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

History
Examination
Differential
Investigations
Diagnosis
Treatment
 The ABCDE approach

Airway & oxygenation

A
Exposure &
examination E B Breathing &
ventilation

Circulation &
Disability due to
neurological
deterioration
D C shock
management
 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 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

AVPU New New - Alert Voice Pain Unrespon

weakness Confusion sive

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

BP 109 160 180 200
The ABCDE approach

Airway & oxygenation

A
Exposure &
examination E B Breathing &
ventilation

Circulation &
Disability due to
neurological
deterioration
D C shock
management
 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

A
Exposure &
examination E B Breathing &
ventilation

Circulation &
Disability due to
neurological
deterioration
D C shock
management
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.: 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 Mrin 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