Clinical Examination of the Critically Ill

OVERVIEW

  • Pros and cons of clinical examination of the critically ill

ARGUMENTS FOR

  • history is often difficult to obtain in the critically ill, clinical signs alone are used to guide treatment and investigation until more definitive information available
  • quick and easy to perform
  • types of information influence management (especially in an emergency):
    • airway: not patent or protected -> intubate, ETT position
    • breathing: chest movement, breath sounds (e.g. wheeze)
    • circulation: presence of pulses, peripheral and central cyanosis, estimation of peripheral perfusion
    • neurological: AVPU, GCS, pupils, localising signs, tone and reflexes, sensation
    • skin: lesions, rash, purpura, erythema, papular, spider naevi
    • localised tenderness: limb, abdominal quadrant
    • abnormal masses: lymph nodes, hepatosplenomegaly
    • fundoscopy: subhyaloid haemorrhages, papilloedema
    • assessment of invasive devices, dressings, drains…
  • important information for neuro-prognostication (e.g. post-cardiac arrest, severe TBI)

ARGUMENTS AGAINST

  • lack of sensitivity (missing disease states)
  • lack of specificity (wrongly excluding differential diagnoses)
  • few high quality studies address the benefits of clinical examination in the critically ill
  • general benefits of clinical examination are only supported by lower levels of evidence (including extrapolation from other patient populations)

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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