What is the priority approach for an ICU nurse or practitioner in managing a critically ill patient?

ICU Nursing and Practitioner Prioritization

As an ICU nurse or practitioner, your absolute first priority is airway management and oxygenation, followed immediately by hemodynamic monitoring and stabilization—this approach directly prevents the majority of critical incidents and deaths in the ICU setting. 1, 2

Primary Priority Framework: ABC with Critical Care Modifications

1. Airway Assessment and Management (Always First)

• Systematically evaluate the airway in ALL unstable critically ill patients, as deterioration may not initially appear to be an airway emergency but often involves airway compromise 1, 3, 4
• Immediately assess for airway patency: look for obstruction, displacement of existing tubes, or secretion blockage 1
• Check tracheal tube depth every shift and document on bedside chart—apparent cuff leak should be assumed to be partial extubation until proven otherwise 1
• Maintain endotracheal tube cuff pressure at 20-30 cm H₂O 1
• Use continuous waveform capnography for all intubated patients—failure to use capnography contributes to >70% of ICU airway-related deaths 1

Critical Pitfall: Over 80% of airway-related critical incidents occur AFTER initial intubation, with 30% being serious and 25% contributing to death 1. Most relate to tube displacement or blockage, not the initial intubation itself.

2. Breathing and Oxygenation (Second Priority)

• Continuously monitor oxygen saturation, respiratory rate, and work of breathing 2, 5
• Assess for severe hypoxemia (SpO₂ <80%), which occurs in up to 25% of ICU intubations 1
• Monitor ventilator settings and ensure appropriate alarm parameters are active 1
• Position patients with head of bed elevated at 45° for all ventilated patients to prevent ventilator-associated pneumonia 2

3. Circulation and Hemodynamic Management (Third Priority)

• Assign a dedicated team member to monitor and manage hemodynamic status during any high-risk procedure or unstable period 1
• Recognize that significant hemodynamic instability occurs in up to 25% of ICU intubations, with cardiac arrest in approximately 2% 1
• Ensure reliable IV or intraosseous access for rapid volume replacement and vasopressor administration 1
• Monitor for hypotension from vasodilation (anesthetic agents), hypovolemia, or positive pressure ventilation reducing venous return 1

Organizational Priorities for Patient Management

Daily Ward Round Safety Briefings

• Identify and communicate patients with known difficult airways to the entire team (consultant, charge nurse, bedside nurse, physiotherapist) 1
• Include specific details: initial airway management, laryngoscopy grade, patient-specific strategies for preventing/managing airway risks 1
• Document re-intubation and extubation strategies with plans visible at bedside 1
• Pre-emptively escalate airway management in difficult patients before experienced staff become non-resident (e.g., perform daytime intubation) 1

Staffing and Team Structure

• Match patient acuity with nurse experience levels immediately—the most experienced charge nurse should make these assignments 2
• Use a pod-based model: one critical care nurse oversees a "pod" of patients and mentors non-critical care nurses 2
• Non-critical care nurses should be assigned no more than 2 critically ill patients and work in collaboration with one critical care nurse 2
• Maintain 1:1 nurse-to-patient ratio for Level III care (highest acuity) 1

Environmental and Monitoring Requirements

• Maintain constant visual contact with patients through large windows or glass doors 2
• Ensure monitoring equipment detects 95% of critical incidents, with 67% detected before organ damage occurs 1
• Position service outlets 120-180 cm from floor with adequate access to head of bed for intubation and resuscitation 2
• Use standardized equipment arrangement for easy identification in emergencies 2

High-Risk Situations Requiring Immediate Escalation

Indicators for Pre-emptive Action

• Four or more intubation attempts dramatically increase cardiac arrest risk (one in eight emergency intubations) 1
• Failure of "first pass success" occurs in up to 30% of ICU intubations 1
• Patients with predicted difficult airways (approximately 6% of ICU patients) require consultant notification and documented management plans 1

Peri-Intubation Crisis Prevention

• Administer 500 mL crystalloid bolus before or during intubation in absence of cardiac failure to mitigate hemodynamic collapse 1
• Use effective preoxygenation with CPAP to reduce myocardial depression and left ventricular afterload 1
• Balance risks of delaying intubation against benefits of stabilization—this requires experienced clinical judgment 1

Communication and Documentation Priorities

• Multiprofessional ward rounds should include relevant clinicians, nurse in charge, bedside nurse, and physiotherapist 1
• Document all airway management details, tube depth, and patient-specific strategies on bedside charts 1
• Use bedhead signage for tracheostomy, laryngectomy, or identified airway difficulty 1
• Ensure immediately available equipment and appropriately skilled clinicians with documented plans visible at bedside 1

Resource Allocation During Mass Casualty or Surge Capacity

• Prioritize interventions that improve survival without requiring extraordinarily expensive equipment: basic mechanical ventilation, hemodynamic support with IV fluids and vasopressors, antibiotic therapy, and prophylactic interventions 2
• Stockpile sufficient equipment for IV fluid resuscitation and vasopressor administration for at least 48 hours 2
• If resources are limited, triage decisions should seek to help the greatest number of people survive 2
• Expand capacity in this order: existing ICUs, post-anesthesia care units, emergency departments, then step-down units 1