structured approach for critically ill patient
DESCRIPTION
د/ماجد الوراقي Structured approach for critically ill patient المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب و ضمن موديول الطوارئ و التخدير و العناية المركزةTRANSCRIPT
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Structured Approach to critically ill patient
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1) Who is the critically ill patient
2) Importance of early recognition of the critically ill pt.
3) Causes of cardiac arrest
4) Identify and treat pt. at risk of cardiac arrest using the ABCDE approach
Objectives
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Critically ill patient
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Early recognition prevents:• Cardiac arrests and deaths• Admissions to ICU• Inappropriate resuscitation attempts
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Early recognition of critically ill pt.
• Most arrests are predictable
• Deterioration prior to 50 - 80% of cardiac arrests
• Hypoxia and hypotension are common antecedents
• Delays in referral to higher levels of care
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Main Enemy in ER
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Rules of this approach
• Complete initial assessment
• Treat first what kills first
• Assess effects of treatment/interventions
• Reassessment
• Call for help early
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The ABCDE approach to the deteriorating patient
Airway BreathingCirculationDisabilityExposure
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Initial assessment
• Personal safety
• Patient responsiveness
• First impression
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Assess – Treat – Reassess
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ABCDE approach: Airway
• CNS depression• Blood • Vomit • Foreign body
• Infection • Inflammation • Laryngospasm • Bronchospasm
Causes of airway obstruction:
• Trauma• Compression
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Recognition of airway obstruction
ABCDE approach: Airway
Talk to the pt.
ObstructedClear & Patent At risk
& LOOK , LISTEN , FEEL
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Treatment of airway obstructionObstructedClear & Patent At risk
Suction
Maintain Maintain
open airway
ABCDE approach: Airway
No Action
Opening Airway Head-tilt chain-lift Jaw thrust
Maintaining airway Basic adjunct (OPA – NPA ) Supraglottic devices ( LMA ) Definitive airway ( ETT )
O2
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• Decreased respiratory effort– Muscle weakness – Nerve damage– Restrictive chest defect
– Pain from fractured ribs
• Lung disorders – Pneumothorax– Haemothorax – Infection– Acute exacerbation COPD– Asthma– Pulmonary embolus– ARDS
Causes of breathing problems
ABCDE approach: Breathing
• Decreased respiratory drive – CNS depression
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ABCDE approach: Breathing
Recognition of breathing problemsInspection RR Expansion Wounds , Bruises, Etc….
Palpation Confirm Expansion Tenderness , surgical emphysema Trachea
Percussion Note Equality
Auscultation Equality Additional Sounds
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• Airway
• Oxygen
• Treat underlying cause– e.g. drain pneumothorax
• Support breathing if inadequate – e.g. ventilate with bag-mask
• Establish continuous monitoring
ABCDE approach: Breathing
Treatment of breathing problems
SpO2
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ABCDE approach: Breathing
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Primary– Acute coronary syndromes– Arrhythmias– Hypertensive heart disease– Valve disease– Hereditary cardiac diseases– (Drugs)– (Electrolyte/acid base
abnormalities)
Secondary – Asphyxia– Hypoxaemia– Blood loss– Hypothermia– Septic shock– (Drugs)– (Electrolyte/acid
base abnormalities)
Causes of circulation problems
ABCDE approach: Circulation
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Recognition of circulation problemsPulse Central Central-to-Peripheral Peripheral-to-Peripheral HR Volume Regularity
BP Hypertensive Normotensive Hypotensive
Perfusion CRT (N <2 sec )
ABCDE approach: Circulation
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• Airway, Breathing• Oxygen• Treat cause ( Stop Haemorrhage )• Fluid challenge ( Normal saline , Ringer
lactate )• Inotropes/vasopressors
ABCDE approach: Circulation
Treatment of circulation problems
• IV/IO access, take bloods• Establish ECG monitoring
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Recognition
• AVPU or GCS• Pupils• Lateralising signs
ABCDE approach: Disability
Blood glucose
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Treatment
• ABC• Treat underlying cause• Blood glucose– If < 72 mg/dcl ( 4 mmol/L) give glucose
ABCDE approach: Disability
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• Remove clothes to enable examination– e.g. injuries, bleeding, rashes
• Avoid heat loss
• Maintain dignity
ABCDE approach: Exposure
Sheet
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Item Recognition Intervention Aid
ALook , Listen , Feel
Patent & ClearAt riskObstructed
NothingSuction + MaintainOpen + Maintain O2 Supply
Titrate 94% - 99/&
BInspection RR Expansion Wounds , Bruises, Etc….Palpation Confirm Expansion Tenderness , surgical emphysemaPercussion Note EqualityAuscultation Equality Additional Sounds
Consider Assisted Ventilation SpO2
CPulse Central Central-to-Peripheral Peripheral-to-Peripheral HR Volume RegularityBP Hypertensive Normotensive HypotensiveCRT
Fluids Cannula( Draw Samples first )ECG Monitor
DConsciousness GCS AVPUPupil
RBG (bedside)
EAffected area Full Exposure Unexplained
Polytrauma Pt. Sheet to cover the pt.
ABCDE approach
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Handover
SBAR
Situation Doctor & Pt. data
Background History
Assessment ABCDE approach Interventions Investigations
Recommendation what I want from you
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Any Question ?!
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1) Who is the critically ill patient2) Importance of early recognition of the
critically ill pt.3) Causes of cardiac arrest4) Identify and treat pt. at risk of cardiac arrest
using the ABCDE approach
Summary