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ABCDE The Safe Approach to the Critically Ill Patient Helen Pickard Consultant Nurse Acute Medicine.

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Presentation on theme: "ABCDE The Safe Approach to the Critically Ill Patient Helen Pickard Consultant Nurse Acute Medicine."— Presentation transcript:

1 ABCDE The Safe Approach to the Critically Ill Patient Helen Pickard Consultant Nurse Acute Medicine

2 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

3 Traditional medical approach Treatment Diagnosis Investigations Differential Examination History

4 The ABCDE approach ABCDE Airway & oxygenation Breathing & ventilation Circulation & shock management Disability due to neurological deterioration Exposure & examination

5 The Safe Approach 1.Primary survey using ABCDE 2.Then secondary survey with traditional medical clerking this should you

6 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

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

8 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

9 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

10 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’

11 Details Observations on admission: Temperature 35.7 Heart Rate 94 BP 83/52 Respiratory Rate 24 O2 Saturations 96% on air. MEWS Score = 3

12 Mews Chart Score Pulse Rate < =130- >130 Resp Rate < >30 Temp °C -=35 or < =38.5 or > AVPU New weakness New Confusion -AlertVoicePain Unrespon sive Systolic BP < >200

13 The ABCDE approach ABCDE Airway & oxygenation Breathing & ventilation Circulation & shock management Disability due to neurological deterioration Exposure & examination

14 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.

15 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

16 ABG result pH pCO pO Base excess HCO3 5.6

17 Impression… ‘Significant metabolic acidosis with attempt at respiratory compensation …secondary to acute kidney injury’ Na 127 K 7.2 Urea 39 Creatinine 900

18 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

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

20 Airway - causes  GCS Body fluids Foreign body Inflammation Infection Trauma

21 Airway - assessment Unresponsive Added sounds –Snoring, gurgling, wheeze, stridor Accessory muscles See-saw respiratory pattern

22 Airway – interventions (basic) Head tilt chin lift Jaw thrust Suction Oral airways Nasal airways

23 Airway – interventions (advanced) GET HELP!!! Nebulised adrenaline for stridor LMA Intubation Cricothyroidotomy –Needle or surgical

24 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%

25 Breathing - causes  GCS Resp depressions Muscle weakness Exhaustion Asthma COPD Sepsis Cardiac event Pulmonary oedema Pulmonary embolus ARDS Pneumothorax Haemothorax Open pneumothorax Flail chest

26 Breathing - assessment Look –Rate ( 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

27 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

28 Circulation - assessment Look at colour Examine peripheries Pulse, BP & CRT Hypotension (late sign) –sBP< 100mmHg –sBP < 20mmHg below pts norm  Urine output

29 Circulation – shock Loss of volume –Hypovolaemia Pump failure –Myocardial & non-myocardial causes Vasodilatation –Sepsis, anaphylaxis, neurogenic Inadequate tissue perfusion

30 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

31 Disability - causes Inadequate perfusion of the brain Sedative side effects of drugs  BM Toxins and poisons CVA  ICP

32 Disability - assessment AVPU (or GCS) –Alert, responds to Voice, responds to Pain, Unresponsive Pupil size/response Posture BM Pain relief

33 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

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

35 Secondary survey Detailed history Order investigations –ABG, CXR, 12 lead ECG, Specific bloods Management plan including monitoring plan Referral Handover

36 ITUATION ACKGROUND SSESSMENT ECCOMENDATION Handover

37 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

38 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

39 Assessment The assessment of the patient using the ABCDE approach

40 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

41 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.

42 Questions ?


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