An overview of the ABCDE approach towards keeping the patient safe, esp. useful for interns

1. Recognizing and
responding to
deteriorating patients-
the mindset!
Arun Radhakrishnan
Intensive Care Specialist
Werribee Mercy Hospital
VIC

2. Outline
• Introduction
• Importance of vital signs
• Monitoring trends
• Instituting basic treatment
• Your role and responsibilities

3. Clinical scenario
• 85 year old female from home
• Admitted to ED with severe b/l CAP, to ward from there
• O/E patient confused, HR 125, BP 92/55 mm Hg, SpO2 on 2L NP
82%
• How do you manage this patient?

4. MET calls
• What?
• Why?
• How?
• When?
• Where?
• Who?

5. • Detect deteriorating patients
• ~3-9% of hospitalized patients
• In over 60% of Code Blues, vitals would
have been abnormal for over 8 hrs!
Philosophy behind MET
calls

6. Why do
patients
deteriorate?
Primary pathology
Complication of primary pathology
Hospitalization-associated or acquired
complication
Iatrogenic factors
De novo factors

7. What kills the patient?
• Pneumonia or severe hypoxaemia?
• STEMI or severe shock?
• Opiate overdose or airway obstruction?

8. Important to have a
systematic approach to
recognize and institute
treatment rapidly
Why?
What sort of decisions need to
be made?

9. The purpose…
The fundamental
underlying principle is to
reduce harm
What things can harm the
patient?

10. How do we recognize
deterioration?
• Change in the vital signs
• What are the vital signs?
• Changes in trends
• Important to know how to read and
interpret Observation charts
• What are the ‘obs’ that are routinely
recorded?
• Have you heard of any scoring systems for
this?

11. Most common reasons for MET calls
• Hypotension
• Respiratory distress or hypoxaemia
• Altered mental status
• Others
• Tachy-or brady cardia
• Decreased urine output
• Fever
• Threatened airway
• Worry

12. The role of
junior doctors

13. Recognizing
unwell or
deteriorating
patients
How do you
identify
them prior
to MET calls?
What is the
importance of early
recognition?
When do you
call for help?

14. The COAT & Review
approach
• Structured framework
• Rapid identification, prioritization
and basic treatment.

15. • Confirm and Optimize phases:
• Early identification of potentially life-threatening problems
• Identifying and supporting issues with the ABCD
• Assess and Treat phases:
• Finding and treating the underlying causes
• Review phase:
• Reassess the DRS ABCD
When do you reassess?

16. Assessing ABCD and ‘Yellow’ Flags

17. Quantifying the degree of danger
• What signs would make you worried?
• Seizures/GCS < 14/new onset delirium
• Unresponsive (AVPU P or U)
• Airway obstruction or compromise
• HR < 40 > 140 or dangerous
arrhythmias/heart blocks
• SBP persistently less than 100 or not
responding to treatment
• SpO2 < 85%, or < 90% on FiO2 > 0.4
• Urine output < 0.3 mL/kg/hr for the last
6-8 hrs (despite therapy)

18. Context is everything!
• High Risk Contexts:
• Emergency admission
• Severe illness
• Recent discharge from higher acuity areas
• Recent invasive procedure or GA
• Trauma
• Recent transfer from another hospital
• Barriers to assessment

19. High Alert conditions

20. The Optimize phase
• Usually occurs simultaneously with the
Confirm phase
• Possible to support problems with the
ABCD without necessarily knowing the
diagnosis
• Optimization vs. Normalization
• Conditions that would need to have
immediate supportive/specific
treatment?
• VT/VF
• Low BSLs

21. Optimize phase-summarized
• 1. Support ABCD
• 2. Remove Precipitants and aggravating factors
• 3. Prepare resources
• What are the resources you’d need for optimization at this point?
• Equipment
• Monitoring
• Environment
• Staff
• Medications

22. The
Assessment
phase
Identify the issues
History and patient notes
Physical examination
How would you
examine?
Obs charts
Monitoring
Investigations
Diagnosis and differentials

23. • How would you conduct a rapid review?

24. Rapid review
• Is the airway patent?
• Is the patient breathing? Are they hypoxaemic?
• Do they have supplemental O2 ?
• Do they have a blood pressure?
• Is the pulse palpable?
• What is the Cardiac output like?
• Do they have monitoring attached?
• Status of the vital signs?
• Degree of support needed?
• Cause for deterioration - 4Hs and 4Ts?

25. Investigating organ dysfunction
What would you look for?
What tests would you send?
Why?

26. Red Flags
• Abnormal LFTs
• Deranged Coags

27. Treat
• Therapy
• Supportive
• Specific
• Symptomatic
• Anticipatory
• Notification
• Communication and Escalation
• Ongoing care
• Documentation

28. Notification and escalation
• When would you escalate?
• Worrying current status or anticipated trajectory
• No or minimal response to treatment
• Ongoing compromise
• Level of required treatment unable to be provided on ward
• Red flags on investigations

29. Review –timely reassessment
• When do you review?
• Why?
• What additional information do you need when reviewing the
patient?

30. Basic management of deteriorating patient
• Airway
• Breathing with O2 supplementation
• Circulation with Secure IV access
• Basic blood tests (including a blood gas)
• Radiology, ECG as indicated
• Communicate
• Escalate (Disposition)

31. Keeping the patient safe
• Positioning
• Avoid unnecessary transport
• Ensure safety during transfer
• Communicate (including handover)

32. How would you prioritize dysfunction of more
than one organ system?
Prioritization

33. Disposition-where does the patient go?
• General indications for ICU/HDU level of care
• Airway compromise
• Desaturation- needing more than FiO2 0.5
• Need for ventilatory support
• Need for vasopressor support
• Need for monitoring
• Metabolic derangements needing aggressive (controlled) correction
• No response to treatment or anticipated deterioration
• Care that cannot be provided in any other ward

34. Summary
• The COAT & Review approach is highly recommended
• Remember the basics for every patient – DRS ABCD
• Do not hesitate to (over)call for help

35. Case review: What are your concerns?
• 85 year old female from home
• Admitted to ED with severe b/l CAP, to ward from there
• O/E patient confused, HR 125, BP 92/55 mm Hg, SpO2 on 2L NP 82%

36. What would you do?

37. Any questions? 

38. References
• Grimes N & Harrison J. The-coat-review-approach-how-to-recognize-and-
manage-unwell-patients.pdf
• Jones D et al: Defining Clinical deterioration. Resuscitation 84 (2013) 1029-
1034
• All images courtesy of Google Images