Assessing the Critically Ill Surgical Patient
Key Points
1. CCrISP system: ABCDE, Assess, Decide and Plan
2. Diagnose and plan definitive timely treatment.
3. Investigations selective and meaningful.
4. Repeat clinical assessment is the cornerstone of good practice.
5. Inform and involve seniors early.
6. Communicate and document
Introduction
Immediate Assessment / Treatment
- Airway
- Breathing
- Circulation
- Dysfunction of CNS
- Exposure
- Reassessment
The Stable Patient Assessment
- Decisions & Planning
Introduction
Two patient categories:
i) acutely unwell or acute deterioration: require simultaneous resuscitation, diagnosis and definitive treatment.
ii) the longer term unwell: require ongoing re-evaluation and management plans (at least twice-daily) with attention to improvement and detecting problems early.

The approach is systematic: (same for all)
1.  Immediate Management
- ABCDE
2. Full Patient Assessment
- chart review
- history and physical
- available results
3. Decisions and Plans
- stable? --> daily plans
- unstable? --> diagnose, definitive care.
Immediate Assessment & Treatment
Although ABCDE, it occurs virtually simultaneously
- and be alert for blood-borne infections.

Airway
Look: cyanosis, seesaw resps, accessory use, tracheal tug, consciousness, obstruction (eg vomit).
Listen: sounds, eg grunting, hoarseness, gurgling, stridor.
Feel: airflow, inspiration
Intervene: immediately to prevent hypoxic brain damage
- high flow O2 via reservoir bag (pref. humidified)
- chin lift, jaw thrust, guedel, suction.
- bag / mask while awaiting help
- definitive airway if required
--> get an anaesthetist
--> not pre-oxygenating is futile and dangerous
--> cricothyroidotomy is the preferred surgical airway
--> in-line C-spine immobilisation if needed.
Breathing
Observe: cyanosis, accessory use, rate, equality, respiration depth, sweating, JVP, chest drain patency, FiO2 and saturation (remember can't tell hypercapnia), abdo distension.
Palpate: chest expansion, trachea, surgical emphysema, paradoxical respiration, fremitus.
Percuss: superiorly and laterally.
Auscultate: noisy breathing, secretions, talking, confusion, breath sounds, HS, rhythm.
Intervene: specifically for life threats:
- tension pneumo, massive haemothorax, flail chest, tamponade, open pneumothorax
- consider bronchial obstruction, bronchoconstriction, PE, cardiac failure, unconsciousness.
Circulation
Consider hypovolaemia until proved otherwise.
- exclude haemorrhage rapidly.
- any cool tachycardic pt should have a large bore cannula, cross match and rapid fluids.
- (unless there is clear cardiogenic cause)

Fluid challenge:
--> use 10ml/kg in a normotensive pt.
--> 20ml/kg in a hypotensive pt
--> 5 ml/kg in a heart failure pt (and consider closer monitoring)
- no amount of fluid replacement will work in the face of continued haemorrhage.
- rarely is uncrossed match blood needed
- type-specific blood is adequately safe, obtained in 10-20mins.

 Look for:
- reduced peripheral perfusion
- obvious external haemorrhage
- concealed haemorrhage
--> eg thoracic and abdominal
--> don't be reassured by empty drains
--> gut or from pelvic #s
--> alteration of consciousness.

Remember to assess perfusion rather than blood pressure
- BP may be preserved despite significant problems.
- marked hypotension is a late sign.
--> feel pulses, both peripheral and central

3 Categories of Shocked Pts:
i) Exsanguinating: immediate control required.
- found on the post-op ward as commonly as in ED
- call for help, x-match 8 units, alert theatre & anaesthetist and orderly.
ii) Transient responders: unstable, need repeated reassessment & management.
iii) Rapid responders: minor problem, remains stable.

Reassessment will determine who is responding.
- pts requiring large ongoing fluid loads are unstable
- most patients benefit from O2 and fluids while assessment is undertaken.
Dysfunction of the CNS
Rapidly assess using the AVPU.
Think of hypoxia and hypercapnia
- you should have picked these up already.
Think of drugs
- eg sedatives, anaesthetics or analgesics
Think of hypoglycaemia
Exposure
Expose the pt
- be aware for hypothermia
- and dignity
Reassessment
By now your patient should be improving and not in emmediate danger.
- perhaps moved to ICU, and with senior help on hand.
Attach a pulse oximeter: sats should be >94%.
Arrange tests: ABG, CXR, ECG.
Catheterise
Reassess the ABCs.
- if at any point the patient deteriorates, return to ABCs.
The Stable Patient Assessment
Gather information to diagnoses or predict problems, and plan for them.

Chart Review
Obs and fluid charts are essential
- look at absolute values and trends

Logical approach
R : Respiratory
- rate
- FiO2, Sats
C : Circulation
- rate and rhythm
- BP
- urine output
- IV lines & fluid balance
- CVP and pulmonary wedge P
S : Surgical
- temperature
- drainage (nature and volume)
- special requirements
D : Drug chart

History and Physical
Remember comorbid conditions are almost as important as their present illness.
Examine fully paying attention to regions involved in surgery or underlying disease.
- remember wounds and stomas
Repeated clinical examination is essential.
- eg atelectasis is much more likely to be detected clinically.

Review results
Even in emergencies recent routine blood tests, microbiology or imaging may be available.
In ward rounds, wait at the end of the bed for tests to become available.
Decisions and Planning

Stable Patients
Be cautious about calling recent-responders stable.
Plan daily for wards, twice daily in HDU.
Predict complications based on comorbid conditions.

Daily Plan:
Investigations
Removal of drains / tubes
Oral intake
Fluid balance and Rx
Nutrition
- requirement and route
- is it being given?
Physiotherapy
Drugs / analgesia
- therapeutic
- preventive eg DVT prophylaxis
- routine meds
Move to lower level of care

Unstable Patients
If progress is not satisfactory then further investigations and definitive Rx is required.
- review your priorities
- is resuscitation required?
- begin treatments early.
- inform your senior
- is a higher level of care required?
- are you reaching a diagnosis quick enough?
- are you even reaching the diagnosis?

Investigations:
- Find out why the pt is unwell.
- eg CXR, ECG, Blds, Cultures.
--> Remember the radiology department is unsafe for unstable pts.
Specialist opinions may be required.

Note Writing
Name (capitals), date, time, pager
Assessment:
- past and present events
- present clinical features
- response to treatments given
Differential diagnosis
Plans, including:
- communications
- review (by you or others, when)
- parameters for change.