Abcde

ABCDE - The approach to the critically ill patient
Undergraduate Medical Education Nick Smith
www.cmft.nhs.uk/undergrad
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
The ABCDE approach

Airway & oxygenation
A
Exposure & examination
E
D C
Breathing & ventilation
Disability due to neurological deterioration www.cmft.nhs.uk/undergrad
Circulation & shock management
Ask 6 questions
1.
2.
3. 4.
5.
6.
Are they conscious? Do they have a patient airway? Is their breathing adequate? Is their circulation adequate? Are they neurologically intact? Is the rest of them ok?
If at any point the answer is NO then do something!

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 Treat life threatening conditions Rapid intervention including
15L O2 via a non-rebreathing mask IV access & fluid challenge
specific treatment
Re-assess after any intervention

The primary survey

No longer than 5 min Repeated as necessary Get experienced help Delegate jobs
1st person assess Airway, O2 & Breathing
2nd person assesses Circulation

3rd person IV access & fluids
The secondary survey

Performed when patient more stable Get a brief focused 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
Talking patients have a patent airway! Unresponsive patients have a threatened airway
Added sounds indicate partial obstruction

Snoring, gurgling, wheeze, stridor
Airway interventions (basic)

Head tilt chin lift Jaw thrust Suction Oral airways
Nasal airways
Airway interventions (advanced practitioners)

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 nonrebreathing mask For COPD patients re-assess after primary survey: keep SpO2 90-93%
Breathing - causes
GCS Resp depressions Muscle weakness Pulmonary oedema Pulmonary embolus ARDS
Exhaustion
Asthma
Pneumothorax
Haemothorax
COPD
Infection
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 BVM + O2 if RR < 8 Sit upright if conscious & SoB Specific treatment
i.e.: 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
Inadequate tissue perfusion
Loss of volume
Hypovolaemia
Pump failure
Myocardial & nonmyocardial causes
Vasodilatation
Sepsis, anaphylaxis, neurogenic
Compensation mechanism
PRE-LOAD Fluid Volume (CVP/JVP) Cardiac Output (SV x HR) AFTER-LOAD Vascular Diameter (SVR)
Loss of volume 1
PRE-LOAD Fluid Volume (CVP/JVP) 1 Cardiac Output (SV x HR) AFTER-LOAD Vascular Diameter (SVR)
Loss of volume 2
PRE-LOAD Fluid Volume (CVP/JVP) 1 Cardiac Output (SV x HR) 2 AFTER-LOAD Vascular Diameter (SVR)
Loss of volume 3
PRE-LOAD Fluid Volume (CVP/JVP) 1 Cardiac Output (SV x HR) 2 AFTER-LOAD Vascular Diameter (SVR) 3
Pump failure 1
PRE-LOAD Fluid Volume (CVP/JVP) Cardiac Output (SV x HR) 1 AFTER-LOAD Vascular Diameter (SVR)
Pump failure 2
PRE-LOAD Fluid Volume (CVP/JVP) Cardiac Output (SV x HR) 1 AFTER-LOAD Vascular Diameter (SVR) 2
Pump failure 3
Vasodilatation 1
PRE-LOAD Fluid Volume (CVP/JVP) Cardiac Output (SV x HR) AFTER-LOAD Vascular Diameter (SVR) 1
Vasodilatation 2
PRE-LOAD Fluid Volume (CVP/JVP) 2 Cardiac Output (SV x HR) AFTER-LOAD Vascular Diameter (SVR) 1
Vasodilatation 3
Circulation - interventions
Position supine with legs raised
Caution if DiB 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 benzos
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

Handover
Grab their attention by telling them the Situation Give them a little relevant Background on what's happened Tell them your Assessment of the patient Recommend to them what you want the to do
Situation
Check you are talking to the right person State your name & department
The headline grabber

I think this patient is haemorrhaging internally
Background
Admission diagnosis and date of admission Relevant medical history
Brief summary of treatment to date
Assessment
Your 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
CPR & Emergency Defibrillation

For OSCEs Nick Smith Head of Clinical Skills
Objectives
To be fully aware of the new CPR guidelines To have knowledge of the new ALS guidelines To be aware of the pitfalls
The station
Could just be CPR Could be just defibrillation Could be combined CPR with defib Maybe just you in the station or maybe an assistant (plus an examiner)
Basic Life Support

DANGER?
RESPONSE?
SHOUT 4 HELP OPEN AIRWAY CHECK BREATHING & CIRCULATION
GET HELP! 2222 (or 999)
30 CHEST COMPRESSIONS
ATTEMPT 2 BREATHS CONTINUE CPR 30:2 UNTIL DEFIB ARRIVES www.cmft.nhs.uk/undergrad
Assess the patient

DANGER?
Ask the examiner if it is safe to approach

RESPONSE?
Firmly shake the manikins shoulders and ask loudly are you alright
SHOUT 4 HELP
Shout loudly for someone to assist you

Look for signs of life

OPEN AIRWAY
An obvious headtilt/chin lift

CHECK BREATHING & CIRCULATION
Get close to the patient & look listen and feel for breathing At the same time feel for the carotid pulse Count out 10 second
Get expert help

GET HELP 2222 (or 999)
Send some one or leave the victim to call the resuscitation team (2222) State clearly Cardiac arrest; *location+ and repeat Return to the victim
Circulate oxygen
30 CHEST COMPRESSIONS
Heel of hands in middle of chest Interlock fingers and keep elbows locked Compress 5 6 cm Rate of 100 - 120 per min Allow chest to recoil
Reoxygenate
ATTEMPT 2 BREATHS
Assemble pocket mask Create a seal around the nose & mouth Open the airway Attempt 2 breaths If chest fails to rise go back to 30 chest compressions Continue CPR 30:2 Minimise interrutions
Keep them going!

CONTINUE CPR 30:2 UNTIL DEFIB ARRIVES
Get assistant to take over CPR where available Connect defib Turn defib on by turning the dial to ON
ALS algorithm
Analyse Rhythm
Shockable
VF/Puleless VT
Non- shockable
Asystole/PEA
1 shock
150 joules
Immediately resume
Return of spontaneous circulation

Immediate post arrest treatment
Assess using ABCDE approach Control oxygenation and ventilation 12-lead ECG Treat precipitating causes Temperature control / therapeutic hypothermia
Immediately resume
CPR 30:2 for 2 min

Minimise interruptions
CPR 30:2 for 2 min

Push drugs
when indicated
Push drugs
when indicated
Adrenaline 1mg & Amiodarone 300mg IV/IO after 3rd shock then repeat adrenaline after every alternate shock
Adrenaline 1mg (IV/IO) as soon as access obtained and then every alternate loop
Decide what rhythm they are in

Analyse Rhythm
Briefly pause CPR to assess rhythm Restart chest compressions Verbalise the rhythm to the examiner Shockable or non-shockable
Shockable
Analyse Rhythm
Shockable
VF/Puleless VT
VF
Bizzare, irregular
Pulseless VT
Rapid, regular, broad QRS
Deliver shock
Analyse Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Turn dial to 150 STAND CLEAR OXYGEN AWAY Push button 2 to charge When charged stop compressions SHOCKING Press button 3 to shock
Restart CPR
Analyse Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min

Push drugs
when indicated
Immediately resume CPR for 2 min Do not re-check rhythm! Minimise interruptions to CPR Only stop if patient shows obvious signs of life
During 2 min CPR

Time it out Ensure quality CPR Plan actions when interrupt CPR IV Access +/- fluids Ensure O2 via BVM Prepare drugs Consider reversible causes Hypovolaemia Hypoxia Hypo/er kalaemia Hypothermia Tension pneumothorax Tamponade (cardiac) Toxins Thrombus
After 2 min CPR

Analyse Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min

Re-analyse the rhythm If still shockable then repeat the process If not VF or VT then move to non-shockable side of algorythm
Push drugs
when indicated
After 3rd shock

Analyse Rhythm
Shockable
VF/Puleless VT
1 shock
150 joules
Immediately resume
CPR 30:2 for 2 min

Give 1mg adrenaline & 300mg amiodarone immediately after shock during CPR Repeat adrenaline after every alternate shock
Push drugs
when indicated
Non-shockable
Analyse Rhythm
Non- shockable
Asystole/PEA
Asystole
No electrical activity Occasionally P waves
PEA
Any non-shockable rhythm with a QRS complex and no pulse
Signs of life (SoL) check

Analyse Rhythm
Non- shockable
10sec only Dont check in asystole Only used to distinguish PEA from a perfusing rhythm
Asystole/PEA
Restart CPR
Analyse Rhythm
Non- shockable
Uninterrupted CPR for 2 min Do not re-check rhythm! Unless patient shows obvious signs of life
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min

Push drugs
when indicated
Drugs
Analyse Rhythm
Non- shockable
During CPR as soon as access available Adrenaline 1mg Repeat every alternate 2 min cycle
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min

Push drugs
when indicated
After 2min CPR

Analyse Rhythm
Non- shockable
Analyse rhythm If still non-shockable then repeat the process If shockable then go to shockable side of algorithm If SoL then reassess using A-E approach
Asystole/PEA
Immediately resume
CPR 30:2 for 2 min

Push drugs
when indicated
ALS algorithm
Analyse Rhythm
Shockable
VF/Puleless VT
Non- shockable
Asystole/PEA
1 shock
150 joules
Immediately resume
Return of spontaneous circulation

Immediate post arrest treatment
Assess using ABCDE approach Control oxygenation and ventilation 12-lead ECG Treat precipitating causes Temperature control / therapeutic hypothermia
Immediately resume
CPR 30:2 for 2 min

CPR 30:2 for 2 min

Push drugs
when indicated
Push drugs
when indicated
Adrenaline 1mg & Amiodarone 300mg IV/IO after 3rd shock then repeat adrenaline after every alternate shock
Adrenaline 1mg (IV/IO) as soon as access obtained and then every alternate loop
Questions
Summary
DRS ABC Get help CPR (minimise interruptions) Attach defib Analyse rhythm Shock (or dont) 2 min CPR (minimise interruptions) Reassess
Acute severe asthma SVR

Any one of: PEF 33 50% of best or predicted RR> 24 HR> 110 Inability to complete sentences in 1 breath
HR
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 preterminal sign
HR
Silent chest Cyanosis Poor respiratory effort Arrhythmias Exhaustion / GCS
Get expert help quickly and treat as for acute severe asthma
Sepsis
HR SVR
Signs and symptoms of infection (SSI) or Systemic Inflammatory Response (SIRs) Temperature > 38.2C or <36C 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 SSIs + suspicion of a new infection = SEPSIS
Severe Sepsis 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 >34mol/L Platelets <100 x 109/L Lactate>2 mmol/L Coagulopathy INR>1.5 or APTT>60sec
HR
Oxygen Blood cultures IV antibiotics (within 1 hour)
Fluids +++ Monitor lactate & Hb Urinary Catheter & hourly monitoring
AnaphylaxisSVR
Highly likely if 1. Sudden onset and rapid progression 2. Life threatening problem to airway &/or breathing &/or circulation 3. Skin changes (rash or angioedema) +/- Exposure to known allergen
HR
Get expert help quickly Oxygen IM adrenaline 500mcg

repeat every 5 min if needed
Chlorphenamine 10mg IV Hydrocortisone 200mg IV +/- fluids +++
Hypovolaemia SVR
Haemorrhagic External Drains GI tract Abdomen Trauma On the floor and 4 more
Chest, abdo, pelvis, long bones
HR
Fluid loss D&V Polyuria Pancreatitis Iatrogenic Diuretics +++ Inadequate fluid prescription
Hypovolaemia
Give fluid challenge 250ml over 2 min and reassess after 5 min Partial or transient responders Patient improve and Patient improves remains improved. but shows a gradual deterioration on-going loss or reequilibration No further boluses maybe needed but investigate cause Responders Non-responders
No improvement. Exsanguination though severe dehydration & sepsis should be considered Further boluses and Further boluses and investigations get help quickly
Haemorrhagic shock
Class I < 15% <750ml Class II 15-30% 750 1500ml Class III 30 40% 1500 2000ml Class IV >40% >2000ml
RR HR BP Pulse pressure
14-20 <100 Normal Normal
20-30 >100 Normal Decreased
30+ >120 Decreased Decreased
35+ >140 Decreased Decreased
Neuro
Urine Output
Slightly Anxious
> 30
Mildly anxious
20 30
Anxious or confused
5 - 15
Confused or lethargic
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
BradycardiaSVR
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
HR
Get expert help quickly! Atropine 500 mcg IV

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

Tachyarrhythmia SVR
Get expert help quickly Unstable*
Sedate and synchronised cardiovertion
HR
Stable SVT
Vagal manoeuvers Adenosine 6mg, 12mg, 12mg
Stable VT
Amiodarone 300mg 20 60 min
Stable tachy AF
Amiodarone 300mg 20 60 min if onset < 48hrs -blocker IV or digoxin IV
(*rate related symptoms are uncommon at less than 150 beats min-1)

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ABCDE - The approach to the critically ill patient

Undergraduate Medical Education Nick Smith

Traditional medical approach

The ABCDE approach

Breathing & ventilation

Disability due to neurological deterioration www.cmft.nhs.uk/undergrad

Circulation & shock management

If at any point the answer is NO then do something!

The primary survey

Re-assess after any intervention

The primary survey

2nd person assesses Circulation

The secondary survey

Added sounds indicate partial obstruction

Airway interventions (basic)

Airway interventions (advanced practitioners)

Once airway open...

Urine output Consider compensation mechanisms

IV access - 16G or larger x2

ECG Monitoring Specific treatment

Control seizures Seek expert help for CVA or ICP

Keep warm (unless post cardiac arrest)

Management plan Referral Handover

The headline grabber

Brief summary of treatment to date

CPR & Emergency Defibrillation

Basic Life Support

GET HELP! 2222 (or 999)

Assess the patient

Ask the examiner if it is safe to approach

Shout loudly for someone to assist you

Look for signs of life

An obvious headtilt/chin lift

Get expert help

Keep them going!

Return of spontaneous circulation

CPR 30:2 for 2 min

CPR 30:2 for 2 min

Decide what rhythm they are in

CPR 30:2 for 2 min

During 2 min CPR

After 2 min CPR

CPR 30:2 for 2 min

After 3rd shock

CPR 30:2 for 2 min

Signs of life (SoL) check

CPR 30:2 for 2 min

CPR 30:2 for 2 min

After 2min CPR

CPR 30:2 for 2 min

Return of spontaneous circulation

CPR 30:2 for 2 min

CPR 30:2 for 2 min

Acute severe asthma SVR

Nebulised salbutamol (5mg) - O2 driven

Nebulised ipratropium (500mcg) - O2 driven

Hydrocortisone 100mg IV or Prednisolone 50 60mg po MgSO4 IV 1.2 2g

Life threatening asthma SVR

Silent chest Cyanosis Poor respiratory effort Arrhythmias Exhaustion / GCS

Severe Sepsis SVR

Oxygen Blood cultures IV antibiotics (within 1 hour)

Get expert help quickly Oxygen IM adrenaline 500mcg

Chlorphenamine 10mg IV Hydrocortisone 200mg IV +/- fluids +++