ABCDE The Safe Approach to the Critically Ill Patient Clinical Teaching Fellows

Objectives The rational of ABCDE The process of primary & secondary survey Recognition of life threatening events when you work in ED/AMU Handover: highlight your concern to the treating team

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 Circulation & shock management Disability due to neurological deterioration

The Safe Approach Primary survey using ABCDE Then secondary survey with traditional medical clerking this should you

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

Important First survey will allow you to decide to continue for second survey or ask for immediate senior review

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

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

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’

Details Observations on admission: Temperature 35.7 Heart Rate 94 BP 83/52 Respiratory Rate 24 O2 Saturations 96% on air. MEWS Score = 3

Mews Chart Score 3 2 1 Pulse Rate <40 - 40-50 51-100 101-110 Pulse Rate <40 - 40-50 51-100 101-110 111-129 =130->130 Resp Rate <8 8-20 21-25 26-30 >30 Temp °C =35 or <35 35.1-37.9 38-38.4 =38.5 or >38.5 AVPU New weakness New Confusion Alert Voice Pain Unresponsive Systolic BP <80 80-89 90 - 109 110 - 160 161 - 180 181 - 200 >200

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

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.

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

ABG result pH 7.028 pCO2 1.11 pO2 18.5 Base excess -27.4 HCO3 5.6

Impression… ‘Significant metabolic acidosis with attempt at respiratory compensation …secondary to acute kidney injury’ Na 127 K 7.2 Urea 39 Creatinine 900

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

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

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

A Airway - assessment Unresponsive Added sounds Accessory muscles Snoring, gurgling, wheeze, stridor, crowing Accessory muscles See-saw respiratory pattern If you find a life threatening abnormality, then call for help

Airway – interventions (basic) Head tilt chin lift Jaw thrust Suction Oral airways Nasal airways

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%

B Breathing - causes  GCS Muscle weakness Exhaustion Asthma/COPD Sepsis Pulmonary oedema Pulmonary embolus ARDS Pneumo/haemothorax

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 If you find a life threatening abnormality, then call for help

Breathing - interventions Consider ventilation with bag-valve mask if resp rate < 10 Position upright if struggling to breathe Specific treatment i.e.: β agonist for wheeze, chest drain for pneumothorax

Circulation - assessment Look at colour Examine peripheries Pulse, BP & central cap refill Hypotension (late sign) sBP< 100mmHg sBP < 20mmHg below pts norm  Urine output

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

Circulation - interventions Position supine with legs raised IV access - 16G or larger x2 +/- bloods if new cannula Fluid challenge Crystalloid 250-500ml bolus ECG Monitoring Specific treatment (eg IV antibiotics for sepsis) Consider catheterisation If you find a life threatening abnormality, then call for help

Disability – causes (AEIOU TIPS) Alcohol/acidosis Electrolytes/Epilepsy/Environmental/Electricity Insulin (hypoglycaemia) Oxygen (hypoxia) Uraemia Trauma Infection Poisons/psychosis Seizure/stroke/shock

Disability - assessment AVPU (or GCS) Alert, responds to Voice, responds to Pain, Unresponsive Pupil size/response Capillary blood glucose Pain relief If you find a life threatening abnormality, then call for help

Disability - interventions Optimise airway, breathing & circulation Treat underlying cause i.e.: naloxone for opiate toxicity Treat hypoglycaemia 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, rashes, swelling, sores, syringe drivers, catheter etc Keep warm Maintain dignity If you find a life threatening abnormality, then call for help

Secondary survey Detailed history Order investigations ABG, CXR, 12 lead ECG, Specific bloods Management plan including monitoring plan Referral Handover

Handover S ITUATION B ACKGROUND A SSESSMENT R ECOMMENDATION

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

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

Assessment A 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 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

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.

Questions ?