A 53-year-old female patient with history of coronary artery bypass grafting 6 years ago underwent bilateral knee replacement 7 days back. She was shifted to the ICU from the ward with fever, respiratory distress, and altered sensorium. Her heart rate was 134 beats/min with frequent ventricular ectopic beats, blood pressure 98/50 mmHg, respiratory rate 30/min, temperature 38.1°C in axilla, and SpO2 88% on 60% oxygen by a Venturi mask.

Outcome in the ICU is predominantly determined by initial management of patients. Early identification of the patient at risk of life-threatening illness is essential to manage them appropriately and prevent further deterioration. “Time is tissue” in critically ill patients, and a prompt and protocolized resuscitation regimen will help in salvaging these patients.

Step 1: Assign responsibilities

•Quickly make a team and assign job responsibilities to every member clearly and appropriately.

•In the initial phase, the patient should be seen by a senior member of the ICU team for initial resuscitation, investigation, management planning, and family briefing.

•Assign two residents for initial resuscitation.

•Assign two nurses initially for unstable patients.

•Take early assistance whenever needed from other members of the team.

J. Sharma, M.D.

Critical Care, Medanta – The Medicity Hospital, Gurgaon, India

Y. Mehta, M.D., F.R.C.A. (*)

Medanta Institute of Critical Care & Anaesthesia, Medanta – The Medicity Hospital, Gurgaon, India

e-mail: yatinmehta@hotmail.com

Step 2: Start initial assessment and resuscitation

•Initial aim is to determine immediate life-threatening problems. Time is usually short and not enough to be certain about the cause of the problem, and correcting physiological abnormalities should take precedence over arriving at an accurate diagnosis. However, a working diagnosis is essential for deciding treatment options once physiological stability is achieved.

•For the patient in cardiorespiratory arrest, follow ACLS protocol (see Chap. 19).

•History taking, physical examination, sending investigations, and resuscitation need to be carried out simultaneously rather than sequentially as time is limited.

•For hemodynamically unstable patients, resuscitation should be systematic and aimed toward assessment and management of A (airway), B (breathing), and C (circulation).

•All three components can be managed simultaneously; sequential approach is not necessary.

Airway (A)

Assess the airway. Need for definitive airway by endotracheal intubation or airway adjunct (oral/nasal airway), supralaryngeal devices, or surgical cricothyrotomy in a patient is mainly based on clinical assessment and should not be delayed.

•Ask for assistance whenever in doubt about a difficult airway.

–Look, listen, and feel for features of airway obstruction and secure airway and intubate when necessary (for details, see Chap. 1).

–Snoring—due to obstruction of upper airway by tongue and oropharyngeal soft tissue—insert oro-/nasopharyngeal airway.

–Gurgling—due to obstruction of upper airway by liquid—perform suctioning.

–Stridor—due to obstruction by foreign body or stenosis of upper airway, usually inspiratory—remove foreign body or intubate.

–Wheeze—due to spasm in small airways—give bronchodilators.

–Complete airway obstruction is silent—intubate.

Breathing (B)

•Assess the need for oxygen and ventilation. It can be assessed clinically along with pulse oximetry and arterial blood gas analysis:

–Look for clinical signs of respiratory distress:

•Breathlessness

•Tachypnea

•Inability to talk

•Open-mouth breathing

•Flaring of ala nasi

•Use of accessory muscles of respiration

•Paradoxical breathing (inward movement of abdomen during inspiration)

–Look for clinical features suggestive of inadequate oxygenation or ventilation:

•Restlessness

•Delirium

•Drowsiness

•Cool extremities

•Cyanosis

•Tachycardia

•Arrhythmia

•Hypotension

•Flapping tremor (asterixis)

•Remember that these clinical presentations are a very late feature of respiratory failure and imply impending cardiorespiratory arrest. Patients need to be identified much earlier, and appropriate management should be instituted.

•Look for features of tension pneumothorax and evidence of massive pleural effusion or hemothorax and drain immediately.

•Any evidence of massive lung collapse with desaturation requires intubation, suctioning, and positive-pressure ventilation.

•Some clinical conditions, for example, deep unconsciousness (GCS <8), severe hemodynamic instability, or severe respiratory distress, require immediate endotracheal intubation and mechanical ventilation (see Chap. 4).

•Noninvasive ventilation can be tried in relatively stable patients if they are suffering from a condition where noninvasive ventilation has been shown to be effective (see Chap. 3).

•Normal oxygen saturation does not exclude compromised airway and need for intubation and ventilation.

Circulation (C)

•Assess adequacy of circulation. Assessment and management should go side by side.

–Examine the following:

•Peripheral and central pulse for rate, regularity, volume, and symmetry

•Skin temperature

•Heart rate and rhythm

•Blood pressure (supine and sitting for orthostatic hypotension)

•Capillary refill

•Jugular venous pressure

•Urine output

•Bedside echocardiography (see Chap. 17).

•Consider invasive monitoring (see Chap. 16).

•Central venous catheter insertion

•Arterial catheter insertion

•Advanced hemodynamic monitoring

•Judiciously use volume, inotropes, and vasopressor support (see Chap. 18).

•Early volume challenge is appropriate in most hypotensive patients.

•Identify cardiogenic shock and rapidly triage to appropriate facility.

•Look for pericardial tamponade causing hemodynamic instability requiring immediate pericardiocentesis.

•Any suspicion of pulmonary embolism should lead to urgent anticoagulation if not contraindicated, and then arrange for appropriate investigation.

•Patients presenting with features suggestive of aortic dissection should have urgent control of hypertension and heart rate and should be urgently investigated to confirm diagnosis.

•In patients with features of severe sepsis and septic shock, prompt broad-spec- trum antibiotics and early goal-directed resuscitation should be started (see Chap. 50).

•Consciousness—frequent neurological examination needs to be performed in drowsy patients (see Chap. 30):

–Lateralizing features like hemiplegia are usually a feature of neurological disease.

–A depressed conscious level in the absence of a primary neurological cause is indicative of severe systemic disease.

–Check for hypoglycemia and correct urgently.

–Control ongoing seizures with appropriate measures.

–Consider urgent antibiotics for patients with features suggestive of bacterial meningitis.

Step 3: Take focused history

•Obtain history from relatives and medical and nursing staff in the unstable patient.

•Review patients’ clinical chart and perioperative note.

•Presenting problem in chronological order with duration and temporal profile of illness needs to be documented.

•Take history of mechanism of injury in trauma patients.

•Ask for significant comorbidities such as cardiac, pulmonary, renal diseases, previous surgery, or any other significant past medical problem.

•Enquire about previous hospitalization or use of NIV at home.

•Enquire about functional state at home—bedbound, ambulatory with support or independent.

•Enquire regarding exercise tolerance.

•In the elderly, enquire about mental state and cognition.

•Take detailed medication history with doses and duration. Enquire about any recent change of medication, drug allergies, over-the-counter medications, alternative medication, and self-administration of medications.

•Ask for any routine use of sedatives or psychiatric medication.

•Enquire about addictions such as alcohol and tobacco.

•A problem list of active and inactive problems needs to be documented in the clinical notes.

•Ascertain patients’ resuscitation status as per family’s wish.

Step 6: Recognize the patient at risk

•Take special precautions in the following group of patients:

–The elderly and immunocompromised may not show features of decompensation such as fever and tachycardia.

–Polytrauma patients, due to multiple injuries and effect of distracting pain, are difficult to assess.

–In young adults, decompensation is late due to physiological reserve.

Step 7: Assess response to initial resuscitation

•Assess changes in vital signs with initial resuscitation—pulse rate, rhythm, blood pressure, oxygen saturation, urine output, and mental state.

•Continuous assessment is mandatory, and one needs to be vigilant and present at the bedside.

Step 8: Assess intensity of support

•Inspired oxygen fraction needed to maintain saturation above 90%

•Intensity of ventilatory support—positive end-expiratory pressure, minute ventilation

•Dose of vasopressor and inotrope needed to maintain mean arterial pressure above 60 mmHg

•Need for volume support to keep adequate urine output

•Need for blood transfusion to keep hemoglobin above 8 g/dL

•Need for sedation in agitated patients

•Need for dialysis support

•Worsening biochemistry

Step 9: Seek help for specific problems that might require expertise

•Cardiologist—complete heart block, acute coronary syndrome, cardiogenic shock, intra-aortic balloon pump insertion, pericardial tamponade, massive pulmonary embolism

•Nephrologist—dialysis

•Neurologist—acute stroke or undiagnosed depressed conscious level

•Neurosurgeon—intracranial hemorrhage, head injury, severe cerebral edema

•Trauma surgeon—polytrauma, abdominal trauma, thoracic trauma, compartment syndrome

•Obstetrician—ruptured ectopic pregnancy, postpartum hemorrhage

Step 10: Construct a working diagnosis and plan for further management

•After initial resuscitation, assessment, investigation, and response, a differential diagnosis should be arrived at.

•Reassess the patient frequently to modify initial plan if needed.

Step 11: Brief relatives

•After initial resuscitation, assessment, investigation, and response, the family should be briefed about the likely diagnosis, treatment plan, and approximate