The approach to the critically ill patient B C D E The approach to the critically ill patient Nick Smith Clinical 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 History Examination Differential Investigations Diagnosis Treatment

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

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

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

A Airway - assessment Unresponsive Added sounds Tracheal tug 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

A 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%

B 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

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

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

D 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

E 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

Handover S ITUATION B ACKGROUND A SSESSMENT R ECCOMENDATION

S Situation Check you are talking o the right person State your name & department I am calling about... (patient) The reason I am calling is...

B Background Admission diagnosis and date of admission Relevant medical history Brief summary of treatment to date

A Assessment The assessment of the patient using the ABCDE approach

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

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

Life threatening asthma SVR Severe asthma plus one of the following: PEF <33% SpO2 <92% PaO2 <8 kPa Normal PaCO2 PaCO2 is a pre-terminal sign Silent chest Cyanosis Poor respiratory effort Arrhythmias Exhaustion / GCS Get expert help quickly and treat as for acute severe asthma

Sepsis Signs and symptoms of infection (SSI) or HR SVR Signs and symptoms of infection (SSI) or Systemic 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

SEPSIS + Organ dysfunction = SEVERE SEPSIS HR SVR SEPSIS + Organ dysfunction = SEVERE SEPSIS 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 Oxygen Blood cultures IV antibiotics (within 1 hour) Fluids +++ Monitor lactate & Hb Urinary Catheter & hourly monitoring

Anaphylaxis Get expert help quickly Oxygen IM adrenaline 500mcg HR SVR Highly likely if… Sudden onset and rapid progression Life threatening problem to airway &/or breathing &/or circulation Skin changes (rash or angioedema) +/- Exposure to known allergen Get expert help quickly Oxygen IM adrenaline 500mcg repeat every 5 min if needed Chlorphenamine 10mg IV Hydrocortisone 200mg IV +/- fluids +++

Hypovolaemia Haemorrhagic External Drains GI tract Abdomen Trauma HR SVR  Haemorrhagic External Drains GI tract Abdomen Trauma On the floor and 4 more Chest, abdo, pelvis, long bones Fluid loss D&V Polyuria Pancreatitis Iatrogenic Diuretics +++ Inadequate fluid prescription

Hypovolaemia Give fluid challenge 250ml over 2 min and reassess after 5 min Responders Partial or transient responders Non-responders Patient improve and remains improved. Patient improves but shows a gradual deterioration on-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

Figures based on a young healthy adult with a compressible haemorrhage Haemorrhagic shock Class I < 15% <750ml Class 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 Decreased Pulse pressure 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 Get expert help quickly! Atropine 500 mcg IV HR SVR 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

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