ABCDE ASSESSMENT Flashcards
If the patients condition changes always return to
Airway
Airway initial observations
Strange if uncomfortable sensations in the mouth, chest or throat
- hoarseness
- itching
- burning
- swallowing difficulty
- chest tightness
Breathing difficulty
- airway and breathing systems are so closely linked that airway compromise is highly likely to impact on breathing
Airway ; aural inspection
When airflow through the airways are unimpeded, breath sounds are quiet but audible.
In the absence of any breath sounds, use DRS ABC or the choking algorithm as necessary.
Noisy breathing may be a sign of airway compromise.
Abnormal airway sounds: wheeze
Inflammation and narrowing of the airway can result in wheezing.
When wheeze is identified, a pause point from treatment with a bronchodilator (salbutamol) should be created within the ABCDE assessment
Conditions associated with bronchospasm - where the small airways of the lungs become narrowed - such as asthma, chronic obstructive pulmonary disease (COPD) and anaphylaxis, are all associated with wheezing.
Inflammation in larger airways can cause wheezing.
Common causes include infection, an allergic reaction or physical obstruction, such as a foreign body.
Abnormal airway sounds: Stridor
Stridor is the sign of a blockage within the upper airways, should be treated as a life-threatening sign.
In a dental setting, identification of a stridor may be supported with a bronchodilator (salbutamol).
Anaphylaxis, choking, infection and injury are all associated with stridor.
Stridor can occur at any phase of respiration and may be uniphasic or biphasic, dependent on where the blockage is in the airway.
Abnormal airway sounds: Cough
Associated with asthma, anaphylaxis, allergic reaction, infection and partial obstruction choking episodes
Abnormal airway sounds: Snore
May indicate deterioration in pt conscious level indicating decreased ability to protect their own airway.
Use airway manoeuvres (head/chin tilt), airway adjuncts (oropharyngeal airways) and/or the recovery position should be considered.
Abnormal airway sounds: Gurgle
Gurgling may be heard if liquids are present within the oropharyngeal airway, such as excessive saliva, vomit, blood or mucus.
Typically, liquids in the oropharynx are managed by swallowing to reduce liquid volumes or coughing to expel liquid from the airways.
When considered in the context of an actually unwell patient, a gurgle may suggest that deterioration in the patient’s conscious level has impacted on their ability to protect their own airway.
The use of suction and/or the recovery position should be considered.
Airway: visual inspection
Lips mouth and tongue may look
- irritated
- swollen
- injured
- presence of foreign body
Breathing
A problem with the airways will quickly cause a problem with breathing.
Pulse oximetry
- measures the oxygen level in the blood
- target range for oxygen saturation 94-98%
- if below 94%, pt is hypoxic
- in pt with a high risk of hypercapnia, a lower target range of 88-92% is accepted
Hypercapnia
Used to describe elevated carbon dioxide levels in the blood
Circulation - palpitations / chest pain
What do they indicate
Palpitations may suggest cardiac arrhythmia
Chest pain may suggest cardiac ischaemia / panic attacks
Circulation: peripheral
Feeling of coldness and/or tingling in the limbs may be a sign of compensation in response to shock (low BP)
Circulation: Central
Experiencing visual / auditory disturbance, dizziness and/or feeling faint may be a sign of shock
Circulation: heart rate and rhythm
The body will accommodate for changes in blood flow and oxygen demand by increasing or decreasing heart rate as necessary
Low heart rate: sleep / high physical fitness
High heart rate: physical exertion (more oxygen consumed so body will respond by increasing heart rate / emotional stress (fight or flight response)
How will the body respond to insufficiencies in oxygen: Airway
Airway compromise may reduce blood oxygen levels, requiring the heart to work harder to maintain oxygen delivery
How will the body respond to insufficiencies in oxygen: Breathing
Airway compromise causes breathing difficulty
Breathing difficulty can both originate from or result in circulatory compromise
How will the body respond to insufficiencies in oxygen: Disability
When the brain fails to receive adequate oxygenated blood, it fails as to function
This results in reduced consciousness which in turn may result in airway compromise - reducing the available oxygen for the heart to pump
How will the body respond to insufficiencies in oxygen: Circulation
When circulation is compromised, the heart may not be able to deliver oxygenated blood around the body
In contrast airway and breathing compromise may cause circulatory compromise if the heart is not receiving adequate oxygenated blood
Circulation: capillary refill times
Can be used to assess perfusion status in addition to blood pressure measurements or as an alternative if blood pressure monitors are not available
When body is adequately perfused both peripherally and centrally, oxygen is delivered to all areas of the body
In this state capillary refill times less than 2 seconds
When body unable to meet demand for blood flow and oxygen, it priorities core with aim to maintain perfusion to vital organs. It does this by reducing blood flow to the peripheries.
In this state, capillary refill times more than 2 seconds for periphery but normal range for centrally.
Compensatory mechanisms, such as reducing blood flow to the peripheries and/or increasing heart rate, will exhaust if circulatory compromise is prolonged. In this state, capillary refill times may be prolonged both peripherally and centrally. When the body is unable to meet perfusion requirements centrally, the vital organs will begin to shut down and the patients condition should be considered life-threatening.
Circulation: Blood pressure
Blood pressure is a measure of circulatory status.
Systolic blood pressure measures the force as the heart contracts and diastolic when the heart relaxes and refills. Systolic blood pressure is used to assess perfusion status during acute illness.
The significance of values differs considerable when considering acute and chronic illness.
For example, a chronic systolic blood pressure of 160mmg increases the risk of other condition and may lead to a diagnosis of hypertension.
The same systolic pressure recorded during an acute illness is noteworthy but not treated as an emergency itself.
Systolic blood pressure categories
<90 - critically low
(critical cardiovascular collapse, risk of organ failure)
91-100 - Very Low
(signs of cardiovascular collapse)
101-110 - Low
(early signs of cardiovascular collapse)
111-180 - Normal
(circulation sufficient to maintain normal central and peripheral perfusion)
181-219 - High
(potential risk of ACS, stroke, kidney damage, eye damage, seizure)
> 220 - Critical
(acute risk of ACS, stroke, kidney damage, eye damage, seizure)
Disability: capillary blood glucose
Relevant to every acutely unwell pt
Particularly important if hypoglycaemia, seizure or syncope is suspected
Normal blood glucose - 4.0-8.0mmol/L
Disability: AVPU
AVPU is a simple neurological assessment which aims to identify what level of stimulus is required for a patient to open their eyes and make an attempt to verbalise.
Verbalisation does not have to be intelligible, meaningful or appropriate.
New confusion in any patient should be viewed as clinically significant and used to help inform working impression.
Disability: pain assessment
Exposure: visual inspection
Finalise assessment
Useful when you have an unclear working diagnosis of asthma / hyperventilation / acute cardiac ischaemia (which all share symptoms of anaphylaxis), or in syncope / seizure (where the pt may have sustained an injury)
