What are the initial steps in managing a critically ill patient?

From the Guidelines

The initial management of a critically ill patient should follow the ABCDE approach, prioritizing airway, breathing, circulation, disability, and exposure, with the most recent guidelines from 2024 emphasizing the importance of recognizing and responding to clinical deterioration outside the ICU 1.

Initial Assessment and Management

The first step is to ensure airway patency by checking for obstruction and positioning the head appropriately; if needed, perform jaw thrust maneuvers or insert airway adjuncts like oropharyngeal or nasopharyngeal airways. For compromised airways, prepare for endotracheal intubation using rapid sequence induction with medications such as propofol (1.5-3 mg/kg) or etomidate (0.3 mg/kg) for sedation and succinylcholine (1-2 mg/kg) or rocuronium (1-1.2 mg/kg) for paralysis.

Breathing and Circulation

Next, assess breathing by checking respiratory rate, oxygen saturation, and work of breathing; provide supplemental oxygen targeting SpO2 >94% for most patients. Circulation assessment includes checking pulse, blood pressure, capillary refill, and obtaining IV access (preferably two large-bore IVs, 16-18G); administer crystalloid fluids like normal saline or Ringer's lactate at 20-30 ml/kg for hypotension or signs of shock, as recommended by the Surviving Sepsis Campaign guidelines 1.

Disability and Exposure

Disability evaluation involves assessing neurological status using the AVPU scale (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale, and checking blood glucose levels. Finally, completely expose the patient to identify additional injuries or abnormalities while maintaining dignity and preventing hypothermia.

Key Recommendations

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 1.
• Use dynamic over static variables to predict fluid responsiveness, where available 1.
• Target a mean arterial pressure (MAP) of 65 mm Hg in patients with septic shock requiring vasopressors 1.
• Guide resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion 1. These steps and recommendations are crucial for the initial management of critically ill patients, focusing on minimizing morbidity, mortality, and improving quality of life.

From the Research

Initial Steps in Managing a Critically Ill Patient

The initial steps in managing a critically ill patient involve a systematic approach to assessment and treatment.

• The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is widely accepted and applicable in all clinical emergencies for immediate assessment and treatment 2.
• This approach helps healthcare professionals focus on the most life-threatening clinical problems and improves outcomes by saving valuable time and improving team performance.

Assessment and Treatment of Sepsis

Sepsis is a major cause of mortality among hospitalized patients, and early recognition and appropriate treatment are essential to reducing organ system injury and mortality 3, 4.

• The treatment of sepsis includes appropriate antimicrobial agents to target the underlying infection, optimization of intravascular volume to improve stroke volume, vasopressors to counteract vasoplegic shock, and high-quality supportive care 4.
• Studies have shown that optimized dosing of antibiotics such as ceftriaxone and vancomycin is crucial in achieving therapeutic exposure and improving patient outcomes 5, 6.
• For example, a study found that a 2-g once-daily dose of ceftriaxone is likely to achieve therapeutic exposure against target pathogens in patients with a creatinine clearance ≤ 140 mL/min 5.
• Another study suggested that vancomycin doses of ≥ 2 g every 8 h are required to consistently achieve key therapeutic targets in patients with a creatinine clearance ≥ 80 mL/min/1.73 m2 6.