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
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 O 2, 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
• Acute alteration in mental
status
• O2 sats < 90%
• UO < 0.5ml/kg/hr for 2
hours
• Bilirubin >34µmol/L
• Platelets <100 x 109/L
• Lactate>2 mmol/L
• Coagulopathy – INR>1.5 or
APTT>60sec

• 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
• IM adrenaline 500mcg • Hydrocortisone 200mg
IV
– repeat every 5 min if
needed • +/- fluids +++
 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 but No improvement.
remains improved. shows a gradual Exsanguination
deterioration though severe
on-going loss or re- dehydration & sepsis
equilibration 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)