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AssessmentoftheSeriouslyIllPatientAssessmentoftheSeriouslyIl1ObjectivesEarlyidentificationofpatientsatriskforlife-threateningillnessRecognizeearlysignsofcriticalillnessReviewtheinitialassessmentofcriticallyillpatientsObjectivesEarlyidentification2Whyidentifypatientsatrisk?EasiermanagementwithsimplerinterventionsPreventfurtherdeteriorationProvidetimeforinvestigationandtreatmentWhyidentifypatientsat3ChallengingPatientsYoung,fitpatientsImmunosuppressedpatientsDebilitatedpatientsPatientswithabruptdeteriorationPatientswithlimitedreserveChallengingPatientsYoung,fit4RiskAssessmentBackgroundhealthSeverityofacutephysiologyVitalsignsOtherclinicalmonitoringTrendsandrateofdeteriorationGoalsRecognitionthatproblemexistsMaintainstabilityRiskAssessmentBackgroundheal5RiskAssessmentMakingadiagnosisOftensecondarytotreatmentofphysiologicalabnormalitiesInvestigatewhilestabilizingRequiresdisciplinedapproachRiskAssessmentMakingadiagno6AssessmentPrimarysurveyWhatismainphysiologicalproblem?FirstminutesofinitialcontactSecondarysurveyWhatisunderlyingcause?SubsequentreviewsAssessmentPrimarysurvey7AssessmentoftheSeriouslyIllPatientHistoryPhysicalexaminationChartreviewanddocumentationInvestigationsTreatmentAssessmentoftheSeriouslyIl8Patient54yearolddiabeticwithshortnessofbreath3dayspostoperativeforlaparoscopiccholecystectomyWhathistorywouldyouobtaininitially?Patient54yearolddiabeticwi9InitialSurveyHistoryMainsymptomsPhysiologicalabnormalitiesCo-existingillnessMajorsurgerySeverehemorrhage/transfusionLackofimprovementInitialSurveyHistory10Patient54yearolddiabeticwithshortnessofbreath3dayspostoperativeforlaporoscopiccholecystectomyWhatadditionaldetailswouldbehelpful?Patient54yearolddiabeticwi11SecondarySurveyHistoryPasthistory,chronicdiseasesPsychosocialissuesMedications/allergiesFamilyhistoryEthical/legalissuesSystemsreviewSecondarySurveyHistory12Patient54yearolddiabeticwithshortnessofbreath3dayspostoperativeforlaporoscopiccholecystectomyWhatpartsofthephysicalexaminationwouldyouconcentrateoninitially?Patient54yearolddiabeticwi13InitialSurveyExaminationAirwayBreathingCirculationLevelofconsciousnessInitialSurveyExamination14SecondarySurveyExaminationRespiratoryCardiovascularAbdomenandgenitourinarytractCentralnervoussystemMusculoskeletalsystemEndocrine,hematologicsystemsSecondarySurveyExamination15PatientBP100/40P96RR26T37.8ºCPulseoximetry92%on2LcannulaAppearsanxious,slightlyconfusedBibasilarralesDecreasebowelsounds,distendedabdomenWarmextremitiesWhichfindingsaremostconcerning?PatientBP100/40P96RR16Airway/RespiratorySystemObservemouthandchestRespiratoryrateandpatternTachypneaisthesinglemostimportantindicatorofcriticalillnessUseofaccessorymusclesLevelofconsciousnessOxyhemoglobinsaturationAirway/RespiratorySystemObser17CirculationPeripheralpulsesandbloodpressureEvidenceofdecreasedperfusionMostcommoncardiovasculardisturbanceintheseriouslyillishypotensioncausedbyhypovolemiaand/orsepsisCirculationPeripheralpulsesa18PatientBP100/40P96RR26T37.8ºCPulseoximetry92%on2LcannulaAppearsanxious,slightlyconfusedBibasilarralesDecreasebowelsounds,distendedabdomenWarmextremitiesWhatinformationfromthechartwouldbehelpful?PatientBP100/40P96RR19ChartReviewandDocumentationInitialsurveyVitalsignsFluidbalanceInspiredoxygenconcentrationMedicationsInvasiveparametersChartReviewandDocumentation20ChartReviewandDocumentationSecondarysurveyReviewmedicalrecordsDocumentcurrenteventsDocumentdiagnosisandtreatmentrationaleChartReviewandDocumentation21PatientBP100/40P96RR26T37.8ºCPulseoximetry92%on2LcannulaAppearsanxious,slightlyconfusedBibasilarralesDecreasebowelsounds,distendedabdomenWarmextremitiesWhatinvestigationsshouldbeordered?PatientBP100/40P96RR22InvestigationsGuidedbyhistoryandphysicalexaminationStandardbiochemistry,hematology,microbiology,radiographsArterialorvenousbloodgasLactatelevelMetabolicacidosisisanimportantindicatorofcriticalillnessInvestigationsGuidedbyhistor23PatientBP150/90,HR70-80,RR16,T37.8Pulseox97%(RA)DistendedabdomenWarmextremitiesWBC16,000/mm3BUN/creatininenormBP100/40,HR96,RR26,T37.8Pulseox92%on2LDistendedabdomenWarmextremitiesWBC21,000/mm3BUN/creatinineABG7.3/30/65PreviousexamCurrentexamWhatnow?PatientBP150/90,HR70-80,RR24InformationActionEnsurephysiologicalsafetyOxygenIntravenousaccessCirculatorysupportDeterminepatient’sreserveAssesslikelydiagnosisandtreatmentsInformationActionEns25InformationActionRefinetreatmentAssessresponsetotreatmentProvideorgansystemsupportDeterminebestsiteforcareCallforadviceandassistanceInformationActionRefin26KeyPointsIdentifypatientsatriskearlyRecognizesignsofcriticalillnessStabilizefirst,thendeterminediagnosisObtaindetailedhistoryMonitorresponsetotreatmentKeyPointsIden27AssessmentoftheSeriouslyIllPatientAssessmentoftheSeriouslyIl28ObjectivesEarlyidentificationofpatientsatriskforlife-threateningillnessRecognizeearlysignsofcriticalillnessReviewtheinitialassessmentofcriticallyillpatientsObjectivesEarlyidentification29Whyidentifypatientsatrisk?EasiermanagementwithsimplerinterventionsPreventfurtherdeteriorationProvidetimeforinvestigationandtreatmentWhyidentifypatientsat30ChallengingPatientsYoung,fitpatientsImmunosuppressedpatientsDebilitatedpatientsPatientswithabruptdeteriorationPatientswithlimitedreserveChallengingPatientsYoung,fit31RiskAssessmentBackgroundhealthSeverityofacutephysiologyVitalsignsOtherclinicalmonitoringTrendsandrateofdeteriorationGoalsRecognitionthatproblemexistsMaintainstabilityRiskAssessmentBackgroundheal32RiskAssessmentMakingadiagnosisOftensecondarytotreatmentofphysiologicalabnormalitiesInvestigatewhilestabilizingRequiresdisciplinedapproachRiskAssessmentMakingadiagno33AssessmentPrimarysurveyWhatismainphysiologicalproblem?FirstminutesofinitialcontactSecondarysurveyWhatisunderlyingcause?SubsequentreviewsAssessmentPrimarysurvey34AssessmentoftheSeriouslyIllPatientHistoryPhysicalexaminationChartreviewanddocumentationInvestigationsTreatmentAssessmentoftheSeriouslyIl35Patient54yearolddiabeticwithshortnessofbreath3dayspostoperativeforlaparoscopiccholecystectomyWhathistorywouldyouobtaininitially?Patient54yearolddiabeticwi36InitialSurveyHistoryMainsymptomsPhysiologicalabnormalitiesCo-existingillnessMajorsurgerySeverehemorrhage/transfusionLackofimprovementInitialSurveyHistory37Patient54yearolddiabeticwithshortnessofbreath3dayspostoperativeforlaporoscopiccholecystectomyWhatadditionaldetailswouldbehelpful?Patient54yearolddiabeticwi38SecondarySurveyHistoryPasthistory,chronicdiseasesPsychosocialissuesMedications/allergiesFamilyhistoryEthical/legalissuesSystemsreviewSecondarySurveyHistory39Patient54yearolddiabeticwithshortnessofbreath3dayspostoperativeforlaporoscopiccholecystectomyWhatpartsofthephysicalexaminationwouldyouconcentrateoninitially?Patient54yearolddiabeticwi40InitialSurveyExaminationAirwayBreathingCirculationLevelofconsciousnessInitialSurveyExamination41SecondarySurveyExaminationRespiratoryCardiovascularAbdomenandgenitourinarytractCentralnervoussystemMusculoskeletalsystemEndocrine,hematologicsystemsSecondarySurveyExamination42PatientBP100/40P96RR26T37.8ºCPulseoximetry92%on2LcannulaAppearsanxious,slightlyconfusedBibasilarralesDecreasebowelsounds,distendedabdomenWarmextremitiesWhichfindingsaremostconcerning?PatientBP100/40P96RR43Airway/RespiratorySystemObservemouthandchestRespiratoryrateandpatternTachypneaisthesinglemostimportantindicatorofcriticalillnessUseofaccessorymusclesLevelofconsciousnessOxyhemoglobinsaturationAirway/RespiratorySystemObser44CirculationPeripheralpulsesandbloodpressureEvidenceofdecreasedperfusionMostcommoncardiovasculardisturbanceintheseriouslyillishypotensioncausedbyhypovolemiaand/orsepsisCirculationPeripheralpulsesa45PatientBP100/40P96RR26T37.8ºCPulseoximetry92%on2LcannulaAppearsanxious,slightlyconfusedBibasilarralesDecreasebowelsounds,distendedabdomenWarmextremitiesWhatinformationfromthechartwouldbehelpful?PatientBP100/40P96RR46ChartReviewandDocumentationInitialsurveyVitalsignsFluidbalanceInspiredoxygenconcentrationMedicationsInvasiveparametersChartReviewandDocumentation47ChartReviewandDocumentationSecondarysurveyReviewmedicalrecordsDocumentcurrenteventsDocumentdiagnosisandtreatmentrationaleChartReviewandDocumentation48PatientBP100/40P96RR26T37.8ºCPulseoximetry92%on2LcannulaAppearsanxious,slightlyconfusedBibasilarralesDecreasebowelsounds,distendedabdomenWarmextremitiesWhatinvestigationsshouldbeordered?PatientBP100/40P96RR49InvestigationsGuidedbyhistoryandphysicalexaminationStandardbiochemistry,hematology,microbiology,radiographsArterialorvenous

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