Structured (Checklist) Approach to Critically Ill and Injured Patient

Dr Ognjen Gajic Mayo Clinic Rochester MN USA Rochester MN, USA Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.)

@

[email protected]

Disclosure

• Research support from NIH, CMS, Philips Research North America and Mayo Clinic • IP rights for critical care related software tools -

The related research has been reviewed by the Mayo Clinic Conflict of Interest Review Board and is being conducted in compliance with Mayo Clinic Conflict of Interest policies. Mayo Clinic and Dr Gajic have a financial conflict of interest related to software applications licensed to Ambient Clinical Analytics Inc.

• No other financial relationships with commercial companies and no other relevant disclosures

Objectives • • •

•

Discuss the importance of “golden hour” in critical illness Outline structured pathophysiologic approach to critical illness Introduce CERTAIN method (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) Practical explanation on interactive critical care case

Critical care support for potentially reversible acute illness

Incomplete knowledge

Delayed, errorprone care delivery

One of the most cost-effective healthcare interventions

Golden Hour

“The most sophisticated intensive care becomes unnecessarily expensive terminal care…” Peter Safar

Safar P. Critical care medicine – Quo Vadis? Crit Care Med 1974; 2:1–5

Critical Importance of Timing

Crit Care Med 2007 Vol. 35, No. 11

Challenges during golden hour

Runciman et al. Qual Saf Health Care 2005

Approach to acutely ill unstable patient

Basic Clinical Examination ESICM PACT module 2005

Peter Safar: A Pioneer of a Structured ABCs

1964

Safar P. Community-wide cardiopulmonary resuscitation. J Iowa Med Soc 1964; 54:629–635

ATLS – Primary Survey A

Airway with Cervical Spine Protection

B

Breathing and Ventilation

C

Circulation with Hemorrhage Control

D

Disability (Neurologic Evaluation)

E

Exposure / Environmental control

Mind the gap

• Focus on specific condition/specialty/setting • CPR (too late) • Heart attack/stroke • Trauma • ~90% of acute critical illness not covered by a structured approach • Focus on training and remembering • Expensive

CERTAIN: Checklist for Early Recognition and Treatment of Acute Illness and Injury

EVALUATION

ROUNDS

Stabilization Module

Optimization Module

Admission

Rounding

Resuscitation http://www.icertain.org/

- Unconscious AND - Apneic or gasping

Primary Survey

Address immediate life threats (ABCDE): Airway, Work of Breathing, Poor Circulation (shock, arrhythmia), Disability (neurodeficit, seizure), Exposure (bleeding, acute abdomen, rash)

Interventions

Secondary survey

CPR

- Emergency interventions in parallel with evaluation (Oxygen, fluid, vasopressor, antiarrhytmic, ventilator, cardioversion, pacing) -Targeted intervention as syndrome is defined (antibiotics) -Refine based on response to therapy and information -Assure timely completion

Focused history : - Patient /family Point of care diagnostics - Ultrasound, ECG, laboratory Syndrome recognition - Generate problem list - Review CERTAIN recommended interventions for specific scenario - Review differential diagnosis

When Stabilized System-based assessment and plan Kilickaya O, Bonneton B, Gajic O. Yearbook of Intensive Care and Emergency Medicine 2014

CERTAIN Dashboard

Assessment

Decision support

Keeping track of interventions

Checklist with timer for critical procedures

Mobile Phone Version

(Back up) Paper Version

Participant ICUs

CERTAIN METHOD: Initial EVALUATION

• Organize your team – Role assignment – Assure effective communication • Close loop communication • Safety culture: speak up!

– Team dynamics

Start basic procedures as you inspect the patient • • • • • •

Vital signs ECG monitor Pulse oximetry Obtain IV access Administer oxygen Point-of-care labs (glucose, pH, PaCO2, Hb, K+, Ca++, lactate)

• Airway • Stridor • Wheezing • Airway compromise

• Breathing:

• Air entry • Crackles • Work of Breathing

– Respirations; increased, decreased or normal? – SpO2/Cyanosis

• Circulation

• Pulse • Skin mottling/pallor/cyanosis/prolonged capillary refill? • Rhythm on ECG monitor

– Heart rate • Fast • Slow

– Blood pressure • High • Low

– Urine output

• Low/adequate?

• Disability (neuro) • AVPU/D

– Awake, Verbal response, Pain only, Unresponsive, Delirium

• Seizure/clonus? • Focal deficits/eyes/pupils • Pain

• Exposure • • • •

Abdomen distended? Obvious sources of blood loss? Gross rashes and wounds? Edema?

– Temperature

• Fever? • Hypothermic?

• Always keep an eye on the patient • Communicate compassionately to patient and/or family – Hand holding and reassurance

• If an immediate threat is detected at any time, go back to primary survey

• Focused history – Why are they here? – Any relevant history? – Relevant meds? – Allergies?

• Bedside diagnostics – Ultrasound – ECG – Laboratory – Other testing

• Emergent interventions – Anything you need to do immediately – Simultaneously with diagnostic work up – Emergent consults (surgery/endoscopy)

• Review differential diagnosis – Identify syndromic diagnoses for problem list – Perform emergent activities based on possible diagnoses

After stabilization: System-based plan of care

50 year old • Chief Complaint:

– 50 year old with two days history of cough, hemoptysis and worsening shortness of breath

• Past History:

– Hepatitis C – Previous substance abuse on Methadone – Seizure disorder – Paroxysmal A fib, s/p ablation, on chronic Coumadin

Temperature : 38.4 C Anxious, Increased work of breathing with accessory muscles use Bronchial breath sounds over R lung Weak, irregular radial pulse, warm skin, brisk capillary refill Ultrasound: hyperdynamic LV/RV, collapsing IVC; B lines RUL, no effusion

Ceftriaxone 2 gr IV Rapid sequence intubation Adequate fluid resuscitation Levofloxacine 750 mg IV Lung protective ventilation No FFP prior to line placement

Furosemide Spontaneous awakening and breathing trial Short monitoring after extubation De-escalation to oral antibiotics, steroid taper and transfer

We need to be AWARE & CERTAIN

Special thanks to AWARE and CERTAIN teams

[email protected] http://www.icertain.org/

…to prevent DEATH (Diagnostic Errors and Therapeutic Harm)

Evaluate if you need to start CPR • If the patient is unconscious and gasping/apneic, STOP and move to BLS protocol (CPR) – These interventions are immediate and should precede any further diagnostic workup

Applied Physiology in Critical Illness O2

CO2

What can kill the brain? • Local damage –Head injury –Stroke • Cardiopulmonary dysfunction –Airway –Lungs/chest/diaphragm –Heart • Muscle dysfunction • Arrhythmia (coronary obstruction, preload, afterload, contractility, acidosis, electrolyte disturbance poisoning)

Applied Physiology in Critical Illness Mechanical ventilation Analgesia & sedation Pacemaker Paralysis Fever control/Hypothermia

Inotrope

Fluid bolus Decreased tissue O2 delivery

preload / contractility / afterload

O2

• Cardiac output = stroke volume x heart rate

Increased O2 consumption

Hgb

• Anemia, Hypoxemia

•Stress response

• Decreased perfusion pressure (coronaries)

•Pain

• Mechanical heart support (VAD, ECMO)

•Dyspnea

Vasopressor Imbalance between O2 supply and demand

Cell injury and organ failure