Editing CCrISP assessment



* Important to simultaneously assess and treat the critically ill patient
* Don't get distracted by obvious, but less important, conditions. ASSESS AND TREAT SYSTEMATICALLY.
* If the patient deteriorates, go back to ABCD and start again


== '''Airway''': Look, listen, feel, TREAT ==

* LOOK: 
** Central cyanosis
** Obstructed patterns of breathing or abdominal breathing
** Accessory muscle use
** Tracheal tug
** Altered level of consciousness
** Any obvious obstruction by FB or vomitus
* LISTEN: 
** Grunting
** Snoring
** Gurgling
** Hoarseness
** Stridor
* FEEL:
** Feel for air flow on inspiration and expiration
* TREAT with 15L/min oxygen, preferably humidified, via a reservoir bag
** Plus airway adjunct manoeuvres
** Plus suction
** Guedel if tolerated, or soft NPA if gag reflex is present
** If that doesn't work, '''call for help''', as definitive airway may required

== '''Breathing:''' Look, listen, feel, TREAT ==

* LOOK:
** Central cyanosis
** Use of accessory muscles
** Sweating
** Raised JVP
** Patency of chest drains
** Presence of any paradoxical abdominal movement
* LISTEN:
** Noisy breathing
** Clearance of secretions by coughing
** Ability of the patient to talk in complete sentences
*** Confusion - hypoxia
*** Decreased GCS - hypercarbia
** Change in percussion note
** Auscultate for breath sounds, heart sounds and rhythm
* FEEL: 
** Equality of chest movement
** Position of trachea
** Presence of surgical emphysema or crepitus
** Paradoxical respiration
** Tactile vocal fremitus
** Abdominal distension may limit diaphragmatic movement
* TREAT:
** Depends on cause
** Assist ventilation with bag/mask
** Sitting up often helps
** Remember to consider life-threatening resp conditions first (PTX, HTX, open PTX, flail, cardiac tamponade)
** Consider bronchial obstruction, bronchoconstriction, PE, cardiac failure, unconsciousness

== '''Circulation:''' ==

* Assume hypovolaemia in circulatory dysfunction until proven otherwise (for surgical patients)
** Large canula (says 16G in CCrISP), with bloods sent incl G+H
** IVF 10-20ml/kg stat (10mL/kg if normotensive, 20mL/kg if hypotensive, but obviously be more tentative in cardiac patients maybe 5mL/kg)
* LOOK: (assess PERFUSION rather than BP)
** Reduced peripheral perfusion: (easiest to see in skin, kidneys and brain)
*** Confusion/reduced LoC
*** Prolonged cap refill time - easiest and best way - press for 5 seconds over nailbed and sternum
*** Pallor
*** Coolness
*** Collapsed or underfilled veins (including JVP)
*** Peripheral cyanosis - low cardiac output
** Obvious external haemorrhage from either wounds or drains
** Evidence of concealed haemorrhage (thoracic or abdominal, into the gut, pelvic/femoral fractures)
* LISTEN:
** Auscultate chest and heart
* FEEL:
** Pulses - both central and peripheral
*** First radial, then carotid/femoral
*** Assess rate, quality, regularity, equality
* TREAT:
** Obviously exsanguinating - need immediate definitive treatment
** Unstable - rapid resuscitation and reassessment over a short period
*** '''<nowiki/>'Transient responder''''
*** '''<nowiki/>'Non-responder''''
**** Different treatment
**** If this is a bleeding patient, call for help, cross-match 6 units and alert theatre, anaesthetist and PSAs
** Stable patients with a minor problem - '''<nowiki/>'responder''''
** Don't 'blindly' fill up patients with blood - if they are not stabilising with reasonable resus, they are not stable, and need definitive management

== D: Pupils then AVPU score ==

* A - alert
* V - responds to verbal stimulus
* P - responds only to pain
* U - unresponsive to any stimulus
* Consider - hypoglycaemic, hypoxia, drugs, etc

== Exposure ==

* Don't let them get cold
* Preserve dignity

== End of immediate management: ==

* Patient should be thoroughly assessed, a firm diagnosis reached, and receiving treatment including oxygen and IV fluids. They should have basic monitoring on.
* Determine frequency of observations and investigations
* Arrange investigations
* Reassess ABCs
* If patient is not improving at this point, you need help

== '''Full patient assessment''' ==

* Chart assessment
** Respiratory
*** RR
**** Most sensitive marker of the unwell patient, often the first thing to change
**** Low: opiate/sedative overdose, CNS depression (can be due to low cardiac output)
**** High: early sign of many kinds of shock; respiratory disease; cardiac failure; compensation for metabolic acidosis/hypoxia
*** FiO2
*** SaO2
** Circulation
*** HR, rhythm
**** Beware those on beta-blockers or mechanical pacing
**** Tachycardia: autonomic - pain, anxiety, pyrexia
**** Rhythm change in shock is generally a sign of physiological derangement, sepsis or MI
*** BP
**** Often late signs when present
**** Perfusion is more important than BP - consider the patient's usual BP, as relative hypotension can cause problems
*** CVP
**** Collapsed JVP with patient flat is always abnormal
**** Consider formal central monitoring if very difficult fluid management
**** High: temporary following a rapid fluid bolus; fluid overload; RV failure (MI or PE); cardiac failure; chronic respiratory disease; caused by pericardial effusion with tamponade
*** UO
**** Look for trends
**** Remember it gives a delayed picture of perfusion
**** Sudden complete anuria - blocked catheter
*** Fluid balance
**** Tally input vs output for past 24 hours
**** Look at overall FB
*** IV lines
*** Cardiac output measurements
** Surgical
*** Special requirements of this operation
*** Temperature
*** Drainages (nature and volume)
** Medication chart
* History
** Patient
** Junior staff
** Nurses
* Examination
** See above
* Review results
** Check blood tests - FBE, UEC as a minimum
** Order necessary additional tests
** CXR - very helpful to differentiate respiratory conditions from cardiovascular
** ECG

== '''Decide and plan''' ==

* Stable - daily plan (see above)
* Unstable - further investigation or definitive treatment will be needed

== '''Document''' ==

== Assessment of stable patient in ICU ==

* R - respiratory
* C - circulatory
* S - surgical (special requirements of this operation, temp, drainages)

Clinical examination

Review pathology and radiology

Decide whether STABLE or UNSTABLE
[[Category:Critical care]]