The approach to the critically ill patient

1. A E B The approach to the critically ill patient D C Nick Smith Clinical Skills

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

3. Traditional medical approach

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

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

6. 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

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

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

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

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

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

12. 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%

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

14. 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

15. 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

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

17. 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

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

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

20. Disability - assessment • AVPU (or GCS) • Alert, responds to Voice, responds to Pain, Unresponsive • Pupil size/response • Posture • BM • Pain relief D

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

22. 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

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

24. Handover S ITUATION B ACKGROUND A SSESSMENT R ECCOMENDATION

25. 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...

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

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

28. 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

29. Questions ?

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

31. 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

32. 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

33. 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

34. 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

35. 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 +++

36. 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 

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

38. 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

39. 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

40. 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)