abcde the safe approach to the critically ill patient clinical teaching fellows
TRANSCRIPT
Objectives
• The rational of ABCDE
• The process of primary & secondary survey
• Recognition of life threatening events when you work in ED/AMU
• Handover: highlight your concern to the treating team
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 immediate 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
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 assessment
Airway & oxygenation
Breathing & ventilation
Circulation & shock management
Disability due to neurological deterioration
Exposure & examination
Airway - assessment
• Unresponsive
• Added sounds– Snoring, gurgling, wheeze, stridor, crowing
• Accessory muscles
• See-saw respiratory pattern
• If you find a life threatening abnormality, then call for help
Airway – interventions(basic)
• Head tilt chin lift
• Jaw thrust
• Suction
• Oral airways
• Nasal airways
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
• Muscle weakness
• Exhaustion
• Asthma/COPD
• Sepsis
• Pulmonary oedema
• Pulmonary embolus
• ARDS
• Pneumo/haemothorax
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
• If you find a life threatening abnormality, then call for help
Breathing - interventions
• Consider ventilation with bag-valve mask if resp rate < 10
• Position upright if struggling to breathe
• Specific treatment
– i.e.: β agonist for wheeze, chest drain for pneumothorax
Circulation - assessment
• Look at colour
• Examine peripheries
• Pulse, BP & central cap refill
• 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
• IV access - 16G or larger x2– +/- bloods if new cannula
• Fluid challenge– Crystalloid 250-500ml bolus
• ECG Monitoring
• Specific treatment (eg IV antibiotics for sepsis)
• Consider catheterisation
• If you find a life threatening abnormality, then call for help
Disability – causes (AEIOU TIPS)
• Alcohol/acidosis
• Electrolytes/Epilepsy/Environmental/Electricity
• Insulin (hypoglycaemia)
• Oxygen (hypoxia)
• Uraemia
• Trauma
• Infection
• Poisons/psychosis
• Seizure/stroke/shock
Disability - assessment
• AVPU (or GCS)
– Alert, responds to Voice, responds to Pain, Unresponsive
• Pupil size/response
• Capillary blood glucose
• Pain relief
• If you find a life threatening abnormality, then call for help
Disability - interventions
• Optimise airway, breathing & circulation
• Treat underlying cause– i.e.: naloxone for opiate toxicity
• Treat hypoglycaemia– 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
• If you find a life threatening abnormality, then call for help
Secondary survey
• Detailed history
• Order investigations– ABG, CXR, 12 lead ECG, Specific bloods
• Management plan including monitoring plan
• Referral
• 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
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.