Thread by @jholloway_MD

An INCREDIBLY intimidating part of the ICU can be the patient exam in the AM:
A 🧵on what to assess at bedside while taking care of an intubated/sedated patient.

(Because @tammamtu made an excellent point on another 🧵)
#MedTwitter #MedEd #Medicine #CritCare #ICU #CriticalCare

1. Talk to the patient, no matter their mental status. You should introduce yourself & announce what you’re doing during a physical exam. Sometimes we forget that there’s a loved one surrounded by all those machines & forget to act the same way we would if they were awake. Don’t.

2. Mental status: If they’re relatively responsive this one is much easier. If they’re not, this one is tough.

Assess sedation level. RASS is a commonly used descriptor. Most patients (not all) should be +1 to -1. If they’re -5 and on max sedation, you should explore that.

Alternatively, if they’re -5 and on zero sedation, that’s meaningful.

If not spontaneously able to move extremities on command, this is typically where you’d assess response to pain and see if they respond/localize/etc.

If you’re new to an ICU, I’d ask the nurse or a senior resident to help you and show you how to do this. ESPECIALLY if the patient has been wildly agitated.

Same with cough reflex - this is important to check/know, but ask for help if you haven’t done it.

Check pupils!

2. Auscultate for heart/lung sounds. Look at tele.

Take a look at the ventilator.
Look at the waveforms: synchronous with the vent or struggling with dyssynchrony? Note peak pressures.

Look at suctioned secretions and characterize! Copious? None? Frothy? Etc.

3. Palpate peripheral pulses, especially in your patients on pressors. If you cannot palpate, you can try your hand at Doppler (will usually be at bedside) & talk to the bedside nurse about where they’ve been dopplering.

Also assess skin warmth/color/edema & CAP REFILL.

4. Controversially maybe, I don’t auscultate for bowel sounds because of articles like this: ncbi.nlm.nih.gov/pmc/articles/P… but it would not be wrong to.

I do palpate the abdomen. Assess for grimace with palpation. Ask nurse about BMs or examine the bag if there’s a FMS.

Also check for NGT output if an NGT is in place for suction. Alternatively, in patients being fed, check to see if feeds are running and if not, inquire why (e.g. were they stopped after emesis overnight?)

5. Drains! Look at drains the patient has & characterize output (sanguineous, serosang etc.)

This would include:
- JP drain
- Chest tube (also look for air leak, assess if suction is on or not)
- NGT
- ETT output
- Foley
- Woundvac
Etc.

Look at surgical dressings if present.

6. Also assess the lines a patient has. Think about whether or not they need said lines.

No pressors and IV access? Think about pulling a central line.

Good BP and adequate blood draw access without pressors? Maybe pull the art line.

7. Extra credit:
- ECMO: assess the oxygenator for clots
- CAM-ICU: I usually ask the nurses about this one as they’re better at administering it than I am, but you can try your hand at it! Assesses for delirium.
- If something is off, roll the ultrasound in the room for POCUS!

8. DO NOTS in the ICU:
- Don’t touch a gtt pump. If it is beeping, let it beep. If you silence an empty Levo/propofol gtt that is BAD.
- Don’t change vent settings. Talk to RT.
- Don’t remove restraints and forget to replace them. This is DANGEROUS.

- Don’t change settings on CRRT, ECMO, etc.
- Don’t pull at lines/drains/etc. ECMO cannulae are BIG. Just look at the site, and don’t move or pull cannulae/tubes.
- Don’t suction ETTs for cough and leave the suction in the airway.
Etc.

In summary of the DO NOTS:
If you are uncomfortable w/ something, talk to a nurse/senior resident & ask them to show you how to do something. Everyone was new at some point & everyone values safety.

Be thoughtful when near life support devices. Flippancy is 👎 in the ICU.

That’s it! There’s certainly nuances and this doesn’t apply to EVERY patient nor is it fully comprehensive of EVERY patient.

Anything missed? Things you assess that I haven’t listed? Things you don’t regularly do in here? Drop a comment!