Identifying the sick patient

Identifying the sick patient

Jun 28, 2017 0
critical care,emergency,General medicine,intensive care,onthepods

James talks to Dr Oliver Flower about identifying a sick patient and how to examine the critically ill patient.

Summary Writer:  Sam Orton

Editor:  Nhi Nguyen

Interviewee: Oliver Flower

About Dr Oliver Flower

Oliver Flower is a staff specialist in Intensive Care Medicine at Royal North Shore Hospital, Sydney.

He is a believer in the power of the big crit care community and a believer in Cadogan’s FOAMed ethos. Oli runs the educational and networking crit care website Intensive Care Network.

Identifying the Sick Patient

 With Dr Oliver Flower, Staff Specialist Intensivist, Royal North Shore Hospital, New South Wales, Australia

 

Indications for admission to Intensive Care

In general, when a patient needs organ support or when their needs cannot be provided for on the ward.

 

  • There are many ways of “being sick” and defining critical illness
    • Abnormal vital signs – Many hospitals have rapid response teams that are alerted when certain/multiple vital signs are abnormal
      • It is important to remember that a patient can be sick with normal vital signs
      • If a patient’s vital signs are becoming deranged, it is acute to review and assess them and consider escalation of care
      • Respiratory rate is a powerful indicator
      • Oxygen saturations
      • Pulse rate and rhythm
      • Blood glucose levels
  • Remember: A patient may be unwell with normal vital signs. Things to look out for:
    • Compensation
      • E.g. Respiratory compensation for metabolic acidosis, tachycardia as compensation for hypotension
    • Age and medications
      • May lead to a blunted response to illness, e.g. beta blockers blunt thetachycardic response to sepsis
  • Gestalt
    • The gut feeling of someone being unwell/deteriorating. As a clinician becomes more experienced it is possible to hone this and base your impression and intuition on a greater amount of previous experiences
  • Family Input
    • More hospitals are instituting the role of family in escalation of care
    • It is important to remember that the family has a longitudinal impression of the patient and a better understanding of their relative’s “baseline”
  • Sepsis
    • Many patients can compensate effectively for a period of time but then deteriorate quickly when their mechanisms to compensate are overwhelmed/insufficient
  • Heart Failure
    • Limited reserve in the setting of illness. These patients can develop acute pulmonary oedema and cardiovascular collapse very quickly
  • Immunosuppressed patients
    • Often look very well for an extended period but due to a poor immunological response to stress can deteriorate rapidly
  • Cool peripheries
    • Concern regarding a shock state and inadequate cardiac output (even in the presence of normal vitals)
    • This is best examined by feeling the peripheries for warmth
  • Rashes
    • Often missed but may point towards an infectious cause of deterioration that may be life-threatening such as meningococcal sepsis
  • Changes in conscious state
    • Particularly in the elderly
    • E.g. The hyponatraemic patient may appear otherwise well except for a slightly altered mental state
  • Increased work of breathing and respiratory effort
    • Tachypnoea is a sensitive marker of an unwell patient
  • Blood tests
    • A blood gas (either arterial or venous) can be a helpful adjunct for increased information about the acid-base status of the patient as well as some electrolytes and BGL
    • Lactate –Available from arterial and venous blood gases
      • Important marker of “badness”
      • Can be elevated for a variety of reasons
      • Elevation in the context of sepsis is an indicator or worsening clinical condition and need for increasing observation and resuscitation
      • Although not necessarily secondary to anaerobic metabolism, in sepsis is a marker of beta-adrenergic stimulation and increased glycolysis and pyruvate metabolism and indication of an increasingly unwell state
      • >4mmol/L is associated with poor outcomes. However, any level >2mmol/L is abnormal and warrants attention. Monitoring the trend is also useful to help identify a deteriorating patient
    • Blood glucose level
    • EUC panel gives a bicarbonate level which can give a marker of acidosis
    • Blood cultures are pertinent if sepsis is a possibility. Particularly important prior to initiation of empirical antibiotic therapy
  • Relates back to the early warning systems (such as the between the flags) that are instituted for nurse and doctor led escalation of care. These indicate deranged physiology as a marker of the
    • Tachy/bradycardia
    • Hyper/hypotension
    • Hypoxia
    • Temperature
    • Altered mental state
    • (Don’t forget your gestalt!)
  • Often a critically unwell patient will have multiple, complex derangements in their physiology. It is important to view all the investigations and signs and symptoms in conjunction with the history in putting the story together
    • Trends are very important, often more important than isolated readings
    • Always thinking about the underlying aetiology
  • If you are worried about a patient – There is no shame in asking for help. Asking a colleague to come and review the patient and discuss them may provide clarity and understanding on the important management priorities
  • If you are acutely worried about someone – Call an arrest or initiate a rapid response. This is what the rapid response team is there for

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Tags: #bradycardia,#Cool peripheries,#gestalt,#heart failure,#hypotension,#Hypoxia,#ICU,#intensive care unit,#rashes,#sepsis,#tachycardia

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