Assessment of the Acutely Ill Patient

• Don’t panic!  There are very few emergencies to which you have to run
• Taking the time to do a systematic (ABCDE) assessment is the only way to get anywhere
• If in doubt, a CXR, ECG and ABG are useful in most sick patients
• Don’t assume in confused/drowsy/unresponsive patients that this is their normal status
• Think in terms of physiology and pathophysiology

PRIMARY SURVEY – eyeball the patient – do they look sick?
Airway assessment + C-spine

• If possible trauma – protect the C-spine
• *Can the patient talk normally?  (If so, the airway is patent)
• Stridor/gurgling/snoring (partial airway obstruction)
• Chest wall movement
• Feel for breath
• Look in mouth
• *Oxygen if patient sick

Airway problems:

If evidence of actual or potential airway obstruction – get anaesthetics help early

Don’t wait for O2 saturations to drop – by that stage your patient may be in big trouble

Remember airway adjuncts if inability to maintain an airway due to decreased conscious level

Consider suctioning (call chest physio) if evidence of retained secretions i.e. gurgling noises

Breathing assessment – look/feel/listen

• *Obvious distress?
• Use of accessory muscles?
• Cyanosis?
• *Respiratory rate (This is the single most useful marker of critical illness)
• Tracheal tug/deviation
• Chest wall movement + expansion
• Percussion
• *Air entry/breath sounds
• *Added sounds
• Vocal resonance
• *Oxygen Saturations (aim for >93%, but if <97% in a normally healthy young person, think about why)

Breathing problems:
There are only a few things that commonly cause life-threatening breathing problems:

• Pneumonia
• COPD + Asthma (i.e. bronchospasm)
• Pulmonary oedema
• Pulmonary embolus
• Pneumothorax

These can co-exist.
O2 Saturations of 92% in a young, previously healthy patient are not ok.
Not everyone with tachypnoea has a primary respiratory problem, it can be secondary to a metabolic acidosis or a CNS problem
O2 Sats of 97% might be ok on room air, but if it takes high-flow oxygen to achieve this, something is badly wrong with gas exchange in the lungs
Circulation assessment (Hands-face-chest-abdomen-legs)

• *Cool, clammy/warm and flushed?
• Colour – pale?  Grey? Mottling?
• *Peripheries warm or cool
• Capillary refill time
• *Central pulse – rate, volume, regular (Need SBP>80mmHg for radial pulse)
• JVP
• *BP
• Heart sounds
• ?DVT
• Peripheral oedema – ankles/legs/arms/flanks
• Peripheral pulses
• *IV access

Circulatory problems:
Shock is a failure to adequately perfuse organs, not just hypotension.  Hypotension means advanced shock.
Think of the cardiovascular system as plumbing.  Things that can go wrong:

• Not enough fluid (Hypovolaemia e.g. bleeding, vomiting)
• Pump failure (Cardiogenic shock – MI, fluid overload, arrhythmia, valve disease, cardiomyopathy, myocardial depression due to drugs or acidosis)
• Blocked pipes (Obstruction to flow – PE, cardiac tamponade, high intrathoracic pressures)
• Leaky or poorly functioning pipes (Vasodilatation – septic shock, anaphylaxis)
• Finally, neurogenic shock - rare, due to loss of sympathetic input in C/T- spine injuries, causing vasodilatation and bradycardia.

In most cases, fluid resuscitation is the first-line treatment for shock, but not always.
In cardiogenic shock, fluids will tend to make a bad situation worse, and the management is to treat any immediate cause eg arrhythmia or MI, and/or use inotropes.
Unless there is obvious pulmonary oedema, a fluid challenge is worthwhile (250-500mls of colloid e.g. Voluven or Gelofusin over15-30mins, and assess response – HR, BP, urine output and CVP if available).  Never use hypotonic fluids e.g. 5% dextrose for resuscitation purposes.  If bleeding + hypotensive, use blood, ideally cross-matched.
Disability assessment
Quick neurological screen – time to do a full assessment later:

• AVPU score – Alert/Repsonsive to Voice/Responsive to Pain/Unresponsive
• Pupils – equal & reactive?
• *GCS (E,M,V) esp. posturing
• *Check capillary blood glucose

Disability problems
New focal neurology?  Is it haemorrhage? – this is the most treatable cause.
Generalised deterioration in conscious level- 1 CNS cause, or a response to other pathology?
Confusion/agitation can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment.
Check capillary blood glucose

E-exposure (SECONDARY ASSESSMENT + INVESTIGATIONS)
History (Chest pain/SOB/palpitations/thirst/pain/fatigue/dizziness)
Examine abdomen including for AAA, Neuro or other exam as indicated
Input/output chart – consider urinary catheter and hourly urometry
Medications
CXR / ECG / ABG / Blood tests / Other investigations – as indicated
ABG analysis is not just for diagnosing respiratory failure – it gives information on perfusion and lots of other useful things.
Find out normal state – ask nurses/check notes/call relative
Are they an ICU/HDU candidate? If so, inform them early.
Are you competent to deal with this patient by yourself?