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ABCDE: Assessment and treatment of the acutely Ill patient

Box 1.1 ABCDE assessment

A

Airway

B

Breathing

C	Circulation

D	Disability

E

Exposure

ABCDE approach: Guiding principles

• Undertake a complete initial ABCDE assessment (Box 1.1); reassess regularly
• Treat life‐threatening problems first, before proceeding to the next part of assessment.
• Evaluate the effects of treatment and/or other interventions
• Recognise the circumstances when additional help is required
• Ensure effective communication
• Call for help early (SBAR) (Box 1.2)

Box 1.2 SBAR: Structured approach to calling for help

S

Situation

B	Background

A	Assessment

R	Recommendation

Initial approach

Safety

• Ensure safe approach: check the environment and remove any hazards
• Take measures to minimise the risk of cross infection

Simple question

• Ask the patient a simple question, e.g. ‘How are you, sir?’ If there is a normal verbal response the patient has a patent airway, is breathing, and has cerebral perfusion. If the patient can only speak in short sentences, they may have extreme respiratory distress, and failure to respond is a clear indicator of serious illness. If there is an inappropriate response or if there is no response, the patient may be acutely ill

NB If the patent is unconscious: summon help from colleagues immediately.

General appearance

• Note the general appearance of the patient, e.g. comfortable or distressed, content or concerned, colour and posture

Vital signs monitoring

• Attach vital signs monitoring, e.g. pulse oximetry, electrocardiogram () and continuous non‐invasive blood pressure () monitoring

Airway

• Patient talking: there is a patent airway
• Complete airway obstruction: there are no breath sounds at the mouth or nose
• Partial airway obstruction: air entry diminished, often noisy breathing

Look

• Look for the signs of airway obstruction, e.g. paradoxical chest and abdominal movements (‘see‐saw’ respirations); central cyanosis is a late sign of airway obstruction

Listen

• Gurgling: fluid in the mouth or upper airway
• Snoring: tongue partially obstructing the pharynx
• Crowing: laryngeal spasm
• Inspiratory stridor: ‘croaking respirations’ indicating partial upper airway obstruction, e.g. foreign body, laryngeal oedema
• Expiratory wheeze: noisy musical sound caused by turbulent flow of air through narrowed bronchi and bronchioles, more pronounced on expiration; causes include asthma and chronic obstructive pulmonary disease ()

Feel

• Feel for signs of airway obstruction. Place your face or hand in front of the patient's mouth to determine whether there is movement of air

OSCE Key Learning Points

Causes of airway obstruction

• Tongue: commonest cause of airway obstruction in a semi‐conscious or unconscious patient – relaxation of the muscles supporting the tongue can result in it falling back and blocking the pharynx
• Vomit, blood, and secretions
• Foreign body
• Tissue swelling: causes include anaphylaxis, trauma, or infection
• Laryngeal oedema (due to burns, inflammation, or allergy occurring at the level of the larynx)
• Laryngeal spasm (due to foreign body, airway stimulation, or secretions/blood in the airway)
• Tracheobronchial obstruction (due to aspiration of gastric contents, secretions, pulmonary oedema fluid, or bronchospasm)

Treatment of airway obstruction

• If airway obstruction is identified, treat appropriately; for example suction, lateral position, and insertion of oropharyngeal airway are often effective
• Administer oxygen 15 l min−1 via a non‐rebreathe oxygen mask as appropriate
• If necessary, call for help early (SBAR)

Breathing

Inspect

• Look for signs of respiratory distress: tachypnoea, sweating, central cyanosis, use of the accessory muscles of respiration, abdominal breathing, and posture (e.g. pyramid position)
• Count the respiratory rate (normal respiratory rate in adults is approximately 12–20 min−1): tachypnoea is often the first sign that the patient is becoming acutely ill and causes include pneumonia, pulmonary embolism (), heart failure, and shock; bradypnoea is an ominous sign and possible causes include drugs, opiates, fatigue, hypothermia, head injury, and central nervous system () depression

OSCE Key Learning Points

Causes of tachypnoea

• Respiratory pathology, e.g. acute asthma attack, PE
• Heart failure
• Acidosis
• Normal physiological response, e.g. exercise

OSCE Key Learning Points

Causes of bradypnoea

• Medications, e.g. opiates
• Head injury
• CNS depression
• Hypothermia

• Assess the depth of breathing. Ascertain whether chest movement is equal on both sides. Unilateral movement of the chest suggests unilateral disease, e.g. pneumothorax, pneumonia, or pleural effusion. Kussmaul's breathing (air hunger) is characterised by deep, rapid respirations due to stimulation of the respiratory centre by metabolic acidosis, e.g. in ketoacidosis and chronic renal failure.
• Assess the pattern (rhythm) of breathing. A Cheyne–Stokes breathing pattern (periods of apnoea alternating with periods of hyperpnoea) can be associated with brainstem ischaemia, cerebral injury, and severe left ventricular failure (altered carbon dioxide sensitivity of the respiratory centre)
• Note the presence of any chest deformity, e.g. kyphosis, as this could increase the risk of deterioration in the patient's ability to breathe normally
• If the patient has a chest drain, check it is patent and functioning effectively
• Note the presence of abdominal distension (could limit diaphragmatic movement, thereby exacerbating respiratory distress)
• Note the oxygen saturation (SaO2) reading (normal is 94–100%); in a COPD patient normal can be 88–92%
• Check the inspired oxygen concentration (%) being administered to the patient; adjust if necessary

Common misinterpretations and pitfalls

Pulse oximetry does not detect hypercapnia and that, if the patient is receiving oxygen therapy, the SaO2 may be normal in the presence of a very high PaCO2.

Palpate

• Check chest expansion
• Palpate the chest wall to detect surgical emphysema or crepitus (suggesting a pneumothorax until proven otherwise)
• Perform chest percussion

OSCE Key Learning Points

Causes of different percussion notes

• Resonant: air‐filled lung
• Dull: liver, spleen, heart, lung consolidation/collapse
• Stoney dull: pleural effusion/thickening
• Hyper‐resonant: pneumothorax, emphysema
• Tympanitic: gas‐filled viscus

• Check the position of the trachea. Place the tip of your index finger into the supersternal notch, let it slip either side of the trachea and determine whether it fits more easily into one or other side of the trachea; deviation of the trachea to one side indicates mediastinal shift (e.g. pneumothorax, lung fibrosis, pleural fluid)

Auscultate

• Auscultate the chest: assess the depth of breathing and the equality of breath sounds on both sides of the chest. Any additional sounds, e.g. crackles, wheeze, and pleural rubs should be noted. Bronchial breathing indicates lung consolidation; absent or reduced sounds suggest a pneumothorax or pleural fluid

Assessing efficacy of breathing, work of breathing, and adequacy of ventilation

• Efficacy of breathing: can be assessed by air entry, chest movement, pulse oximetry, arterial blood gas analysis, and capnography
• Work of breathing: can be assessed by respiratory rate and accessory muscle use, e.g. neck and abdominal muscles
• Adequacy of ventilation: can be assessed by heart rate, skin colour, and mental status

Causes of compromised breathing

Causes of...