The ABCDE approach to assessment Workshop Version: Jan 2016

Learning outcomes At the end of this workshop candidates should be able to: use a structured approach to provide a handover apply the ABCDE approach when assessing and treating a deteriorating patient identify and treat life-threatening problems as they are found recognise when to call for help/escalate/refer to a specialist

Communication use a simple and reliable structure convey only important facts and degree of urgency ISBARRSVP Identify SituationReason BackgroundStory AssessmentVital signs RecommendationPlan

Assessment Use the ABCDE approach: Airway Breathing (ventilation) Circulation Disability (neurological status) Exposure (including temperature) Treat life-threatening problems as they are discovered

Clinical setting and history IYou have received a call from a nurse SRequesting urgent help with a patient no longer tolerating NIV BBernard is aged 75, a life-long heavy smoker and he was admitted yesterday with an infective exacerbation of COPD, and was started on non-invasive ventilation (NIV) AHe is unresponsive, hardly breathing, appears blue and the NIV mask is on the floor RHe needs urgent assessment Case 1

Case 1 (continued) Airway Assessment – snoring-like noises – using accessory muscles He has signs of airway obstruction Treatment/Action – head tilt, chin lift – attempt insertion of airway adjunct – high flow oxygen via facemask Response – snoring noise clears – see-saw movement stops – airway not tolerated

Breathing Assessment – centrally cyanosed – R - RR 10 min -1 – A - wheezes heard bilaterally – coarse crackles at left lung base – T - Nil – E - accessory muscle use – paradoxical movement of chest and abdomen – S - SpO 2 84% on high flow oxygen He requires urgent support of his ventilation Case 1 (continued) Treatment/Action – ventilation started with bag mask and oxygen – expert help/resuscitation team called Response – SpO 2 improves to 89%

Case 1 (continued) Circulation Assessment – Cool, clammy peripheries – radial pulse ‘bounding’, regular 110 min -1 – BP 135/95 mmHg, CRT <2 s He looks as though he may be severely hypercapnic Treatment/Action – IV cannulation, fluids started slowly – arterial blood sample taken Response – no change

Case 1 (continued) Disability Assessment – responds to voice by lifting his head – pupils equal, react to light – blood glucose 6.4 mmol L -1 Treatment/Action – nil Response – no change Exposure Assessment – temperature 36.8 ˚C Treatment/Action – nil Response – N/A Plan: He requires urgent critical care review

Clinical setting and History IStaff calling requesting urgent assistance SA patient observations have triggered an escalation in care is required BMary was admitted last night with abdominal pain AShe has a rapid weak pulse, an increased respiratory rate, and is unresponsive to voice RMary requires an immediate assessment Case 2

Case 2 (continued) Airway Assessment – making snoring noises – increased effort to breathe – see-saw movement of abdomen She has signs of airway obstruction Treatment/Action – head tilt, chin lift – oropharyngeal airway – nasopharyngeal airway – high flow oxygen via facemask Response – oropharyngeal airway not tolerated – nasopharyngeal airway tolerated – snoring noise clears – see-saw movement stops

Case 2 (continued) Breathing Assessment – R - RR 28 min -1 – A - bilateral reduced chest expansion and breath sounds – percussion note resonant L=R – T - nil – E - increased effort – S - SpO 2 poor signal Treatment/Action – continue high flow oxygen Response – no change – SpO 2 eventually displays 97%

Case 2 (continued) Circulation Assessment – cool peripheries – radial pulse is absent – low volume, regular carotid pulse rate 110 min -1 – BP 75/40 mmHg – CRT >6 s She has signs of hypovolaemia Treatment/Action – IV access obtained – blood sample taken – IV fluid bolus 500mL given – expert help/resuscitation team called Response – radial pulse present

Case 2 (continued) Disability Assessment – responds to pain with a grimace – pupils equal, react to light – blood glucose 4.8 mmol L -1 Treatment/Action – urgent critical care review Response – no change Exposure Assessment – no bleeding or rashes – cold and clammy centrally – warmer peripherally – temp 37.8 ˚C Treatment/action – nil Response – no change Plan: Start treatment for sepsis

Case 2 (continued) Treatment for sepsis: – high flow oxygen – initiate fluid resuscitation – take blood cultures – give appropriate antibiotics – measure lactate – measure urine output

Clinical setting and history I You receive a call from a junior colleague SAsking you to review urgently a 35-year-old man with a decreased consciousness BUndergoing preparation for colonoscopy tomorrow, insulin controlled diabetic with chronic renal impairment AHe has been increasingly confused this morning RPlease assess her immediately Case 3

Case 3 (continued) Airway Assessment – clear airway – no abnormal sounds – dry lips/mouth There is no evidence of airway obstruction Treatment/Action – high flow oxygen considered Response – no change

Case 3 (continued) Breathing Assessment – R - RR 28 min -1 – A - normal, symmetrical chest expansion, breath sounds and percussion note – T - nil – E – no increased effort – S - SpO 2 100% on high flow oxygen His SpO 2 indicates that the oxygen concentration could be reduced Treatment – inspired oxygen concentration reduced Response – SpO 2 96%

Case 3 (continued) Circulation Assessment – regular radial pulse - rate 90 min -1 – BP 120/55 mmHg – CRT <2 s – normal heart sounds – ECG monitor Treatment/Action – IV access obtained – IV fluids considered – blood samples taken – 12-lead ECG requested Response – await results

Case 3 (continued) Disability Assessment – A V PU - confused/drowsy – pupils equal, react to light – blood glucose 23.6 mmol L -1 – no insulin given today – keytones present in urine – previous bloods (from records) Creatanine 186 μmol L -1 (60 – 110) K mmol L -1 (3.5-5) Treatment/Action – insulin – fluids – follow local DKA protocol – consider obtaining second IV access Response – next glucose 17.6 mmol L -1 – conscious level improving Plan: Requires urgent ICU review

Case 3 (continued) Exposure Assessment – warm dry skin – reduced skin turgor – no bleeding or rashes – temperature 36.2 C Treatment/action – nil Response – no change

Any questions?

Summary You should now be able to: use a structured approach when giving a handover apply the ABCDE approach to a deteriorating patient identify and treat life-threatening problems as they are found recognise when to call for help/escalate/refer to specialist

Advanced Life Support Level 2 Course Slide set All rights reserved © Australian Resuscitation Council (June 2016)