Table of Contents AirwayAssessment Management Breathing Assessment Management Circulation Assessment ManagementDisabilityAssessment Management Everything else Assessment Management Investigations to find cause Condition specific treatment Request help as required Document in patient’s notes Test your knowledgeScenario 1Scenario 2Scenario 3Try some full A-E OSCE stations When to use an ABCDE assessment This protocol should be used for critically ill patients. For example those with very unstable observations or reduced GCS. Airway Assessment It’s patent if the patient can talk and breathing is not noisy It’s not if: there are secretions; the patient has aspirated; is snoring/ GCS<8; or stridor is present Look inside the mouth – are there any obstructions? Is there mucosal oedema? Management Consider: Remove dentures/debris (Magill forceps are in crash trolley) Suction Airway opening manoeuvres (e.g. jaw-thrust or head-tilt/chin lift) Recovery position if vomiting/aspiration risk Oropharyngeal / nasopharyngeal airways Intubation (if GCS <8) Cricothyroidotomy may be required in upper airway obstruction where intubation is not possible Treat cause Treat any evident causes (e.g. anaphylaxis, foreign body) Breathing Assessment Pulse oximetry Respiratory rate Chest exam Cyanosis Tracheal deviation Chest inspection (accessory muscle use, deformities) Expansion Percussion Auscultation Calves Tests ABG (if low saturations or low GCS) CXR (if lung pathology suspected) Management 15L/minute O2 via non-rebreather mask WARNING: take care if COPD (unless they are in respiratory distress/critically unwell and need high-flow oxygen, start at 24-28% venturi and aim for sats 88-92%. Titrate to ABG results. See notes on oxygen therapy.) Consider non-invasive or invasive ventilation if hypoxaemic, or hypercapnic respiratory acidosis despite maximal therapy If respiratory effort is inadequate, it must be supported (e.g. ventilate with bag-mask) Treat cause Treat any evident causes (e.g. pneumothorax, asthma/COPD exacerbation, opiate overdose, PE) Circulation Assessment Capillary refill (central) Pulse rate, rhythm and volume Blood pressure (look at trend) Temperature Auscultate heart, check JVP and look for signs of fluid overload Assess fluid balance and organ perfusion (IN e.g. fluids, intake; OUT e.g. catheter/urine, drains, vomit) Tests Place wide-bore IV Cannula and take bloods (also do VBG for fast results if ABG not required) Apply 3-lead cardiac monitoring ECG (if any concern) Catheter and fluid balance monitoring (if hypotensive/unwell) Management Hypotension Lay supine and elevate legs Fluid challenge = 500ml 0.9% saline/Hartmann’s solution STAT and monitor response by HR, BP and UO (see prescribing notes on fluids) WARNING: take care if significant heart failure history (use 250ml if they need it) Shock 2 large bore IV cannulas Fluid challenge = 1L 0.9% saline/Hartmann’s solution STAT Replace blood with blood (can give O negative or urgent typing takes 15 minutes). In massive blood loss, call 2222/lab and activate the massive blood loss protocol to get packed red cells + FFP ± platelets Further management– use clinical judgement and assessment of fluid status Respond fully: consider maintenance fluids Responds but BP falls again: may require further fluids (adequate resuscitation depends on patient and degree of deficit but is usually 20-30ml/kg given quickly) No response: patient may be fluid overloaded/in cardiogenic shock (avoid further fluids) or very deplete (requiring further fluids) Escalation If patient is hypotensive and overloaded, they need inotropes If patient is still hypotensive despite adequate fluid resuscitation (20-30ml/kg), they need vasopressors Treat cause e.g. arrhythmia, sepsis, bleeding etc. Disability Assessment DEFG – Don’t Ever Forget Glucose GCS/AVPU score Pupils reactivity and symmetry Pain assessment Check drug chart Tests CT brain (if intracerebral pathology needs to be excluded) Management Correct glucose if low Give analgesia if pain (e.g. morphine 10mg in 10ml slow IV injection titrated to pain) Look for and treat cause Look for and treat causes of low GCS, e.g. hypoglycaemia, morphine/sedative use, focal neurology to suggest intracranial pathology, hypercapnia, post-ictal Everything else Assessment Exposure (look for bleeds, rashes, injuries, drain/catheter output, lines) Examine abdomen Focussed exam of relevant systems Management Manage any other abnormal findings as appropriate Note on ABCDE assessment Only move to the next letter when the one before has been treated, and keep re-assessing ABCDE from the start as necessary. Investigations to find cause Review patient’s notes Investigations (BOXES): Bloods (mark as urgent)ABG (if low saturations/low GCS), venous bloods (group and save, FBC, U&Es, CRP, LFTs ± amylase, clotting, troponin, VBG etc.), capillary glucose, blood cultures (if pyrexial)Orifice testsUrine dip, urine/sputum/faeces culture, urine βHCGX-rays / imagingPortable CXR, CT brain (if neurology or low GCS in the absence of other causes)ECG± 3-lead cardiac monitoringSpecial testsDepending on likely cause Condition specific treatment See acute management notes on specific conditions e.g. MOAN for MI, furosemide for heart failure, anticoagulation/thrombolysis for PE, sepsis six, fluids and insulin for DKA, terlipressin and OGD for bleeding varices Request help as required Inform senior Refer to other specialty if indicated, for example: Medical registrar: medical problems Endoscopist on call: upper GI bleeding Surgical registrar: surgical problems and bleeding Cardiology registrar: MI/arrhythmia Gynaecological registrar: ruptured ectopic Intensive/high-dependency care registrar: if patient may need higher level of care / airway concerns Document in patient’s notes Document with a brief case summary, ABCDE headings with findings and management Review patient and results as necessary Test your knowledge Scenario 1 You are reviewing a breathless patient on the acute medical unit waiting to be clerked with known COPD, admitted with breathlessness. You undertake an A-E assessment. His airway is patent. His respiratory rate is 32, and the nurse has put him on 35% oxygen via Venturi mask as he had low oxygen saturations. His chest sounds very wheezy. You perform an arterial blood gas. ABG result (click to enlarge) What does the ABG show? Oops! This section is restricted to members. What would you do next? Oops! This section is restricted to members. The patient has now had all of the treatment you prescribed and you repeat an ABG. This shows ongoing type 2 respiratory failure with acidosis. What would you do now? Oops! This section is restricted to members. Scenario 2 You are in the resuscitation area of the emergency department. A male patient is brought in with a low GCS. The patient’s name, details and medical history are unknown. You immediately undertake a rapid A-E assessment: A: talking but confused B: RR 8, Sats 91% on air, chest sounds clear C: BP 122/80, HR 69, capillary refill <2 seconds, nurses unable to succeed in establishing IV access D: eyes open in response to pain; pupils pinpoint; withdraws from pain but does not follow commands; confused speech; capillary glucose 5.8 E: unkempt; no rashes or bleeding; needle marks noted in groins What is the patient’s GCS? Oops! This section is restricted to members. What is the likely cause of the low GCS? Which medication would you give (include dose)? Oops! This section is restricted to members. The patient responds and his GCS improves. You also try to insert an IV cannula and have no success. What are the options for IV access? Oops! This section is restricted to members. IV access is established. A couple of hours later the patient’s GCS drops again. What would you do now? Oops! This section is restricted to members. Scenario 3 You are asked to see a 49 year old female patient on a surgical ward who has been admitted for an elective Whipple’s procedure for pancreatic cancer. The procedure was undertaken 6 days previously. She has had no other medical problems previously. The nurse has asked you to see the patient because of a high NEWS score. Observations are as follows: HR 145, BP 98/68, RR 22, Sats 90% on air (improved to 95% on 4L nasal oxygen), temperature 38.2, GCS 15 The nurse has already performed an ECG prior to your arrival. There was a previous normal pre-op ECG 8 days ago. ECG (click to enlarge You examine the patient and hear coarse crepitations in the left lower zone posteriorly. Heart sounds are normal but irregular. Mucus membranes look dry. You are unable to see the JVP. There is no peripheral oedema or rashes. The surgical wound is clean. What initial investigations would you request? Oops! This section is restricted to members. What is the main finding on the ECG? Oops! This section is restricted to members. What is your initial management? Oops! This section is restricted to members. How would you manage the patient’s arrhythmia? Oops! This section is restricted to members. Try some full A-E OSCE stations Upper GI bleed Anaphylaxis DKA Sepsis Status epilepticus Hyperkalaemia Severe asthma More here!