The approach to the critically
ill patient
Nick Smith
Clinical Skills
Objectives
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The rational of ABCDE
The process of primary & secondary survey
Recognition of life threatening events
Treatment of life-threatening conditions
Handover
Traditional medical approach
History
Examination
Differential
Investigations
Diagnosis
Treatment
The ABCDE approach
Airway & oxygenation
A
Exposure &
examination
E
B
D
Disability due to
neurological
deterioration
Breathing &
ventilation
C
Circulation &
shock
management
The principles
• Perform primary ABCDE survey (5 min)
• Instigate treatment for life threatening
conditions as you find them
• Reassess when any treatment is completed
• Perform more detailed secondary ABCDE
survey including investigations
• If condition deteriorates repeat primary
survey
The primary survey
• ABCDE assessment looking for immediately
life threatening conditions
• Rapid intervention usually includes max O2, IV
access, fluid challenge +/- specific treatment
• Should take no longer than 5 min
• Can be repeated as many times as necessary
• Get experienced help as soon as you need it
• If you have a team delegate jobs
The secondary survey
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Performed when patient more stable
Get a brief relevant HPC & Hx
More detailed examination of patient (ABCDE)
Order investigations to aid diagnosis
IF PATIENT DETERIORATES RETURN TO
PRIMARY SURVEY
Airway - causes
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 GCS
Body fluids
Foreign body
Inflammation
Infection
Trauma
Airway - assessment
• Unresponsive
• Added sounds
– Snoring, gurgling, wheeze, stridor
• Tracheal tug
• Accessory muscles
• See-saw respiratory pattern
Airway – interventions
(basic)
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Head tilt chin lift
Jaw thrust
Suction
Oral airways
Nasal airways
Airway – interventions
(advanced)
• GET HELP!!!
• Nebulised adrenaline
for stridor
• LMA
• Intubation
• Cricothyroidotomy
– Needle or surgical
Once airway open...
• Give 15 litres of
oxygen to all
patients via a nonrebreathing mask
• For COPD patients
re-assess after the
primary survey has
been complete &
keep Sats 90-93%
Breathing - causes
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 GCS
Resp depressions
Muscle weakness
Exhaustion
Asthma
COPD
Infection
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Pulmonary oedema
Pulmonary embolus
ARDS
Pneumothorax
Haemothorax
Open pneumothorax
Flail chest
Breathing - assessment
• Look
– Rate (<10 or >20), symmetry, effort, SpO2, colour
• Listen
– Taking: sentences, phrases, words
– Bilateral air entry, wheeze, silent chest other
added sounds
• Feel
– Central trachea, Percussion, expansion
Breathing - interventions
• Consider ventilation
with AMBU™ bag if
resp rate < 10
• Position upright if
struggling to breath
• Specific treatment
– i.e.: β agonist for
wheeze, chest drain
for pneumothorax
Circulation - assessment
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Look at colour
Examine peripheries
Pulse, BP & CRT
Hypotension (late sign)
– sBP< 100mmHg
– sBP < 20mmHg below pts norm
•  Urine output
• Consider compensation
mechanisms
Circulation – shock
Inadequate tissue perfusion
• Loss of volume
– Hypovolaemia
• Pump failure
– Myocardial & nonmyocardial causes
• Vasodilatation
– Sepsis, anaphylaxis,
neurogenic
BP = HR x SV x SVR
Circulation - interventions
• Position supine with legs raised
– Left lateral tilt in pregnancy
• IV access - 16G or larger x2
– +/- bloods if new cannula
• Fluid challenge
– colloid or crystalloid?
• ECG Monitoring
• Specific treatment
Disability - causes
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Inadequate perfusion of the brain
Sedative side effects of drugs
 BM
Toxins and poisons
CVA
 ICP
Disability - assessment
• AVPU (or GCS)
– Alert, responds to Voice, responds to Pain,
Unresponsive
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Pupil size/response
Posture
BM
Pain relief
Disability - interventions
• Optimise airway, breathing & circulation
• Treat underlying cause
– i.e.: naloxone for opiate toxicity
– Caution if reversing benzo’s
• Treat  BM
– 100ml of 10% dextrose (or 20ml of 50% dextrose)
• Control seizures
• Seek expert help for CVA or ICP
Exposure
• Remove clothes and examine head to toe
front and back
– Haemorrhage (inc concealed), rashes, swelling etc
• Keep warm (unless post cardiac arrest)
• Maintain dignity
Secondary survey
• Repeat ABCDE in more detail
• History
• Order investigations
– ABG, CXR, 12 lead ECG, Specific bloods
• Management plan
• Referral
• Handover
Handover
ITUATION
ACKGROUND
SSESSMENT
ECCOMENDATION
Situation
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Check you are talking o the right person
State your name & department
I am calling about... (patient)
The reason I am calling is...
Background
• Admission diagnosis and date of admission
• Relevant medical history
• Brief summary of treatment to date
Assessment
• The assessment of the patient using the
ABCDE approach
Recommendation
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I would like you to...
Determine the time scale
Is there anything else I should do?
Record the name and contact number of your
contact
Questions
Summary
• Assess ABCDE in turn
• Instigate treatments for life-threatening
problems as you find them
• Reassess following treatment
• If anything changes go back to A
Acute severe asthma
HR
SVR
Any one of:
• PEF 33 – 50% of best or predicted
• RR> 24
• HR> 110
• Inability to complete sentences in 1 breath
• Nebulised salbutamol
(5mg) - O2 driven
– Repeat as needed
• Nebulised ipratropium
(500mcg) - O2 driven
• Hydrocortisone 100mg
IV or Prednisolone 50 –
60mg po
• MgSO4 IV 1.2 – 2g
– Seek guidance first
Life threatening asthma
HR
SVR
Severe asthma plus one of the following:
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PEF <33%
SpO2 <92%
PaO2 <8 kPa
Normal PaCO2
– PaCO2 is a preterminal sign
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Silent chest
Cyanosis
Poor respiratory effort
Arrhythmias
Exhaustion / GCS
Get expert help quickly and treat as for acute severe
asthma
Sepsis
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HR
SVR
Signs and symptoms of infection (SSI) or
Systemic Inflammatory Response (SIRs)
Temperature > 38.2°C or <36°C
HR>90 beats/min
Respiratory rate >20 breaths/min
WBC count > 12,000 or <4,000/mL
Hyperglycaemia (in absence or DM)
2 or more SSI’s + suspicion of a new infection = SEPSIS
HR
Severe Sepsis
SVR
SEPSIS + Organ dysfunction = SEVERE SEPSIS
• BP < 90 systolic
• Acute alteration in mental
status
• O2 sats < 90%
• UO < 0.5ml/kg/hr for 2
hours
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• Oxygen
• Blood cultures
• IV antibiotics (within 1
hour)
• Fluids +++
• Monitor lactate & Hb
• Urinary Catheter &
hourly monitoring
Bilirubin >34µmol/L
Platelets <100 x 109/L
Lactate>2 mmol/L
Coagulopathy – INR>1.5 or
APTT>60sec
Anaphylaxis
HR
SVR
Highly likely if…
1. Sudden onset and rapid progression
2. Life threatening problem to airway &/or breathing &/or
circulation
3. Skin changes (rash or angioedema)
+/- Exposure to known allergen
• Get expert help quickly
• Oxygen
• IM adrenaline 500mcg
– repeat every 5 min if
needed
• Chlorphenamine 10mg
IV
• Hydrocortisone 200mg
IV
• +/- fluids +++
Hypovolaemia
Haemorrhagic
• External
• Drains
• GI tract
• Abdomen
Trauma
• On the floor and 4 more
– Chest, abdo, pelvis, long
bones
HR
SVR 
Fluid loss
• D&V
• Polyuria
• Pancreatitis
Iatrogenic
• Diuretics +++
• Inadequate fluid
prescription
Hypovolaemia
Give fluid challenge 250ml over 2 min and reassess after 5 min
Responders
Partial or transient
responders
Patient improve and Patient improves
remains improved. but shows a gradual
deterioration
on-going loss or reequilibration
No further boluses
maybe needed but
investigate cause
Non-responders
No improvement.
Exsanguination
though severe
dehydration &
sepsis should be
considered
Further boluses and Further boluses and
investigations
get help quickly
Haemorrhagic shock
Class I < 15%
<750ml
Class II 15-30%
750 – 1500ml
Class III 30 – 40%
1500 – 2000ml
Class IV >40%
>2000ml
RR
14-20
20-30
30+
35+
HR
<100
>100
>120
>140
BP
Normal
Normal
Decreased
Decreased
Pulse pressure
Normal
Decreased
Decreased
Decreased
Neuro
Slighty Anxious
Mildly anxious
Anxious or
confused
Confused or
lethargic
Urine Output
> 30
20 – 30
5 - 15
Bladder sweat
Use patients obs to estimate the blood loss then replace with crystalloid at 1.5
to 3ml for every 1ml of estimated blood loss
Figures based on a young healthy adult with a compressible haemorrhage
HR
Bradycardia
Adverse signs
• BP
• HR < 40
• Heart failure
• Ventricular arrhythmias
compromising BP
SVR
No adverse signs with a risk of
asystole?
• Recent asystole
• Mobitz II AV block
• 3rd degree HB w QRS
• QRS pauses > 3 sec
• Get expert help quickly!
• Atropine 500 mcg IV
– Repeat to a max total dose of 3mg
• External cardiac pacing
Tachyarrhythmia
• Get expert help quickly
• Unstable*
– Sedate and synchronised
cardiovertion
• Stable VT
– Amiodarone 300mg 20 –
60 min
HR
SVR
• Stable SVT
– Vagal manoeuvers
– Adenosine 6mg, 12mg,
12mg
• Stable tachy AF
– Amiodarone 300mg 20 –
60 min if onset < 48hrs
– Β-blocker IV or digoxin IV
(*rate related symptoms are uncommon at less than 150 beats min-1)