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The clinical approach to the patient who is very ill 

The clinical approach to the patient who is very ill

The clinical approach to the patient who is very ill

John D. Firth

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date: 24 March 2017

When dealing with emergency admissions (and sometimes in other contexts), always ask yourself the question ‘is this patient well, ill, very ill, or nearly dead?’ Airway, breathing, and circulation (ABC) must be assessed immediately in the patient who is very ill or worse, a key further question being ‘do you think that this patient can keep breathing like this for the next 10 min?’ If not, summon help from someone with advanced airway skills immediately.

Key things to remember and/or do when dealing with a patient who is very ill include: (1) Hypoxia kills, hypercarbia merely intoxicates—give oxygen in as high a concentration as possible by face mask—and remember that elective intubation and ventilation are preferable to cardiorespiratory arrest. (2) Always consider tension pneumothorax and decompress the chest immediately if this is present. (3) Obtain venous access safely: if veins in the forearm or antecubital fossa cannot be cannulated in the patient who is hypovolaemic, then cannulate the femoral vein, which lies medial to the femoral artery (nerve, artery, vein, Y-fronts—NAVY). An attempt to insert a central venous cannula into the internal jugular or subclavian vein of a patient who is in extremis can kill. (4) If the patient is clearly volume depleted, give 500 ml of blood, plasma expander, or 0.9% saline/balanced salt solution (as appropriate and as available) as fast as possible, then recheck the signs (peripheral perfusion, pulse rate, blood pressure). Repeat cycles of rapid infusion until there is clear evidence of improvement. Consider vasopressors, inotropes, or vasodilators when this is not sufficient (see Chapter 17.4). (5) As soon as resuscitation is underway, attention must turn towards making a diagnosis. A pragmatic approach uses a ‘surgical sieve’ technique to look for features on history, examination, and investigation to diagnose conditions that can kill. In many cases treatment must be started ‘on suspicion’, in particular if the diagnoses of pulmonary embolism or sepsis are possible. (6) Do not forget to speak to the patient’s relatives.

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