Structured approach for critically ill patient
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د/ماجد الوراقي Structured approach for critically ill patient المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب و ضمن موديول الطوارئ و التخدير و العناية المركزة
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Structured approach for critically ill patient
- 2. 1)Who is the critically ill patient 2)Importance of early recognition of the critically ill pt. 3)Causes of cardiac arrest 4)Identify and treat pt. at risk of cardiac arrest using the ABCDE approach Objectives
- 5. Early recognition prevents: • Cardiac arrests and deaths • Admissions to ICU • Inappropriate resuscitation attempts
- 6. Early recognition of critically ill pt. • Most arrests are predictable • Deterioration prior to 50 - 80% of cardiac arrests • Hypoxia and hypotension are common antecedents • Delays in referral to higher levels of care
- 7. Main Enemy in ER
- 8. Rules of this approach • Complete initial assessment • Treat first what kills first • Assess effects of treatment/interventions • Reassessment • Call for help early
- 9. The ABCDE approach to the deteriorating patient Airway Breathing Circulation Disability Exposure
- 10. Initial assessment • Personal safety • Patient responsiveness • First impression
- 11. Assess – Treat – Reassess
- 12. ABCDE approach: Airway • CNS depression • Blood • Vomit • Foreign body • Infection • Inflammation • Laryngospasm • Bronchospasm Causes of airway obstruction: • Trauma • Compression
- 13. Recognition of airway obstruction ABCDE approach: Airway Talk to the pt. ObstructedClear & Patent At risk & LOOK , LISTEN , FEEL
- 14. Treatment of airway obstruction ObstructedClear & Patent At risk Suction Maintain Maintain open airway ABCDE approach: Airway No Action Opening Airway Head-tilt chain-lift Jaw thrust Maintaining airway Basic adjunct (OPA – NPA ) Supraglottic devices ( LMA ) Definitive airway ( ETT ) O2
- 15. • Decreased respiratory effort – Muscle weakness – Nerve damage – Restrictive chest defect – Pain from fractured ribs • Lung disorders – Pneumothorax – Haemothorax – Infection – Acute exacerbation COPD – Asthma – Pulmonary embolus – ARDS ABCDE approach: Breathing • Decreased respiratory drive – CNS depression
- 16. ABCDE approach: Breathing Recognition of breathing problems Inspection RR Expansion Wounds , Bruises, Etc…. Palpation Confirm Expansion Tenderness , surgical emphysema Trachea Percussion Note Equality Auscultation Equality Additional Sounds
- 17. • Airway • Oxygen • Treat underlying cause – e.g. drain pneumothorax • Support breathing if inadequate – e.g. ventilate with bag-mask • Establish continuous monitoring ABCDE approach: Breathing Treatment of breathing problems SpO2
- 19. Primary – Acute coronary syndromes – Arrhythmias – Hypertensive heart disease – Valve disease – Hereditary cardiac diseases – (Drugs) – (Electrolyte/acid base abnormalities) Secondary – Asphyxia – Hypoxaemia – Blood loss – Hypothermia – Septic shock – (Drugs) – (Electrolyte/acid base abnormalities) Causes of circulation problems ABCDE approach: Circulation
- 20. Recognition of circulation problems Pulse Central Central-to-Peripheral Peripheral-to-Peripheral HR Volume Regularity BP Hypertensive Normotensive Hypotensive Perfusion CRT (N <2 sec ) ABCDE approach: Circulation
- 21. • Airway, Breathing • Oxygen • Treat cause ( Stop Haemorrhage ) • Fluid challenge ( Normal saline , Ringer lactate ) • Inotropes/vasopressors ABCDE approach: Circulation Treatment of circulation problems • IV/IO access, take bloods • Establish ECG monitoring
- 22. Recognition • AVPU or GCS • Pupils • Lateralising signs ABCDE approach: Disability Blood glucose
- 23. Treatment • ABC • Treat underlying cause • Blood glucose – If < 72 mg/dcl ( 4 mmol/L) give glucose ABCDE approach: Disability
- 24. • Remove clothes to enable examination – e.g. injuries, bleeding, rashes • Avoid heat loss • Maintain dignity ABCDE approach: Exposure Sheet
- 25. Item Recognition Intervention Aid A Look , Listen , Feel Patent & Clear At risk Obstructed Nothing Suction + Maintain Open + Maintain O2 Supply Titrate 94% - 99/& B Inspection RR Expansion Wounds , Bruises, Etc…. Palpation Confirm Expansion Tenderness , surgical emphysema Percussion Note Equality Auscultation Equality Additional Sounds Consider Assisted Ventilation SpO2 C Pulse Central Central-to-Peripheral Peripheral-to-Peripheral HR Volume Regularity BP Hypertensive Normotensive Hypotensive CRT Fluids Cannula ( Draw Samples first ) ECG Monitor D Consciousness GCS AVPU Pupil RBG (bedside) E Affected area Full Exposure Unexplained Polytrauma Pt. Sheet to cover the pt. ABCDE approach
- 26. Handover SBAR Situation Doctor & Pt. data Background History Assessment ABCDE approach Interventions Investigations Recommendation what I want from you
- 28. 1)Who is the critically ill patient 2)Importance of early recognition of the critically ill pt. 3)Causes of cardiac arrest 4)Identify and treat pt. at risk of cardiac arrest using the ABCDE approach
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