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Guidelinesandguidance

TheABCDEapproach

Underlyingprinciples
Theapproachtoalldeterioratingorcriticallyillpatientsisthesame.Theunderlyingprinciplesare:

1.UsetheAirway,Breathing,Circulation,Disability,Exposure(ABCDE)approachtoassessandtreatthepatient.
2.Doacompleteinitialassessmentandreassessregularly.
3.Treatlifethreateningproblemsbeforemovingtothenextpartofassessment.
4.Assesstheeffectsoftreatment.
5.Recognisewhenyouwillneedextrahelp.Callforappropriatehelpearly.
6.Useallmembersoftheteam.Thisenablesinterventions(e.g.assessment,attachingmonitors,intravenousaccess),tobeundertaken
simultaneously.
7.CommunicateeffectivelyusetheSituation,Background,Assessment,Recommendation(SBAR)orReason,Story,Vitalsigns,Plan
(RSVP)approach.
8.Theaimoftheinitialtreatmentistokeepthepatientalive,andachievesomeclinicalimprovement.Thiswillbuytimeforfurthertreatment
andmakingadiagnosis.
9.Rememberitcantakeafewminutesfortreatmentstowork,sowaitashortwhilebeforereassessingthepatientafteranintervention.

Firststeps
1.Ensurepersonalsafety.Wearapronandglovesasappropriate.
2.Firstlookatthepatientingeneraltoseeifthepatientappearsunwell.
3.Ifthepatientisawake,askHowareyou?.Ifthepatientappearsunconsciousorhascollapsed,shakehimandaskAreyoualright?Ifhe
respondsnormallyhehasapatentairway,isbreathingandhasbrainperfusion.Ifhespeaksonlyinshortsentences,hemayhavebreathing
problems.Failureofthepatienttorespondisaclearmarkerofcriticalillness.
4.ThisfirstrapidLook,ListenandFeelofthepatientshouldtakeabout30sandwilloftenindicateapatientiscriticallyillandthereisaneed
forurgenthelp.Askacolleaguetoensureappropriatehelpiscoming.
5.Ifthepatientisunconscious,unresponsive,andisnotbreathingnormally(occasionalgaspsarenotnormal)startCPRaccordingtothe
resuscitationguidelines.Ifyouareconfidentandtrainedtodoso,feelforapulsetodetermineifthepatienthasarespiratoryarrest.Ifthere
areanydoubtsaboutthepresenceofapulsestartCPR.
6.Monitorthevitalsignsearly.Attachapulseoximeter,ECGmonitorandanoninvasivebloodpressuremonitortoallcriticallyillpatients,as
soonaspossible.
7.Insertanintravenouscannulaassoonaspossible.Takebloodsforinvestigationwheninsertingtheintravenouscannula.

Airway(A)
Airwayobstructionisanemergency.Getexperthelpimmediately.Untreated,airwayobstructioncauseshypoxiaandrisksdamagetothebrain,
kidneysandheart,cardiacarrest,anddeath.

1.Lookforthesignsofairwayobstruction:
Airwayobstructioncausesparadoxicalchestandabdominalmovements(seesawrespirations)andtheuseoftheaccessory
musclesofrespiration.Centralcyanosisisalatesignofairwayobstruction.Incompleteairwayobstruction,therearenobreath
soundsatthemouthornose.Inpartialobstruction,airentryisdiminishedandoftennoisy.
Inthecriticallyillpatient,depressedconsciousnessoftenleadstoairwayobstruction.
2.Treatairwayobstructionasamedicalemergency:
Obtainexperthelpimmediately.Untreated,airwayobstructioncauseshypoxaemia(lowPaO2)withtheriskofhypoxicinjurytothe
brain,kidneysandheart,cardiacarrest,andevendeath.
Inmostcases,onlysimplemethodsofairwayclearancearerequired(e.g.airwayopeningmanoeuvres,airwayssuction,insertionof
anoropharyngealornasopharyngealairway).Trachealintubationmayberequiredwhenthesefail.
3.Giveoxygenathighconcentration:
Providehighconcentrationoxygenusingamaskwithoxygenreservoir.Ensurethattheoxygenflowissufficient(usually15Lmin1)to
preventcollapseofthereservoirduringinspiration.Ifthepatientstracheaisintubated,givehighconcentrationoxygenwithaself
inflatingbag.
Inacuterespiratoryfailure,aimtomaintainanoxygensaturationof9498%.Inpatientsatriskofhypercapnicrespiratoryfailure(see
below)aimforanoxygensaturationof8892%.

Breathing(B)

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Duringtheimmediateassessmentofbreathing,itisvitaltodiagnoseandtreatimmediatelylifethreateningconditions(e.g.acutesevereasthma,
pulmonaryoedema,tensionpneumothorax,andmassivehaemothorax).

1.Look,listenandfeelforthegeneralsignsofrespiratorydistress:sweating,centralcyanosis,useoftheaccessorymusclesofrespiration,and
abdominalbreathing.
2.Counttherespiratoryrate.Thenormalrateis1220breathsmin1.Ahigh(>25min1)orincreasingrespiratoryrateisamarkerofillness
andawarningthatthepatientmaydeterioratesuddenly.
3.Assessthedepthofeachbreath,thepattern(rhythm)ofrespirationandwhetherchestexpansionisequalonbothsides.
4.Noteanychestdeformity(thismayincreasetheriskofdeteriorationintheabilitytobreathenormally)lookforaraisedjugularvenouspulse
(JVP)(e.g.inacutesevereasthmaoratensionpneumothorax)notethepresenceandpatencyofanychestdrainsrememberthat
abdominaldistensionmaylimitdiaphragmaticmovement,therebyworseningrespiratorydistress.
5.Recordtheinspiredoxygenconcentration(%)andtheSpO2readingofthepulseoximeter.Thepulseoximeterdoesnotdetecthypercapnia.
Ifthepatientisreceivingsupplementaloxygen,theSpO2maybenormalinthepresenceofaveryhighPaCO2.
6.Listentothepatientsbreathsoundsashortdistancefromhisface:rattlingairwaynoisesindicatethepresenceofairwaysecretions,usually
causedbytheinabilityofthepatienttocoughsufficientlyortotakeadeepbreath.Stridororwheezesuggestspartial,butsignificant,airway
obstruction.
7.Percussthechest:hyperresonancemaysuggestapneumothoraxdullnessusuallyindicatesconsolidationorpleuralfluid.
8.Auscultatethechest:bronchialbreathingindicateslungconsolidationwithpatentairwaysabsentorreducedsoundssuggesta
pneumothoraxorpleuralfluidorlungconsolidationcausedbycompleteobstruction.
9.Checkthepositionofthetracheainthesuprasternalnotch:deviationtoonesideindicatesmediastinalshift(e.g.pneumothorax,lungfibrosis
orpleuralfluid).
10.Feelthechestwalltodetectsurgicalemphysemaorcrepitus(suggestingapneumothoraxuntilprovenotherwise).
11.Thespecifictreatmentofrespiratorydisordersdependsuponthecause.Nevertheless,allcriticallyillpatientsshouldbegivenoxygen.Ina
subgroupofpatientswithCOPD,highconcentrationsofoxygenmaydepressbreathing(i.e.theyareatriskofhypercapnicrespiratoryfailure
oftenreferredtoastype2respiratoryfailure).Nevertheless,thesepatientswillalsosustainendorgandamageorcardiacarrestiftheir
bloodoxygentensionsareallowedtodecrease.Inthisgroup,aimforalowerthannormalPaO2andoxygensaturation.Giveoxygenviaa
Venturi28%mask(4Lmin1)ora24%Venturimask(4Lmin1)initiallyandreassess.AimfortargetSpO2rangeof8892%inmostCOPD
patients,butevaluatethetargetforeachpatientbasedonthepatientsarterialbloodgasmeasurementsduringpreviousexacerbations(if
available).Somepatientswithchroniclungdiseasecarryanoxygenalertcard(thatdocumentstheirtargetsaturation)andtheirown
appropriateVenturimask.
12.Ifthepatientsdepthorrateofbreathingisjudgedtobeinadequate,orabsent,usebagmaskorpocketmaskventilationtoimprove
oxygenationandventilation,whilstcallingimmediatelyforexperthelp.Incooperativepatientswhodonothaveairwayobstructionconsider
theuseofnoninvasiveventilation(NIV).InpatientswithanacuteexacerbationofCOPD,theuseofNIVisoftenhelpfulandpreventsthe
needfortrachealintubationandinvasiveventilation.

Circulation(C)
Inalmostallmedicalandsurgicalemergencies,considerhypovolaemiatobetheprimarycauseofshock,untilprovenotherwise.Unlessthereare
obvioussignsofacardiaccause,giveintravenousfluidtoanypatientwithcoolperipheriesandafastheartrate.Insurgicalpatients,rapidly
excludehaemorrhage(overtorhidden).Rememberthatbreathingproblems,suchasatensionpneumothorax,canalsocompromiseapatients
circulatorystate.Thisshouldhavebeentreatedearlieronintheassessment.

1.Lookatthecolourofthehandsanddigits:aretheyblue,pink,paleormottled?
2.Assessthelimbtemperaturebyfeelingthepatientshands:aretheycoolorwarm?
3.Measurethecapillaryrefilltime(CRT).Applycutaneouspressurefor5sonafingertipheldatheartlevel(orjustabove)withenough
pressuretocauseblanching.Timehowlongittakesfortheskintoreturntothecolourofthesurroundingskinafterreleasingthepressure.
ThenormalvalueforCRTisusually<2s.AprolongedCRTsuggestspoorperipheralperfusion.Otherfactors(e.g.coldsurroundings,poor
lighting,oldage)canprolongCRT.
4.Assessthestateoftheveins:theymaybeunderfilledorcollapsedwhenhypovolaemiaispresent.
5.Countthepatientspulserate(orpreferablyheartratebylisteningtotheheartwithastethoscope).
6.Palpateperipheralandcentralpulses,assessingforpresence,rate,quality,regularityandequality.Barelypalpablecentralpulsessuggesta
poorcardiacoutput,whilstaboundingpulsemayindicatesepsis.
7.Measurethepatientsbloodpressure.Eveninshock,thebloodpressuremaybenormal,becausecompensatorymechanismsincrease
peripheralresistanceinresponsetoreducedcardiacoutput.Alowdiastolicbloodpressuresuggestsarterialvasodilation(asinanaphylaxis
orsepsis).Anarrowedpulsepressure(differencebetweensystolicanddiastolicpressuresnormally3545mmHg)suggestsarterial
vasoconstriction(cardiogenicshockorhypovolaemia)andmayoccurwithrapidtachyarrhythmia.
8.Auscultatetheheart.Isthereamurmurorpericardialrub?Aretheheartsoundsdifficulttohear?Doestheaudibleheartratecorrespondto
thepulserate?
9.Lookforothersignsofapoorcardiacoutput,suchasreducedconsciousleveland,ifthepatienthasaurinarycatheter,oliguria(urine
volume<0.5mLkg1h1).
10.Lookthoroughlyforexternalhaemorrhagefromwoundsordrainsorevidenceofconcealedhaemorrhage(e.g.thoracic,intraperitoneal,
retroperitonealorintogut).Intrathoracic,intraabdominalorpelvicbloodlossmaybesignificant,evenifdrainsareempty.
11.Thespecifictreatmentofcardiovascularcollapsedependsonthecause,butshouldbedirectedatfluidreplacement,haemorrhagecontrol
andrestorationoftissueperfusion.Seekthesignsofconditionsthatareimmediatelylifethreatening(e.g.cardiactamponade,massiveor
continuinghaemorrhage,septicaemicshock),andtreatthemurgently.
12.Insertoneormorelarge(14or16G)intravenouscannulae.Useshort,wideborecannulae,becausetheyenablethehighestflow.
13.Takebloodfromthecannulaforroutinehaematological,biochemical,coagulationandmicrobiologicalinvestigations,andcrossmatching,
beforeinfusingintravenousfluid.
14.Giveabolusof500mLofwarmedcrystalloidsolution(e.g.Hartmannssolutionor0.9%sodiumchloride)overlessthan15minifthepatient
ishypotensive.Usesmallervolumes(e.g.250mL)forpatientswithknowncardiacfailureortraumaanduseclosermonitoring(listentothe
chestforcracklesaftereachbolus).
15.ReassesstheheartrateandBPregularly(every5min),aimingforthepatientsnormalBPor,ifthisisunknown,atarget>100mmHg
systolic.

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16.Ifthepatientdoesnotimprove,repeatthefluidchallenge.Seekexperthelpifthereisalackofresponsetorepeatedfluidboluses.
17.Ifsymptomsandsignsofcardiacfailure(dyspnoea,increasedheartrate,raisedJVP,athirdheartsoundandpulmonarycrackleson
auscultation)occur,decreasethefluidinfusionrateorstopthefluidsaltogether.Seekalternativemeansofimprovingtissueperfusion(e.g.
inotropesorvasopressors).
18.IfthepatienthasprimarychestpainandasuspectedACS,recorda12leadECGearly.
19.ImmediategeneraltreatmentforACSincludes:
Aspirin300mg,orally,crushedorchewed,assoonaspossible.
Nitroglycerine,assublingualglyceryltrinitrate(tabletorspray).
Oxygen:onlygiveoxygenifthepatientsSpO2islessthan94%breathingairalone.
Morphine(ordiamorphine)titratedintravenouslytoavoidsedationandrespiratorydepression.

Disability(D)
Commoncausesofunconsciousnessincludeprofoundhypoxia,hypercapnia,cerebralhypoperfusion,ortherecentadministrationofsedativesor
analgesicdrugs.

1.ReviewandtreattheABCs:excludeortreathypoxiaandhypotension.
2.Checkthepatientsdrugchartforreversibledruginducedcausesofdepressedconsciousness.Giveanantagonistwhereappropriate(e.g.
naloxoneforopioidtoxicity).
3.Examinethepupils(size,equalityandreactiontolight).
4.MakearapidinitialassessmentofthepatientsconsciouslevelusingtheAVPUmethod:Alert,respondstoVocalstimuli,respondstoPainful
stimuliorUnresponsivetoallstimuli.Alternatively,usetheGlasgowComaScalescore.Apainfulstimulicanbegivenbyapplyingsupra
orbitalpressure(atthesupraorbitalnotch).
5.Measurethebloodglucosetoexcludehypoglycaemiausingarapidfingerprickbedsidetestingmethod.Inaperiarrestpatientusea
venousorarterialbloodsampleforglucosemeasurementasfingerpricksampleglucosemeasurementscanbeunreliableinsickpatients.
Followlocalprotocolsformanagementofhypoglycaemia.Forexample,ifthebloodsugarislessthan4.0mmolL1inanunconscious
patient,giveaninitialdoseof50mLof10%glucosesolutionintravenously.Ifnecessary,givefurtherdosesofintravenous10%glucose
everyminuteuntilthepatienthasfullyregainedconsciousness,oratotalof250mLof10%glucosehasbeengiven.Repeatbloodglucose
measurementstomonitortheeffectsoftreatment.Ifthereisnoimprovementconsiderfurtherdosesof10%glucose.Specificnational
guidanceexistsforthemanagementofhypoglycaemiainadultswithdiabetesmellitus.
6.Nurseunconsciouspatientsinthelateralpositioniftheirairwayisnotprotected.

Exposure(E)
Toexaminethepatientproperlyfullexposureofthebodymaybenecessary.Respectthepatientsdignityandminimiseheatloss.

Additionalinformation
1.Takeafullclinicalhistoryfromthepatient,anyrelativesorfriends,andotherstaff.
2.Reviewthepatientsnotesandcharts:
Studybothabsoluteandtrendedvaluesofvitalsigns.
Checkthatimportantroutinemedicationsareprescribedandbeinggiven.
3.Reviewtheresultsoflaboratoryorradiologicalinvestigations.
4.Considerwhichlevelofcareisrequiredbythepatient(e.g.ward,HDU,ICU).
5.Makecompleteentriesinthepatientsnotesofyourfindings,assessmentandtreatment.Wherenecessary,handoverthepatienttoyour
colleagues.
6.Recordthepatientsresponsetotherapy.
7.Considerdefinitivetreatmentofthepatientsunderlyingcondition.

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