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ABCDE The Safe Approach to the Critically Ill Patient

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Presentation on theme: "ABCDE The Safe Approach to the Critically Ill Patient"— 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
History Examination Differential Investigations Diagnosis Treatment

4 A E B D C The ABCDE approach Airway & oxygenation
Exposure & examination Breathing & ventilation D C Circulation & shock management Disability due to neurological deterioration

5 The Safe Approach Primary survey using ABCDE
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 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

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 3 2 1 Pulse Rate <40 - 40-50 51-100 101-110
Pulse Rate <40 - 40-50 51-100 =130->130 Resp Rate <8 8-20 21-25 26-30 >30 Temp °C =35 or <35 =38.5 or >38.5 AVPU New weakness New Confusion Alert Voice Pain Unresponsive Systolic BP <80 80-89 >200

13 A E B D C The ABCDE approach Airway & oxygenation
Exposure & examination Breathing & ventilation D C Circulation & shock management Disability due to neurological deterioration

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 HCO

17 Impression… ‘Significant metabolic acidosis with attempt at respiratory compensation …secondary to acute kidney injury’ Na K Urea 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
Airway & oxygenation A B C D E A E B Exposure & examination Breathing & ventilation D C Circulation & shock management Disability due to neurological deterioration

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

21 A Airway - assessment Unresponsive Added sounds Accessory muscles
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... A 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 B 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 (<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

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

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 D 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 E 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


37 S 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 B 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 A The assessment of the patient using the ABCDE approach

40 R 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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