Examining the Critically Ill

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Examining the Critically Ill

• Art Wheeler, M.D.
• Director, Medical Intensive Care
• Division of Allergy, Pulmonary and Critical Care
  Medicine
• Vanderbilt University Medical Center

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Traditional examination doesnt work
Physical exam
History
Treatment
Diagnostic testing
Differential dx
repeat prn
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General Principles

• Examination and treatment alternate.
• Look first for what kills.
• Look at every inch of the body.
• Use multiple observers one person in charge.
• Patient-technology interactions are instructive.
• Avoid preoccupation with obvious but
  non-life-threatening findings.

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What kills?

• Shock
• hemorrhage
• arrhythmia
• heart failure
• sepsis
• High intracranial pressure

• Airway obstruction
• Hypoxemia
• hypoventilation
• pulmonary edema
• heart failure
• ARDS
• pulmonary embolism
• hemo-pneumothorax

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Priorities

• Airway
• Breathing
• Circulation
• Neurological status

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The Forensic History

• Scan documents
• transfer (especially nurses) notes
• Run sheets

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The Forensic History

• Review medications
• diseases
• overdose potential
• doctor / hospital names and dates

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The Forensic History

• Exam findings
• clothing
• scars
• dental appliances
• tattoos, piercing
• indwelling IV's
• weight
• skin and hair condition

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The Critically Ills History

• You never get the truth, the whole truth and
  nothing but the truth.
• Patients lie.
• If the patient is unable to lie their family and
  friends will do it for them.

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Limitations of the exam

• Unless one person in charge-chaos.
• Noise is tremendous.
• Time pressure is large
• Lighting is artificial and inadequate
• Patient mobility is limited

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Enter every orifice make new ones prn

• Mouth smells, dental health, foreign bodies,
  gag
• Nose blood, CSF, black discharge
• Ears blood, CSF
• Rectum muscle tone, trauma, masses and foreign
  bodies, melena or hematochezia
• Vagina masses, trauma, blood, foreign bodies,
  products of conception
• Urethra urine, blood, pus

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Under-used senses Touch

• Skin temperature
• Skin texture
• calluses (hands and feet)
• corticosteroids
• Hypothyroidism
• Sweating
• Anticholinergic toxicity

• Sub-cutaneous gas
• necrotizing fascitis
• Pneumothorax
• Hair distribution and texture
• Hypothyroidism
• HIV

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Under-used senses Smell

• Hepatic failure
• Infections
• Anaerobes
• Pseudomonas
• Candida

• Ketones
• Alcohols
• Poisons
• hydrocarbons
• insecticides
• anti-freeze
• Melena

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Critically Ill Neurologic exam

• Immediately follows A-B-Cs
• Classic examination cannot be done.
• Exam to detect correctable neurological
  emergencies. (expanding mass lesions)
• Abandon non-specific terms
• Coma, stupor, lethargy, delirium
• Describe best level of function.

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Abbreviated Neuro ExamLife is too short for a
complete neurological exam

• Cognition.
• Spontaneous motor activity.
• Response to commands.
• Response to pain.
• Examine the eyes
• contacts, gaze, pupils, fundi, corneal response.
• Check for gag.
• Deep tendon reflexes.

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The eyes window to the mid-brain

• Gaze
• Anisocoria
• Pupillary response
• Corneal reflexes
• Fundoscopic examination

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Special settings

• Found down
• Had it before doesnt mean Got it again.
• Assume trauma.
• Assume more than one problem.
• Drugs and alcohol are present.

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Special Settings

• Chronic care transfers
• Infection most common.
• lung, urinary tract
• Assume baseline chronic organ impairment.
• Inattention often part of the problem.
• Old (non-hospital) records nearly useless.

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Special Settings

• Hospital transfers
• Start over.
• Trust no one.
• Nurses notes and radiology reports helpful.
• Some (maybe all) of the problem is iatrogenic.
• Old records essential.

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Technology as part of the exam

• Oximetry single most important vital sign.
• Integrates saturation, hemoglobin, BP, and
  cardiac output.
• Inability to obtain tracing suspect low cardiac
  output or vasoconstriction
• Wide respiratory swings in tracing suspect
  obstructive lung disease, volume depletion,
  tamponade.

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Technology as part of the exam

• Record the position of all tubes.
• Ventilators provide valuable clues
• Large difference between peak and plateau
  pressures airflow obstruction
• Little difference between peak and plateau
  pressures poor lung compliance

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The first 30 minutes labs

• Possible
• Oximetry
• Finger stick glucose
• ECG
• ABG

• Rarely Possible
• CXR
• CT scan(s)
• electrolytes
• CBC
• enzymes
• coagulation studies
• toxicology studies
• microbiologic data