ABCDE approach to the critically ill patient

Document Sample
ABCDE approach to the critically ill patient Powered By Docstoc
					The approach to the critically
         ill patient
           Nick Smith
          Clinical Skills
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




 Exposure &                                          Breathing &
 examination                                         ventilation




    Disability due to                          Circulation &
       neurological                            shock
       deterioration                           management
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 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
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
Airway - causes
•    GCS
•   Body fluids
•   Foreign body
•   Inflammation
•   Infection
•   Trauma
Airway - assessment
• Unresponsive
• Added sounds
  – Snoring, gurgling, wheeze, stridor
• Tracheal tug
• Accessory muscles
• See-saw respiratory pattern
Airway – interventions
(basic)
•   Head tilt chin lift
•   Jaw thrust
•   Suction
•   Oral airways
•   Nasal airways
Airway – interventions
(advanced)
• 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 non-
  rebreathing mask
• For COPD patients
  re-assess after the
  primary survey has
  been complete &
  keep Sats 90-93%
Breathing - causes
•    GCS              •   Pulmonary oedema
•   Resp depressions   •   Pulmonary embolus
•   Muscle weakness    •   ARDS
•   Exhaustion         •   Pneumothorax
•   Asthma             •   Haemothorax
•   COPD               •   Open pneumothorax
•   Infection          •   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 AMBU™ bag if
  resp rate < 10
• Position upright if
  struggling to breath
• Specific treatment
  – i.e.: β 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 & non-
     myocardial causes
• Vasodilatation
   – Sepsis, anaphylaxis,
     neurogenic
BP = HR x SV x SVR
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
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 benzo’s
• 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

           ITUATION




           ACKGROUND




           SSESSMENT




           ECCOMENDATION
Situation
•   Check you are talking o the right person
•   State your name & department
•   I am calling about... (patient)
•   The reason I am calling is...
Background
• Admission diagnosis and date of admission
• Relevant medical history
• Brief summary of treatment to date
Assessment
•   The 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
                                           HR
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

• Nebulised salbutamol     • Hydrocortisone 100mg
  (5mg) - O2 driven          IV or Prednisolone 50 –
   – Repeat as needed        60mg po
• Nebulised ipratropium    • MgSO4 IV 1.2 – 2g
  (500mcg) - O2 driven         – Seek guidance first
                                              HR
Life threatening asthma                      SVR


         Severe asthma plus one of the following:

•   PEF <33%                   •   Silent chest
•   SpO2 <92%                  •   Cyanosis
•   PaO2 <8 kPa                •   Poor respiratory effort
•   Normal PaCO2               •   Arrhythmias
     – PaCO2 is a pre-        •   Exhaustion / GCS
       terminal sign

    Get expert help quickly and treat as for acute severe
                          asthma
                                         HR
Sepsis                                  SVR


          Signs and symptoms of infection (SSI) or
           Systemic Inflammatory Response (SIRs)
•    Temperature > 38.2°C or <36°C
•    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 SSI’s + suspicion of a new infection = SEPSIS
                                          HR
Severe Sepsis                            SVR


      SEPSIS + Organ dysfunction = SEVERE SEPSIS
• BP < 90 systolic             •   Bilirubin >34µmol/L
• Acute alteration in mental   •   Platelets <100 x 109/L
  status                       •   Lactate>2 mmol/L
• O2 sats < 90%                •   Coagulopathy – INR>1.5 or
• UO < 0.5ml/kg/hr for 2           APTT>60sec
  hours

• Oxygen                       • Fluids +++
• Blood cultures               • Monitor lactate & Hb
• IV antibiotics (within 1     • Urinary Catheter &
  hour)                          hourly monitoring
                                          HR
Anaphylaxis                              SVR

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

• Get expert help quickly      • Chlorphenamine 10mg
• Oxygen                         IV
                               • Hydrocortisone 200mg
• IM adrenaline 500mcg           IV
   – repeat every 5 min if
                               • +/- fluids +++
     needed
                                        HR
Hypovolaemia                           SVR 


Haemorrhagic                    Fluid loss
• External                      • D&V
• Drains                        • Polyuria
• GI tract                      • Pancreatitis
• Abdomen
Trauma                          Iatrogenic
• On the floor and 4 more       • Diuretics +++
  – Chest, abdo, pelvis, long   • Inadequate fluid
    bones                          prescription
Hypovolaemia
Give fluid challenge 250ml over 2 min and reassess after 5 min
    Responders      Partial or transient     Non-responders
                        responders
Patient improve and Patient improves        No improvement.
 remains improved. but shows a gradual       Exsanguination
                       deterioration         though severe
                    on-going loss or re-     dehydration &
                       equilibration        sepsis should be
                                               considered
No further boluses   Further boluses and Further boluses and
maybe needed but        investigations     get help quickly
 investigate cause
Haemorrhagic shock
                   Class I < 15%    Class II 15-30%   Class III 30 – 40%    Class IV >40%
                      <750ml        750 – 1500ml       1500 – 2000ml          >2000ml
     RR              14-20             20-30                30+                 35+
     HR               <100              >100               >120                >140
     BP             Normal            Normal           Decreased            Decreased
Pulse pressure      Normal          Decreased          Decreased            Decreased

   Neuro         Slighty Anxious   Mildly anxious      Anxious or          Confused or
                                                       confused             lethargic
Urine Output          > 30            20 – 30              5 - 15          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
                                          HR
Bradycardia                               SVR


Adverse signs                  No adverse signs with a risk of
• BP                            asystole?
• HR < 40                      • Recent asystole
• Heart failure                • Mobitz II AV block
• Ventricular arrhythmias      • 3rd degree HB w QRS
  compromising BP              • QRS pauses > 3 sec

• Get expert help quickly!
• Atropine 500 mcg IV
    – Repeat to a max total dose of 3mg
• External cardiac pacing
                                             HR
Tachyarrhythmia                              SVR


• Get expert help quickly          • Stable SVT
• Unstable*                            – Vagal manoeuvers
   – Sedate and synchronised           – Adenosine 6mg, 12mg,
     cardiovertion                       12mg
• Stable VT                        • Stable tachy AF
   – Amiodarone 300mg 20 –             – Amiodarone 300mg 20 –
     60 min                              60 min if onset < 48hrs
                                       – Β-blocker IV or digoxin IV




 (*rate related symptoms are uncommon at less than 150 beats min-1)

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:613
posted:4/7/2010
language:English
pages:40