Metkus: Should we examine our ICU patients? The subtle art of physical exams in the ICU

Today we are fortunate to have convinced Dr. Thomas Stephen Metkus to cross the interstate and join us for CCP rounds here at the University of Maryland. Dr. Metkus is an assistant professor of cardiology at the Johns Hopkins University School of Medicine whose research focuses on using cardiac physiology for risk stratification and therapeutics in non-cardiac critical illness (mainly sepsis & ARDS). Dr. Metkus started his career with an undergraduate degree from Boston University College of Engineering, moving down 95 to collect a medical degree from the University of Pennsylvania School of Medicine. Keeping the Ivy League streak going he went onto to complete a medicine residency at Brigham and Women’s Hospital, and then a fellowship at both Harvard Medical School and Johns Hopkins Hospital. Fresh off publication of a highly lauded article focusing on bedside diagnoses in the ICU, today he is gracious enough to take the reigns of the late/great Osler and discuss why physical exam in the ICU is NOT a dead art!

Clinical Pearls

  • Physical exam is the cornerstone of medicine, but is it truly worthless in the ICU?
    • If applied, should it be integrated into rounds? All beforehand? All afterwards? Is there science behind these choices?
      • Data is sparse, but shows that the higher the level of medical education (medical student, resident, to attending) the less likely an exam will occur
      • Additionally, the addition of contact precautions cuts the amount of examined patients by an attending physician in half!
    • Upwards of 40% of notes are copy/pasted, mostly including the physical exam findings
  • Why are physical exams rare in the ICU?
    • Barriers to examination (noise, dressings, clinical instability)
    • Lack of time vs. amount of patients to round upon
    • Lack of emphasis to overall outcome
    • PE does not predict day to day needs, especially volume responsiveness Monnet 2016
  • Are we atrophying?
    • We are not great at evaluating JVP or performing lung auscultation (via numerous publications)
    • Even more concerning, 60% of mainstem intubations had BL breath sounds! Brunel 1989
  • However, there are success stories!
    • Gurgling breath sounds at trachea predict PNAs and ICU requirements Vazquez 2010
    • Bedside “gestalt” is superior predictor of “need for intubation” Tulaimat 2014
    • Physical exam findings predict long term outcomes in heart failure and A fib Caldentey 2014
      • Hemodynamic profiles in CHF are especially important for management and prognosis!

Metkus 1

Nohria 2002

  • So whats the prognosis?
    • A thorough exam allows for a multidisciplinary approach to learning/teaching/collaborating
    • Bedside dx allows contextualizing of data from labs, monitors, and radiology
      • Can lead astray when interpreted in isolation
    • Increases exposure to pt and family, improving overall satisfaction scores
    • “Laying on of hands” humanizes the efforts
  • ICU assessments are far more broad then the average exam:
    • Standard assessment of whole body
    • Implanted devices, incisions, access points
    • Eval of monitors, waveforms (vent and tele)
    • Discussion with family and visitors at bedside (concerns, etc.)
  • Standard approach
    1. First impression/global view from across the room
    2. Pupils
      • 30% of population have anisocoria at baseline
        • If both react, the smaller one is most likely abnormal (Horner’s syndrome)
        • If larger one reacts poorly
          • CN 3, iris, or ciliary ganglion damage OR parasympathetic blockage
    3. ENT
      • ETT eval, lip eval, nasal eval
      • Mouth investigation
    4. Neck
      • Catheters- IJ/SC
      • JVP with proper technique

      Cook 1996

    5. Chest
      • Auscultation
        • Third heart sound correlates with LVEDP and mortality 
    6. Abdomen
      • Palpation is key!
    7. Extremities
      • Pulses and their deficit are indicative of survival
    8. Neuro
      • LOC/CAM-ICU
      • EOM/Pupils
      • Vent trigger, cough, gag
      • Breathing pattern
        • Cheyne-Stokes, Apneustic, Ataxic
      • Spont extremity movement
      • Reflexes/Babinski
    9. Skin
      • Livedo?
      • Cap refill time = CO
    10. Miscellaneous
      • Chest tubes, Foley catheter, Vent waveforms, HD on monitor VADs, ECMO, etc…..
  • Future directions
    • POC Echocardiography 
      • Need to focus the exam on areas for intervention
      • Issues: QAL, training? maintenance?
    • Personal accountability for 100% examinations
    • Address burn out, need to address patient care as a holistic view
      • Erase the view of a organ system and re-integrate them to a person again

Suggested Reading

  1. Metkus TS, Kim BS. Bedside Diagnosis in the Intensive Care Unit. Is Looking Overlooked? Ann Am Thorac Soc. 2015 Oct;12(10):1447-50. [Pubmed Link]
  2. Schneiderman H. Toward a Renascence of Physical Diagnosis in the Intensive Care Unit. Ann Am Thorac Soc. 2015 Oct; 12(10):1423–24. [ATS Link]
  3. Metkus TS. The Physical Examination and the Fifth Maneuver. J Am Coll Cardiol. 2015 Nov 3;66(18):2048-50. [Pubmed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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