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
  - 'Transient responder'
  - '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 - '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