A to E approach

Question 1

Prior to performing an A to E approach, what should you do

Answer 1

Safety net any other patients and let SHO/Reg know there are potentially x unwell patients
SBAR handover - NEWS score
Drug chart and notes to consider ceiling of care
PPE

If undergoing surgery then NBM and group and save

Question 2

What are the components of B in an A to E approach

Answer 2

Observations: SpO2, RR
Look: respiratory distress, chest expansion (if even between sides)
Listen: air entry, added sounds
Feel: trachea, chest expansion, percussion

Investigation:
- ABG (CCOT nurses may be able to get this in advance, nurses can take VBGs)
- Portable CXR

Management
Do - non-rebreather mask and 15L/min O2
Do - bag valve mask if poor or absent breathing effort
If tension pneumothorax then perform immediate needle decompression
If poor or absent respiratory effort then call cardiac arrest team

Question 3

What are the components of C in an A to E approach

Answer 3

Observations: HR, BP
Look: colour, diaphoresis, oedema, bleeding, cyanosis, distended neck veins
Feel: temperature, central pulses (carotid/femoral), CRT
Listen: heart sounds

Investigations:
- 12 lead ECG
- Blood pressure
- IV access + bloods (FBC, U&E, LFTs, coagulation, group and save, troponin)
- Catheter: input / output

Management
If no pulse - call cardiac arrest team
Do: get venous access and send bloods
Do: get VBG with bloods or ABG if spO2 <95
Do: give fluids if hypotension or high pulse - 500mL stat unless pt in over heart failure

sepsis, STEMI, arrhythmia, haemorrhage

Question 4

What are the components of D in an A to E approach

Answer 4

Assess AVPU or GCS
Observations: Glucose
Pupils - size, reaction to light
Feel tone in all 4 limbs
Drug chart

Management
Do give glucose if <4 mmol/l, 100mL of 20% glucose IV)
stroke, hypoglycaemia

Question 5

What are the components of E in an A to E approach

Answer 5

Observations: temperature
Focused examination:
- Skin
- Abdomen
- Calves
- Lines / drains

Investigations:
- USS/ FAST scan
- Urinalysis + pregnancy test

Management:
Do warm patient if hypothermic
Look all over body for injuries - MUST keep patient covered to protect dignitiy

Question 6

Following the acute setting, what needs to be done

Answer 6

COVID nudge test if not already done
Referral to team
Document in notes
Update family
Thromboprophylaxis
Update seniors

Question 7

What are the components of A in an A to E approach and what would you say after completing A

Answer 7

Is the patient vocalising?
- Are they talking - look inside mouth, remove obvious objects
- Are there upper airway noises - listen for stridor, snoring, gurgling

Do: Suction under direct vision if secretions present
Do: Jaw thrust/head tilt/chin lift (with cervical spine control in trauma)
Do: Insert and oropharyngeal or nasopharyngeal airway as tolerated
If airway still compromised call arrest team
Do: Give oxygen - Maintain an oxygen saturation of 94–98% – always give oxygen initially in the acutely unwell patient
Ask nurse to put monitoring on now – this will speed things up

Extra: if the patient is peri-arrest ask for the crash trolley now

If I’m happy that the airway is patent or being managed by a suitably qualified colleague, I’d move on to assess breathing