ABCDE Assessment Flashcards
What does ABCDE stand for?
How is it conducted?
Airway Breathing Circulation Disability Exposure
Start the initial treatment as areas of concern are discovered before moving on. e.g. low O2 sats discovered = oxygen given before moving on
How is airway assessed?
Look for airway obstruction e.g. paradoxical chest movements, cyanosis, no breath sounds or diminished/noisy breath sounds
How is airway managed?
Airway manoeuvres: head tilt, chin lift, jaw thrusts
Adjuncts: oropharyngeal airway tubes, nasopharyngeal airway tubes
Advanced: laryngeal mask, intubation, cricothyroidectomy
How is breathing assessed?
- Get the patient to talk
- Look listen and feel for general signs of respiratory distress - sweating, cyanosis etc.
- Count RR and look at O2 sats
- Look for symmetrical chest expansion
- Note chest deformities and raised JVP (present in acute severe asthma, tension pneumothorax)
- Listen to patient’s breath sounds
- Percuss the chest - hyper-resonance = pneumothorax; dullness = lung consolidation, pleural fluid
- Auscultate the chest - absent / reduced sounds = pneumothorax, pleural fluid or lung consolidation by complete obstruction
- Check trachea positional - mediastinal shift = pneumothorax, lung fibrosis, or pleural fluid
- Fell chest wall for surgical emphysema (air trapped within subcutaneous tissue)
How is breathing treated?
Oxygen given usually via non-rebreather mask - 15L/min
What are the 3 different oxygen devices below:
Nasal cannulae
Venturi masks
Non-rebreather masks
Nasal cannulae = most comfortable, delivers moderate amounts of oxygen (2-4L/min)
Venturi masks = deliver more O2, can control the % of O2 being delivered
Non-rebeathe mask = allows high flow of O2 (up to 15L/min)
How is Circulation assessed?
- Look at colour of hands - blue, pink, pale, mottled
- Hand temperature - cool, warm
- Measure SRT (Capillary refill time) - apply cutaneous pressure for 5secs on fingertip at heart level, normal =<2secs
- Assess state of veins
- HR
- Palpate peripheral and central pulses - presence, rate, quality, regularity, and equality
- BP
- Auscultate heart
- Look for other signs of reduced CO - reduced consciousness
- Look for external haemorrhage / wounds / bleeds
- Urine output
- Oedema in the legs
How is circulation treated?
Hypovolaemia = fluids
ACS (Acute coronary syndrome) e.g. MI = Aspirin 300 mg, orally, crushed or chewed, ASAP Nitroglycerine Oxygen Morphine (avoid sedation)
How is disability assessed?
A measure of a person’s reduced or loss of consciousness
What are common causes of unonsciousness?
Hypoglycaemia
Hyperglycaemia
Hypoxia
Hypotension
How is disability treated?
Treat underlying cause
Nurse unconscious patients in pateral position is airway is not protected
How is exposure assessed?
Expose patient more fully for complete examination
Respect patient’s dignity and minimise heat loss
ABCDE Scenario 1:
32F - neurosurgery ward, being monitored overnight for small intracranial bleed
On sound on inspiration and not inspiration and expiration
Patient only groans to voice stimuli
How would you assess for signs of airway obstruction?
Paradoxical chest rise and abdominal movements (use of accessory muscles of respiration)
Central cyanosis
No breath sounds / noisy or diminished air entry
What are the initial steps to protect an airway?
Head tilt, chin lift
Suction
Oropharyngeal or nasopharyngeal airway tube
Intubation
Cricothyroidectomy
Ventilation
Do you wait for a nurse to come in five minutes? Or who do you call immediately?
Call someone with advanced airway skills - e.g. anaesthestist, intensive care doctor, critical care outreach team
ABCDE Scenario 2:
65M - has COPD, sat up, talking comfortably
Respiratory rate 19 Oxygen saturations 89 (2L/O2) Heart rate 92 Blood pressure 101/84 Temperature 36.5 Consciousness Alert
What is his NEWS2?
2 - oxygen
1 - pulse
1 - systolic BP
= 4
How would you determine if this oxygen saturation of 89% is adequate for Mr Khans?
Holistic assessment - look at the clinical context, particularly his baseline oxygen saturations
Look for signs of respiratory distress as per the ABCDE assessment
What oxygen delivery device do you think he is on? Why?
Venturi mask = most likely as they allow for the flow and concentnration of oxygen delivered to be carefully controlled
Over-oxygenation is dangerous
ABCDE Scenario 3:
34F - admitted today with diarrhoea and vomiting, mentions cannula has been hurting and swollen for past 2 hours
Respiratory rate 19 Oxygen saturations 98 (air) Heart rate 129 Blood pressure 96/81 Temperature 36.4 Consciousness Alert
What do you think is going on?
Patient is receiving IV fluids for rehydration, but the cannula is no longer in the vein
Fluid is now going into the subcutanous tissue rather than the vein
Patient is now risking hypovolaemia
Is this likely to be hypovolemic, cardiac or distributary shock?
Hypovolaemic shock
How do you assess circulation beyond pulse and BP?
See whether all the tissues are able to utilise the oxygen being delivered
Use urine output, lactate levels, capillary refill time, consciousness level etc.
The pulse pressure is narrow. Why might the diastolic pressure be maintained?
Falling BP = sympathetic activation
Leads to systemic vasoconstriction and increased peripheral resistance = preserves diastolic pressure
But if circulating volume is low, then cardiac myocyte stretch (preload) is limited, so CO is limited = limited systolic BP rise
