Critically Ill Patient

A patient is defined “critically ill” when he develops one or more organ failures that need a rapid correction to prevent clinical deterioration that could escalate until cardiopulmonary arrest.
A large amount of cardiac arrests is almost always preceded by a worsening of the clinical condition of the patient, often unrecognized or underestimated. Preventing cardiac arrest is very imporatant since only 20% of in-hospital patients with cardiac arrest will survive.
The goal of this session is to learn to recognize clinical and instrumental alterations that precede cardiac arrest.
It’s relatively easy to recognize a critically ill patient, even by unskilled personnel. It’s important, however, to recognize alterations that precede this phase.
When you have gained some experience, it will be easier to recognize early warning signs that a critically ill patient launches: increased heart and respiratory rate, level of consciousness and so on. For a better orientation it’s a good practice to utilize medical score, like Early Warning Score (EWS).
Score 3 2 1 0 1 2 3
HR (bpm) ≤ 40 41 – 50 51- 90 91 – 110 111 – 130 ≥ 131
RR (rpm) ≤ 8 9 – 11 12 – 20 21 – 24 ≥ 25
Temp (°C) ≤ 35,0 35,1 – 36,0 36,1 – 38,0 38,1 – 39,0 ≥ 39,1
SBP (mmHg) ≤ 90 91 – 100 101 – 110 111-249 ≥ 250
SaO2 (%) ≤ 91 92 – 93 94 – 95 ≥ 96
FiO2 Air (21%) O2 (>21%)
AVPU Alert-A Voice-V
Pain-P
Unresponsive-U

Legend: HR: heart rate, RR: respiratory rate, SBP: Sistolic Blood Pressure, SaO2: oxygen saturation, FiO2: percentage of oxygen breathed; AVPU: simplified scale of assessment of the state of consciousness (A-Awake: patient awake, V-Voice: the patient wakes up if called, P-Pain: the patient responds only to pain, U-Unresponsive: the patient does not respond to any stimulus).

It’s unlikely to be able to use this scale in emergency situation because there’re too many informations and it is not immediately applicable. In the era of smartphones it will not be difficult to find applications that can speed up the process of calculation. Alternatively it will be sufficient to register “acceptable” values, ie those who earn 0 points and values more dangerous, that is, those who earn 3 points. A patient with blood pressure below 90 mm Hg, with an oxygen saturation <91%, with a respiratory rate of less than 8 / min or greater than 25 / min, with a heart rate less than 40 / min or greater than 131 / min , will need a close follow up, even if apparently “asymptomatic”.
For precision lovers, however, it is possible knowing “what to do” according to the final score (see table below).
EWS
New control
What to do ?
I’m a nurse I’m a physician
3-5 every 4 hours Inform nurse in charge
6 every 4 hours Call the doctor Visit patient within 1 hour
7-8 every hour Call the doctor, consider continous monitoring (SBP,HR, SaO2) Visit patient within 1 hour and discuss clinical case with expert/competent colleague
≥ 9 every 30 minutes Call the MET and start continous monitoring (SBP,HR, SaO2). Stay with the patient See patient within 15 min and contact intensive care team
Well, my patient is a critical patient. And now?
Recognizing that your patient is critical is  the first step to try to get him out of trouble.
A good approach is given by Advance Life Support (ALS).
The ALS method for the evaluation of critically ill patients provides a sequential approach to explore vital functions in order of importance in relation to the possibility of progression to cardiopulmonary arrest.
The approach provides a sequence that must be respected using the following formula: seek, recognize and treat. It’s clear that you can step forward only when you have solved the problem in the step you’re in. If there are more physicians/paramedics you can divide the tasks to speed things up.
The first thing to do when you manage a critically ill patient, is to ensure your safety. Always wear  gloves and all protections that may be necessary (safety glasses, disposable gowns, facial mask).
Start introducing yourself and asking the patient, “how are you?” for an initial assessment of the state of consciousness. If the patient is unresponsive  go to the cardiopulmonary resuscitation (CPR).
The ABCDE approach is the same for all critically ill patients: Airways, Breathing, Circulation, Disability, Exposure.

A- Airways

It’s the first aspect that should be considered in a critically ill patient because the presence of airway obstruction, if not quickly resolved, will lead to cardiopulmonary arrest. The initial approach begins with presentations: “Good morning I’m Dr / nurse … how are you?”.
If the patient is able to speak normally without breath sounds the airway are patent.
Clinical signs of airway obstruction are characterized by a fluctuating or paradoxical breathing (dyssinchrony between ribcage and abdomen, causing a “seesaw” type motion – see video), by the use of accessory muscles of respiration and respiratory sounds.
NB: the presence of paradoxical breathing indicates almost complete obstruction of the airway and requires immediate treatment (emergency) while the presence of breath sounds indicates partial obstruction and needs urgent treatment.
Noises of snoring generally are due to a fall of the soft palate on the tongue (typical of the unconscious patient / sedated / intoxicated). The presence of inspiratory noise (triage, Cornage) argues for an obstruction of the upper airway (larynx). The presence of noise of “bubbling” reflect, however, the presence of fluid material in the airways.
If you detect the clinical signs of airway obstruction (A problem) you have to correct it before proceeding to the next step (try, recognize and treat) otherwise you may encounter clinical worsening of the patient (it’s not useful giving extra oxygen if it can’t reach the lungs!).
Most “A problems” are due to a lowering of the level of consciousness that causes a fall of the soft palate on the tongue. To overcome this drawback, the first operation to do is hyperextend the head (in patient without cervical spine trauma). The head tilt is performed by placing a hand on the patient’s forehead and two fingers under his chin, lifting it upwards. This procedure is temporary (you can not stay in this position for a long time!). If the level of consciousness is sufficiently depressed you should put an oropharyngeal airway (Guedel) or a nasopharyngeal cannula (the latter better tolerated in the case of altered levels of consciousness less pronounced). If case of retching the Guedel must be removed to avoid inalation.
A GCS score (Glasgow Coma Scale) less than 8 indicates that the patient’s airway patency is at high risk (of occlusion) and oropharyngeal intubation must be considered.
Another cause of airway obstruction can be given by the presence of material (liquid or solid) inside the mouth. The aspiration of a foreign body is not, fortunately, an event so frequent and often the patient communicates, verbally or with gestures, the ingestion. You can hear tirage and/or cornage inspiratory (partial obstruction). The inhalation of foreign body is an emergency especially when the object is localized in the first airway (larynx, trachea) and requires an immediate evaluation by an expert. The otolaryngologist will be contacted for the upper airways, the pulmonologist for lower airways. The presence of an anesthetist is however strongly recommended given the possibility of evolution to the ACR in this type of patient. If the foreign body is viewable without direct fibroscope you can try to remove it with a Magill forceps, avoiding to push foreign body deeper into the airways. The impaction of a foreign body in a peripheral bronchus, even if it requires removal, is not an emergency in the absence of clinical signs of alarm.
The presence of secretions fluid or semisolid (vomiting, mucopurulent secretions) presents clinically with gurgling noises, with parodoxical breathing in severe cases, and must be settled by bronchoscopy.
Once resolved the airway obstruction, before moving to the next step (Breathing), you must place additional oxygen (generally Reservoir in the early stages of evaluation) with the goal of maintaining a pulsossimetry of 94-98% (88- 92% in patient with COPD). Using the reservoir, it is necessary to ensure a high flow of oxygen (12-15 l / min) with the aim of maintaining the balloon swollen. In this way you have a FiO2 about 85%.

GCS

B- Breathing

Once A is finished, you can switch to evaluation of B (breath). It’s important to reiterate that at this point our critically ill patients should have already received high flow oxygen with reservoir (in patients at risk of hypercapnia – eg. COPD known – utilize venturi-mask oxygen in order to maintain pulseoximetry up to 88-92%).
(to be continued…)

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