Module 4: The ABCDE assessment

Question 1

Most (50–80%) of patients show signs of deterioration prior to arrest. What are common sings of deterioration?

Answer 1

Hypoxia or hypotension

Question 2

Airways

Answer 2

1. Look for signs of airways obstruction
   - See-saw respirations
   - No breath sounds (complete) vs diminished/noisy breath sounds (partial)
2. Treat as a medical emergency
   - Simple methods (suction, Mcgills forceps, basic manoeuvres, adjuncts)
   - Tracheal intubation failing this
3. High concentration oxygen
   - At flow rate 15 L min-1
   - Use self-inflating bag if tracheal tube in situ
   - Sats aim acute RF 94-98%, if risk hypercapnic RF 88-92%

Question 3

Breathing

Answer 3

1. Treat life-threatening conditions immediately (e.g. acute severe asthma, tension pneumo, pulmonary oedema)
2. Assess: RR, depth & pattern, sats, chest expansion, breath sounds, percuss, auscultate, tracheal position, palpate chest wall
3. Give oxygen to all critically ill patient

Question 4

What are you assessing for when listening to breath sounds from a short distance away?

Answer 4

Rattling = airway secretions

Stridor/wheeze = partial (!but significant) obstruction

Question 5

What are you assessing for when percussing?

Answer 5

Dullness = consolidation or pleural fluid
Hyper-resonance = pneumothorax

Question 6

What are you assessing for when auscultating?

Answer 6

Bronchial breath sounds = lung consolidation with patent airways

Absent/reduced breath sounds = pneumothorax, pleural fluid, lung consolidation causing complete obstruction

Question 7

Where and why do you check tracheal deviation?

Answer 7

Suprasternal notch

Towards affected side (loss of volume on that side)
- Pneumonectomy, atelectasis

Away from affected side (increase in pressure or volume on that side)
- Tension pneumothorax, large pleural effusion, upper mediastinal mass e.g. MNG

Question 8

Feel the chest wall to detect?

Answer 8

Crepitus = the crackling/popping noise from air under the skin) =surgical emphysema, pneumothorax, ruptured airway/oesophagus

Question 9

True/false: all critically ill patients should be given oxygen.

Answer 9

True.

In the COPD subgroup: still give oxygen but aim for a lower partial pressure and oxygen saturation. High concentrations of O2 may depress their breathing (i.e. risk of hypercapnic or ‘T2’ respiratory failure).

Give oxygen via a Venturi 28% mask (4 L min-1) or Venturi 24% mask (4 L min-1) initially then reassess.

Aim for SpO2 88-92%.

They may have an oxygen alert card, or ABGs from previous exacerbations, to guide you.

Question 10

If the patient’s depth or rate of breathing is judged to be inadequate, or absent, you should?

Answer 10

Use bag-mask or pocket-mask ventilation to improve oxygenation and ventilation.
In cooperative patients without airway obstruction, consider NIV.
In patients with acute exacerbation COPD, NIV is useful and can prevent needing tracheal intubation & invasive ventilation.

Question 11

Circulation

Answer 11

1.Hypovolaemia should be considered as the primary cause of shock u.p.o.
2. Assess hand colour & temp, CRT (press for 5s on a fingertip at heart level), peripheral & central pulse (rate, quality, regularity, equality), BP, HS
3. Give IVF to all patients with fast HR and cool peripheries
4. Exclude haemorrhage in surgical patients (overt/hidden)
5. Insert one/more 14 or 16 G cannulae (short & wide-bore = enables highest flow)
6. Take bloods, give fluids
7. Reassess HR and BP every 5 mins, aiming for the patient’s normal BP or, if unknown, aim >100 mmHg systolic. Repeat fluid challenge if no improvement.

Question 12

Why may CRT be prolonged i.e. >2s?

Answer 12

Poor peripheral perfusion
Cool surroundings
Old age

Question 13

How would you interpret pulse quality?

Answer 13

Bounding – sepsis
Thready –poor CO

Question 14

How would you interpret BP?

Answer 14

Low dBP –arterial vasodilation –anaphylaxis, sepsis

Narrow pulse pressure (35-45 mmHg) –arterial vasoconstriction –cardiogenic shock, hypovolaemia –may occur with rapid tachyarrhythmia

Question 15

What bloods are you taking? What fluids are you giving?

Answer 15

Bloods: routine haematological, biochemical, coagulation, microbial, cross-matching (before IVF)

Fluid: 500 mL crystalloid (Hartmann’s or NaCl) over <15 min. 250 mL if know cardiac failure or trauma.

Question 16

What would signs of HF be? What should you do?

Answer 16

Dyspnoea, raised HR, raised JVP, pulmonary crackles on auscultation, a 3rd HS

Decrease/stop the fluid infusion)
Alternative means to increase tissue perfusion – inotropes, vasopressors

Question 17

If the patient has primary chest pain and suspected ACS?

Answer 17

Record a 12-lead ECG early
Immediate general treatment for ACS:
1. 300 mg aspirin oral (crushed/chewed) asap
2. GTN spray
3. Oxygen only if SpO2 <94% on RA
4. Morphine or diamorphine, titrated IV to avoid sedation/respiratory depression

Question 18

Disability

Answer 18

1. Examine pupils
2. Rapid consciousness assessment: AVPU or GCS
3. Blood glucose, rapid finger-prick (ABG or VBG in sick/periarrest patients)
4. Lateral position for unconscious patients if airway not protected

Question 19

Management of hypoglycaemia, <4.0 mmol L-1 in unconscious patient?

Answer 19

50 mL of 10% glucose IV

Give further doses until consciousness regained, up to 250 mL 10%.
Repeat BMs.

Question 20

Exposure

Answer 20

1. Fully expose the patient, respecting dignity and minimising heat loss
2. Abdomen
3. Calves