Approach to an acutely ill Adult

1. Assessment and treatment of
acutely ill adult
Dr uzair ahmed

2. Educational Objectives:
1. Understand and be able to apply the ABCDEF approach to
assessment and treatment of the acutely ill adult
2. Understand the importance of making a diagnosis and applying
definitive treatment in parallel with resuscitation
3. Know about physiological monitoring, what is available and how it is
applied to the sick patient
4. Appreciate the approach to illness severity assessment and its role
in the escalation of patient treatment

3. Bedside Assessments of Acutely Ill Patients:
 The clinical management of acutely ill patients requires that life threatening
problems are immediately addressed whilst adiagnosis is sought sothat
definitive treatmentcanbe administered.
 TheABCDEapproach and diagnostic synthesis are complementary and
simultaneous processes . Junior doctors can co-ordinate these activities by
proceeding in a step wise fashion.

4. General rules:
"these are more rules than guidelines"
 Oxygen is good for you and your patient: the vast majority of sick
patients will benefit from high concentration oxygen so give them it!
The correct amount is enough
 In parallel with the patient being resuscitated and stabilized, someone
should be getting a full history e.g. from relatives, paramedics, GP,
ward staff. Delay in doing this can result in serious morbidity and
occasionally mortality as delay in definitive treatment may result. Most
likely in vascular events (i.e. thrombosis or bleeds)

5. General rules: (continued)
 Any IV access is better than none (for fluids and drugs)
 If there is a cannula already in place, make sure it works
 Avoid the ante-cubital fossa for iv access except as a last resort.

6. General rules: (continued)
 Do a blood gas, Hb, K+, glucose and lactate on any sick patient. Base
deficit may alert you to how sick they are.
 If you're not sure what is wrong with the patient could they have sepsis?
Obtain cultures including blood cultures. Identifying sepsis early.

7. If the patient isn't improving despite your
treatment consider:
 Calling for help
 Is the diagnosis correct ?
 Is this patient sick enough to require Intensive Care transfer? common
reasons for ICU referral
 Is there something else going on? ie a second diagnosis or a complication
of the original diagnosis or its therapy.

8. Introduction to ABCDE Approach
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXPOSURE
Acutely ill patients are best approached using an ABCDE assessment in
conjunction with a targeted history and examination in order to reach a
diagnosis so that definitive treatment can be administered.
A B C D E

9. Step 1: Initial Assessment
 Much of the ABCDEassessment canbe accomplished within moments of arrival at the bedside by
observation of the patient and their charts.
 Offering ahandshakeis agood way to start the bedside assessment,not only will this provide clinical
information about the level of consciousness,airway patency and peripheral perfusion but will also
reassure apotentially frightened and distressed patient.
 Diagnosisrequires afocused history, examination and investigations – history from the patient maybe
limited and mayneed to be supplemented by information obtained from the bedside nurse, medical
notes andrelatives.
 TheABCDEapproach requires that concerns regarding eachelement of this
bedside assessment have to be addressedbefore proceeding to the next
element.

10. Initial approach: 'Advanced first aid'
A = Airway assessment and management
B = Breathing assessment and management with Oxygen Therapy
C = Circulation assessment and management + IV access & blood tests
D = Disability assessment
E = Exposure, Examination, and review of Evidence
F = Frequent re-assessment and establish monitoring

11. As you walk up to the patient and introduce yourself shake hands and ask
"how are you doing ? " Immediately (ie within 5 seconds) you will have
assessed airway (they can/can't talk, noises eg stridor, snoring/gurgling,
none), breathing (rate, symmetry, work of breathing: accessory muscle use,
paradoxical or see-saw pattern), circulation (warm/cold peripheries) and
conscious level (their response to you). In this short time you should be
thinking " can I take some time to assess or should I ?"
a) start treatment
b) call for help
c) both a and b

12. Airway Assessment:
 Complete airway obstruction is very rare (patients usually dies within minutes) but
partial airway obstruction is quite common and can be recognised by noisy
breathing such as snoring or gurgling and evidence of increased work of breathing
such as intercostal recession.
 The commonest cause of partially obstructed airway is a reduced level of
consciousness (due to reduced airway muscular tone, loss of protective airway
reflexes, principally the gag and cough reflexes, retention of oropharyngeal
secretions and tongue mal-position).
 A partially obstructed airway can be relieved with simple manoeuvres such as jaw
thrust or a chin lift. Airway adjuncts such as oropharyngeal or nasopharyngeal
devices can also be useful.
AIRWAY
A

13. Airway Assessment:
 The earliest, most sensitive feature of developing severe illness is an increased
respiratory rate: look, count, respond.
 Increased work of breathing due to increased respiratory rate and excessive
respiratory muscle activity causes oxygen consumption to increase (often ten fold)
at the same time as oxygen delivery is compromised .
 Give supplemental oxygen and consider how we can reduce the effort of breathing
(eg salbutamol for wheeze, nitrates for LVF). Sometimes the work of breathing is
so high that the patient requires intubation and ventilation to reduce this work and
divert oxygen delivery to vital organs.
AIRWAY
A

14. Breathing Assessment:
 Begin by counting the respiratory rate, breaths per minute (bpm).
 Increased respiratory work commonly accompanies acute illness as a result of an
increased metabolic rate and oxygen consumption. This may lead to respiratory
distress, signs of which include: inability to complete sentences, high respiratory
rate, diaphoresis, accessory muscle use and cyanosis.
 Focused clinical examination including tracheal palpation, percussion and
auscultation may uncover the diagnosis. (Tracheal deviation-tension pneumothorax,
hyper-resonance-tension pneumothorax, dull percussion note-pleural
effusion/empyema, wheeze, silent chest-acute severe asthma, left ventricular failure,
diminished or bronchial breath sounds-pneumonia)
B

15. Breathing Assessment:
 High flow oxygen should be administered to all acutely patients the
effects of therapy should be assessed using pulse oximetery and the
target oxygen saturations should be between 94% and above.
 Theappropriate oxygen delivery device to use is anoxygen mask with a
reservoir bag. It is vital that the reservoir is kept inflated at all times this is
usually achieved by setting the flow rate of oxygen to 15 L/min. This mask
will usually deliver an inspired oxygen concentration (FiO2) of60-85%
B

16. CIRCULATION
C
Circulatory Assessment
Begin by assessing the radial pulse, beats per minute (bpm), rhythm and character. Attach
cardiac monitoring if available. Note the blood pressure.
Clinical signs that are common to hypovolemic, obstructive and cardiogenic shock include:
 Confusion or agitation
 Cold extremities
 Reduced capillary refill
 Tachycardia
 Absent or small volume peripheral pulses
 Hypotension
 Oliguria

17. CIRCULATION
C
 If the patient is speaking to you they must have a carotid pulse. Feel for the radial
and if it is thready or absent that gives qualitative information on the state of the
circulation. Consider performing a manual BP with a sphygmomanometer. The need
for invasive blood pressure monitoring (reliable, real time, accurate) should
precipitate early Intensive Care transfer.
 With the exception of cardiogenic shock, complicated by pulmonary oedema, the
management of shocked patients invariably requires the administration of
intravenous fluid.
 Peripheral cannulae can usually be inserted into antecubital fossa or external jugular
veins whilst central lines can be into internal jugular, subclavian and femoral veins.
Very rarely venous access may require cut-down approach or an intraosseous
approach may be needed if venous access cannot be obtained at all.

18.  Secure or ensure vascular access. Any working cannula is worthwhile. If you
are giving drugs or slow IV fluids an 18 gauge cannula is fine. If you need to
rapidly infuse fluid or blood larger cannulae are needed.
 If the patient is shut down this may be difficult to achieve. This is another
reason for early Intensive Care referral. Insert any size of cannula and call for
help. An 8 F line inserted in the femoral vein can be achieved quickly by a
skilled operator and is excellent for rapid volume resuscitation in many cases.
Insertion of a central venous cannula at this stage is not usually a priority; get
good big peripheral access and an arterial line in first.
 Administer intravenous fluids if hypotensive. Bolus of 500 ml of crystalloid
(containing sodium in the range of 130-154mmol/L) over 15 minutes. (NICEIV
Fluid Therapy Guidelines2013).
CIRCULATION
C

19. • Sizesof peripheral cannula are determined by
gauge(12 largest, 14, 16, 18, 20, 22, 24
smallest)
• Poiseuille’s law states that flow is inversely
related to the length of the IVcatheter and
directly related to its radiusto the fourth
power.
• Therefore flow fastest down short cannula
with large diameter. Therefore two 16-
gaugelines are recommended for
resuscitation.
Poiseuille’sLaw
Flow Rate
Pressure
Radius
Fluid Viscosity
Length of Tubing
CIRCULATION
C

20. CIRCULATION
C
 If there is good flow from your iv cannula take blood for immediate investigations. If flow is
sluggish don't compromise the cannula by trying to get blood samples, do a venepuncture.
In any patient where volume resuscitation is a priority (hypovolaemia, haemorrhage, sepsis)
send blood for cross matching.
 Rapid infusion can be facilitated by the use of pressure infusors and in major fluid
resuscitation the early application of a fluid warmer reduces coagulopathy and the
development of hypothermia.
 As you infuse fluids the haemoglobin will fall due to haemodilution (even if the patient is not
bleeding). The optimisation of tissue oxygen delivery is pivotal to management.

21. Immediate Investigations:
 Arterial blood gases: O2, CO2, acid-base
 Potassium
 Glucose
 Hemoglobin
 Lactate*
 12 lead ECG
 CXR
 Blood cultures, if sepsis is suspected
 Specific Targeted tests
CIRCULATION
C
*Elevated lactate and
base deficit worse
than -4 correlates
with severe illness.

22. Disability Assessment
 Disability refers to neurological status, relevant clinical examination
would include assessment of the level of consciousness, focal and
localizing neurological signs, pupillary reflexes and signs of
meningism.
 Assess the GCS or AVPU score, check the pupils for symmetry, size
and reactivity and quickly assess limb function.
 A letter is assigned based on the patient's best response. E.g. AVPU
score of V means the patient responds to verbal stimulus such as
calling his name.
DISABILITY
D

23. E for Exposure, Examination, and review of
Evidence
 In the standard scheme derived from Advanced Trauma Life Support this is exposure to
look for important injuries. Although this is relevant in that context we would suggest that
E is for targeted secondary Examination, review of Evidence (notes, drug/
fluid/observation charts) and Environment (what is the patient attached to? eg iv infusions
such as GTN in the hypotensive patient, epidural infusions or PCA pumps in the post-
operative patient and so on).
 Exposure is a prompt to ensure the body is examined as a whole. Paying particular
attention to wound sites or other injuries on the body. During examination, being mindful
of environmental temperature and potential adverse effects of cooling (shivering causes
increased metabolic work and contributing to further cardiovascular decompensation).
 Both body temperature and bedside blood glucose levels should be assessed.
EXPOSURE
E

24. DEFG: DON’T EVER FORGET GLUCOSE
 DEFG: in any confused patient or patient with reduced conscious level
Don't Ever Forget Glucose. Hypoglycaemia is a common cause of reduced
level of consciousness (usually insulin or drug induced) . Hypoglycemia
can be caused by severe sepsis; this is a poor prognositic indicator.
 If the patient is hypoglycaemic but hasn't taken exogenous insulin or oral
hypoglycaemic agents consider:
 liver failure (check prothrombin ratio, another dynamic monitor of
hepatic synthetic function) hypoadrenalism (Addison's disease).
 Insulinoma is very rare.

25. F for Frequent examination and establish
monitoring
 It is often important to examine the patient more than once to assess the
severity of illness (is the patient improving or getting worse?). Use of
appropriate non-invasive or invasive monitors should be considered.
 At the same time as ABCDEF assessment and treatment are proceeding
immediate monitoring with ECG and pulse oximetry should be established
and consideration should be given to whether invasive monitoring is
required. Think about the definitive diagnosis and treatment.

26. Diagnostic synthesis, investigation and
definitive management
 Once diagnosis is obtained and/or the causes of deterioration understood,
definitive treatment can be started.
 This may require transfer of the patient to the operating theatre, interventional
cardiology laboratory, endoscopy suite, intensive care unit or high dependency
unit.
 Regardless, transfer will need to be conducted by trained personnel and the
proposed management carefully communicated to the patient and those close
to the patient.

27. The equations of life
This ABCDE approach is grounded in what we might call 'the equations of life'. These
delineate the physiology which keeps us alive from minute to minute.
 MAP = CO x SVR
Mean arterial pressure = cardiac output x systemic vascular resistance
Blood pressure is the product of flow and peripheral resistance
 CO = HR x SV
Cardiac output is the product of heart rate and stroke volume. Stroke volume relies on
preload (mainly influenced by venous return and circulating blood volume), afterload (SVR)
and cardiac muscle contractility.

28.  DO2 = CO x CaO2
DO2 is oxygen delivery, the amount of oxygen leaving the left ventricle (and delivered to
the respiring tissues in health) which is the product of blood flow and the amount of oxygen
in the blood. In most situations this depends on the amount of haemoglobin and the level of
oxygen linked to it (Oxy-haemoglobin concentration). In shock and other acute conditions this
system is disrupted eg in sepsis oxygenated blood is mal-distributed in the micro-circulation
resulting in impaired oxygen consumption.

29.  VO2 = CO x (CaO2 - CvO2)
VO2 is oxygen consumption which is flow weighted (related to cardiac output) and
reflects the amount of oxygen utilized throughout the body (the oxygen content difference in
arterial and mixed venous i.e. pulmonary arterial blood). In the acutely ill patient we should
be aiming to reduce oxygen consumption as well as optimizing oxygen delivery and this will
be covered in detail in the appropriate modules.

30. TheABCDEapproach and diagnostic synthesis should be simultaneous and complementaryprocesses.