Recognizig the unwell patient -ABCDE

Štefan Trenkler

I. klinika anestéziológie a intenzívnej medicíny

UPJŠ LF Košice

2017

Vital functions (VF)

1. Ventilation, airways

2. Cardiovascular system

3. Central nervous system

• Diagnostics of decompensation/failure of VFSame signs and symptoms!

• VF support

• Worst - CPR

Traditional medical approach

Treatment

Diagnosis

Investigations

Differential

Examination

History

The ABCDE approach

A

B

CD

E

Airway & oxygenation

Breathing &

ventilation

Circulation &

shock

management

Disability due to

neurological

deterioration

Exposure &

examinatio

n

The principles

• Perform primary ABCDE survey (< 5 min); use your senses

• Instigate treatment for life threatening conditions as you find them

• Reassess when any treatment is completed

• Perform more detailed secondary ABCDE survey including investigations

• If condition deteriorates repeat primary survey

The primary survey

• ABCDE assessment looking for immediately life threatening conditions

• Rapid intervention usually includes: 1) securing airways, 2) O2, 3) IV access, fluid challenge, 4) +/- specific treatment

• Should take no longer than 5 min

• Can be repeated as many times as necessary

• Get help (bystander/experienced) as soon as you need it

• If you have a team delegate jobs

• Communicate

The secondary survey

• Performed when patient more stable

• Get a brief relevant history

• More detailed examination of patient (ABCDE)

• Existing documents

• Order investigations to aid diagnosis

• IF PATIENT DETERIORATES RETURN TO PRIMARY SURVEY

Assessment

• Watch

• Listen

• Feel (palpation)

Airways / ventilation

• Oxygenation

• Elimination of CO2

• ABG

• First aid: rescue breathes / mechanical ventilation

A – airways obstruction, causes

• Coma

• Foreign body

- blood, vomits, tooth, food, toys ...

• Face, neck injury

• Oedema (inflammation, alergy ..)

• Larynx spasmus

• Epiglottitis, laryngitis

• Bronchial secretions

• Obstruction of arteficial airways (endotracheal, tracheostomy

tube)

Partial obstruction

• Inspiratory stridor

• Cough

• Sitting position

• Cyanosis (late symptom)

• Paradoxical movement

• Auxilliary muscles

Total obstruction

• Silent patient

• No air movement

• Paradoxical breathing

A airways obstruction, signs

Airways total obstruction

(Forman, Amadeus)

Airways -management

1. Chin lift / head tilt

2. Airway

3. Supraglottic device

4. Endotracheal intubation

5. Coniopunction, tracheostomy

B. Breathing failure Causes

1. Brain (vessel, trauma, inflammation, tumor, intoxication)

2. Spinal cord (trauma, inflammation, tumor)

3. Peripheral nerves (polyradiculoneuritis)

4. Neuromuscular connection (myasthenia)

5. Diaphragma, thorax wall (injury)

6. Airways (obstruction)

7. Parenchyma (ARDS, pneumonia, aspiration)

Brain

Nerves

Thorax

AirwaysAlveolus

Breathing failure - causes

• GCS

• Resp depressions

• Muscle weakness

• Exhaustion

• Asthma

• COPD

• Infection

• Pulmonary oedema

• Pulmonary embolus

• ARDS

• Pneumothorax

• Haemothorax

• Open pneumothorax

• Flail chest

Breathing - assessment

• Look

• Rate (<10 or >25), symmetry, effort, SpO2, colour

• Listen

• Taking: sentences, phrases, words

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

• Feel

• Central trachea, Percussion, expansion

Rescue breathes

Self infalting (ambu) bag + mask

Automatic ventilator

Mouth suction

Oxygen therapy

Oxygen mask + reservoir

• Nasal prongs

Oxygen therapy

FLOW(l/min)

FiO2 (%)

Oxygen prongs 0,5 - 4 22 - 40

Oxygen mask without reservoir 5 - 10 40 - 60

Oxygen mask with reservoir 10 - 15 40 - 80

Self inflating bag - 21

Self inflating bag with oxygen 5 - 10 40 - 60

Self inflating bag with oxygen reservoir 5 - 10 90 - 100

Fraction of inspiratory oxygen (FiO2) (%)

Air: FiO2 0,21 ~ 21%, pure oxygen: FiO2 1,0 ~ 100%

Monitoring of oxygenation –pulse oxymeter (SpO2)

Circulation

• Watch: skin (colour)

• Feel: skin temperature, moisture

• Feel: pulse, capillary refill time

• <35 HR >140

• SBP <80 mmHg

Cireculation – first aid

• Position

• Vascular access (i.v., i.o.)

• Infusion therapy – crystaloid (NS)

• Drugs (catecholamines)

• Causal therapy ....- stop of bleedong- ECG (STEMI)

Vascular access – i.v.

Intraosseous space

Vascular access - intraosseous

BIG - gun

EZ-IO - drill

Needle insertion

Disability - brain

• Consciouss Reaction to word, question

• UnconscioussMotor response

- localized movement- flexion- extension- none

AVPU score (alert, voice, pain, unresponsive)Normal response to „Are you OK?“ = OK.

Glasgow coma scale

Recovery position

Consiousless, breathing (no cardiac arrest)

Exposure

• Examination from hairs to big toe

• Full history

• Charts

• Body temperature (early sepsis)

• Glycaemia

• Lactate, ABG

• Urine output

Chain of prevention

Measures

A: chin lift head tilt, recovery position, airway, SGD

B: Oxygen mask, pronges; oxygen

C: I.V./IO; fluids (normal saline), inotropes

D: recovery position, glycaemia, trauma

End of presentation

ITUATION

ACKGROUND

SSESSMENT

ECCOMENDATION

Handover

Situation

• Check you are talking o the right person

• State your name & department

• I am calling about... (patient)

• The reason I am calling is...

Background

• Admission diagnosis and date of admission

• Relevant medical history

• Brief summary of treatment to date

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

2nd End of presentation