Assessment of the

Seriously Ill Patient

Objectives
Early identification of patients at risk
for life-threatening illness
Recognize early signs of critical
illness
Review the initial assessment of
critically ill patients

Why identify patients

at risk?
Easier management with simpler
interventions
Prevent further deterioration
Provide time for investigation and
treatment

Challenging Patients

Young, fit patients

Immunosuppressed patients
Debilitated patients
Patients with abrupt deterioration
Patients with limited reserve

Risk Assessment

Background health
Severity of acute physiology
Vital signs
Other clinical monitoring
Trends and rate of deterioration
Goals
Recognition that problem exists
Maintain stability

Risk Assessment
Making a diagnosis
Often secondary to treatment of
physiological abnormalities
Investigate while stabilizing
Requires disciplined approach

Assessment
Primary survey
What is main physiological
problem?
First minutes of initial contact
Secondary survey
What is underlying cause?
Subsequent reviews

Assessment of the
Seriously Ill Patient

History
Physical examination
Chart review and documentation
Investigations
Treatment

Patient
54 year old diabetic with shortness
of breath
3 days postoperative for
laparoscopic cholecystectomy
What history would you obtain initially?

Initial Survey
History
Main symptoms
Physiological abnormalities
Co-existing illness
Major surgery
Severe hemorrhage/transfusion
Lack of improvement

Patient
54 year old diabetic with shortness
of breath
3 days postoperative for
laporoscopic cholecystectomy
What additional details would be helpful?

Secondary Survey
History
Past history, chronic diseases
Psychosocial issues
Medications/allergies
Family history
Ethical/legal issues
Systems review

Patient
54 year old diabetic with shortness
of breath
3 days postoperative for
laporoscopic cholecystectomy
What parts of the physical examination
would you concentrate on initially?

Initial Survey
Examination
Airway
Breathing
Circulation
Level of consciousness

Secondary Survey
Examination
Respiratory
Cardiovascular
Abdomen and genitourinary tract
Central nervous system
Musculoskeletal system
Endocrine, hematologic systems

Patient

BP 100/40 P 96 RR 26 T 37.8 C
Pulse oximetry 92% on 2 L cannula
Appears anxious, slightly confused
Bibasilar rales
Decrease bowel sounds, distended
abdomen
Warm extremities
Which findings are most concerning?

Airway/Respiratory
System
Observe mouth and chest
Respiratory rate and pattern
Tachypnea is the single most
important indicator of critical illness
Use of accessory muscles
Level of consciousness
Oxyhemoglobin saturation

Circulation
Peripheral pulses and blood
pressure
Evidence of decreased perfusion
Most common cardiovascular
disturbance in the seriously ill is
hypotension caused by hypovolemia
and/or sepsis

Patient

BP 100/40 P 96 RR 26 T 37.8 C
Pulse oximetry 92% on 2 L cannula
Appears anxious, slightly confused
Bibasilar rales
Decrease bowel sounds, distended
abdomen
Warm extremities
What information from the chart would
be helpful?

Chart Review and

Documentation
Initial survey
Vital signs
Fluid balance
Inspired oxygen concentration
Medications
Invasive parameters

Chart Review and

Documentation
Secondary survey
Review medical records
Document current events
Document diagnosis and treatment
rationale

Patient

BP 100/40 P 96 RR 26 T 37.8 C
Pulse oximetry 92% on 2 L cannula
Appears anxious, slightly confused
Bibasilar rales
Decrease bowel sounds, distended
abdomen
Warm extremities
What investigations should be ordered?

Investigations
Guided by history and physical
examination
Standard biochemistry, hematology,
microbiology, radiographs
Arterial or venous blood gas
Lactate level
Metabolic acidosis is an important
indicator of critical illness

Patient

Previous exam
BP 150/90, HR 70-80,
RR 16, T 37.8
Pulse ox 97%(RA)
Distended abdomen
Warm extremities
WBC 16,000/mm3
BUN/creatinine norm

What now?

Current exam

BP 100/40, HR 96,
RR 26, T 37.8
Pulse ox 92% on 2L
Distended abdomen
Warm extremities
WBC 21,000/mm3
BUN/creatinine
ABG 7.3/30/65

Information

Action

Ensure physiological safety

Oxygen
Intravenous access
Circulatory support

Determine patients reserve

Assess likely diagnosis and
treatments

Information

Action

Refine treatment
Assess response to treatment
Provide organ system support
Determine best site for care

Call for advice and assistance

Key Points

Identify patients at risk early

Recognize signs of critical illness
Stabilize first, then determine
diagnosis
Obtain detailed history
Monitor response to treatment