Abcde approach-to-the-critically-ill-patient

Critical care medicine specializes in caring for the most seriously ill patients. These patients are best treated in an intensive care unit (ICU) staffed by experienced personnel. Some hospitals maintain separate units for special populations (eg, cardiac, trauma, surgical, neurologic, pediatric, or neonatal patients). ICUs have a high nurse:patient ratio to provide the necessary high intensity of service, including treatment and monitoring of physiologic parameters.

1. The approach to the critically ill patient A B C D E

2. Objectives The rational of ABCDE The process of primary & secondary survey Recognition of life threatening events Treatment of life-threatening conditions Handover 2

3. Traditional medical approach 3 3

4. The ABCDE approach Airway & oxygenation Breathing & ventilation Circulation & shock management Disability due to neurological deterioration Exposure & examination E D C A B 4 4

5. 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 5 5

6. The primary survey ABCDE assessment looking for immediately life threatening conditions Rapid intervention usually includes max O 2 , 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 6 6

7. 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 7 7

8. Airway - causes  GCS Body fluids Foreign body Inflammation Infection Trauma A 8 8

9. Airway - assessment Unresponsive Added sounds Snoring, gurgling, wheeze, stridor Tracheal tug Accessory muscles See-saw respiratory pattern A 9 9

10. Airway – interventions (basic) Head tilt chin lift Jaw thrust Suction Oral airways Nasal airways A 10 10

11. Airway – interventions (advanced) GET HELP!!! Nebulised adrenaline for stridor LMA Intubation Cricothyroidotomy Needle or surgical A 11 11

12. 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% A 12 1 2

13. Breathing - causes  GCS Resp depressions Muscle weakness Exhaustion Asthma COPD Infection Pulmonary oedema Pulmonary embolus ARDS Pneumothorax Haemothorax Open pneumothorax Flail chest B 13 13

14. Breathing - assessment Look Rate (<10 or >20), symmetry, effort, SpO 2 , colour Listen Taking: sentences, phrases, words Bilateral air entry, wheeze, silent chest other added sounds Feel Central trachea, Percussion, expansion B 14 14

15. 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 B 15 15

16. 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 16 16

17. Circulation – shock Loss of volume Hypovolaemia Pump failure Myocardial & non-myocardial causes Vasodilatation Sepsis, anaphylaxis, neurogenic C BP = HR x SV x SVR Inadequate tissue perfusion 17 17

18. 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 C 18 18

19. Disability - causes Inadequate perfusion of the brain Sedative side effects of drugs  BM Toxins and poisons CVA  ICP D 19 19

20. Disability - assessment AVPU (or GCS) A lert, responds to V oice, responds to P ain, U nresponsive Pupil size/response Posture BM Pain relief D 20 2

21. 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 D 21 2 1

22. 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 E 22 2 2

23. Secondary survey Repeat ABCDE in more detail History Order investigations ABG, CXR, 12 lead ECG, Specific bloods Management plan Referral Handover 23 2 3

24. S B A R ITUATION ACKGROUND SSESSMENT ECCOMENDATION Handover 24 2 4

25. Situation Check you are talking o the right person State your name & department I am calling about... (patient) The reason I am calling is... S 25 2 5

26. Background Admission diagnosis and date of admission Relevant medical history Brief summary of treatment to date B 26 2 6

27. Assessment The assessment of the patient using the ABCDE approach A 27 2 7

28. 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 R 28 2 8

29. Questions ? 29 2 9

30. 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 30 30