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
The primary survey
ABCDE assessment looking for immediately life
threatening conditions
Rapid intervention usually includes max O
2
, 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 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
Unrespon
sive
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, SpO
2
, 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
AMBUbag if resp rate
< 10
Position upright if
struggling to breath
Specific treatment
i.e.: 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 Mrin 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