Acute care: Recognising critical illness

In the first part of our series about acute medicine, Nicola Cooper describes how to recognise a critically ill patient

"In the beginning of the malady it is easy to cure but difficult to detect, but in the course of time, not having been either detected or treated it becomes easy to detect but difficult to cure."

Niccolo Machiavelli, The Prince

Doctors are trained to take a history, do a thorough examination, and make a diagnosis. Unsurprisingly, when faced with a critically ill patient, our focus is on making a diagnosis to do something about it. Most of us learn how to deal with emergencies from the recipes we carry in our pocket handbooks. Few of us are trained to deal with the generic altered physiology that accompanies acute illness. Lots of studies show that the result is suboptimal care.

Some arrests can be avoided

Surprisingly, most cardiac arrests in hospital are predictable. One study found that 84% of patients had documented observations of clinical deterioration or new complaints within eight hours of arrest.¹ In another study, two thirds of patients had documented physiological deterioration within 6 hours of arrest, which was not acted on.² The predominantly respiratory and metabolic derangements which precede cardiac arrest--hypoxaemia, hypo- tension, and acidosis--are not rapidly fatal. But earlier intervention would be better when the abnormalities were potentially reversible, rather than at the time of cardiac arrest, which has poor prognosis.²

Other studies have considered emergency admissions to intensive care. In one study of 100 patients, most had received suboptimal care beforehand on the ward.³ Of these, 70% were admitted late and nearly half were avoidable. Suboptimal care in the vital hours before admission to an intensive care unit has been found to increase mortality by around 50%⁴. These important findings show that the system fails to recognise and effectively intervene when patients in hospital deteriorate.

On your first day as a doctor, you may be part of the cardiac arrest team. But how many of us have been trained to understand that seriously abnormal vital signs are an emergency? Resuscitation is much more than cardiopulmonary resuscitation; it is about recognising seriously abnormal vital signs and doing something about them. Training, organisation, and resources have been neglected in this area of medicine.

Early warning scores

A common mistake is assuming that a patient who is sitting up in bed and talking cannot be critically ill. Patients with signs of severe asthma or severe sepsis are easily missed this way. The clue is nearly always in the vital signs. Respiratory rate is one of the most useful vital signs--how often do you measure it? If the respiratory rate is above 20 breaths/min ask yourself why. If the rate is greater than 30 breaths/min then the patient may have a life threatening condition.

Early warning scores are now commonly used in UK hospitals. All patients have their vital signs measured by nursing staff and these are converted into a score. Normal vital signs give a score of zero. The more abnormal the vital signs, the higher the score; above a certain threshold, a doctor should assess the patient quickly. These scores are common sense, but they have improved outcomes because they force inexperienced staff to call for help (table).⁵

Good care is simple

The difference between suboptimal and good care is simple: give the right oxygen and the right fluid and call early for the right help. Practical courses which teach the ABCDE system are becoming more common. In the United Kingdom, this system is often taught during an attachment with an emergency medicine department. This system is easy to use in a panic, and even experienced doctors need to use it in an emergency to ensure nothing is missed.

Communication

A new doctor once asked a senior doctor how to treat a patient who had taken too much ß blocker. The senior was half listening, writing in some notes. Another senior was nearby and asked, "What do you mean. What are the pulse and blood pressure?" The new doctor replied, "Pulse 30, blood pressure unrecordable." Both seniors dashed to the patient's bedside. Communicating well is essential if you want other people to act, especially when discussing emergencies.It is important to bear in mind:

• Where you are and your request
• A brief history
• Current physiology

SPL/MAURO FERMARIELLO

Critical care encompasses more than just cardiopulmonary ressusciation

Example

Can you come to the emergency department now? I have a 29 year old with severe asthma. Drowsy, respiratory rate 40, oxygen saturation 86% on 15 l oxygen via a reservoir bag, pulse 130, blood pressure 100/60, silent chest.

The best call I ever received in the middle of the night as a medical registrar was from my senior house officer who said, "Periarrest ward 8," and put the phone down.

*If a patient scores 3 or more, a nurse should make observations more often. If a patient scores 5 or more (trigger scores vary between institutions), a doctor should be called to assess the patient urgently. If the patient does not improve, a senior doctor must assess the patient and make decisions about intensive care and cardiopulmonary resuscitation. If a patient scores 7 or more, a senior doctor should be called immediately.

Signs of critical illness

Physiological

• Signs of sympathetic activation--tachycardia, hypertension, pallor, clamminess, and shut down
• Signs of systemic inflammation--fever or hypothermia, tachycardia, and increased respiratory rate
• Signs of organ hypoperfusion--cold peripheries, hypoxaemia, confusion, hypotension, and oliguria

Biochemical

• Metabolic acidosis
• High or low white cell count
• Low platelet count
• Raised urea and creatinine concentrations
• Raised C reactive protein concentration

The ABCDE system for assessing patients

Do not progress from one stage to the next until you have dealt with the first. Ask for help as soon as you find yourself dealing with a critically ill patient.

A is for airway--Assess the airway by asking the patient a question. If he or she speaks then the airway is clear. Otherwise look, listen, and feel for signs of obstruction. Use the head tilt and chin lift manoeuvre and consider suction and the use of airway adjuncts. Give high concentration oxygen.

B is for breathing--Look at the chest and calculate respiratory rate. Look at the depth and symmetry of chest movements, and measure oxygen saturations. Quickly listen for equal air entry, wheeze, or crackles, and treat accordingly. You may need to help feeble respirations with a bag and mask.

C is for circulation--Feel for cold clammy extremities and measure the pulse and blood pressure. Check capillary refill time. If the blood pressure is low then give a fluid challenge (250-500 ml colloid over 10 minutes). This may need to be repeated.

D is for disability--Use the AVPU scale--is the patient Alert, responding to Voice, responding to Pain, or Unresponsive? Check pupils for equal size and reactivity to light, and measure a bedside glucose.

E is for examination--Examine the abdomen, heart sounds, and any other system in more detail. Examine the story, any witnesses, and the notes and charts.

Summary

If one area of medicine is evidence based, it is that patients with serious abnormal physiology are an emergency. Managing such patients requires proactivity, a sense of urgency, and the continuous presence of the attending doctor. For most things in your medical career, you will have time to look things up, but the one thing you really need to know is what to do in an emergency.

1. Schein RM, Hazday N, Pena N, Ruben BH. Clinical antecedents to in-hospital cardio-pulmonary arrest. Chest 1990;98:1388-92.
2. Franklin C, Matthew J. Developing strategies to prevent in-hospital cardiac arrest: analysing the response of physicians and nurses in the hours before the event. Crit Care Med 1994;22:244-7.
3. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853-8.
4. McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to intensive care of patients on general wards: are some potentially avoidable? J R Coll Physicians 1999;33:255-9.
5. Goldhill D. Medical emergency teams. Care Crit Ill 2000;16:209-12.