ABCDE approach to the critically ill patient by sdfwerte

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									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)

								
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