General Approach to the Critically Ill Patient

Published on 07/03/2015 by admin

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Last modified 07/03/2015

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Chapter 1 General Approach to the Critically Ill Patient

Manuel Pardo, Jr. , MD, Michael A. Gropper, MD, PhD

This book deals with many different aspects of critical care. Each disorder has specific diagnostic and management issues. However, when initially evaluating a patient, one must have a conceptual framework for the patterns of organ system dysfunction that are common to many types of critical illness. Furthermore, in the patient with multiple organ failure, resuscitation or stabilization is often more important than establishing an immediate, specific diagnosis.

1 Which organ systems are most commonly dysfunctional in critically ill patients?

The respiratory system, the cardiovascular system, the internal or metabolic environment, the central nervous system (CNS), and the gastrointestinal tract.

2 What system should be evaluated first?

The first few minutes of evaluation should address life-threatening physiologic abnormalities, usually involving the airway, the respiratory system, and the cardiovascular system. The evaluation should then expand to include all organ systems.

3 Which should be performed first—diagnostic maneuvers or therapeutic maneuvers?

The management of a critically ill patient differs from the typical sequence of history and physical examination followed by diagnostic tests and therapeutic plans. The pace of assessment and therapy is quicker, and simultaneous evaluation and treatment are necessary to prevent further physiologic deterioration. For example, if a patient has a tension pneumothorax, the immediate placement of a chest tube may be lifesaving. Extra time should not be taken to transport the patient to a monitored setting. If there are no obvious life-threatening abnormalities, it may be appropriate to transfer the patient to the intensive care unit (ICU) for further evaluation. Many patients are admitted to the ICU solely for continuous electrocardiogram monitoring and more frequent nursing care.

4 How do you evaluate the respiratory system?

The most important function of the lungs is to facilitate oxygenation and ventilation. Physical examination may reveal evidence of airway obstruction or respiratory failure. These signs include cyanosis, tachypnea, apnea, accessory muscle use, gasping respirations, and paradoxic respirations. Auscultation may reveal rales, rhonchi, wheezing, or asymmetric breath sounds.

5 Define paradoxic respirations and accessory muscle use. What is their significance?

Normal breathing involves simultaneous rise and fall of the abdomen and chest wall.

A patient with paradoxic respirations has asynchrony of abdominal and chest wall movement. With inspiration, the chest wall rises as the abdomen falls. The opposite occurs with exhalation.

Accessory muscle use refers to the contraction of the sternocleidomastoid and scalene muscles with inspiration. These patients have increased work of breathing, which is the amount of energy the body consumes for the work of the respiratory muscles. Most patients use accessory muscles before they have development of paradoxic respirations. Without support from a mechanical ventilator, patients with paradoxic respirations or increased work of breathing will eventually have respiratory muscle fatigue, hypoxemia, and hypoventilation.

6 What supplemental tests are useful in evaluating the respiratory system?

Although all tests should be individualized to the particular clinical situation, arterial blood gas (ABG) analysis, pulse oximetry, and chest radiography rapidly provide useful information at a relatively low cost-benefit ratio.

7 What therapy should be considered immediately in a patient with obvious respiratory failure?

Mechanical ventilation may be an immediate life-sustaining therapy in a patient with obvious or impending respiratory failure. Mechanical ventilation can be carried out invasively or noninvasively. Invasive ventilation is carried out via endotracheal intubation or tracheotomy. Noninvasive ventilation is instituted with a nasal mask or a full face mask. Even if the patient does not have obvious respiratory distress, supplemental oxygen should be administered until the oxygen saturation is measured. The risk of development of oxygen-induced hypercarbia is rare in any patient, including those with an acute exacerbation of chronic obstructive pulmonary disease.

8 How do you evaluate the cardiovascular system?

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