skin. Take a temperature, just to make sure they are not missing anything out.
What should you do after performing ABCDE
Assess, intervene stabilise.
History, backgrounds, obervation chart, drug chart. Blood tests: ABG, pH, pCO2, pO2, BE, HCO3, lactate, imaging. Review of investigations, impression, plan.
How to communicate your findings?
Once you’ve identified that your patient is sick and you are worried, you then have to communicate your findings in a robust, consice way, so person you have called can prioritise their situation with yours.
S: Situation ( a concise statement of the problem)
B: Background (pertinent and brief information related to the situation.
A: Assessment (analysis and consideration of options -what you found/think).
R: Recommendation (action requested.recommended-what you want).
Communication
If you think patient is about to arrest, call the cardiac arrest team.
UBG vs ABG
Both give the same info, except pO2.
If patient doesn’t have a primary breathing problem, then there is very little difference in the two. You are taking blood anyway, as part of Circulation, so you can take some for for VBG as it will give you lactate and HB. VBG doesnt take a lot of time in scheme of ABCDE. Each patient has an Ob chart. Score will trigger alert based on oxygen, HR, conscious level.
Emergency medicine:
Initial steps
You are likely to see this patient after a brief handover from another member of staff.
Introduction
Introduce yourself to whoever has requested a review of the patient.
Inspection
Perform a quick general inspection of the patient to get a sense of how unwell they are:
Check consciousness level using AVPU How do they look? Are they pale? How is their breathing? Are there obvious signs of bleeding? What is around the bedside? (look for IV lines, monitoring equipment etc)
Interaction
Introduce yourself to the patient
Ask the patient how they are doing – in what way are they feeling unwell?
Are they in pain?
Preparation
Make sure the patient notes, observation chart and prescription chart are on hand
Ask for another clinical member of staff to assist you if possible
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Assessment
Can the patient talk?
YES:
The airway is patent; move on to Breathing assessment
NO:
Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles, diminished breath sounds, added sounds)
Is the patient cyanosed?
Open the mouth and inspect: Is there anything obviously compromising the airway (e.g. secretions)?
Possible causes of airway compromise:
Inhaled foreign body (acute onset, may be unilateral, classically stridor)
Secretions, blood, vomit (often obvious, may have gurgling breath sounds)
Soft tissue swelling: anaphylaxis (rash, shock, angioedema); infection (e.g. quinsy)
Mass in the surrounding tissues (e.g. a tumour)
Laryngospasm
Depressed level of consciousness (e.g. opioid overdose, head injury)
Intervention
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain the airway.
Maintain the airway whilst awaiting senior input
1. Perform head tilt, chin lift manoeuvre.
- If noisy breathing persists try a jaw thrust.
- If airway still appears compromised use an airway adjunct:
Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise may gag/aspirate)
Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially conscious)
Anaphylaxis
Commence algorithm as per guidelines.
See anaphylaxis case
Re-assess after any intervention
Breathing
Assessment
Observations
Respiratory rate (12-20 breaths per minute)
Bradypnoea may be due to sedation, opioid toxicity, raised intracranial pressure (ICP), or exhaustion in airway obstruction (e.g. COPD)
n.b. respiratory acidosis
Tachypnoea may be due to airway obstruction, asthma, pneumonia, PE, pneumothorax, pulmonary oedema, heart failure, or anxiety
n.b. respiratory alkalosis
Oxygen saturation (88%-92% in COPD; 94%-98% otherwise)
Hypoxaemia may be seen in PE, aspiration, COPD, asthma, and pulmonary oedema
Examination
Check for central cyanosis: hypoxia can have CNS, respiratory, cardiac and haematological causes
Listen to the breath sounds- rattling suggests secretions
Expose the chest
Inspect:
Jugular venous pressure (JVP): raised in acute severe asthma, heart failure, fluid overload
Signs of respiratory distress: sweating, use of accessory muscles, abdominal breathing
Deformity affecting breathing
Rhythm and depth of inspiration:
Cheyne-Stokes respiration (cyclical apnoeas, then varying depth of inspiration/rate of breathing) may be due to stroke, raised intracranial pressure, pulmonary oedema, opioid toxicity, hyponatraemia, or carbon monoxide poisoning
Kussmaul’s respiration (deep, sighing) can be seen in metabolic acidosis (e.g. DKA)
Feel:
Trachea: Is there a mediastinal shift? (e.g. tension pneumothorax)
Chest expansion: Unequal chest expansion may indicate underlying pathology (e.g. pulmonary fibrosis, consolidation, tension pneumothorax)
Percuss:
Hyper-resonance can be caused by pneumothorax
Dullness can be caused by consolidation or pleural effusion
Auscultate:
Bronchial breathing (e.g. pneumonia)
Reduced breath sounds with pneumothorax, pleural fluid, or consolidation
Unilateral crackles suggest consolidation
Bibasilar crackles may indicate pulmonary oedema or bronchitis
Investigations/Procedures
ABG
Take an ABG if indicated by any abnormal observations or examination findings.
See how to take an ABG and how to interpret results
Chest X-Ray
Order a portable chest X-ray if you suspect lung pathology.
See chest x-ray interpretation guide
Intervention
Any patient who is short of breath should be sat up in the bed if possible to aid inspiration.
Oxygen
Give oxygen to all critically unwell patients: 15L via a non-rebreathe mask
In COPD, target saturations accordingly (88-92%). Consider using a Venturi mask: 24% (4L) or 28% (4L)
Consider non-invasive ventilation (NIV) in acute exacerbations of COPD after appropriate review
See airway device overview
Acute severe asthma
Use guidelines to treat accordingly with nebulisers.
See acute management of asthma case
Acute exacerbation of COPD
Manage an acute exacerbation of COPD with oxygen, steroids, nebulisers (+/- antibiotics).
See acute exacerbation of COPD guide
Other
Treat problems such as pneumonia, pneumothorax, PE as you identify them.
Re-assess after any intervention
Circulation
Assessment
Observations
Temperature (36.0°c – 37.9°c)
Pyrexia most commonly suggests infection. Beware febrile neutropenia!
Septic patients may have a high or low temperature
Consider warming (e.g. Bair Hugger™) in hypothermia – seek senior help
Heart rate (60-99 beats per minute)
Causes of tachycardia (HR>99) include hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain, and iatrogenic causes (e.g. salbutamol).
Causes of bradycardia (HR<60) include acute coronary syndrome (ACS), ischaemic heart disease (IHD), electrolyte imbalance, and iatrogenic causes (e.g. beta-blockers).
Blood pressure
Target is patient’s normal BP or systolic >100mmHg
Check patient’s normal BP
Hypertension in women of childbearing age – consider pre-eclampsia
Hypertension may suggest fluid overload or endocrine abnormalities (e.g. Conn’s syndrome, Cushing’s syndrome)
Hypertensive emergency (systolic > 180 mmHg or diastolic > 100 mmHg): confusion, drowsiness, breathlessness, chest pain, visual disturbances (seek immediate senior help)
Causes of hypotension include hypovolaemia, sepsis, iatrogenic (e.g. opioids, antihypertensives, diuretics).
Extremes of heart rate or blood pressure with any worrying features such as shock, new heart failure, syncope or myocardial ischaemia suggest the patient may be peri-arrest. Seek immediate senior help and alert the crash team as appropriate.
Is the patient septic?
You have enough information to identify SIRS at this point. Perform the sepsis 6 immediately in suspected sepsis.
Administer oxygen Take blood cultures Give IV antibiotics Give IV fluids Check serial lactates Measure urine output Examination Check peripheries: warm/cold/cyanosed
Measure central cap refill time: CRT>2 seconds may suggest shock or dehydration
Inspect:
JVP (if not already assessed) – raised in fluid overload, sunken in dehydration
Feel:
Central and peripheral pulse for rate, rhythm, volume, and quality:
A bounding pulse suggests sepsis or fluid overload, a weak pulse suggests poor cardiac output
An irregular pulse may be due to atrial fibrillation (AF)
Check ankles/sacrum for oedema
Is the patient in heart failure?
Are they overloaded with fluid?
Auscultate:
Does the patient have a new murmur suggestive of endocarditis?
Is there a pericardial rub or muffled heart sounds? (e.g. pericarditis)
A third heart sound may indicate heart failure
Fluid output
What is the patient’s fluid output?
Oliguria may suggest hypovolaemia, poor cardiac output, acute kidney injury (AKI) or dehydration. Suspect retention or obstruction if the patient is otherwise stable.
The output may be high in fluid overload.
Investigations/Procedures
Cannulation
Insert at least one wide-bore IV cannula (14G or 16G) and take bloods as below.
See cannulation guide
Bloods and blood cultures
Collect blood cultures and bloods as you cannulate. Request FBC, U&E, LFTs for all patients, and any other relevant bloods:
Sepsis: CRP, lactate, blood cultures
Haemorrhage or surgical emergency: Coagulation and cross-match
Acute coronary syndrome (ACS): Cardiac enzymes
Arrhythmia: Calcium, magnesium, phosphate, TFTs, coagulation
PE: D-dimer (depending on Well’s score)
Overdose: Toxicology screen
Electrolyte imbalance: Calcium, magnesium, phosphate
Ruptured ectopic: Coagulation, cross-match, ß-HCG levels
Anaphylaxis: Consider serial mast cell tryptase levels
See blood cultures guide
See blood bottles guide
ECG Record a 12-lead ECG if appropriate (e.g. if the patient has chest pain, arrhythmia, a murmur, or suspected electrolyte imbalance). Consider continuous ECG monitoring. See recording an ECG guide See ECG interpretation guide
Bladder scan
Perform a bladder scan in suspected retention or obstruction.
Urine pregnancy test
Perform a urine pregnancy test in any fertile woman presenting with shock/abdominal pain/gynaecological symptoms.
Other cultures/swabs
Plan to collect and send any other appropriate cultures in suspected sepsis (e.g. sputum, urine, swabs from lines).
Fluid output/catheterisation
Commence a fluid balance chart if not already in place.
Plan to catheterise if appropriate.
See catheterisation guide
Intervention
Hypovolaemia: Fluid challenge
Hypovolaemic patients require fluid resuscitation:
Lay patient supine and raise legs if appropriate
Give 500ml bolus Hartmann’s solution/0.9% sodium chloride (warmed if available) over 15 mins
In heart failure: Give 250ml fluid as above; check the chest for crackles after each bolus as there is a risk of fluid overload and pulmonary oedema
Repeat up to 4 times (2000ml/1000ml), monitoring response
Stop and seek help if the patient has a negative response (e.g. increased chest crackles).
Seek senior help if the patient isn’t responding adequately to repeated boluses.
See fluid prescribing guide for more details on resuscitation fluids.
Acute coronary syndrome (ACS)
In suspected ACS, manage with pain relief, nitrites, aspirin and oxygen as per guidelines.
Seek senior input.
See ACS case (coming soon)
Sepsis
Perform sepsis 6 as per guidelines. Seek senior input.
See sepsis guide
Haemorrhage
Restore intravascular volume with blood products and slow bleeding. Seek urgent senior input.
See post-operative bleed case
See upper GI bleed guide
Fluid overload
Manage with diuretics.
Seek senior input.
See pulmonary oedema guide
Atrial fibrillation (AF) Manage atrial fibrillation with rate/rhythm control or cardioversion. Seek senior input. See atrial fibrillation guide Re-assess after any intervention
Disability
Assessment
Consciousness
Repeat AVPU
Assess pupils (size, symmetry, reaction to light):
Pinpoint pupils in opioid overdose
Dilated pupils may indicate TCA overdose or intracerebral pathology
Calculate Glasgow Coma Scale (GCS) if appropriate
Check drugs chart for opioids, sedatives, anxiolytics and antihypertensives
Causes of depressed consciousness
Acute deterioration in consciousness level may be due to a number of causes including:
Hypovolaemia
Hypoxia
Hypercapnia
Metabolic disturbance (hypoglycaemia)
Seizure
Raised intracranial pressure/other neurological insults
Drug overdose
Iatrogenic causes (e.g. administration of opiates for pain relief)
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. A crash team may be needed.
Re-assess and maintain the airway.
Blood glucose (4.0-11.0 mmols/L)
Measure capillary blood glucose to identify hypo/hyperglycaemia
An arterial blood glucose may already be available as part of your ABG results
Is the patient diabetic?
Check for ketones if BM > 15mmols as the patient may be in diabetic ketoacidosis (DKA)
See hypoglycaemia guide
See diabetic ketoacidosis guide
Investigations/Procedures
Capillary blood glucose
Measure capillary blood glucose as above
See measuring blood glucose guide
Urine dip/ketostick
Check urine for ketones in suspected DKA
See urinalysis guide
See diabetic ketoacidosis guide
Imaging
Request a CT head in suspected intracranial pathology after discussion with senior.
See CT head interpretation guide
Intervention
Concerns about consciousness level always warrant senior input. Re-assess and maintain the airway.
Maintain the airway
Maintain the airway as above (Airway- Intervention) in any patient with depressed consciousness.
Opioid toxicity
In opioid overdose, use Naloxone as per local policy. Seek senior advice.
See opioid toxicity guide
Hypoglycaemia
In hypoglycaemia, administer glucose as per guidelines.
Seek senior advice.
See hypoglycaemia guide
Diabetic ketoacidosis (DKA) In DKA, manage with fluids and insulin according to local guidelines. Seek senior advice. See DKA case Re-assess after any intervention
Exposure
It may be necessary to fully expose the patient for a full assessment.
Remember to prioritise patient dignity and conservation of body heat.
Assessment
Ask again: Is the patient in any pain?
This can help to guide your assessment.
Inspection
Check skin for rashes (adverse drug reaction, meningococcal sepsis), other signs of infection, and bruising (coagulation disorders)
Calves: Are they red, tender or swollen? (e.g. DVT)
Lines in: Are there any signs of phlebitis or infection? Replace and remove any concerning lines- consider line tip culture
Catheter output: Is there pus or blood suggestive of infection or injury?
Surgical wounds: Are there signs of bleeding or infection?
There could be concealed internal bleeding into (e.g. peritoneum, pelvis or thoracic cavity)
Drains: What is the output? Worrying signs include pus, blood, or high/low output
If you identify bleeding:
Estimate the total blood loss and the rate of blood loss.
Is the patient in shock? (e.g. hypotension and tachycardia)
In cases of severe haemorrhage or shock, seek immediate expert help. Be aware of the major haemorrhage protocol in your local hospital.
Investigations/Procedures
Other cultures/swabs
Take and send swabs or samples of any potential infection source- don’t forget line tip cultures if appropriate!
Intervention
Haemorrhage
Seek advice from the surgical registrar in any post-operative bleeding.
Severe bleeding should be managed as an emergency.
Manage a post-operative bleed with blood products as appropriate.
See post-operative bleed case
See upper GI bleed case
See blood transfusion guide
Infection
Screen any patient with suspected infection for sepsis.
Manage sepsis as per guidelines using the sepsis 6.
Consult local guidelines and/or microbiology advice to guide appropriate antibiotic treatment of infection.
See sepsis case
Deep vein thrombosis (DVT)
In suspected DVT, calculate a Well’s score and manage appropriately.
Seek senior advice.
Re-assess after any intervention
Re-assessment and seeking help
Re-assess the patient in the same systematic manner as above. Your aim is to improve the clinical outcome of the patient.
React to any changes and evaluate the effectiveness of your interventions.
Deterioration should be recognised quickly and acted upon immediately.
Seek help if the patient shows no signs of improvement or if you have any concerns.
Who can help?
You should have another member of the clinical team aiding you in your ABCDE assessment, such as the patient’s nurse, who can perform observations, take samples to the lab, catheterise if appropriate etc.
You may need further help or advice from a senior staff member.
Do not delay seeking help if you have concerns about your patient.
Use an effective SBARR handover for best practice. See SBAR handover guide.
Who to contact:
In any critical situation: Critical care team/anaesthetist on call/crash team as appropriate
Airway
Always contact the anaesthetist on call in anyone with airway concerns
Breathing
Medical registrar on call
Critical care team to assess for NIV/invasive ventilation
Circulation
Medical registrar on call and others as advised
Sepsis: Medical registrar on call and microbiologist on call
ACS/arrhythmia: Medical registrar on call, then cardiologist on call if advised
Poor urine output: Medical registrar on call, then renal team if advised
Haemorrhage: Surgical registrar on call, haematology, transfusion lab
Ruptured ectopic: Gynaecological registrar on call
Upper/lower GI bleed: Gastroenterologist/endoscopist on call
Patients who have had recent surgery: As above plus surgical registrar on call
Disability:
Anaesthetist on call if the airway is threatened
Medical registrar on call
DKA: Medical registrar on call, then endocrinologist on call if advised
Exposure:
DVT: Medical registrar on call
Concerning rash: Medical registrar on call. Dermatologist on call. Microbiologist on call if advised
Next steps
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to do…
Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or family members as appropriate.
Check out our history taking guides here
Review Patient notes Observation charts Fluid charts Investigation findings Additionally, make sure to check the medications you have just prescribed and what they are normally taking. It might be that their current regime is inappropriate for them Document Document your ABCDE assessment clearly, including examination, observations, investigations, interventions, and patient response/changing condition. Write down any pertinent details from your history taking. See documentation guide
Discuss
If a senior doctor hasn’t already been involved, it is important to contact them and make them aware of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Should they be referred for a review by a speciality doctor?
Should any changes be made to the management of their underlying conditions?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has become acutely unwell.
