Applying ABCDE Approach in the Assessment and Management of Patients with COVID-19

1. Assessment and Management of
Suspected COVID- 19 Patients:
E
B
C
D
A
Head to Toe Assessment
Prepared by:
Kristine S. Luzano, BSN, RN
As simple as…
Reviewed by:
Dr. DAVID HALI DE JESUS, RN, PgDip, FISQua
Associate Professor, School of Nursing
Philippine Women's University

2. Disclosure:
I have no relevant conflict of interest to disclose

3. Learning Outcome
At the end of the slideshow presentation, the learner will
be able to apply the ABCDE approach in the assessment
and management of suspected COVID-19 patients in their
clinical practice.

4. What is COVID-19?

5. What is ABCDE Approach?
• The mnemonic “ABCDE” stands for Airway, Breathing,
Circulation, Disability, and Exposure.
• The aim is to quickly identify life-threatening problems and
institute treatment to correct them.
• It is applicable for all patients, both adults and children as the
clinical signs of critical conditions are similar regardless of the
underlying cause.
“The ABCDE approach is not recommended in cardiac arrest.”

6. Aims of ABCDE Approach
321
PRIOTIZE
To provide life
saving
treatment
SIMPLIFY
To breakdown
complex
situations into
more
manageable
parts
DIRECT
To serve as an
assessment and
treatment
algorithm
4
ALERT
To establish
common
situational
awareness
among all
treatment
providers
5
BUY TIME
To buy time to
establish a final
diagnosis and
treatment.

7. Safety First
Perform a risk assessment of personal safety, and identify any immediate
environmental hazards. Screen patient using for possible signs and
symptoms of COVID-19 as well as any risk exposure to known COVID
cases according to your local protocol.
Infection Control
Perform hand hygiene according to local policy, and consider the need for
any personal protective equipment, such as gloves, masks and gown.
Before caring for patients with confirmed or suspected COVID-19,
healthcare personnel (HCP) must:
• Receive comprehensive training on when and what PPE is necessary,
how to don (put on) and doff (take off) PPE, limitations of PPE, and
proper care, maintenance, and disposal of PPE.
• Demonstrate competency in performing appropriate infection control
practices and procedures.
General/ Preliminary Assessment Principles

8. General/ Preliminary Assessment Principles
Visual Assessment of the
Patient
Observe the patient’s skin color, posture, body habitus and non-verbal
cues such as facial expression. Non-verbal cues may indicate distress,
pain, anxiety and breathlessness. Check also the patient’s environment
such as oxygen delivery devices, inhalers, hearing or visual aids, and
mobility aids, to gain insight into their wider health status
Communication
The healthcare practitioner should begin dialogue with the patient by
asking an open question, for example ‘how are you?’. It is important to
demonstrate active listening by showing genuine interest, offering
encouraging comments or responses while the patient is speaking, and
paraphrasing important points to clarify understanding of the patient’s
concerns

9. General/ Preliminary Assessment Principles
Consider Privacy, Comfort and
Dignity
The healthcare practitioner should begin dialogue with the patient by
asking an open question, for example ‘how are you?’. It is important to
demonstrate active listening by showing genuine interest, offering
encouraging comments or responses while the patient is speaking, and
paraphrasing important points to clarify understanding of the patient’s
concerns

10. Assessment
Yes
Can the patient talk?
Airway is open, continue ABCDE
Assessment
Yes, but not
normally
• Look for signs of airway obstruction (foreign body,
laryngeal edema, tongue, or vomitus)
• Listen for abnormal sounds (stridor/ grunting/
gurgling)
No
• Look for signs of airway obstruction (foreign body,
laryngeal edema, tongue, or vomitus)
• Look for paradoxical chest movements (seesaw/ labored
breathing)
• Listen for abnormal sounds (stridor/ grunting/ gurgling/
snoring)
AIRWAY
With Cervical Spine
Immobilization
A
(Click on the boxes to reveal the next course of action)

11. Management
Visible
foreign body
For conscious patients:
• Remove foreign body
• Encourage patient to cough (for partial obstruction)
• Administer age appropriate back blows and abdominal
thrusts (for complete obstruction)
Secretions • Suction secretions and wipe clean
Swelling,
stridor or
hives
• Consider ANAPHYLAXIS
• Administer IM Adrenaline
• Allow the patient to stay in position of comfort and
prepare for rapid HANDOVER/TRANSFER to a
center capable of advanced airway management.
AIRWAY
With Cervical Spine
Immobilization
A
(Click on the boxes to reveal the next course of action)

12. Management
No signs of
Trauma
For unconscious patients:
• Open airway using HEAD TILT and CHIN LIFT
MANEUVER
Suspected
Trauma
• Open Airway using JAW THRUST MANEUVER
AIRWAY
With Cervical Spine
Immobilization
A
(Click on the boxes to reveal the next course of action)
Consider placing airway
adjuncts (Nasopharyngeal
and Oropharyngeal
Airway)

13. Management
In case there is a need for definitive airway, consider this:
AIRWAY
With Cervical Spine
Immobilization
A
Always REASSESS after any
intervention.

14. Assessment
Remember to LOOK, LISTEN and FEEL.
BREATHING
Plus OXYGEN if needed
B
(Click on the boxes for more information)
Check for Respiratory
Rate and Oxygen
Saturation
Look
• Central Cyanosis
• Jugular vein distention
• Signs of respiratory distress (Sweating, use of
accessory muscles, abdominal breathing)
• Chest wall deformity
• Depth and rhythm of respirations
Listen
• Breath sounds
• Bronchial breathing
• Air entry
• Percuss to listen for hyperresonance and dullness
• Presence of cough ( Productive/ Unproductive)
Feel
• Palpate the trachea to check for deviation
• Chest Expansion
• Subcutaneous emphysema

15. Management
The WHO suggests titrating oxygen to a target
peripheral SpO2 of ≥90 percent.
BREATHING
Plus OXYGEN if needed
B
(Click on the boxes for more information)
Non-
Invasive
• For patients with COVID-19, supplemental oxygenation with a low
flow system via nasal cannula is appropriate (up to 6 L/min)
• Higher flows of oxygen may be administered using a simple face mask,
venturi face mask, or nonrebreather mask (up to 10 to 20L/ minute)
• WHO clinical guidelines on COVID-19 (Mar, 2020) also recommend use
of High Flow Nasal Cannula in selected patients.
Invasive
• Patients with COVID-19 pneumonia who develop ARDS requiring
mechanical ventilation should receive LTVV targeting ≤6 mL/kg
predicted body weight
• Prone ventilation has been recommended by intensivists who noted
that patients with COVID-19-related ARDS respond well to this
maneuver
Always REASSESS
after any
intervention.

16. Assessment
CIRCULATION
With Bleeding Control
and IV Fluids
C
Remember to LOOK, LISTEN and FEEL.
(Click on the boxes for more information)
Look
• Internal and external signs of bleeding
• Distended neck veins
• Observe skin color for pallor
Listen
• Heart sounds- muffled heart sounds may
suggest cardiac tamponade
• Presence of pericardial rubs/ murmurs/ third
beat
Feel
• Palpate for peripheral and central pulses
• Check for capillary refill
• Check for skin temperature and moisture
Check for:
• Blood Pressure
• Heart Rate and Rhythm
(ECG)
• Temperature
• Strict Intake and Output
• Cardiac Enzymes
Putative causes of myocardial injury in patients with COVID-19 include myocarditis, hypoxic injury, stress (takotsubo) cardiomyopathy,
ischemic injury caused by cardiac microvascular damage or epicardial coronary artery disease and systemic inflammatory response
syndrome (cytokine storm)

17. Assessment
CIRCULATION
With Bleeding Control
and IV Fluids
C
Some of the potential CV sequelae that may
result from COVID-19 infection.

18. Management
CIRCULATION
With Bleeding Control
and IV Fluids
C
Cardiovascular Management for COVID-19 Patients.
(Click on the boxes for more information)
Sepsis
• Initiate local sepsis care pathway
For sepsis guidelines click here
• Avoid overaggressive fluid resuscitation given
challenges with oxygenation (target CVP 6-8 mm Hg).
Acute
Cardiac
Injury
• Seek specialist cardiology advice on treatment,
further tests and imaging
Follow local treatment protocols or click here
Cardiac Arrest
• Follow Advanced Life Support Algorithm for
COVID-19 Patients
Click for ERC and AHA guidelines
Investigations/
Procedures:
• IV Access
• (ECG)
• Urinary Catheterization
• Blood Investigations
• Cultures and Swabs
The mainstay of managing patients with severe COVID-19 disease who have cardiac involvement is supportive care. There is currently
no evidence to direct the management of these patients differently than any other inflammatory or "mixed" shock state.
Always REASSESS
after any
intervention.

19. Assessment
DISABILITY
D
Check for level of consciousness (LOC) and pupillary
reaction.
(Click on the boxes for more information)
LOC
• AVPUC scale (Alert, Voice, Pain, Unresponsive,
Confusion or delirium)
• In trauma cases, the Glasgow Coma Scale (GCS).
Pupils
• Assess pupils (size, symmetry, reaction to
light):
• Pinpoint pupils in opioid overdose
• Dilated pupils may indicate TCA overdose or
intracerebral pathology
Movement
• Check movement and sensation in all four limbs
• Look for abnormal repetitive movements or shaking
(seizures/ convulsions)
Check:
• Blood sugar
levels
• Medications

20. Management
DISABILITY
D
Concerns about consciousness level always
warrant expert advice. Re-assess and maintain
the airway.
(Click on the boxes for more information)
Airway
• Maintain the airway as above (Airway- Intervention) in
any patient with depressed consciousness.
Drugs • In opioid overdose, use Naloxone as per local
policy.
Glycemic
Control
• In hypoglycemia, administer glucose as per guidelines.
• In Diabetic Ketoacidosis, manage with fluids and insulin
according to local guidelines.
Perform:
• Brain Imaging
• Urine dip/
ketostick
Always REASSESS
after any
intervention.

21. Assessment
EXPOSURE
E
Examine the entire body for hidden injuries, rashes, bites
or other lesions
(Click on the boxes for more information)
Head to Toe
Assessment
• Observe for evidence of bleeding, which may be internal –
indicated by abdominal distension or abnormal patterns of
bruising on the abdominal wall – or external (wound sites,
wound drains, per rectum or per vagina).
• Check integrity and patency of drains, lines and wound
dressing
Skin
Assessment
Location of rashes or skin changes that may
indicate hypersensitivity reaction
Edema
• Observe for signs of DVT
• (If the patient is wearing anti-embolic stockings, assess
for peripheral or sacral edema, which is a common
finding in patients with heart failure.)
Maintain the dignity
and temperature of the
patient while exposing
him sufficiently to do
visual head to toe
assessment

22. Management
EXPOSURE
E
Examine the entire body for hidden injuries, rashes, bites
or other lesions
(Click on the boxes for more information)
Remove Remove restrictive clothing and
accessories
Prevent
• Skin breakdown
• Hypothermia
• Nosocomial Infections by using care bundles (SSKIN,
CAUTI, CLABSI, etc)
Reassess • To identify any new problems that have developed and
make sure that the management you gave was effective
Seek help if the patient
shows no signs of
improvement or if you
have any concerns.

23. Remember
• If you have to intervene in any of the ABCDE categories,
immediately consider HANDOVER/TRANSFER to a higher
level of care
• A good handover includes:
• Brief identification of the patient
• Relevant elements of the SAMPLE history
• Physical exam findings
• Record of interventions given
• Plans for future care
• Things you may be concerned about

24. Communication/ Escalation
Identify
Yourself and your role /
Patient with three
identifiers
I
Situation
What is going on with the
patient?S
Background
Why is the patient in hospital
and what occurred
immediately before the
deterioration?
B
Assessment
What are the findings of
the ABCDE assessment that has
been
performed?
A
Recommendati
on• What do I recommend?
• Check back/Confirm for a shared
understanding
• Assign and accept
responsibility/accountability
R
Using a structured communication tool improves
the quality of healthcare practitioner handovers
and the consistency of information delivered in
the context of a deteriorating patient.

25. Summary
Airway with cervical spine immobilization
Breathing plus oxygen if needed
Circulation IV fluids and bleeding control
Disability AVPU/GCS, pupils and glucose
Exposure and keep warm

26. References:
• [World Health Organization]. (January, 2020). Novel coronavirus (2019-covid). [Video file]. Retrieved
from https://youtu.be/mOV1aBVYKGA
• Thim, T., Krarup, N. H., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and
treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE)
approach. International journal of general medicine, 5, 117–121.
https://doi.org/10.2147/IJGM.S28478
• https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf
• https://www.who.int/csr/resources/publications/WHO_HSE_EPR_2008_2.pdf
• https://www.safeairwaysociety.org/covid19/
• https://www.m3india.in/contents/editor_pick/138083/oxygen-therapy-by-hfnc-practical-points-on
• https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-critical-care-and-airway-
management-
issues?sectionName=SUMMARY%20AND%20RECOMMENDATIONS&topicRef=8355&anchor=H40802
33186&source=see_link
• https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-myocardial-
injury?topicRef=127419&source=see_link

27. References:
• https://www.nice.org.uk/guidance/ng171/resources/acute-myocardial-injury-algorithm-pdf-
8717541373
• https://geekymedics.com/acute-management-of-sepsis/
• https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-
coronavirus-cpr-and-resuscitation/in-hospital-settings/
• https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463
Disclaimer:
The presentation is intended for educational purposes only-
as a partial requirement by PWU to complete my MAN.
Any information presented herein does not aim to replace
individual professional judgement.

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