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

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The approach to the critically ill patient

A

E

B

The approach to the critically ill patient

D

C

Nick Smith

Clinical Skills


Objectives

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

Traditional medical approach


The abcde approach

The ABCDE approach

A

E

B

Airway & oxygenation

D

C

Exposure & examination

Breathing & ventilation

Disability due to neurological deterioration

Circulation & shock management


The principles

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

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

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

Airway - causes

A

  •  GCS

  • Body fluids

  • Foreign body

  • Inflammation

  • Infection

  • Trauma


Airway assessment

Airway - assessment

A

  • Unresponsive

  • Added sounds

    • Snoring, gurgling, wheeze, stridor

  • Tracheal tug

  • Accessory muscles

  • See-saw respiratory pattern


Airway interventions basic

Airway – interventions(basic)

A

  • Head tilt chin lift

  • Jaw thrust

  • Suction

  • Oral airways

  • Nasal airways


Airway interventions advanced

Airway – interventions(advanced)

A

  • GET HELP!!!

  • Nebulised adrenaline for stridor

  • LMA

  • Intubation

  • Cricothyroidotomy

    • Needle or surgical


Once airway open

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%


Breathing causes

Breathing - causes

B

  •  GCS

  • Resp depressions

  • Muscle weakness

  • Exhaustion

  • Asthma

  • COPD

  • Infection

  • Pulmonary oedema

  • Pulmonary embolus

  • ARDS

  • Pneumothorax

  • Haemothorax

  • Open pneumothorax

  • Flail chest


Breathing assessment

Breathing - assessment

B

  • 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

Breathing - interventions

B

  • 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

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


Circulation shock

Circulation – shock

  • Loss of volume

    • Hypovolaemia

  • Pump failure

    • Myocardial & non-myocardial causes

  • Vasodilatation

    • Sepsis, anaphylaxis, neurogenic

Inadequate tissue perfusion

C

BP = HR x SV x SVR


Circulation interventions

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


Disability causes

Disability - causes

  • Inadequate perfusion of the brain

  • Sedative side effects of drugs

  •  BM

  • Toxins and poisons

  • CVA

  •  ICP

D


Disability assessment

Disability - assessment

  • AVPU (or GCS)

    • Alert, responds to Voice, responds to Pain, Unresponsive

  • Pupil size/response

  • Posture

  • BM

  • Pain relief

D


Disability interventions

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


Exposure

Exposure

E

  • 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

Secondary survey

  • Repeat ABCDE in more detail

  • History

  • Order investigations

    • ABG, CXR, 12 lead ECG, Specific bloods

  • Management plan

  • Referral

  • Handover


Handover

Handover

S

ITUATION

B

ACKGROUND

A

SSESSMENT

R

ECCOMENDATION


Situation

S

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

B

Background

  • Admission diagnosis and date of admission

  • Relevant medical history

  • Brief summary of treatment to date


Assessment

A

Assessment

  • The assessment of the patient using the ABCDE approach


Recommendation

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


Questions

Questions

?


Summary

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


Acute severe asthma

Nebulised salbutamol (5mg) - O2 driven

Repeat as needed

Nebulised ipratropium (500mcg) - O2 driven

Hydrocortisone 100mg IV or Prednisolone 50 – 60mg po

MgSO4 IV 1.2 – 2g

Seek guidance first

Acute severe asthma

HR

SVR

  • Any one of:

  • PEF 33 – 50% of best or predicted

  • RR> 24

  • HR> 110

  • Inability to complete sentences in 1 breath


Life threatening asthma

PEF <33%

SpO2 <92%

PaO2 <8 kPa

Normal PaCO2

PaCO2 is a pre-terminal sign

Silent chest

Cyanosis

Poor respiratory effort

Arrhythmias

Exhaustion / GCS

Life threatening asthma

HR

SVR

Severe asthma plus one of the following:

Get expert help quickly and treat as for acute severe asthma


Sepsis

Sepsis

HR

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


Severe sepsis

Oxygen

Blood cultures

IV antibiotics (within 1 hour)

BP < 90 systolic

Acute alteration in mental status

O2 sats < 90%

UO < 0.5ml/kg/hr for 2 hours

Severe Sepsis

HR

SVR

SEPSIS + Organ dysfunction = SEVERE SEPSIS

  • Bilirubin >34µmol/L

  • Platelets <100 x 109/L

  • Lactate>2 mmol/L

  • Coagulopathy – INR>1.5 or APTT>60sec

  • Fluids +++

  • Monitor lactate & Hb

  • Urinary Catheter & hourly monitoring


Anaphylaxis

Get expert help quickly

Oxygen

IM adrenaline 500mcg

repeat every 5 min if needed

Highly likely if…

Sudden onset and rapid progression

Life threatening problem to airway &/or breathing &/or circulation

Skin changes (rash or angioedema)

+/- Exposure to known allergen

Anaphylaxis

HR

SVR

  • Chlorphenamine 10mg IV

  • Hydrocortisone 200mg IV

  • +/- fluids +++


Hypovolaemia

Haemorrhagic

External

Drains

GI tract

Abdomen

Trauma

On the floor and 4 more

Chest, abdo, pelvis, long bones

Fluid loss

D&V

Polyuria

Pancreatitis

Iatrogenic

Diuretics +++

Inadequate fluid prescription

Hypovolaemia

HR

SVR 


Hypovolaemia1

Hypovolaemia

Give fluid challenge 250ml over 2 min and reassess after 5 min


Haemorrhagic shock

Haemorrhagic shock

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


Bradycardia

Adverse signs

BP

HR < 40

Heart failure

Ventricular arrhythmias compromising BP

No adverse signs with a risk of asystole?

Recent asystole

Mobitz II AV block

3rd degree HB w QRS

QRS pauses > 3 sec

Bradycardia

HR

SVR

  • Get expert help quickly!

  • Atropine 500 mcg IV

    • Repeat to a max total dose of 3mg

  • External cardiac pacing


Tachyarrhythmia

Get expert help quickly

Unstable*

Sedate and synchronised cardiovertion

Stable VT

Amiodarone 300mg 20 – 60 min

Stable SVT

Vagal manoeuvers

Adenosine 6mg, 12mg, 12mg

Stable tachy AF

Amiodarone 300mg 20 – 60 min if onset < 48hrs

Β-blocker IV or digoxin IV

Tachyarrhythmia

HR

SVR

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


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