ABCDE

The Safe Approach to the Critically Ill

Patient

Helen Pickard
Consultant Nurse Acute Medicine
Objectives

• The rational of ABCDE

• The process of primary & secondary survey
• Recognition of life threatening events when you work in
ED
• Handover: highlight your concern to the treating team
Traditional medical approach
 The ABCDE approach

Airway & oxygenation

Exposure & Breathing &

examination ventilation

Circulation &
Disability due to shock
neurological management
deterioration
 The Safe Approach

1. Primary survey using ABCDE

2. Then secondary survey with traditional medical
clerking
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
Important
• First survey will allow you to decide to continue for
second survey or ask for inmediate senior review
The secondary survey

• Performed when patient more stable

• Get a relevant history - PC, HPC, PMH, DH, SH, FH,
SR & examination
• More detailed examination of patient
• Order investigations to aid diagnosis
• Diagnosis/impression and plan
• IF PATIENT DETERIORATES RETURN TO PRIMARY
SURVEY
 Case Study
66 year old gentleman admitted to ED having become
generally unwell for 3 days. Vomiting all food and
fluids, and not passing much urine via ileoconduit
(previous Ca bladder with subsequent
cystoprostatectomy). Also complains of breathlessness
and anterior chest pain which he describes as sharp,
stabbing and worse on inspiration and cough.

Seen in ED by a medical student in the first instance

 Then…..
Subsequent Clinical Adverse Event report completed by
on call consultant read:

‘Admitted from GP referral to Emergency Department with

breathlessness. Initial observations showed tachypnoea
and hypotension 83/52. Managed for 3 ½ hours by a
first year clinical medical student with no medical input.
Asked by medical student if they could present the
case. Obviously unwell – urgent medical investigations
then arranged’
 Details
Observations on admission:
• Temperature 35.7
• Heart Rate 94
• BP 83/52
• Respiratory Rate 24
• O2 Saturations 96% on air.

• MEWS Score = 3
 Mews Chart
Score 3 2 1 0 1 2 3

Pulse <40 - 40-50 51-100 101- 111- =130-

Rate 110 129 >130
Resp <8 - - 8-20 21-25 26-30 >30
Rate
Temp - =35 or - 35.1- 38- =38.5 or -
°C <35 37.9 38.4 >38.5
New New Unrespon
AVPU weakness Confusion
- Alert Voice Pain sive

Systolic <80 80-89 90 - 110 - 161 - 181 - >200

BP 109 160 180 200
The ABCDE approach

Airway & oxygenation

Exposure & Breathing &

examination ventilation

Circulation &
Disability due to shock
neurological management
deterioration
 Registrar notes in Resus read…
A – airway patent. Talks short sentences due to ↑RR

B - kussmauls respiration, ↑↑RR, trachea central, chest

clear, no cyanosis, O2 sats 94% on 2l O2 via nasal
specs

C – HR 94 regular, peripherally cold, BP 83 systolic,

calves soft non-tender, no pedal oedema, heart sounds
normal, no urine output since admission.
D – AVPU = alert, GCS 15/15, BM 6.5

E – ileo-conduit noted, small amount of purulent urine in

bag approx 50mls, apyrexial, abdo soft and non-tender
 ABG result

pH 7.028
pCO2 1.11
pO2 18.5
Base excess -27.4
HCO3 5.6
 Impression…

‘Significant metabolic acidosis with attempt at respiratory

compensation …secondary to acute kidney injury’

Na 127
K 7.2
Urea 39
Creatinine 900
 Plan
• Aggressive IV fluid resuscitation
• Strict fluid balance
• Hourly urine output monitoring
• IV sodium bicarbonate
• Calcium gluconate, dextrose and insulin IV
• Renal team review
• For ITU
The ABCDE approach is paramount in
first assessmnet

Airway & oxygenation

Exposure & Breathing &

examination ventilation

Circulation &
Disability due to shock
neurological management
deterioration
Airway - causes

•  GCS
• Body fluids
• Foreign body
• Inflammation
• Infection
• Trauma
Airway - assessment

• Unresponsive
• Added sounds
– Snoring, gurgling, wheeze, stridor
• 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
• Sepsis • Flail chest
• Cardiac event
Breathing - assessment

• Look
– Rate (<10 or >20), symmetry, effort, SpO2, colour
• Listen
– Talking: 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
Circulation – shock

Inadequate tissue perfusion

• Loss of volume
– Hypovolaemia
• Pump failure
– Myocardial & non-myocardial
causes
• Vasodilatation
– Sepsis, anaphylaxis, neurogenic
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
• 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, rashes, swelling, sores, syringe drivers,
catheter etc
• Keep warm
• Maintain dignity
Secondary survey

• Detailed history
• Order investigations
– ABG, CXR, 12 lead ECG, Specific bloods
• Management plan including monitoring plan
• Referral
• Handover
Handover

ITUATION

ACKGROUND

SSESSMENT

ECCOMENDATION
Situation

• Check you are talking to the right person

• State your name & department
• I am calling about... (patient)
• The reason I am calling is...
Medical student in our case:
• Consultant on call
• I am a medical student in the acute block
• I went to review Mr…in cubicle 3
• I need you to review him as he is hypotensive tachypnoeic
and looks unwell
Background
• Admission diagnosis and date of admission
• Relevant medical history
• Brief summary of treatment to date
• Medical student in our case
• He was admitted today referred by his GP to ED:
unwell for 3 days vomiting all food and fluids
not passing much urine via ileoconduit
is breathlessness
has anterior chest sharp, stabbing and worse on
inspiration and cough
• Has had no treatment yet
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
• Medical student in our case
• I would like you to come and review him now
• Is there anything I should do?
• Record the name and contact of the person you have
spoken to
Summary

• Primary survey - ABCDE

• Call for senior review as a medical student and with you
senior support instigate treatments for life-threatening
problems as you find them – Get Involved
• Reassess following treatment
• If anything changes go back to A
• Secondary survey – detailed history and examination
• only after primary survey completed and only if the
patient is stable with MEWS 0.
Questions