ABCDE The Safe Approach to the Critically Ill

Patient

Helen Pickard

Consultant Nurse Acute Medicine

Objectives

• The rational of ABCDE

• The process of primary & secondary survey

• Recognition of life threatening events when you work in ED

• Handover: highlight your concern to the treating team

Traditional medical approach

The ABCDE approach

Airway & oxygenation

Breathing & ventilation

Circulation & shock management

Disability due to neurological deterioration

Exposure & examination

The Safe Approach

1. Primary survey using ABCDE

2. Then secondary survey with traditional medical clerking

this should you

The primary survey

• ABCDE assessment looking for immediately life threatening conditions

• Rapid intervention usually includes max O2, IV access, fluid challenge +/- specific treatment

• Should take no longer than 5 min

• Can be repeated as many times as necessary

• Get experienced help as soon as you need it

• If you have a team delegate jobs

Important

• First survey will allow you to decide to continue for second survey or ask for inmediate senior review

The secondary survey

• Performed when patient more stable

• Get a relevant history - PC, HPC, PMH, DH, SH, FH, SR & examination

• More detailed examination of patient

• Order investigations to aid diagnosis

• Diagnosis/impression and plan

• IF PATIENT DETERIORATES RETURN TO PRIMARY SURVEY

Case Study

66 year old gentleman admitted to ED having become generally unwell for 3 days. Vomiting all food and fluids, and not passing much urine via ileoconduit (previous Ca bladder with subsequent cystoprostatectomy). Also complains of breathlessness and anterior chest pain which he describes as sharp, stabbing and worse on inspiration and cough.

Seen in ED by a medical student in the first instance

Then…..

Subsequent Clinical Adverse Event report completed by on call consultant read:

‘Admitted from GP referral to Emergency Department with breathlessness. Initial observations showed tachypnoea and hypotension 83/52. Managed for 3 ½ hours by a first year clinical medical student with no medical input. Asked by medical student if they could present the case. Obviously unwell – urgent medical investigations then arranged’

Details

Observations on admission:

• Temperature 35.7

• Heart Rate 94

• BP 83/52

• Respiratory Rate 24

• O2 Saturations 96% on air.

• MEWS Score = 3

Mews Chart

Score 3 2 1 0 1 2 3

Pulse Rate

<40 - 40-50 51-100 101-110

111-129

=130->130

Resp Rate

<8 - - 8-20 21-25 26-30 >30

Temp °C

- =35 or <35

- 35.1-37.9

38-38.4

=38.5 or >38.5

-

AVPU New weakness

New Confusion

- Alert Voice Pain Unresponsive

Systolic BP

<80 80-89 90 - 109

110 - 160

161 - 180

181 - 200

>200

The ABCDE approach

Airway & oxygenation

Breathing & ventilation

Circulation & shock management

Disability due to neurological deterioration

Exposure & examination

Registrar notes in Resus read…

A – airway patent. Talks short sentences due to ↑RR

B - kussmauls respiration, ↑↑RR, trachea central, chest clear, no cyanosis, O2 sats 94% on 2l O2 via nasal specs

C – HR 94 regular, peripherally cold, BP 83 systolic, calves soft non-tender, no pedal oedema, heart sounds normal, no urine output since admission.

D – AVPU = alert, GCS 15/15, BM 6.5

E – ileo-conduit noted, small amount of purulent urine in bag approx 50mls, apyrexial, abdo soft and non-tender

ABG result

pH 7.028

pCO2 1.11

pO2 18.5

Base excess -27.4

HCO3 5.6

Impression…

‘Significant metabolic acidosis with attempt at respiratory compensation …secondary to acute kidney injury’

Na 127

K 7.2

Urea 39

Creatinine 900

Plan

• Aggressive IV fluid resuscitation

• Strict fluid balance

• Hourly urine output monitoring

• IV sodium bicarbonate

• Calcium gluconate, dextrose and insulin IV

• Renal team review

• For ITU

The ABCDE approach is paramount in first assessmnet

Airway & oxygenation

Breathing & ventilation

Circulation & shock management

Disability due to neurological deterioration

Exposure & examination

Airway - causes

• GCS

• Body fluids

• Foreign body

• Inflammation

• Infection

• Trauma

Airway - assessment

• Unresponsive

• Added sounds– Snoring, gurgling, wheeze, stridor

• Accessory muscles

• See-saw respiratory pattern

Airway – interventions(basic)

• Head tilt chin lift

• Jaw thrust

• Suction

• Oral airways

• Nasal airways

Airway – interventions(advanced)

• GET HELP!!!

• Nebulised adrenaline for stridor

• LMA

• Intubation

• Cricothyroidotomy

– Needle or surgical

Once airway open...

• Give 15 litres of oxygen to all patients via a non-rebreathing mask

• For COPD patients re-assess after the primary survey has been complete & keep Sats 90-93%

Breathing - causes

• GCS

• Resp depressions

• Muscle weakness

• Exhaustion

• Asthma

• COPD

• Sepsis

• Cardiac event

• Pulmonary oedema

• Pulmonary embolus

• ARDS

• Pneumothorax

• Haemothorax

• Open pneumothorax

• Flail chest

Breathing - assessment

• Look

– Rate (<10 or >20), symmetry, effort, SpO2, colour

• Listen– Talking: sentences, phrases, words

– Bilateral air entry, wheeze, silent chest other added sounds

• Feel– Central trachea, percussion, expansion

Breathing - interventions

• Consider ventilation with AMBU™ bag if resp rate < 10

• Position upright if struggling to breath

• Specific treatment

– i.e.: β agonist for wheeze, chest drain for pneumothorax

Circulation - assessment

• Look at colour

• Examine peripheries

• Pulse, BP & CRT

• Hypotension (late sign)

– sBP< 100mmHg

– sBP < 20mmHg below pts norm

• Urine output

Circulation – shock

• Loss of volume

– Hypovolaemia

• Pump failure

– Myocardial & non-myocardial causes

• Vasodilatation

– Sepsis, anaphylaxis, neurogenic

Inadequate tissue perfusion

Circulation - interventions

• Position supine with legs raised– Left lateral tilt in pregnancy

• IV access - 16G or larger x2– +/- bloods if new cannula

• Fluid challenge– colloid or crystalloid?

• ECG Monitoring

• Specific treatment

Disability - causes

• Inadequate perfusion of the brain

• Sedative side effects of drugs

• BM

• Toxins and poisons

• CVA

• ICP

Disability - assessment

• AVPU (or GCS)

– Alert, responds to Voice, responds to Pain, Unresponsive

• Pupil size/response

• Posture

• BM

• Pain relief

Disability - interventions

• Optimise airway, breathing & circulation

• Treat underlying cause– i.e.: naloxone for opiate toxicity

• Treat BM– 100ml of 10% dextrose (or 20ml of 50% dextrose)

• Control seizures

• Seek expert help for CVA or ICP

Exposure

• Remove clothes and examine head to toe front and back.

– Haemorrhage, rashes, swelling, sores, syringe drivers, catheter etc

• Keep warm

• Maintain dignity

Secondary survey

• Detailed history

• Order investigations– ABG, CXR, 12 lead ECG, Specific bloods

• Management plan including monitoring plan

• Referral

• Handover

ITUATION

ACKGROUND

SSESSMENT

ECCOMENDATION

Handover

Situation

• Check you are talking to the right person

• State your name & department

• I am calling about... (patient)

• The reason I am calling is...

Medical student in our case:

• Consultant on call

• I am a medical student in the acute block

• I went to review Mr…in cubicle 3

• I need you to review him as he is hypotensive tachypnoeic and looks unwell

Background• Admission diagnosis and date of admission

• Relevant medical history

• Brief summary of treatment to date

• Medical student in our case

• He was admitted today referred by his GP to ED:

unwell for 3 days vomiting all food and fluids

not passing much urine via ileoconduit

is breathlessness

has anterior chest sharp, stabbing and worse on

inspiration and cough

• Has had no treatment yet

Assessment

• The assessment of the patient using the ABCDE approach

Recommendation

• I would like you to...

• Determine the time scale

• Is there anything else I should do?

• Record the name and contact number of your contact

• Medical student in our case

• I would like you to come and review him now

• Is there anything I should do?

• Record the name and contact of the person you have spoken to

Summary

• Primary survey - ABCDE

• Call for senior review as a medical student and with you senior support instigate treatments for life-threatening problems as you find them – Get Involved

• Reassess following treatment

• If anything changes go back to A

• Secondary survey – detailed history and examination

• only after primary survey completed and only if the patient is stable with MEWS 0.

Questions

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