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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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


The ABCDE approach

A

E

B

Airway & oxygenation

D

C

Exposure & examination

Breathing & ventilation

Disability due to neurological deterioration

Circulation & shock 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

A

  •  GCS

  • Body fluids

  • Foreign body

  • Inflammation

  • Infection

  • Trauma


Airway - assessment

A

  • Unresponsive

  • Added sounds

    • Snoring, gurgling, wheeze, stridor

  • Tracheal tug

  • Accessory muscles

  • See-saw respiratory pattern


Airway – interventions(basic)

A

  • Head tilt chin lift

  • Jaw thrust

  • Suction

  • Oral airways

  • Nasal airways


Airway – interventions(advanced)

A

  • GET HELP!!!

  • Nebulised adrenaline for stridor

  • LMA

  • Intubation

  • Cricothyroidotomy

    • Needle or surgical


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

B

  •  GCS

  • Resp depressions

  • Muscle weakness

  • Exhaustion

  • Asthma

  • COPD

  • Infection

  • Pulmonary oedema

  • Pulmonary embolus

  • ARDS

  • Pneumothorax

  • Haemothorax

  • Open pneumothorax

  • Flail chest


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

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

  • 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

  • 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

  • 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

  • Inadequate perfusion of the brain

  • Sedative side effects of drugs

  •  BM

  • Toxins and poisons

  • CVA

  •  ICP

D


Disability - assessment

  • AVPU (or GCS)

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

  • Pupil size/response

  • Posture

  • BM

  • Pain relief

D


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

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

  • Repeat ABCDE in more detail

  • History

  • Order investigations

    • ABG, CXR, 12 lead ECG, Specific bloods

  • Management plan

  • Referral

  • Handover


Handover

S

ITUATION

B

ACKGROUND

A

SSESSMENT

R

ECCOMENDATION


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...


B

Background

  • Admission diagnosis and date of admission

  • Relevant medical history

  • Brief summary of treatment to date


A

Assessment

  • 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


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


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


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

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


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


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 +++


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 


Hypovolaemia

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


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


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


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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