ABCDE management of a critically ill patient

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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.

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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 

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 tests	Urine dip, urine/sputum/faeces culture, urine βHCG
X-rays / imaging	Portable CXR, CT brain (if neurology or low GCS in the absence of other causes)
ECG	± 3-lead cardiac monitoring
Special tests	Depending 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

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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.

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

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.

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.

Try some full A-E OSCE stations

1. Upper GI bleed
2. Anaphylaxis
3. DKA
4. Sepsis
5. Status epilepticus
6. Hyperkalaemia
7. Severe asthma
8. More here!