- Recognition of a Critical IllnessFarokh Udwadia, Chitra Mehta
- ICU Scoring SystemsRajesh Chandra Mishra, Kanwalpreet Sodhi, Ruchira Khasne
- Resuscitation of Cardiac Arrest, Postresuscitation Care and Therapeutic HypothermiaMayuki Aibiki
- Airway ManagementSheila Nainan Myatra, Swapna Chitra Vijayakumaran, Nishanth Baliga
- Hemodynamic MonitoringDaniel De Backer
- Respiratory MonitoringChitra Mehta, Yatin Mehta
- NeuromonitoringNidhi Gupta, HH Dash
- Imaging in Intensive Care UnitDivya Pal, Deepak Govil
- Neuroimaging in Critical CareGaurav Kakkar
- Analgesia, Sedation, Delirium, and Muscle Relaxation in Critically Ill PatientsLavpreet Kaur, E Wesley Ely, Pratik Pandharipande
- Acid–Base Balance and DisordersRahul Pandit
- Noninvasive VentilationSubhal Bhalchandra Dixit, Khalid Ismail Khatib
- Principles of Mechanical VentilationSunil Karanth
- Newer Modes of Mechanical VentilationSrinivas Samavedam, Mithilesh Raut
- Liberation from Mechanical VentilationAmol Kothekar, Nirmalyo Lodh, Jigeeshu Vasishtha Divatia
- Shock and Multiorgan Dysfunction SyndromeRavi Jain, Yash Javeri, Rohit Yadav
- Extracorporeal Membrane OxygenationPoonam Malhotra Kapoor
- Extracorporeal Therapies in ICUChitra Mehta, Yatin Mehta
- Nutrition in Critically Ill PatientsPravin Amin
- Glycemic ControlTarannum Bano, Beena Bansal, Ambrish Mithal
- Pressure Sore Prevention and ManagementJP Sharma, Manal M Khan, Saurabh Saigal, DK Singh
- Critical Care Issues in Elderly and Obese PatientsGaurav Kochhar, Yatin Mehta
- Transport of Critically Ill Patients
INTRODUCTION
A critical illness can be defined as a life-threatening illness where death is likely or imminent. Death may be imminent, e.g., in severe upper airways obstruction, or from severe prolonged hypoxia due to any other cause, or from irreversible cardiogenic shock following acute myocardial infarction. It may not be imminent, yet possible, or even probable, in a patient with acute liver cell failure, acute kidney injury or severe trauma to the head with multiple contusions in the brain. These are merely examples (among several) where the criticality of an illness is obvious and the recognition is easy.
However, there are a number of instances where symptoms, physical examination, and the results of basic investigations are such that the nature of a dangerous problem may go undetected. To give just two examples—(1) a very recent mild sub-sternal discomfort which the patient tends to ignore may well be due to an evolving acute myocardial infarction undetected by either electrocardiography or by estimation of cardiac enzymes at that point of time. (2) Similarly, sudden onset paresthesia in a limb without any positive neurological findings may herald the evolution of a massive cerebral infarct due to a block in the middle cerebral or internal carotid artery. These are just two examples where suspicion could lead to early recognition, which in turn could prompt correct treatment making more often than not a difference between life and death.
Many critical illnesses have a varying gestation period before they become life-threatening. Good medicine lies in suspecting and diagnosing these illnesses well in time. The earlier the recognition the better the prognosis. A major tenet of critical care medicine is to anticipate disaster, and not await it.
Finally, it must be remembered that though most critical illnesses offer time for a careful clinical appraisal, there are some life-threatening illnesses which carry an acute sense of urgency with regard to assessment, diagnosis, and management. In these acute life-threatening problems, assessment, diagnosis, and management often go hand in hand, more or less simultaneously. This is in striking contrast to routine admissions to the medical wards, where definite treatment is offered only after a thorough history, clinical examination and investigations have provided an exact diagnosis.
The initial assessment is necessarily a good clinical bedside evaluation—history and physical examination. In these days of burgeoning science, interns, residents, fellows and even recently qualified consultants in critical care are more concerned with the intricacies of the technological advances in critical care. Their interest is equally overfocused on protocols and guidelines for the management of various problems in critical care medicine. This has led to a progressive loss of bedside skills. The use of gleaming machines, sophisticated gadgetry, advanced imaging techniques, and numerous laboratory tests often performed in blunderbuss fashion have increased exponentially in recent decades, and critical care physicians often substitute these for a careful bedside evaluation. The physician often at the very outset seeks an answer to a problem from the imaging department or from other tests and when armed with the answer (which may well be wrong) sees little purpose in liaising with the patient or evaluating the patient clinically. The intensivist in these circumstances no longer ministers to a distinctive person, but to separate malfunctioning organs. The distressed patient, the human being is frequently forgotten or relegated to the background. Assessment of the patient on daily rounds is more often focused on results of investigations, “numbers” churned out by machines, imaging findings, with a total neglect of bedside evaluation. This is not to belittle the importance of science and technology. After all, it is science and technology which have given a quantum leap to medicine and all its branches into the 21st century. But there is more to medicine than technology. Technology neither substitute for a good history nor for a meticulous physical examination.
HISTORY AND PHYSICAL EXAMINATION
If the exigency of a crisis allows no time for a proper history or a history is unavailable from the patient (as when the patient is obtunded) or from the relatives, the intensivist stands at a great disadvantage. If, however, there is sufficient time for a good history or even a targeted history and if the intensivist can separate the chaff from the grain and get to the heart of the problem, he or she starts with a great advantage. He may even make a shrewd guess as to the diagnosis or at least knows in what direction to proceed.4
Physical examination, time permitting should be thorough and meticulous. If time does not permit, it should start with a quick appraisal of vital signs so as to allow identification of a probable life-threatening illness which demands urgent attention. The signs (when considered together) suggesting severe illness are—heart rate > 120 beats/min or <40 beats/min, respiratory rate > 25 breaths/min or <8 breaths/min, systolic blood pressure < 90 mm Hg, temperature > 102–103°F or <96°F, oxygen saturation < 90% on room air, capillary refill > 3 seconds, urine output < 0.5 mL/kg/hour for > 4 hours, disturbance in higher functions and mental obtundation.
The greater the number of variables that show the abnormalities stated above and the greater the degree of abnormalities of these variables, the greater the likelihood of a severe and often life-threatening illness.
In a critically ill patient with immediate danger to life, the physician should adopt the ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) approach as advocated in the advanced cardiac life support (ACLS), advance trauma life support (ATLS) guidelines. Problems are thereby prioritized according to the derangement which is deemed to be most severe. Severe derangement should be dealt with at each stage before going on to the next step. For example, an obstructed airway should be recognized and opened before assessing breathing and circulation.
In an emergency, the next step is to clinically evaluate basic features of organ dysfunction or failure. The organ systems one needs to consider are the cardiorespiratory system, the kidneys, central nervous system, the gastrointestinal system (which includes the liver) and the hematopoietic system. It is important not to miss out on metabolic abnormalities. Perturbations in a critical illness are most frequently observed in the cardiorespiratory and renal system. Organs in a critical illness often fail sequentially over time and multiple organ failure is frequently the determinant of death. It is important for the intensivist to detect early features of organ dysfunction. Failure of one organ system can adversely affect the function of another organ system. This is because organ systems are not compartmentalized, organs speak to one another. Early recognition of malfunctioning of one organ system and its appropriate management may well alter for the better the natural history of a critical illness.
If an illness is not immediately life-threatening there is always time for a meticulously performed physical examination. Physical examination is both an art and a science. The art lies in detecting physical signs and the science lies in interpreting these. It is often forgotten that careful physical examination can reveal signs which a machine cannot detect or signs which allow a more targeted investigation rather than a plethora of unnecessary tests. Here are a few examples—an experienced eye can often gauge the gravity of a patient's illness from the look and appearance. Examination may reveal an unequal pupil, a flattened nasolabial fold, a markedly depressed bridge of the nose (as in Wegener's), a butterfly rash on the face as in systemic lupus erythematosus, tight skin over the forehead suggesting scleroderma, telangiectasia over the lips in a patient with severe hemoptysis (possible hereditary hemorrhagic telangiectasia). It may reveal a nodule in the thyroid or a discrete palpable cervical node giving a clue to the diagnosis. Gynecomastia, spider nevi, flapping tremors, a soft aortic diastolic murmur, a pleural rub, pericardial rub, an obstructed femoral or inguinal hernia, absent tendon jerks, each in their own way contribute to a diagnosis or allow targeted investigations.
In this machine age, it is so important for the intensivist to cultivate his visual faculty, the ability to hear, feel and smell, to process what he has sensed within his brain to recall past experiences and relate these to the present problem so as to enable him or her to make a considered diagnosis and decide on the management of an illness. He can only do so if he is practiced in the art and science of physical examination. To quote Osler “learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become perfect.”
History, a close communication with the patient on daily morning rounds and the ritual of a physical examination at the first encounter and also on subsequent rounds serve two purposes:
- As stated earlier, they may well provide a diagnosis or suggest how to proceed further in investigations.
- They build a bond between the physician and a critically ill patient, a bond of trust and faith, a bond that in my opinion has a role in healing. It is difficult to give a scientific explanation for this observation. Perhaps faith and trust in the treating physician induce psychological events that causes changes in the neurotransmitters or in the chemistry and circuitry of the patient's brain,3,4 thereby helping in healing and recovery.
It is possible that after an initial assessment and a quick examination of various systems the exact etiology of a critical illness remains undetermined. Even so, there are certain issues which are often present in critical illnesses caused by differing etiologies. The intensivist must run through these issues meticulously, search for them and if present correct them. He or she should also bear in mind acute conditions which if promptly diagnosed and treated could markedly improve outcome. These include:
- Hypoxia as judged by an O2 saturation < 90% on room air. The lower the oxygen saturation the greater the danger and the more imperative is the need to relieve the hypoxia. Even if the cause of severe hypoxia is not immediately evident, oxygen is administered at a high flow rate or better still through a mask and a nonrebreathing reservoir bag. The exception is in hypoxia due to an acute exacerbation of chronic obstructive pulmonary disease (COPD) where controlled oxygen through a ventimask should be administered. It is crucial to recognize and counter hypoxia. Persistent hypoxia leads to increasing organ dysfunction and is an important factor in the pathogenesis of multiple organ failure.
- Acute cardiorespiratory failure and acute cardiorespiratory distress may be due to several causes, but it is vital to recognize tension pneumothorax and cardiac tamponade. Both require urgent intervention, else death results.
- Shock, of course, would be recognized during the initial appraisal of the patient. A targeted history and a quick but careful examination of various systems, in particular the cardiorespiratory system should determine whether shock is hypovolemic, septic, cardiac or anaphylactic, as appropriate treatment for each of these is urgently indicated. Fulminant tropical infections should always be considered in a patient presenting with septic shock.
- It should always be kept in mind that acute metabolic and endocrine problems may present with mental obtundation, disturbed consciousness and even coma, as also with hypotensive shock. Hypoglycemia, diabetic ketoacidosis or hyperosmolar nonketotic diabetic states are generally evident. Acute adrenocortical insufficiency, severe myxedema or an underlying hyperthyroid state presenting with atrial fibrillation, a fast ventricular rate, and heart failure can be missed. Critical illnesses caused by marked hyponatremia, hypernatremia, hypercalcemia, hypocalcemia, hypo- or hypermagnesemia can only be identified with precision by appropriate blood tests.
- Hyperkalemia should always be considered in patients presenting with cardiovascular collapse and a disturbance in rhythm or impulse conduction. It is indeed a surreptitious killer that needs prompt recognition and treatment.
- Among the several causes of obtundation and coma, metabolic acidosis, and respiratory acidosis may not be evident clinically, and may be only evident on an estimation of arterial pH and blood gases.There are a few pit-falls one needs to point out with regard to the recognition of critical illnesses.
- A patient in distress who complains of pain at a particular site should not be dismissed lightly if clinical examination and basic tests reveal no abnormalities. Recent onset pain, particularly if severe should not be ignored.
- Similarly, recent onset dyspnea on exertion or at rest even in a young individual should never be ignored though physical examination, ECG, X-ray chest, and other basic tests are normal. To dub dyspnea as functional because the physician cannot find the cause can be disastrous. Pulmonary embolism is one condition which may show no signs and no positive findings on routine tests.
- Nondescript symptoms and few or no signs may well hide a smouldering problem which can suddenly manifest as a life-threatening illness. To diagnose this correctly before this life-threatening eventually erupts is a credit to the physician and can be lifesaving for the patient.
- In an obscure problem, the possibility of “poisoning” should be kept in mind.
- A critically ill patient may have multiple problems, each life-threatening or potentially life-threatening but in different degrees. The intensivist should learn to prioritize these problems so that the most life-threatening one is addressed first, even if this involves temporarily ignoring the others. What the physician does in correcting one problem should not as far as possible worsen the others. An intensivist solely focused on protocols and guidelines will be at sea in the above situation. Recognition, prioritization, and the ability to handle a complex problem depends not only on knowledge, skill, logic, and experience, but also on clinical judgment, the hallmark of a good physician. In my opinion, good clinical judgment is an inborn faculty. It cannot be equated with intelligence; it can be augmented by experience but not necessarily so. An intensivist, who in addition to his perceptive faculties also has good clinical judgment, is truly blessed by the gods. He has an attribute which no science can invent and no machine can duplicate.
- As a corollary to the above, clinical judgment when dealing with an individual patient should not be sacrificed at the altar of protocols and guidelines.
- There is unquestionably a sense of urgency in the diagnosis and treatment of a critical illness. Immediate action is for example needed to treat cardiorespiratory arrest, a tension pneumothorax, a severe bleed, cardiovascular collapse, a life-threatening disturbance in the cardiac rate or rhythm, or status epilepticus. Most critical illnesses however allow sufficient time for careful thinking and appraisal of the problem before making decisions as to the diagnosis and management. Haste in jumping to conclusions can be dangerous. A good physician invariably takes time to think; he or she does not let an emergency ruffle his equanimity or push him into hasty decision-making.
“There will be time,……‥
Time for all the works and days of
Hands that lift and drop a question on your plate.”
MONITORING THE ILLNESS AND INVESTIGATIONS
Monitoring is started simultaneously with the initial clinical appraisal. The ECG tracing, heart rate, rhythm, O2 saturation, temperature, respiratory rate, arterial blood pressure, central venous pressure, the O2 saturation of blood in the superior vena cava (ScvO2) are all monitored. In special instances the cardiac output, oxygen delivery, oxygen consumption may also need to be monitored.
Investigations should include all basic routine tests, blood cultures and culture of other body secretions if necessary, and a full blood biochemistry, as also base line values of functions of all organ systems. An arterial blood lactate value is important. Arterial pH and blood gases should always be done. When necessary a screen for common poisons should be asked for. Tests should be repeated as and when necessary. Imaging studies are often crucial in establishing the nature of a critical illness.
The final recognition of the nature of a critical illness and the degree of its criticality require both a bedside clinical evaluation as described earlier and an assessment of results of relevant investigations. There are times when the nature of a critical illness cannot be established by bedside clinical evaluation. This is particularly observed when no history is available, or when a patient is obtunded without any localizing signs, or without any other clue as to the cause of the obtunded state. In such a situation, investigations and appropriate imaging tests may give the answer to the problem.
Optimal critical care is the merging of good bedside skills with a judicious use of technology.
CRITICAL CARE WITHOUT WALLS2
It is not often realized that a patient admitted to a ward for a medical problem can worsen and become critically ill. The recognition of this deterioration may come late or not at all and may well be responsible for increased morbidity and mortality. Intensive care unit (ICU) will never have the capacity for all patients who could benefit from being provided with at least 6some degree of critical care. The concept of “critical care without walls” is that the critical care needs of patients should be provided irrespective of their geographical location within the hospital.
Catastrophic deterioration of a patient in ward is most of the times preceded by changes in physiological parameters. Picking up these early warning signs makes it possible to render timely critical care management to such patients. Scores based on these early warning signs can go a long way in timely recognition of critical illness triggering a shift to ICU and in estimating illness severity.
For this concept to achieve a modicum of success the following steps are necessary:
- Basic critical care skills with special reference to cardiopulmonary resuscitation and management of the airway should be taught to all doctors and head nurses. Training in ACLS should be compulsory.
- A “physiological monitoring system”2,5,6 should be introduced so as to measure important physiological variables—heart rate, blood pressure, respiratory rate, temperature, urine output, and level of consciousness. Deviation of each of these variables from normal is scored in numbers (1, 2, 3) depending on the degree of abnormalities observed in each variable. Action (intervention) may be triggered by a single abnormality or an aggregate score. The physiological scoring system (PSS) was developed following the recognition that critically ill patients, particularly patients who suffered a cardiac arrest, were noted to have deteriorated over a number of hours before the acute crisis occurred. The PSS helps to track patients who deteriorate and thereby triggers an appropriate response from the doctor, nurses, and health workers in charge of the patient.
Similar to above, “NEWS” (National early warning score) is being used by NHS in UK.7 Recent sepsis guidelines have recommended use of qSOFA (quickSOFA) score in the wards to recognize sepsis early. qSOFA has three components each allocated a score of 1. The three components are: (1) respiratory rate ≥ 22, (2) systolic blood pressure ≤ 100 mm Hg, and (3) altered mental status. A qSOFA ≥ 2 is considered to indicate organ dysfunction.8
A medical emergency team also called “a critical care outreach team” should be constituted to provide critical care needs to patients in any location within the hospital who are critically ill. This to an extent can redress the comparative lack of skill, manpower or equipment provided in the hospital wards.
The system we follow at Breach Candy Hospital is to keep an emergency trolley (fully equipped with equipment and emergency drugs) together with a defibrillator in every ward in the hospital. A need for help or a sudden emergency triggers an alarm bell to which a medical emergency team headed by a senior registrar of the ICU together with a senior nurse promptly responds. At various other hospitals concept of “Code Orange” is used, wherein on detection of early warning signals in ward patient, critical care personnel attends to him within 15 minutes of raising the code.
POST-INTENSIVE CARE UNIT CARE
The continuum of care post-ICU discharge is equally important, if not more. Patients are still in a vulnerable recovering phase where any lapse can push them back into a critical state again. Every ICU unit should have a discharge criteria based on the vital signs and mental status of the patient. There should not be any break in communication during hand over of the patient to ward staff. “Out of hours” discharge to ward should be avoided as these have been found to be associated with in-hospital death and ICU readmissions. It is essential to keep monitoring the patient to pick up early deterioration.9
KEY POINTS
- The catastrophic deterioration of a critically ill patient is usually not unprecedented. It is usually preceded by a series of physiological signs.
- Early-warning scoring systems have been developed to identify patients at risk of developing severe adverse events, especially in wards.
- There is no shortcut to a proper history taking and physical examination, for timely identification of danger signs and anticipating clinical deterioration.
REFERENCES
- Mitchell E. Recognition of critical illness. In: Smith FG, Yeung J (Eds). Core Topics in Critical Care Medicine. New York: Cambridge University Press; 2010.
- Ridley S. The recognition and early management of critical illness. Ann R Coll Surg Engl. 2005;87(5):315–22.
- Verghese A, Horwitz RI. In praise of the physical examination. [Editorial]. BMJ. 2009;339:b5448.
- Finniss DG, Kaptchuk TJ, Miller F, Benedetti F. Biological, clinical, and ethical advances of placebo effects. Lancet. 2010;375:686–95.
- Morgan RJM, William F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care. 1997;8:100.
- Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a modified early warning score to aid earlier detection of patients developing critical illness on a general surgical ward. Br J Anesath. 2000;84:663.
- Tirkkonen J, Karlsson S, Skrifvars MB. National early warning score (NEWS) and the new alternative SpO2 scale during rapid response team reviews: a prospective observational study. Scand J Trauma Resus Emerg Med. 2019;27:111.
- Marik PE, Taeb AM. SIRS, qSOFA and new sepsis definition. J Thorac Dis. 2017;9(4):943–5.
- Vincent JL. The continuum of critical care. Crit Care. 2019;23:122.