The Acutely Ill Patient

Ther is no thing more precious here than tyme.

Saint Bernard (1090-1153)

The objective of this chapter is to provide a practical approach to acutely ill patients. The emphasis is on diagnosis, not on therapy. In the assessment of acutely ill patients, time is a critical factor. Unlike the assessment of stable patients, the evaluation of acutely ill patients involves not achieving a specific diagnosis but rather identifying a pathophysiologic abnormality that may be identical for several diagnoses. In the evaluation of acutely ill patients, always ask yourself, ''What is the most serious threat to life, and have I ruled it out?'' Remember, also, that your health is important. Exposure to body substances places you at risk. The minimum isolation precaution for an emergency response is the wearing of latex gloves.

When delivering health care in the field, and perhaps even in the hospital, as you approach the apparent patient, always perform a brief evaluation to determine whether you are in a safe environment;if not, protect yourself and your patient to limit exposure to possible injury. This may be a rare situation, but in circumstances in which it is likely that the rescuer could be injured or killed while rendering care, the rescuer should wait until the situation can be made safe. For example, in an automobile accident, a patient trapped in a car in a busy traffic lane should not be given first aid until safety flares or cones can be placed to prevent secondary accidents.

During this evaluation, search for other injured persons who may be hidden from view as you approach the scene of the accident. You should also try to determine the mechanisms of injury and attempt to memorize the scene for later reconsideration in the emergency department and perhaps as a witness for the injured party.

The task for the clinician in approaching most, if not all, patients in acute situations is, first, to ascertain that they are not in cardiopulmonary arrest and do not have major perturbations of their vital signs to the point that their continued viability is threatened. The general approach to these acute, undefined encounters is to consider the patient unstable until you can confirm, through a series of diagnostic steps, that the patient is well enough for you to take the time to perform a more rigorous and complete physical examination and document a complete history.

This strategy involves moving through a series of simple algorithms, which are grouped into two categories termed the primary and secondary surveys. The primary survey is a check for conditions that are an immediate threat to the patient's life. This initial assessment should take no longer than 30 seconds. The primary survey is subdivided into a cardiopulmonary resuscitation (CPR) survey and a key vital functions assessment. The algorithms for the primary survey are shown in Figures 26-1 and 26-2. The secondary survey is a check for conditions that could become life-threatening problems if not recognized and attended to.

1 - Shout for help

2 - Assess airway

Closed

Open airway

1 - Maintain open airway

2 - Monitor airflow

Open

Spontaneous breathing present?

Begin Key Vital Functions Assessment Algorithm

Stable, sp

ontaneous carotid pulse present?

No

1 - Continue closed chest compression

2 - Intubation, if available

Figure 26-1 Cardiopulmonary resuscitation (CPR) survey algorithm.

The primary and secondary surveys are used for both adult and pediatric patients, as well as for medical and injury-related problems. The treatment process is integrated into the diagnostic process. For example, if the patient is not breathing, ventilations are begun immediately, before you move on to the next diagnostic step in the algorithm.

The first task is to recognize when a patient is acutely ill. An unusual appearance or behavior may be the only sign. These include breathing difficulties, clutching the chest or throat, slurring of speech, confusion, unusual odor to the breath, sweating for no apparent reason, or uncharacteristic skin color (e.g., pale, flushed, or bluish).

Remember that an acutely ill patient is anxious and frightened;a calm and reassuring voice can go a long way toward comforting the patient. It is always easier to care for a relaxed patient than for an anxious one.

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