The ABCDE Approach - Underlying principles

The approach to all deteriorating or critically ill patients is the same. The

underlying principles are:

1. Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE)

approach to assess and treat the patient.

2. Do a complete initial assessment and re-assess regularly.

3. Treat life-threatening problems before moving to the next part of the

assessment.

4. Assess the effects of treatment.

5. Recognise when you will need extra help. Call for appropriate help early.

6. Use all members of the team. This enables interventions (e.g. assessment,

attaching monitors, intravenous access) to be undertaken simultaneously.

7. Communicate effectively - use the Situation, Background, Assessment,

Recommendation (SBAR) or Reason, Story, Vital signs, Plan (RSVP)

approach.

8. The aim of the initial treatment is to keep the patient alive and achieve

some clinical improvement. This will buy time for further treatment and

making a diagnosis.

9. Remember – it can take a few minutes for treatments to work, so wait for a

short while before reassessing the patient after an intervention.

First steps

1. Ensure personal safety. Wear an apron and gloves as appropriate.

2. First look at the patient in general to see if the patient appears unwell.

3. If the patient is awake, ask “How are you?” If the patient appears

unconscious or has collapsed, shake him and ask “Are you alright?” If he

responds normally, he has a patent airway, is breathing and has brain

perfusion. If he speaks only in short sentences, he may have breathing

problems. Failure of the patient to respond is a clear marker of critical

illness.

4. This first rapid ‘Look, Listen and Feel” of the patient should take about 30 s

and will often indicate a patient is critically ill and there is a need for urgent

help. Ask a colleague to ensure appropriate help is coming.

5. If the patient is unconscious, unresponsive, and is not breathing normally

(occasional gasps are not normal) start CPR according to the resuscitation

guidelines. If you are confident and trained to do so, feel for a pulse to

determine if the patient has a respiratory arrest. If there are any doubts

about the presence of a pulse start CPR.

6. Monitor the vital signs early. Attach a pulse oximeter, ECG monitor and a

non-invasive blood pressure monitor to all critically ill patients, as soon as

possible.

7. Insert an intravenous cannula as soon as possible. Take blood for

investigation when inserting the intravenous cannula.

Airway (A)

Airway obstruction is an emergency. Get expert help immediately. Untreated,

airway obstruction causes hypoxia and risks damage to the brain, kidneys and

heart, cardiac arrest, and death.

Look for the signs of airway obstruction

Airway obstruction causes paradoxical chest and abdominal movements

(‘see-saw’ respirations) and the use of the accessory muscles of respiration.

Central cyanosis is a late sign of airway obstruction. In complete airway

obstruction, there are no breath sounds at the mouth or nose. In partial

obstruction, air entry is diminished and often noisy.

In the critically ill patient, depressed consciousness often leads to airway

obstruction.

Treat airway obstruction as a medical emergency

Obtain expert help immediately. Untreated, airway obstruction causes

hypoxaemia (low PaO2) with the risk of hypoxic injury to the brain, kidneys

and heart, cardiac arrest, and even death.

In most cases, only simple methods of airway clearance are required (e.g.

airway opening maneuvers, airways suction, insertion of an oropharyngeal

or nasopharyngeal airway). Tracheal intubation may be required when these

fail.

Give oxygen at a high concentration

Provide high-concentration oxygen using a mask with an oxygen reservoir.

Ensure that the oxygen flow is sufficient (usually 15 L min-1) to prevent

The collapse of the reservoir during inspiration. If the patient’s trachea is

intubated, give high concentration oxygen with a self-inflating bag.

In acute respiratory failure, aim to maintain an oxygen saturation of

94–98%. In patients at risk of hypercapnic respiratory failure (see below)

aim for an oxygen saturation of 88–92%.

Breathing (B)

During the immediate assessment of breathing, it is vital to diagnose and treat

immediately life-threatening conditions (e.g. acute severe asthma, pulmonary

oedema, tension pneumothorax, and massive haemothorax).

1. Look, listen and feel for the general signs of respiratory distress: sweating,

central cyanosis, use of the accessory muscles of respiration, and abdominal

breathing.

2. Count the respiratory rate. The normal rate is 12–20 breaths min-1. A high

(> 25 min-1) or increasing respiratory rate is a marker of illness and a

warning that the patient may deteriorate suddenly.

3. Assess the depth of each breath, the pattern (rhythm) of respiration and

whether chest expansion is equal on both sides.

4. Note any chest deformity (this may increase the risk of deterioration in the

ability to breathe normally); look for a raised jugular venous pulse (JVP) (e.g.

in acute severe asthma or tension pneumothorax); note the presence and

patency of any chest drains; remember that abdominal distension may limit

diaphragmatic movement, thereby worsening respiratory distress.

5. Record the inspired oxygen concentration (%) and the SpO2 reading of the

pulse oximeter. The pulse oximeter does not detect hypercapnia. If the

patient is receiving supplemental oxygen, the SpO2 may be normal in the

presence of a very high PaCO2.

6. Listen to the patient’s breath sounds a short distance from his face: rattling

airway noises indicate the presence of airway secretions, usually caused by

the inability of the patient to cough sufficiently or to take a deep breath.

Stridor or wheeze suggests partial, but significant, airway obstruction.

7. Percuss the chest: hyper-resonance may suggest a pneumothorax; dullness

usually indicates consolidation or pleural fluid.

8. Auscultate the chest: bronchial breathing indicates lung consolidation with

patent airways; absent or reduced sounds suggest a pneumothorax or

pleural fluid or lung consolidation caused by complete obstruction.

9. Check the position of the trachea in the suprasternal notch: deviation to one

side indicates mediastinal shift (e.g. pneumothorax, lung fibrosis or pleural

fluid).

10. Feel the chest wall to detect surgical emphysema or crepitus (suggesting a

pneumothorax until proven otherwise).

11. The specific treatment of respiratory disorders depends upon the cause.

Nevertheless, all critically ill patients should be given oxygen. In a subgroup

of patients with COPD, high concentrations of oxygen may depress

breathing (i.e. they are at risk of hypercapnic respiratory failure - often

referred to as type 2 respiratory failure). Nevertheless, these patients will

also sustain end-organ damage or cardiac arrest if their blood oxygen

tensions are allowed to decrease. In this group, aim for a lower than normal

PaO2 and oxygen saturation. Give oxygen via a Venturi 28% mask (4 L min-1

) or a 24% Venturi mask (4 L min-1) initially and reassess. Aim for target

SpO2 range of 88–92% in most COPD patients, but evaluate the target for

each patient based on the patient’s arterial blood gas measurements during

previous exacerbations (if available). Some patients with chronic lung

disease carry an oxygen alert card (that documents their target saturation)

and their own appropriate Venturi mask.

12. If the patient’s depth or rate of breathing is judged to be inadequate, or

absent, use bag-mask or pocket mask ventilation to improve oxygenation

and ventilation, whilst calling immediately for expert help. In cooperative

patients who do not have airway obstruction consider the use of noninvasive

ventilation (NIV). In patients with an acute exacerbation of COPD,

the use of NIV is often helpful and prevents the need for tracheal intubation

and invasive ventilation.

Circulation (C)

In almost all medical and surgical emergencies, consider hypovolaemia to be the

primary cause of shock until proven otherwise. Unless there are obvious signs of

a cardiac cause, give intravenous fluid to any patient with cool peripheries and a

fast heart rate. In surgical patients, rapidly exclude haemorrhage (overt or

hidden). Remember that breathing problems, such as a tension pneumothorax,

can also compromise a patient’s circulatory state. This should have been treated

earlier on in the assessment.

1. Look at the color of the hands and digits: are they blue, pink, pale or

mottled?

2. Assess the limb temperature by feeling the patient’s hands: are they cool or

warm?

3. Measure the capillary refill time (CRT). Apply cutaneous pressure for 5 s on

a fingertip held at heart level (or just above) with enough pressure to cause

blanching. Time: how long it takes for the skin to return to the color of the

surrounding skin after releasing the pressure. The normal value for CRT is

usually < 2 s. A prolonged CRT suggests poor peripheral perfusion. Other

factors (e.g. cold surroundings, poor lighting, old age) can prolong CRT.

4. Assess the state of the veins: they may be underfilled or collapsed when

hypovolaemia is present.

5. Count the patient’s pulse rate (or preferably heart rate by listening to the

heart with a stethoscope).

6. Palpate peripheral and central pulses, assessing for presence, rate, quality,

regularity and equality. Barely palpable central pulses suggest a poor

cardiac output, whilst a bounding pulse may indicate sepsis.

7. Measure the patient’s blood pressure. Even in shock, the blood pressure

may be normal, because compensatory mechanisms increase peripheral

resistance in response to reduced cardiac output. A low diastolic blood

pressure suggests arterial vasodilation (as in anaphylaxis or sepsis). A

narrowed pulse pressure (difference between systolic and diastolic

pressures; normally 35–45 mmHg) suggests arterial vasoconstriction

(cardiogenic shock or hypovolaemia) and may occur with rapid

tachyarrhythmia.

8. Auscultate the heart. Is there a murmur or pericardial rub? Is the heart

sounds difficult to hear? Does the audible heart rate correspond to the pulse

rate?

9. Look for other signs of poor cardiac output, such as reduced conscious

level and, if the patient has a urinary catheter, oliguria (urine volume < 0.5

mL kg-1 h-1).

10. Look thoroughly for external haemorrhage from wounds or drains or

evidence of concealed haemorrhage (e.g. thoracic, intra-peritoneal,

retroperitoneal or into the gut). Intra-thoracic, intra-abdominal or pelvic blood

loss may be significant, even if drains are empty.

11. The specific treatment of cardiovascular collapse depends on the cause, but

should be directed at fluid replacement, haemorrhage control and

restoration of tissue perfusion. Seek the signs of conditions that are

immediately life threatening (e.g. cardiac tamponade, massive or continuing

haemorrhage, septicaemic shock), and treat them urgently.

12. Insert one or more large (14 or 16 G) intravenous cannulae. Use short, widebore

cannulae, because they enable the highest flow.

13. Take blood from the cannula for routine hematological, biochemical,

coagulation and microbiological investigations, and cross-matching, before

infusing intravenous fluid.

14. Give a bolus of 500 mL of warmed crystalloid solution (e.g. Hartmann’s

solution or 0.9% sodium chloride) over less than 15 min if the patient is

hypotensive. Use smaller volumes (e.g. 250 mL) for patients with known

cardiac failure or trauma and use closer monitoring (listen to the chest for

crackles after each bolus).

15. Reassess the heart rate and BP regularly (every 5 min), aiming for the

patient’s normal BP or, if this is unknown, a target > 100 mmHg systolic.

16. If the patient does not improve, repeat the fluid challenge. Seek expert help

if there is a lack of response to repeated fluid boluses.

17. If symptoms and signs of cardiac failure (dyspnoea, increased heart rate,

raised JVP, a third heart sound and pulmonary crackles on auscultation)

occur, decrease the fluid infusion rate or stop the fluids altogether. Seek

alternative means of improving tissue perfusion (e.g. inotropes or

vasopressors).

18. If the patient has primary chest pain and a suspected ACS, record a 12-lead

ECG early.

19. Immediate general treatment for ACS includes:

Aspirin 300 mg, orally, crushed or chewed, as soon as possible.

Nitroglycerine, as sublingual glyceryl trinitrate (tablet or spray).

Oxygen: only give oxygen if the patient’s SpO2 is less than 94%

breathing air alone.

Morphine (or diamorphine) is titrated intravenously to avoid sedation and

respiratory depression.

Disability (D)

Common causes of unconsciousness include profound hypoxia, hypercapnia,

cerebral hypoperfusion, or the recent administration of sedatives or analgesic

drugs.

Review and treat the ABCs: exclude or treat hypoxia and hypotension.

Check the patient’s drug chart for reversible drug-induced causes of

depressed consciousness. Give an antagonist where appropriate (e.g.

naloxone for opioid toxicity).

Examine the pupils (size, equality and reaction to light).

Make a rapid initial assessment of the patient’s conscious level using the

AVPU method: Alert, responds to Vocal stimuli, responds to Painful stimuli or

Unresponsive to all stimuli. Alternatively, use the Glasgow Coma Scale

score. A painful stimulus can be given by applying supra-orbital pressure (at

the supraorbital notch).

Measure the blood glucose to exclude hypoglycaemia using a rapid fingerprick

bedside testing method. In a peri-arrest patient use a venous or

arterial blood sample for glucose measurement as finger prick sample

glucose measurements can be unreliable in sick patients. Follow local

protocols for the management of hypoglycaemia. For example, if the blood

sugar is less than 4.0 mmol L-1 in an unconscious patient, give an initial

dose of 50 mL of 10% glucose solution intravenously. If necessary, give

further doses of intravenous 10% glucose every minute until the patient has

fully regained consciousness, or a total of 250 mL of 10% glucose has been

given. Repeat blood glucose measurements to monitor the effects of

treatment. If there is no improvement consider further doses of 10%

glucose. Specific national guidance exists for the management of

hypoglycaemia in adults with diabetes mellitus.

Nurse unconscious patients in the lateral position if their airway is not

protected.

Exposure (E)

To examine the patient properly full exposure of the body may be necessary.

Respect the patient’s dignity and minimise heat loss.

Additional information

1. Take a full clinical history from the patient, any relatives or friends, and

other staff.

2. Review the patient’s notes and charts:

Study both absolute and trended values of vital signs.

Check that important routine medications are prescribed and being

given.

3. Review the results of laboratory or radiological investigations.

4. Consider which level of care is required by the patient (e.g. ward, HDU, ICU).

5. Make complete entries in the patient’s notes of your findings, assessment

and treatment. Where necessary, hand over the patient to your colleagues.

6. Record the patient’s response to therapy.

7. Consider definitive treatment of the patient’s underlying condition.

 

 

CONCLUSION

This guide presents basic recommendations and rules for passing practical skills on the Final Exam. The team of the Department of Internal Diseases hopes that this guide was useful to you and was of great help in preparing both for exam and real practice.

We wish you a successful exam and further advances in medicine!

 

This manual does not include tests.

 

 

 

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