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

36. Handover S
ITUATION B
ACKGROUND A
SSESSMENT R
ECCOMENDATION

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 ?