Structured Approach to critically ill patient

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

Critically ill patient

Early recognition prevents:• Cardiac arrests and deaths• Admissions to ICU• Inappropriate resuscitation attempts

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

Main Enemy in ER

Rules of this approach

• Complete initial assessment

• Treat first what kills first

• Assess effects of treatment/interventions

• Reassessment

• Call for help early

The ABCDE approach to the deteriorating patient

Airway BreathingCirculationDisabilityExposure

Initial assessment

• Personal safety

• Patient responsiveness

• First impression

Assess – Treat – Reassess

ABCDE approach: Airway

• CNS depression• Blood • Vomit • Foreign body

• Infection • Inflammation • Laryngospasm • Bronchospasm

Causes of airway obstruction:

• Trauma• Compression

Recognition of airway obstruction

ABCDE approach: Airway

Talk to the pt.

ObstructedClear & Patent At risk

& LOOK , LISTEN , FEEL

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

• 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

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

• 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

ABCDE approach: Breathing

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

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

• 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

Recognition

• AVPU or GCS• Pupils• Lateralising signs

ABCDE approach: Disability

Blood glucose

Treatment

• ABC• Treat underlying cause• Blood glucose– If < 72 mg/dcl ( 4 mmol/L) give glucose

ABCDE approach: Disability

• Remove clothes to enable examination– e.g. injuries, bleeding, rashes

• Avoid heat loss

• Maintain dignity

ABCDE approach: Exposure

Sheet

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

Handover

SBAR

Situation Doctor & Pt. data

Background History

Assessment ABCDE approach Interventions Investigations

Recommendation what I want from you

Any Question ?!

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