RECOGNITION & TREATMENT OF ACUTELY SICK
PATIENTS WITHIN PRIMARY CARE TRUSTS
Gayle Harris
1
Jan 2011
Research, as cited in the Resuscitation Council (UK) (2005) guidelines, has established
that many cardiac arrests, deaths and unplanned admissions to intensive care are
associated with the failure to establish appropriate and early preventative treatments.
The Resuscitation Council (UK) (2010) guidelines re-emphasised how early detection of
life threatening illness and initiation of prompt simple actions reduce complications and
saves lives.
It is recognised that the persons most likely to attempt resuscitation are general
practitioners and nursing staff.
However, any professional health care worker may
contribute either directly or indirectly. Published evidence testifies to the effectiveness
of resuscitation by general practitioners and primary care providers equipped with
defibrillators.
The Nottingham Primary Care Organisations have highlighted the need for staff to
have access to information to address the above issues.
The basis of this information package is drawn from scientific papers or reports
published previously by the Resuscitation Council (UK), the Royal College of
Anaesthetists, the British Heart Foundation, the British Medical Association and the
ALERT course manual (2nd edition).
Gayle Harris
Interventions Facilitator
Learning and Development Dept.
Byron Court
Brookfield Gardens
Arnold
Nottingham
NG5 7EW
Tel. 0115 8831811
e-mail-gayle.harris@nottspct.nhs.uk
Gayle Harris
2
Jan 2011
Assessment of Critically Ill Patient
When managing critically ill patients, or those at risk of life threatening illness, it is
vital to undertake frequent reassessments. These are made easier if the assessment
scheme is simplified and if every member of the healthcare team uses the same
systematic approach, to reduce the likelihood of mistakes or misunderstanding. It also
ensures that the whole team is working toward a ‘common goal’.
The system
described below is based on the practices of experienced clinicians and follows the
basic structure of many of the life support courses currently in common use in the UK.
The initial assessment system is directed at making the patient safe, rather than
coming to a definite diagnosis.
In assessing any patient, a simple question such as ‘How are you?’ can provide
significant information.
For example, a normal verbal response from the patient
immediately informs you that the patient has a patent airway, is breathing and is
supplying his/her brain with blood. Patients who can only speak in short sentences, or
say one or two words at a time are usually in extreme respiratory distress and may be
at risk of sudden respiratory arrest. Failure of the patient to respond is a very clear
marker of serious illness.
In keeping with other life support courses, the system we are using begins with the
rapid
detection
and
simultaneous
treatment
of
potentially
life-threatening
emergencies. Consequently, it uses the familiar A-B-C-D-E system in which:

A is for Airway

B is for Breathing

C is for Circulation

D is for Disability (i.e. patients conscious level); and

E stands for Exposure (permitting full patient examination)
Assessment and actions are prioritised in this order because, in general, airway
obstruction kills faster than disordered breathing, which in turn kills faster than
haemorrhage or cardiac dysfunction.
Gayle Harris
3
Jan 2011
A – AIRWAY
Nasal septum
Adenoids
Tonsil
Palate
Tongue
Epiglottis
Larynx –‘voice box’
(shown in blue)
Oesophagus
(Food Pipe)
Vocal cords
Obstruction of the upper airway is a medical emergency.
You should consider
obtaining expert help immediately. The obstruction may be partial or complete, and
may occur at any level of the respiratory tract from mouth to trachea.
Common causes of airway obstruction are:

Tongue

Vomit, secretions, blood or fluid from the stomach

Swelling due to trauma, allergy or infection

Laryngeal oedema (swelling in voice box) due to burns, inflammation or
allergy

Laryngeal spasm (spasm in voice box) due to foreign body, airway irritation
or secretions

Tracheobronchial obstruction (windpipe/lungs) due to secretions, inhaled
stomach contents, fluid with the lungs or irritation of the wind pipe.
Recognition that airway obstruction is present is based on a simple ‘look, listen and
feel’ approach:
Gayle Harris
4
Jan 2011
Look

For
- Use of the accessory muscles of respiration (i.e. neck and shoulder
muscles)

Deviation of wind pipe at throat level (Adams apple)

‘See-saw’ pattern of breathing in which inspiration is accompanied by outward
movement of the chest, but in-drawing of the abdomen and vice versa during
expiration)

Blue/purple colouring of skin is a late sign
Listen
In complete airway obstruction, there are no breath sounds at the mouth or nose. In
partial obstruction, air entry is diminished and often noisy.
Certain noises assist in
localising the level of the obstruction:Gurgling - suggests the presence of liquid in the mouth or upper airway;
Snoring - often caused by tongue and throat muscles losing tone;
Stridor – noise is caused by obstruction above or at the level of the voice box;
Wheeze – noise results from blocked airways during exhalation (e.g. Asthma).
Feel
A simple way of determining whether airway obstruction is present is to feel for the
presence of air movement at the mouth by placing your face or hand immediately in
front of the patient’s mouth.
Emergency management of upper airway obstruction
In the majority of cases within the Primary Care setting, the use of simple measures
are all that is required to open the airway, such as the Head tilt/chin lift or jaw
thrust manoeuvres.
Jaw
Thrust
Head tilt/
chin lift
Gayle Harris
5
Jan 2011
B – BREATHING
Evidence of respiratory distress or inadequate ventilation can also be determined using
a simple ‘look, listen and feel’ approach.
Look

Respiratory rate

The depth of each breath

Effort or work of breathing

Agitation, confusion or reduced conscious levels

Use of abdominal muscles to aid breathing

Both sides of chest moving together.

Sweating
Listen
To the patients breathing a short distance from his/her face. Rattling airway noises
indicate the presence of secretions, usually due to the patient being unable to cough
sufficiently or to take a deep breath.
Stridor or wheeze suggests partial, but
significant, airway obstruction.
Feel
The position of the wind pipe should be assessed for deviation which may indicate air
in the chest causing a collapsed lung (pneumothorax).
Assess the depth and equality of movement on each side of the chest.
Emergency management of breathing disorders
These should be treated urgently and before progressing to any further patient
assessment.
If mouth-to-mouth/mask is not working – check neck for tracheotomy or laryngectomy
stoma.
All critically ill patients should receive oxygen in order to prevent organ damage
or cardiac arrest. For most patients this may be safely achieved by sitting the patient
up and administering high flow oxygen (12-15litres/min) via an oxygen mask with an
oxygen reservoir bag (non re-breath mask).
Oxygen therapy should always be
prescribed, except in an emergency when it may be acceptable to get a doctor’s verbal
Gayle Harris
6
Jan 2011
prescription in order that treatment can commence whilst medical emergency services
are on their way to the patient.
In a subgroup of patients suffering from Chronic
Obstructive Pulmonary Disease (COPD), high concentrations of oxygen may have
disadvantages and some limitations in therapy may be warranted. Nevertheless, this
latter group of patients will also suffer organ damage or cardiac arrest, if their blood
oxygen levels are allowed to fall. Always monitor the effects of the oxygen therapy.
This can be done clinically by observing the patient’s colour, degree of respiratory
distress and respiratory rate.
C – CIRCULATION
Look

For signs of shock – pale, cold, clammy or sweating

Capillary refill (normally less than 2 seconds) can be quickly assessed by
applying pressure for 5 seconds to a fingertip nail, held at heart level, and
counting the time it takes for capillary refill after the pressure has been
released.

Peripheral cyanosis (blue/grey tinge to skin)

Reduced level of consciousness
Examination should include search for obvious external haemorrhage.
Listen
A patient’s blood pressure may be entirely normal, despite the presence of shock due
to the body’s ability to compensate, so careful assessment of other symptoms must be
made.
Feel
assessment of the circulation should include monitoring the pulse, assessing for its
presence, rate quality, regularity and equality.
A thready pulse suggests a poor
cardiac output, whilst a bounding pulse may indicate sepsis.
Emergency management of circulatory disorders
During initial assessment it is vital to seek out the signs that indicate immediately lifethreatening conditions, e.g. massive or continuing bleeding, constricting chest pain or
grey, cold and sweaty to touch. Insertion of a cannular at the earliest time for fluid
and drug administration should be attempted and medical emergency services should
be alerted promptly.
Gayle Harris
7
Jan 2011
D – DISABILITY
A
Alert
V
Responds to Voice
P
Responds to Pain
U
Unresponsive
A rapid assessment of the patient’s conscious level should be performed using
the ‘AVPU’ system.
Where possible note pupil size, equality and reaction to light and test blood sugar level
if possible to establish or eliminate as a cause of collapse.
Patients with adequate spontaneous breathing and circulation who are unconscious are
at risk of developing airway obstruction if lying in their backs.
In addition, airway
protective reflexes may be insufficient to prevent inhalation of secretions, vomit or
blood.
Consequently, unconscious patients are best nursed in the lateral ‘recovery’
position, with consideration to those patients with or suspected of having back or neck
injury.
E – EXPOSURE
In order that patients are examined properly, and details are not missed, full exposure
of the body may be necessary. However, this should be done in a way that respects
the dignity of the patient and prevents heat loss. At this stage the examination should
be focused on the most likely area of the body causing the patient’s poor condition
(e.g. bleeding point, where trauma has occurred).
Do You Need Help?
You should have considered whether you need help, maybe because the situation is
one with which you are unfamiliar, because specialist skills are required or merely
because you need ‘another pair of hands’. Emergency services must be sought at the
earliest possible time if the airway, breathing or circulation has been compromised and
intervention required, during the A.B.C.D.E assessment.
Gayle Harris
8
Jan 2011
Useful questions that may be asked when following the A.B.C.D.E assessment
AIRWAY:
Is it noisy? - What kind of noise can you hear?
Is it silent?
BREATHING:
Is it too fast or too slow?
Can the patient talk normally?
Is there increased effort to breath?
Does the patient have a blue/grey tinge around lips?
CIRCULATION:
Is the patient cold and pale?
Is the patient sweaty?
Does the Patient have Chest Pain?
Is the patient nauseated or vomiting?
Is there evident blood loss
DISABILITY:
Assess patients conscious level with:A – Alert
V – Voice
P – Pain
U – Unresponsive
Observe Pupil size and reaction to light
Check blood sugar level-Bm (if equipment available)
EXPOSURE:
Note any Fitting/seizure
Does Patient have a rash, bleeding or wound?
Look for indications of cause of collapse

TREAT COMPLICATIONS AS YOU FIND THEM.

DO NOT DELAY CALL FOR EMERGENCY SERVICES IF COMPLICATIONS
FOUND.
Gayle Harris
9
Jan 2011
Initial Responder Recognition and Treatment of Heart Attack(Acute Coronary Syndrome)
It is essential that all staff within Primary Care are able to recognise the symptoms
that may indicate the patient is having a Heart Attack, and be able to treat them
promptly to reduce heart muscle damage due to lack of oxygen and in some
patient’s, prevent cardiac arrest. This may simply be recognising the need for an
immediate call for emergency services.
Recognising patients with symptoms suggesting ‘Heart Attack’
Signs and Symptoms
The patient may present with one or more of the following,

Tightness/ache across the chest

Radiating to pain
o
Throat/arms/back/epigastrium (central upper part of the abdomen)

Profuse sweating

Nausea/vomiting

Breathlessness/Pale, grey or blue lips &/or skin
A history of severe or un-resolving angina may be given by the patient alongside these
symptoms, but without a 12 lead ECG and blood test it is impossible to know how
much damage has or is occurring to the heart muscle.
All patients are therefore treated as high risk until symptoms subside or
emergency medical services arrive with more advanced monitoring.
Patients whose symptoms do not subside quickly, but do not proceed into cardiac
arrest may be treated with the aim to reduce heart muscle damage due to lack of
oxygen to heart muscle, with the administration of ‘M.O.N.A’.
NB. Do not delay calling emergency services to administer M.O.N.A.
M – Morphine (or diamorphine) (5-10mg)
O – Oxygen (12-15 l/min)
N – Nitro-glycerine (GTN spray or tablet)
A – Aspirin 300mg orally (crush/chew)
Gayle Harris
10
Jan 2011
Pain will increase oxygen demand, so by reducing the pain with drugs like morphine
and giving high concentration oxygen via a non re-breath mask, a patient might
quickly have improved oxygen supply to the heart muscle.
Give morphine
(diamorphine) slowly and at intervals so as not to induce respiratory compromise.
Nitro-glycerine (GTN) will widen (dilate) blood vessels; consideration must therefore
be given to the effects of blood vessels widening on patients not accustomed to this
medication – dizziness, faint, collapse.
Aspirin may prevent blood clot formation, and even begin to break down existing
clot/s.
It might be advisable to ask patients if they know any reason which may
prevent them taking it, (e.g. Asthma, ‘Stroke’, or Gastric complications).
The Chain Of Survival
The Chain of Survival is only as strong as its weakest link.

Early access to emergency services, drugs and equipment will significantly
increase the patient’s chances of survival.

Start cardiopulmonary resuscitation to ‘sustain’ the patient until emergency
services arrive.

Commencement of basic life support should not delay delivery of shocks, if
Automated External Defibrillation is immediately available that will take
precedence.
(Defibrillation is a treatment; basic life support is a holding
mechanism).

The final link in the chain is to stabilise the patient, and transfer to an
intensive care unit for advanced life support treatment and investigation of
underlying cause of cardiac arrest.
Gayle Harris
11
Jan 2011
In Summary
Patients presenting with acute illness at any Primary Care Trust will undergo initial
assessment using the A.B.C.D.E. approach.
Each stage should be assessed and
treatment provided prior to moving on, (i.e. the airway must be clear and open before
breathing can be assessed).
Those patients with signs and symptoms of severe or un-resolving angina may also be
treated with M.O.N.A., (if available and no contra-indications are found), to reduce
muscle damage due to lack of oxygen and in some cases prevent deterioration into
cardiac arrest.
In cardiac arrest the use of the ‘Chain of Survival’ may be utilised as a reminder of
action and services to be notified.
Gayle Harris
12
Jan 2011
QUESTIONS
1.
What systematic approach is used for rapid detection and treatment of
potentially life-threatening emergencies?
2.
What symptoms may indicate a complication or obstruction of the upper
airway?
3.
Rapid assessment of conscious level can be performed using what method?
4.
Oxygen administration in the critically sick person can prevent cardiac arrest;
discuss how, when and by whom it may be given, and any considerations that
need to be taken into account.
5.
What signs and symptoms might indicate difficulty breathing?
Gayle Harris
13
Jan 2011
6
Vital signs should be monitored whilst carrying out the ABCDE assessment.
Indicate which vital sign should be monitored at each stage of the process.
A–
B–
C–
D–
E-
7.
How do the symptoms associated with unstable angina differ from those of
stable angina?
8.
“The Chain of survival is only as strong as its weakest link”
Discuss the meaning of this statement.
Gayle Harris
14
Jan 2011