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1、Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Assessment of the Seriously Ill Patient,Objectives,Early identification of patients at risk for life-threatening illness,Recognize early signs of critical illness,Review the initial
2、assessment of critically ill patients,Why identify patients at risk?,Easier management with simpler interventions,Prevent further deterioration,Provide time for investigation and treatment,Challenging Patients,Young,fit patients,Immunosuppressed patients,Debilitated patients,Patients with abrupt det
3、erioration,Patients with limited reserve,Risk Assessment,Background health,Severity of acute physiology,Vital signs,Other clinical monitoring,Trends and rate of deterioration,Goals,Recognition that problem exists,Maintain stability,Risk Assessment,Making a diagnosis,Often secondary to treatment of p
4、hysiological abnormalities,Investigate while stabilizing,Requires disciplined approach,Assessment,Primary survey,What is main physiological problem?,First minutes of initial contact,Secondary survey,What is underlying cause?,Subsequent reviews,Assessment of the Seriously Ill Patient,History,Physical
5、 examination,Chart review and documentation,Investigations,Treatment,Patient,54 year old diabetic with shortness of breath,3 days postoperative for laparoscopic cholecystectomy,What history would you obtain initially?,Initial Survey,History,Main symptoms,Physiological abnormalities,Co-existing illne
6、ss,Major surgery,Severe hemorrhage/transfusion,Lack of improvement,Patient,54 year old diabetic with shortness of breath,3 days postoperative for laporoscopic cholecystectomy,What additional details would be helpful?,Secondary Survey,History,Past history,chronic diseases,Psychosocial issues,Medicati
7、ons/allergies,Family history,Ethical/legal issues,Systems review,Patient,54 year old diabetic with shortness of breath,3 days postoperative for laporoscopic cholecystectomy,What parts of the physical examination,would you concentrate on initially?,Initial Survey,Examination,Airway,Breathing,Circulat
8、ion,Level of consciousness,Secondary Survey,Examination,Respiratory,Cardiovascular,Abdomen and genitourinary tract,Central nervous system,Musculoskeletal system,Endocrine,hematologic systems,Patient,BP 100/40 P 96 RR 26 T 37.8 C,Pulse oximetry 92%on 2 L cannula,Appears anxious,slightly confused,Biba
9、silar rales,Decrease bowel sounds,distended abdomen,Warm extremities,Which findings are most concerning?,Airway/Respiratory System,Observe mouth and chest,Respiratory rate and pattern,Tachypnea is the single most important indicator of critical illness,Use of accessory muscles,Level of consciousness
10、,Oxyhemoglobin saturation,Circulation,Peripheral pulses and blood pressure,Evidence of decreased perfusion,Most common cardiovascular disturbance in the seriously ill is hypotension caused by hypovolemia and/or sepsis,Patient,BP 100/40 P 96 RR 26 T 37.8 C,Pulse oximetry 92%on 2 L cannula,Appears anx
11、ious,slightly confused,Bibasilar rales,Decrease bowel sounds,distended abdomen,Warm extremities,What information from the chart would,be helpful?,Chart Review and Documentation,Initial survey,Vital signs,Fluid balance,Inspired oxygen concentration,Medications,Invasive parameters,Chart Review and Doc
12、umentation,Secondary survey,Review medical records,Document current events,Document diagnosis and treatment rationale,Patient,BP 100/40 P 96 RR 26 T 37.8 C,Pulse oximetry 92%on 2 L cannula,Appears anxious,slightly confused,Bibasilar rales,Decrease bowel sounds,distended abdomen,Warm extremities,What
13、 investigations should be ordered?,Investigations,Guided by history and physical examination,Standard biochemistry,hematology,microbiology,radiographs,Arterial or venous blood gas,Lactate level,Metabolic acidosis is an important,indicator of critical illness,Patient,BP 150/90,HR 70-80,RR 16,T 37.8,P
14、ulse ox 97%(RA),Distended abdomen,Warm extremities,WBC 16,000/,mm,3,BUN/creatinine norm,BP 100/40,HR 96,RR 26,T 37.8,Pulse ox 92%on 2L,Distended abdomen,Warm extremities,WBC 21,000/,mm,3,BUN/creatinine,ABG 7.3/30/65,Previous exam Current exam,What now?,Information Action,Ensure physiological safety,
15、Oxygen,Intravenous access,Circulatory support,Determine patients reserve,Assess likely diagnosis and treatments,Information Action,Refine treatment,Assess response to treatment,Provide organ system support,Determine best site for care,Call for advice and assistance,Key Points,Identify patients at risk early,Recognize signs of critical illness,Stabilize first,then determine diagnosis,Obtain detailed history,Monitor response to treatment,
美国重症医学（FCCM）的基础教程-患者评估（英文）
