the approach to the critically ill patient
DESCRIPTION
A. E. B. The approach to the critically ill patient. D. C. 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. - PowerPoint PPT PresentationTRANSCRIPT
The approach to the critically ill patient
Nick SmithClinical 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 approachAirway & oxygenation
Breathing & ventilation
Circulation & shock management
Disability due to neurological deterioration
Exposure & examination
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 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
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• Resp depressions• Muscle weakness• Exhaustion• Asthma• COPD• Infection
• Pulmonary oedema• Pulmonary embolus• ARDS• Pneumothorax• Haemothorax• Open pneumothorax• 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
• Loss of volume– Hypovolaemia
• Pump failure– Myocardial & non-
myocardial causes
• Vasodilatation– Sepsis, anaphylaxis,
neurogenic
BP = HR x SV x SVR
Inadequate tissue perfusion
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
ITUATION
ACKGROUND
SSESSMENT
ECCOMENDATION
Handover
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
Acute severe asthma
• 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
Any one of:• PEF 33 – 50% of best or predicted• RR> 24• HR> 110• Inability to complete sentences in 1 breath
HR
SVR
Life threatening asthma
• PEF <33%• SpO2 <92%• PaO2 <8 kPa• Normal PaCO2
– PaCO2 is a pre-terminal sign
• Silent chest• Cyanosis• Poor respiratory effort• Arrhythmias• Exhaustion / GCS
Severe asthma plus one of the following:
Get expert help quickly and treat as for acute severe asthma
HR
SVR
Sepsis
Signs and symptoms of infection (SSI) orSystemic 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
SVR
Severe Sepsis
• 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
• Bilirubin >34µmol/L• Platelets <100 x 109/L• Lactate>2 mmol/L• Coagulopathy – INR>1.5 or
APTT>60sec
SEPSIS + Organ dysfunction = SEVERE SEPSIS
• Fluids +++• Monitor lactate & Hb• Urinary Catheter &
hourly monitoring
HR
SVR
Anaphylaxis
• Get expert help quickly• Oxygen• IM adrenaline 500mcg
– repeat every 5 min if needed
Highly likely if…1. Sudden onset and rapid progression2. Life threatening problem to airway &/or breathing &/or
circulation3. Skin changes (rash or angioedema)+/- Exposure to known allergen
• Chlorphenamine 10mg IV
• Hydrocortisone 200mg IV
• +/- fluids +++
HR
SVR
Hypovolaemia
Haemorrhagic• External• Drains• GI tract• AbdomenTrauma• On the floor and 4 more
– Chest, abdo, pelvis, long bones
Fluid loss• D&V• Polyuria• Pancreatitis
Iatrogenic• Diuretics +++• Inadequate fluid
prescription
HR
SVR
Hypovolaemia
Responders Partial or transient responders
Non-responders
Patient improve and remains improved.
Patient improves but shows a gradual
deteriorationon-going loss or re-
equilibration
No improvement. Exsanguination though severe dehydration &
sepsis should be considered
No further boluses maybe needed but investigate cause
Further boluses and investigations
Further boluses and get help quickly
Give fluid challenge 250ml over 2 min and reassess after 5 min
Haemorrhagic shock Class I < 15%
<750mlClass II 15-30%750 – 1500ml
Class III 30 – 40%1500 – 2000ml
Class IV >40%>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
Confused or 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
Bradycardia
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
• Get expert help quickly!• Atropine 500 mcg IV
– Repeat to a max total dose of 3mg• External cardiac pacing
HR
SVR
Tachyarrhythmia
• 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
(*rate related symptoms are uncommon at less than 150 beats min-1)
HR
SVR