ABCDE The Safe Approach to the Critically Ill Patient

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ABCDE The Safe Approach to the Critically Ill
Patient

• Helen Pickard
• Consultant Nurse Acute Medicine

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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

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Traditional medical approach
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The ABCDE approach
Airway oxygenation
Breathing ventilation
Exposure examination
Circulation shock management
Disability due to neurological deterioration
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The Safe Approach

• Primary survey using ABCDE
• Then secondary survey with traditional medical
  clerking

this should you
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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

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Important

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

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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

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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

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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

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Details

• Observations on admission
• Temperature 35.7
• Heart Rate 94
• BP 83/52
• Respiratory Rate 24
• O2 Saturations 96 on air.
• MEWS Score 3

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Mews Chart
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The ABCDE approach
Airway oxygenation
Breathing ventilation
Exposure examination
Circulation shock management
Disability due to neurological deterioration
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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.

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• 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

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ABG result

• pH 7.028
• pCO2 1.11
• pO2 18.5
• Base excess -27.4
• HCO3 5.6

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Impression

• Significant metabolic acidosis with attempt at
  respiratory compensation secondary to acute
  kidney injury
• Na 127
• K 7.2
• Urea 39
• Creatinine 900

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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

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The ABCDE approach is paramount in first
assessmnet
Airway oxygenation
Breathing ventilation
Exposure examination
Circulation shock management
Disability due to neurological deterioration
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Airway - causes

• ? GCS
• Body fluids
• Foreign body
• Inflammation
• Infection
• Trauma

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Airway - assessment

• Unresponsive
• Added sounds
• Snoring, gurgling, wheeze, stridor
• Accessory muscles
• See-saw respiratory pattern

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Airway interventions(basic)

• Head tilt chin lift
• Jaw thrust
• Suction
• Oral airways
• Nasal airways

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Airway interventions(advanced)

• GET HELP!!!
• Nebulised adrenaline for stridor
• LMA
• Intubation
• Cricothyroidotomy
• Needle or surgical

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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

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Breathing - causes

• ? GCS
• Resp depressions
• Muscle weakness
• Exhaustion
• Asthma
• COPD
• Sepsis
• Cardiac event

• Pulmonary oedema
• Pulmonary embolus
• ARDS
• Pneumothorax
• Haemothorax
• Open pneumothorax
• Flail chest

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Breathing - assessment

• Look
• Rate (lt10 or gt20), symmetry, effort, SpO2, colour
• Listen
• Talking sentences, phrases, words
• Bilateral air entry, wheeze, silent chest other
  added sounds
• Feel
• Central trachea, percussion, expansion

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Breathing - interventions

• Consider ventilation with AMBU bag if resp rate
  lt 10
• Position upright if struggling to breath
• Specific treatment
• i.e. ß agonist for wheeze, chest drain for
  pneumothorax

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Circulation - assessment

• Look at colour
• Examine peripheries
• Pulse, BP CRT
• Hypotension (late sign)
• sBPlt 100mmHg
• sBP lt 20mmHg below pts norm
• ? Urine output

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Circulation shock
Inadequate tissue perfusion

• Loss of volume
• Hypovolaemia
• Pump failure
• Myocardial non-myocardial causes
• Vasodilatation
• Sepsis, anaphylaxis, neurogenic

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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

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Disability - causes

• Inadequate perfusion of the brain
• Sedative side effects of drugs
• ? BM
• Toxins and poisons
• CVA
• ? ICP

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Disability - assessment

• AVPU (or GCS)
• Alert, responds to Voice, responds to Pain,
  Unresponsive
• Pupil size/response
• Posture
• BM
• Pain relief

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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

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Exposure

• Remove clothes and examine head to toe front and
  back.
• Haemorrhage, rashes, swelling, sores, syringe
  drivers, catheter etc
• Keep warm
• Maintain dignity

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Secondary survey

• Detailed history
• Order investigations
• ABG, CXR, 12 lead ECG, Specific bloods
• Management plan including monitoring plan
• Referral
• Handover

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Handover
S
ITUATION
B
ACKGROUND
A
SSESSMENT
R
ECCOMENDATION
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Situation
S

• 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

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Background
B

• 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

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Assessment
A

• The assessment of the patient using the ABCDE
  approach

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Recommendation
R

• 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

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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.

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Questions

• ?