The approach to the critically ill patient

Nick SmithClinical Skills

Objectives

• The rational of ABCDE• The process of primary & secondary survey• Recognition of life threatening events• Treatment of life-threatening conditions• Handover

Traditional medical approach

The ABCDE approachAirway & oxygenation

Breathing & ventilation

Circulation & shock management

Disability due to neurological deterioration

Exposure & examination

The principles

• Perform primary ABCDE survey (5 min)• 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 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

The secondary survey

• Performed when patient more stable• Get a brief relevant HPC & Hx• More detailed examination of patient (ABCDE)• Order investigations to aid diagnosis• IF PATIENT DETERIORATES RETURN TO

PRIMARY SURVEY

Airway - causes

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

Airway - assessment

• Unresponsive• Added sounds

– Snoring, gurgling, wheeze, stridor

• Tracheal tug• 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• Infection

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

Breathing - assessment

• Look– Rate (<10 or >20), symmetry, effort, SpO2, colour

• Listen– Taking: sentences, phrases, words– Bilateral air entry, wheeze, silent chest other

added sounds

• Feel– Central trachea, Percussion, expansion

Breathing - interventions

• Consider ventilation with AMBU™ bag if resp rate < 10

• Position upright if struggling to breath

• Specific treatment– i.e.: β 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• Consider compensation

mechanisms

Circulation – shock

• Loss of volume– Hypovolaemia

• Pump failure– Myocardial & non-

myocardial causes

• Vasodilatation– Sepsis, anaphylaxis,

neurogenic

BP = HR x SV x SVR

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– Caution if reversing benzo’s

• 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 (inc concealed), rashes, swelling etc

• Keep warm (unless post cardiac arrest)• Maintain dignity

Secondary survey

• Repeat ABCDE in more detail• History• Order investigations

– ABG, CXR, 12 lead ECG, Specific bloods

• Management plan• Referral• Handover

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

Questions

?

Summary

• Assess ABCDE in turn• Instigate treatments for life-threatening

problems as you find them• Reassess following treatment• If anything changes go back to A

Acute severe asthma

• Nebulised salbutamol (5mg) - O2 driven– Repeat as needed

• Nebulised ipratropium (500mcg) - O2 driven

• Hydrocortisone 100mg IV or Prednisolone 50 – 60mg po

• MgSO4 IV 1.2 – 2g– Seek guidance first

Any one of:• PEF 33 – 50% of best or predicted• RR> 24• HR> 110• Inability to complete sentences in 1 breath

HR

SVR

Life threatening asthma

• PEF <33%• SpO2 <92%• PaO2 <8 kPa• Normal PaCO2

– PaCO2 is a pre-terminal sign

• Silent chest• Cyanosis• Poor respiratory effort• Arrhythmias• Exhaustion / GCS

Severe asthma plus one of the following:

Get expert help quickly and treat as for acute severe asthma

HR

SVR

Sepsis

Signs and symptoms of infection (SSI) orSystemic Inflammatory Response (SIRs)

• Temperature > 38.2°C or <36°C• HR>90 beats/min• Respiratory rate >20 breaths/min• WBC count > 12,000 or <4,000/mL• Hyperglycaemia (in absence or DM)

2 or more SSI’s + suspicion of a new infection = SEPSIS

HR

SVR

Severe Sepsis

• Oxygen• Blood cultures• IV antibiotics (within 1

hour)

• BP < 90 systolic• Acute alteration in mental

status• O2 sats < 90%• UO < 0.5ml/kg/hr for 2

hours

• Bilirubin >34µmol/L• Platelets <100 x 109/L• Lactate>2 mmol/L• Coagulopathy – INR>1.5 or

APTT>60sec

SEPSIS + Organ dysfunction = SEVERE SEPSIS

• Fluids +++• Monitor lactate & Hb• Urinary Catheter &

hourly monitoring

HR

SVR

Anaphylaxis

• Get expert help quickly• Oxygen• IM adrenaline 500mcg

– repeat every 5 min if needed

Highly likely if…1. Sudden onset and rapid progression2. Life threatening problem to airway &/or breathing &/or

circulation3. Skin changes (rash or angioedema)+/- Exposure to known allergen

• Chlorphenamine 10mg IV

• Hydrocortisone 200mg IV

• +/- fluids +++

HR

SVR

Hypovolaemia

Haemorrhagic• External• Drains• GI tract• AbdomenTrauma• On the floor and 4 more

– Chest, abdo, pelvis, long bones

Fluid loss• D&V• Polyuria• Pancreatitis

Iatrogenic• Diuretics +++• Inadequate fluid

prescription

HR

SVR

Hypovolaemia

Responders Partial or transient responders

Non-responders

Patient improve and remains improved.

Patient improves but shows a gradual

deteriorationon-going loss or re-

equilibration

No improvement. Exsanguination though severe dehydration &

sepsis should be considered

No further boluses maybe needed but investigate cause

Further boluses and investigations

Further boluses and get help quickly

Give fluid challenge 250ml over 2 min and reassess after 5 min

Haemorrhagic shock Class I < 15%

<750mlClass II 15-30%750 – 1500ml

Class III 30 – 40%1500 – 2000ml

Class IV >40%>2000ml

RR 14-20 20-30 30+ 35+

HR <100 >100 >120 >140

BP Normal Normal Decreased Decreased

Pulse pressure Normal Decreased Decreased Decreased

Neuro Slighty Anxious Mildly anxious Anxious or confused

Confused or lethargic

Urine Output > 30 20 – 30 5 - 15 Bladder sweat

Use patients obs to estimate the blood loss then replace with crystalloid at 1.5 to 3ml for every 1ml of estimated blood loss

Figures based on a young healthy adult with a compressible haemorrhage

Bradycardia

Adverse signs• BP• HR < 40• Heart failure• Ventricular arrhythmias

compromising BP

No adverse signs with a risk of asystole?

• Recent asystole• Mobitz II AV block• 3rd degree HB w QRS• QRS pauses > 3 sec

• Get expert help quickly!• Atropine 500 mcg IV

– Repeat to a max total dose of 3mg• External cardiac pacing

HR

SVR

Tachyarrhythmia

• Get expert help quickly• Unstable*

– Sedate and synchronised cardiovertion

• Stable VT– Amiodarone 300mg 20 –

60 min

• Stable SVT– Vagal manoeuvers– Adenosine 6mg, 12mg,

12mg

• Stable tachy AF– Amiodarone 300mg 20 –

60 min if onset < 48hrs– Β-blocker IV or digoxin IV

(*rate related symptoms are uncommon at less than 150 beats min-1)

HR

SVR