A systematic approach to the acutely ill patient

(adapted from the ALERT course)

June 2005
Contents
Underlying principles
First steps
Airway (A)
Breathing (B)
Circulation (C)
Disability (D)
Exposure / Examination (E)
Additional information

Underlying principles
1. Use a systematic approach, based on airway, breathing and circulation (i.e., the
ABCDEs) to assess and treat the acutely ill patient.

2. Undertake a complete initial assessment and re-assess regularly.

3. Always assess the effects of treatment or other interventions.

4. Always correct life-threatening abnormalities before moving on to the next part of
assessment.

5. Recognise the circumstances when additional help is required and ask for it
early.

6. Use all members of the multidisciplinary team.

7. Communicate effectively.

8. The underlying aim of the initial interventions should be seen as a holding
measure that keeps the patient alive, and produces some clinical improvement,
in order that definitive treatment may be initiated.

9. Remember that it often takes a few minutes for resuscitative measures to have
an effect.



First steps
1. Ask the patient a simple question. In assessing any patient, a simple question
such as How are you can provide valuable information. A normal verbal
response implies that the patient has a patent airway, is breathing and has brain
perfusion. If the patient can only speak in short sentences, they may have
extreme respiratory distress. Failure of the patient to respond is a clear marker of
serious illness.

2. Use vital signs monitoring early. Apply a pulse oximeter, ECG monitor and
continuous non-invasive blood pressure monitor to all critically ill patients, as
soon as is safely possible.

Airway (A)

Treat airway obstruction as a medical emergency and obtain expert help immediately.
Untreated, airway obstruction leads to a lowered PaO
2
and risks hypoxic damage to the
brain, kidneys and heart, cardiac arrest, and even death.
1. Look for the signs of airway obstruction:
o Airway obstruction leads to paradoxical chest and abdominal movements
(see-saw respirations) and the use of the accessory muscles of
respiration. Central cyanosis is a late sign of airway obstruction. In
complete airway obstruction, there are no breath sounds at the mouth or
nose. In partial obstruction, air entry is diminished and often noisy. Certain
noises assist in localizing the level of the obstruction.

o In the critically ill patient, depressed consciousness often leads to airway
obstruction.

2. Treat airway obstruction as a medical emergency:
o Obtain expert help immediately. Untreated, airway obstruction leads to a
lowered PaO
2
and risks hypoxic damage to the brain, kidneys and heart,
cardiac arrest, and even death.

o In the majority of cases, simple methods of airway clearance are all that
are required (e.g., airway opening manoeuvres, airways suction, insertion
of an oropharyngeal or nasopharyngeal airway). Tracheal intubation may
be required, where simple airway opening measures fail.

3. Give oxygen at high concentration:
Provide high concentration oxygen using a mask with an oxygen reservoir.
Ensure that the oxygen flow rate is sufficient (usually > 10 litres min
-1
) to
prevent collapse of the reservoir during inspiration. Where intubation has
been necessary, high concentration oxygen can be given via a bag-valve-
mask system.

o In acute respiratory failure, the PaO
2
should be kept as close to 13kPa
(100 mmHg) as possible, but at least above 8 kPa (60 mmHg) or 90%
saturation on a pulse oximeter.

Breathing (B)

During the immediate assessment of breathing, it is vital to diagnose and treat
immediately life-threatening conditions, e.g., acute severe asthma, pulmonary oedema,
tension pneumothorax, massive haemothorax.
1. Look for the general signs of respiratory distress: sweating, central cyanosis, use
of the accessory muscles of respiration, abdominal breathing.

2. Count the respiratory rate. The normal rate is between 12 and 20 breaths per
minute. High rates, and especially increasing rates, are markers of illness and a
warning that the patient may suddenly deteriorate.

3. Assess the depth of each breath, the pattern (rhythm) of respiration and whether
chest expansion is equal on both sides.

4. Note any chest deformity (this may increase the risk of deterioration in the ability
to breathe normally); look for a raised JVP (e.g., in acute severe asthma or a
tension pneumothorax); note the presence and patency of any chest drains;
remember that abdominal distension may limit diaphragmatic movement, thereby
exacerbating respiratory distress.

5. Record the inspired oxygen concentration (%) given to the patient and the
SaO
2
reading of the pulse oximeter (normally 97-100%). However, remember
that the pulse oximeter does not detect hypercapnia and that, if the patient is
receiving oxygen therapy, the SaO
2
may be normal in the presence of a very high
PaCO
2
.

6. Listen to the patients breath sounds a short distance from his/her face: Rattling
airway noises indicate the presence of airway secretions, usually due to the
inability of the patient to cough sufficiently or to take a deep breath. Stridor or
wheeze suggests partial, but significant, airway obstruction.

7. Percuss the chest; hyper-resonance suggests a pneumothorax, dullness
suggests consolidation or pleural fluid.

8. Auscultate the chest: the quality of the breath sounds should be evaluated.
Bronchial breathing indicates lung consolidation; absent or reduced sounds
suggest a pneumothorax or pleural fluid.

9. Check the position of the trachea in the suprasternal notch. Deviation to one side
indicates mediastinal shift (e.g., pneumothorax, lung fibrosis or pleural fluid).

10. Palpate the chest wall to detect surgical emphysema or crepitus (suggesting a
pneumothorax until proven otherwise).

11. The specific treatment of respiratory disorders depends upon the cause.
Nevertheless, all critically ill patients should receive oxygen. In a subgroup of
patients with chronic obstructive pulmonary disease (COPD), high concentrations
of oxygen may have disadvantages and some limitations in therapy may be
warranted. Nevertheless, this latter group of patients will also sustain end-organ
damage or cardiac arrest if their blood oxygen tensions are allowed to decrease.
In this group, aim for a target PaO
2
of 8 kPa (60 mmHg) or 90% saturation (SaO
2
)
on pulse oximetry.

12. If the depth or rate of breathing of any patient is judged to be inadequate, or
absent, use bag-valve-mask ventilation to improve oxygenation and ventilation,
whilst calling urgently for intensive care assistance.

Circulation (C)

In almost all medical and surgical emergencies, consider hypovolaemia to be the
primary cause of shock, until proven otherwise. Unless there are obvious signs of a
cardiac cause, give intravenous fluid to any patient with cool peripheries and a fast
heart rate. In surgical patients, rapidly exclude haemorrhage (overt or hidden).
Remember that respiratory pathology, such as a tension pneumothorax, can also
compromise a patients circulatory state. This should have been treated earlier on in the
assessment.
1. Look at the colour of the hands and digits: are they blue, pink, pale or mottled?

2. Assess the limb temperature by feeling the patients hands: are they cool or
warm?

3. Measure the capillary refill time (CRT). It is assessed by applying cutaneous
pressure for five seconds on a fingertip held at heart level (or just above) and
counting the time it takes for capillary refill after the pressure has been released.
The normal value for CRT is usually less than two seconds.

4. Assess the state of the veins: they may be under-filled or collapsed when
hypovolaemia is present.

5. Count the patients pulse rate.

6. Palpate all the peripheral and central pulses, assessing for presence, rate,
quality, regularity and equality. Barely palpable pulses suggest a poor cardiac
output, whilst a bounding pulse may indicate sepsis.

7. Measure the patients blood pressure. Even in shock, the blood pressure may be
entirely normal, as compensatory mechanisms increase peripheral resistance in
response to reduced cardiac output. Where possible, the diastolic and systolic
values should be noted. A low diastolic BP suggests arterial vasodilatation (as in
anaphylaxis or sepsis). A narrowed pulse pressure (difference between systolic
and diastolic pressures; normally ~ 35-45 mmHg) suggests arterial
vasoconstriction (cardiogenic shock or hypovolaemia).

8. Auscultate the heart.

9. Look for other signs of a poor cardiac output, such as reduced level of
consciousness and, if the patient has a urinary catheter, oliguria (urine volume <
0.5 ml kg
-1
hour
-1
).

10. Examine the patient thoroughly for external haemorrhage from wounds or drains
or evidence of concealed haemorrhage (e.g., thoracic, intraperitoneal or into gut).
Remember that intrathoracic, intrabdominal or pelvis blood loss may be
significant, even if drains are empty.

11. The specific treatment of cardiovascular collapse will be determined by the
cause, but should be directed at fluid replacement, haemorrhage control and
restoration of tissue perfusion. Seek out the signs of conditions that are
immediately life threatening, e.g., cardiac tamponade, massive or continuing
haemorrhage, septicaemic shock, and treat them urgently.

12. Insert one or more large (14 or 16 G) intravenous cannulae. Use short, wide-bore
cannulae, as they have the highest flow rate.

13. Take blood from the cannula for routine haematological, biochemical, coagulation
and microbiological investigations, and cross-matching, before infusing
intravenous fluid.

14. Give a rapid fluid challenge (over 5-10 minutes) of 500 ml of warmed crystalloid
solution if the patient is normotensive. Give 1 litre, if the patient is hypotensive.
Use smaller volumes (e.g., 250 ml) for patients with known cardiac failure and
use closer monitoring (listen to the chest for crepitations after each bolus,
consider a CVP line).

15. Reassess the pulse rate and BP regularly (every 5 minutes), aiming for the
patient's normal BP or, if this is unknown, a target > 100 mmHg systolic.

16. If the patient shows no signs of improvement, the fluid challenge can be
repeated.

17. If symptoms and signs of cardiac failure (dyspnoea, increased heart rate, raised
JVP, a third heart sound and pulmonary crepitations on auscultation) occur,
decrease the fluid infusion rate or stop the fluids altogether. Seek alternative
means of improving tissue perfusion (e.g., inotropes or vasopressors).


Disability (D)

Common causes of unconsciousness include profound hypoxaemia, hypercapnia,
cerebral hypoperfusion, or the recent administration of sedatives or analgesic drugs.
1. Review the ABCs: exclude hypoxaemia and hypotension.

2. Check the patients drug chart for reversible drug-induced causes of depressed
consciousness. Give the appropriate antagonist, where available.

3. Examine the pupils (size, equality and reaction to light).

4. Assess the patients conscious level using either the AVPU or Glasgow Coma
Scales.

5. Measure the blood glucose using a rapid glucose meter or stick method to
exclude hypoglycaemia. If below 3 mmol l
-1
, give 25-50 ml of 50% glucose
solution intravenously.

6. Nurse unconscious patients in the recovery position, where possible.


Exposure / Examination (E)

In order that patients are examined properly, and detail is not missed, full exposure of
the body may be necessary. Do this in a way that respects the dignity of the patient and
prevents heat loss.



Additional information
1. Take a full clinical history from the patient, his relatives or friends, and other
staff.

2. Review the patient notes and charts
a. Study both absolute and trended values of vital signs.
b. Check that important routine medications are prescribed
and being administered.

3. Review the results of laboratory or radiological investigations.

4. Consider which level of care is required by the patient (e.g., ward, HDU, ICU).

5. Make complete entries in the patients notes of your finding, assessment and
treatment. Record the patients response to therapy.

6. Consider definitive treatment of the patients underlying condition.