ABCDE Approach to Patient Assessment

• The approach to all deteriorating or critically ill patients is consistent.

Underlying Principles of ABCDE Approach

• Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) to assess and treat the patient.
• Perform an initial assessment and reassess regularly.
• Treat life-threatening issues before moving to the next part of assessment.
• Assess the effects of treatment and recognise when to ask for help early.
• Use all team members and communicate effectively using SBAR or RSVP approach.
• Initial treatment aims to keep the patient alive to allow time for further treatment and diagnosis.
• Remember, treatments can take a few minutes to work; wait before reassessing after an intervention.

First Steps

• Ensure personal safety by using appropriate PPE like gloves and aprons.
• Observe the patient’s general appearance to see if they seem unwell.
• If awake, ask “How are you?”
• If unconscious, shake and ask, “Are you alright?”
• A normal response indicates a patent airway, breathing, and brain perfusion.
• Short sentences may indicate breathing problems.
• No response indicates critical illness.
• The rapid initial assessment should take around 30 seconds.
• If the patient is unconscious, unresponsive, and not breathing normally, start CPR.
• If confident, check for a pulse to determine respiratory arrest; if unsure, start CPR.
• Monitor vital signs early with a pulse oximeter, ECG, and non-invasive blood pressure monitor.
• Insert an intravenous cannula as soon as possible to take blood samples for investigation.

Airway

• Airway obstruction is an emergency, seek expert help immediately.
• Untreated airway obstruction risks hypoxia, brain/kidney/heart damage, cardiac arrest, and death.
• Key indicators of airway obstruction are paradoxical chest and abdominal movements and the use of accessory muscles.
• Central cyanosis is a late sign, and there may be no breath sounds with complete obstruction.
• Diminished and noisy air entry indicates partial obstruction.
• Depressed consciousness often leads to airway obstruction.
• Treat airway obstruction as a medical emergency by obtaining expert help.
• Hypoxaemia leads to the risk of hypoxic injury to the brain, kidneys, heart, cardiac arrest, and even death.
• Apply simple methods of airway clearance such as airway opening manoeuvres, airways suction, insertion of an oropharyngeal or nasopharyngeal airway.
• Tracheal intubation may be required when these simple methods fail.
• Administer high-concentration oxygen via a mask with oxygen reservoir at a flow of 15 L min¯¹.
• In intubated patients, provide high concentration oxygen with a self-inflating bag.
• Aim for an oxygen saturation of 94-98% in acute respiratory failure, and 88-92% in patients at risk of hypercapnic respiratory failure.

Breathing

• Life-threatening conditions like acute severe asthma, pulmonary oedema, tension pneumothorax, and massive haemothorax should be diagnosed and treated immediately.
• Signs of respiratory distress include sweating, central cyanosis, use of accessory muscles, and abdominal breathing.
• Count the respiratory rate; the normal rate is 12-20 breaths min¯¹, a high rate (> 25 min¯¹) is a marker of illness.
• Assess the depth and pattern of each breath, and whether the chest expansion is equal.
• Note any chest deformity or raised jugular venous pulse (JVP), and check chest drains for presence and patency.
• Remember that abdominal distension may limit diaphragmatic movement, worsening respiratory distress.
• Record the inspired oxygen concentration (%) and the SpO2 reading of the pulse oximeter, noting that the pulse oximeter does not detect hypercapnia.
• If the patient is receiving supplemental oxygen, the SpO2 may be normal despite a high PaCO2.
• Listen for breath sounds, such as rattling (indicating airway secretions) or stridor/wheeze (suggesting partial airway obstruction).
• Percuss the chest: hyper-resonance may suggest a pneumothorax; dullness suggests consolidation or pleural fluid.
• Auscultate the chest: bronchial breathing suggests lung consolidation with patent airways; absent or reduced sounds suggest a pneumothorax/pleural fluid.
• Check the trachea position in the suprasternal notch: deviation may indicate mediastinal shift.
• Feel the chest wall for surgical emphysema or crepitus, suggesting a pneumothorax.
• All critically ill patients should be given oxygen with COPD patients with high concentrations of oxygen being at risk of hypercapnic respiratory failure.
• COPD patients should be given oxygen via a Venturi 28% mask (4 L min¯¹) or a 24% Venturi mask (4 L min¯¹) initially and reassess.
• Target SpO2 range is 88–92% in most COPD patients, evaluate the target for each patient based on the patient's arterial blood gas measurements during previous exacerbations
• If breathing is inadequate or absent bag-mask or pocket mask ventilation should be used.
• In cooperative patients without airway obstruction, consider non-invasive ventilation (NIV), particularly in acute exacerbations of COPD.
• NIV can help prevent tracheal intubation and invasive ventilation.

Circulation

• Consider hypovolaemia as the primary cause of shock in all medical and surgical emergencies.

• Give intravenous fluid to any patient with cool peripheries and a fast heart rate unless cardiac cause signs are obvious.

• Rapidly exclude haemorrhage, and remember breathing problems can compromise circulation.

• Look at the hands and digits for colour: blue, pink, pale, or mottled. Assess limb temperature by feeling the patient's hands.

• Capillary refill time (CRT) should be measured by applying pressure for 5 seconds on a fingertip at heart level.

• A normal CRT is usually < 2 seconds; prolonged CRT suggests poor peripheral perfusion.

• Assess the state of the veins - underfilled or collapsed when hypovolaemia is present.

• Measure pulse rate (or heart rate with a stethoscope).

• Assess peripheral and central pulses for presence, rate, quality, regularity, and equality.

• Barely palpable central pulses suggest poor cardiac output; a bounding pulse may indicate sepsis.

• Measure blood pressure.

• Low diastolic blood pressure suggests arterial vasodilation, and a narrowed pulse pressure suggests arterial vasoconstriction.

• Auscultate the heart for murmurs or pericardial rubs, assess if heart sounds are difficult to hear.

• Assess if the audible heart rate corresponds to the pulse rate.

• Signs of poor cardiac output includes reduced consciousness level; also check for oliguria with a urinary catheter.

• Check for external haemorrhage or signs of concealed haemorrhage.

• Treatment of cardiovascular collapse should be directed at fluid replacement, haemorrhage control, and restoration of tissue perfusion.

• Insert one or more large (14 or 16 G) intravenous cannulae for high flow.

• Take blood from the cannula before infusing intravenous fluid.

• Give a bolus of 500 mL of warmed crystalloid solution over less than 15 minutes if the patient is hypotensive.

• Use smaller volumes (e.g. 250 mL) and closer monitoring (listen to the chest for crackles after each bolus) for patients with known cardiac failure or trauma.

• Reassess the heart rate and BP every 5 minutes, aiming for > 100 mmHg systolic.

• If there is a lack of response to repeated fluid boluses, seek expert help.

• If symptoms of cardiac failure occur, decrease or stop fluid infusion.

• If the patient has primary chest pain and suspected ACS, record a 12-lead ECG early.

  Immediate treatment consists of:

  • Aspirin 300 mg, orally, crushed or chewed.
  • Nitroglycerine, as sublingual glyceryl trinitrate.
  • Oxygen: only give oxygen if the patient's SpO2 is less than 94% breathing air alone.
  • Morphine/Diamorphine titrated intravenously.

Disability

• Common causes of unconsciousness include profound hypoxia, hypercapnia, cerebral hypoperfusion, sedatives or analgesic drugs.
• Review the patient's ABCs.
• Check the patient's drug chart and give antagonist like naloxone
• Examine the pupils (size, equality and reaction to light).
• Assess the patient as Alert, responds to Vocal stimuli, responds to Painful stimuli or Unresponsive to all stimuli, or use the Glasgow Coma Scale score.
• Measure blood glucose and follow protocols for management of hypoglycaemia.
• Give 50 mL of 10% glucose solution intravenously if blood sugar is less than 4.0 mmol L¯¹.
• Nurse unconscious patients in the lateral position and protect the airway.

Exposure

• Full exposure of the body may be necessary, while respecting patient dignity and minimising heat loss.

Additional Information

• Take a full clinical history from the patient, relatives, friends, and other staff
• Review the patient’s notes and charts.
• Study absolute and trended values of vital signs.
• Review the results of laboratory or radiological investigations.
• Check that important routine medications are prescribed and being given.
• Consider which level of care is required by the patient.
• Make complete entries in the patient’s notes of findings, assessment, and treatment.
• Hand over the patient to colleagues where necessary.
• Record the patient’s response to therapy.
• Consider definitive treatment of the patient’s underlying condition.