The deteriorating patient

1. The deteriorating patient • By Emily Allerton, Jodie Raine and Colin Gorogodo • Learning Outcomes: • Understand what is compromised by a deterioration in the patient • Analysed using the assessment process • Looking at Acute problems

2. Airway and Breathing • Airway compromised, RR^, SPO2v • Caused by Pneumothorax and loss of consciousness • Involves the reduction in the flow of air along the airway and therefore a reduction in the amount of Oxygen and Carbon Dioxide perfused into / out of, the blood stream • Therefore resulting in increase in CO2 levels in the body and a reduction in O2 levels

3. What is compromised by A and B deterioration • Hypercapnia causes: • If CO2 accumulates in the blood then carbonic acid levels rise and the blood pH drops, this can be reversed by rapid deep breathing by a ventilator that flushes out the CO2 • The hypercapnia increases respiratory rate which leads to distress and eventually arrest

4. Hypercapnia cont’d • Increase in acidity of CSF (H+ ions) which can lead to headache and eventually confusion and loss of consciousness, if left unchecked neuropathy as increase in CO2 level is coupled with hypoxia • High blood pH inhibits respiration and hypercapnia reduces efficacy of blood buffering system (HCO3- and H2CO3) • Hypoxia causes tissue death most significantly the heart as this exhausts its use of O2 within 30 seconds

5. Circulation • Pneumothorax compromises the circulation in two ways: • The reduction of O2 levels and accumulation of CO2 in the bloodstream • The decrease of blood volume in circulation due to bleeding

6. Chemoreceptors • As the pH in the blood drops and CO2 accumulates this is detected by the Chemoreceptors. This sends a message to the cardiovascular centre (CVC) in the brain to increase stoke volume, increase heart rate and vasoconstriction. • This mechanism allows greater excretion of CO2 and uptake of O2 into the bloodstream

7. Barorecptors • However because the volume of blood has dropped this causes a drop in the blood pressure. This is detected by the baroreceptors. • The baroreceptors reduce it’s input to the CVC causing an increase of sympathetic drive to the heart to speed it up. • Sympathetic activity is also increased in the blood vessels leading to vasoconstriction

8. Hypovolaemic shock • Occurs when the blood volume is reduced by 15-25%. • Stimulation of the baroreceptors in the aortic arch and carotid sinuses • Sympathetic stimulation of the adrenal glands which causes increased secretion of adrenaline and noradrenaline • Stimulation of the renin angiotensin aldosterone system by diminished blood flow to the kidneys

9. Hypovolaemic shock cont….. • Increased heart rate, following sympathetic stimulation • Water retention by the kidneys, following release of antidiuretic hormone by the posterior lobe of the pituitary gland, increasing salt and water retention

10. Organs compromised • Hypoxia and low blood pressure cause irreversible brain damage • Hypoxia causes the release of chemical substances that increase permeability in the capillaries. More fluid enters the interstitial spaces leading to further hypovolaemia, further reduction in blood pressure and increased hypoxia

11. Organs Compromised cont… • Cerebral and myocardial hypoxia due to reduced blood flow encourages the formation of thrombi and infarcts. • Acute renal failure due to reduced blood flow and fall in blood pressure and a marked reduction in urine output leading to retention of damaging metabolic waste products.

12. GCS Score • GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : • Best Eye Response • Best Verbal Response • Best Motor Response

13. GCS Cont…. • GCS scores range from 3 (no eye opening, verbal response, or motor reactions) to 15 (spontaneous eye opening, fully oriented, and able to follow commands). Following are GCS scores and corresponding injury severity: • GCS Score of 3 to 8: Severe • GCS Score of 9 to 12: Moderate • GCS Score of 13 to 15: Mild

14. GCS Cont…… • The patient's GCS score kept going down indicating that he was getting worse (brain damage) but however mild concussions may have long-term, life altering complications, although such outcomes are more likely for their peers with moderate-to-severe injuries.

15. GCS Cont……. • Studies indicate that 10% of people with mild brain injuries will have life-long difficulties • 33-50% of those with moderate injuries will have disabilities • 80% of people with severe TBIs will have enduring difficulties

16. Disability • A brief assessment of neurological status should be performed. This assessment should include the patient's posture (i.e., any asymmetry, decerebrate or decorticate posturing), pupil asymmetry, pupillary response to light, and a global assessment of patient responsiveness.

17. AVPU scale • The Australasian College of Surgeons and the ACS recommends the AVPU scale as follows: • A = Patient is awake, alert, and appropriate • V = Patient responds to voice • P = Patient responds to pain • U = Patient is unresponsive • A more detailed assessment by using the GCS score can be made at this time or during the secondary survey.

18. Environment • Patients should be completely disrobed during the initial assessment and the subsequent secondary survey. This helps ensure that significant injuries are not missed. At the same time, efforts to prevent significant hypothermia by using a warm ambient room (28-30°C), overhead heating, and warmed IV fluids, should be instituted. The patient's temperature should be monitored as early as possible, and strenuous efforts should be made to avoid significant hypothermia.

19. References • Christensen, J.R. (2001). What is Traumatic Brain Injury? In Schoenbrodt, L., ed • Children with Traumatic Brain Injury: A Parents* Guide. Woodbine House: Bethesda, MD. • Marieb, E. (1998) Human Anatomy and Physiology 4th Ed California: Benjamin / Cummings Science Publishing • Waugh, A. and Grant, A. (2002) Ross and Wilson Anatomy and Physiology in Health and Illness 9th Ed London: Elsevier Science Limited