By: Dr.Wesam Abdelaziz

Early Signs of a critically ill patient

Initial management of a critically ill

patient

ABCDE Approach

Most cardiac arrest cases are predictable

Hypoxia and Hypotension are the most

common causes

Medical Emergency Team (MET)

A: Airway

B: Breathing

C: Circulation

D: Disability

E: Exposure

Safety

Treat life-threatening problems

Assess effects of treatment/interventions

Call for help early

Continuous assessment is very important

Causes of airway obstruction:

1. CNS depression

2. Blood

3. Vomit

4. Foreign body

5. Trauma

Talking means patent airway

Difficulty breathing, distressed, choking

Shortness of breath

Noisy breathing Stridor, wheeze, gurgling

See-saw respiratory pattern, accessory muscles

Head Tilt and chin lift

Jaw thrust if Trauma

Oro-pharyngeal Airway

Naso-pharyngeal Airway

Suction

Laryngeal Mask Airway (LMA)

Endotracheal tube

Oxygen

Causes if breathing problems:

Decreased respiratory drive

CNS depression

Decreased respiratory effort

Muscle weakness

Nerve damage

Restrictive chest

defect

Pain from fractured

ribs

Lung disorders

Pneumothorax

Hemothorax

Infection

COPD

Asthma

Pulmonary

embolus

ARDS

Inspection:

• Respiratory Rate

• Chest expansion

• Working accessory

muscle

• Deformity

Palpation:

• Tenderness

• Surgical emphysema

• Crepitus

Percussion:

• Dullness or hyper-

resonance

Auscultation:

• For breath sounds and

equality

Open Airway

Oxygen Supply

Treat Underlying Problem:

Bronchodilator Nebulizer is wheezy chest

Needle Thoracocentesis if Tension Pneumothorax

Assisted Ventilation if inadequate breathing

Causes of circulation problems:

Primary

Acute coronary syndromes

Arrhythmias

Hypertensive disease

Valve disease

Drugs

Inherited cardiac diseases

Electrolyte/acid base

abnormalities

Secondary

Aasphyxia

Hypoxemia

Blood loss

Hypothermia

Septic shock

Pulse :

Central & peripheral

Rate, Rhythm, Equality

Blood pressure

Peripheral perfusion - capillary refill time ( < 2 sec)

Organ perfusion

– Chest pain, mental state, urine output

Look at the patient : Pallor, Bleeding

Airway ,Oxygen

Breathing

IV/IO access, take bloods

Treat cause : ACS

Fluid challenge

Monitor

Recognition: AVPU

A: Alert

V: Responsive to verbal Stimuli

P: Responsive to Painful stimuli

U: Unresponsive

Pupils

Blood glucose

Normally is 4 mmol/ L (70 mg/dl)

Treatment:

ABC

Treat underlying

Cause:

Check for drug chart

Remove clothes to enable examination

e.g. injuries, bleeding, rashes

Avoid heat loss

Maintain dignity

Indication of complete Exposure

• Consult Specialist and Admission

• Investigations

• Continuous Assessment

Follow the ABCDE in assessment of any

patient.

Assess and re-assess all the time.

Don’t delay Calling senior Help

Basic Life Support

The ALS algorithm

Treatment of shockable and non-shockable rhythms

Potentially reversible causes of cardiac arrest

Role of resuscitation team

Approach safely

Check response

Open airway

Check breathing

Call 123

30 chest compressions

2 rescue breaths

Patient response

Open airway

Look, Listen, Feel

Check for normal breathing

Caution agonal breathing

Check for signs of life

Pulse check if trained to do so

Take less than 10 seconds for

assessment

Call for help early

30:2

Compressions

Centre of chest

5-6 cm depth

2 per second (100-120 min-1)

Maintain high quality compressions

with minimal interruption

Continuous compressions once

airway secured

Switch compression provider

every 2 min to avoid fatigue

Team Means:

Monitor

Skilled Persons

Drugs

Start With Monitor

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

START PAUSE

Assess

rhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

CPR

Bizarre irregular

waveform

No recognisable QRS

complexes

Random frequency and

amplitude

Uncoordinated electrical

activity

Coarse/fine

Exclude artefact

– Movement

– Electrical interference

Monomorphic VT – Broad complex rythm

– Rapif rate

– Constant QRS morphology

Polymorphic VT – Torsade de pointes

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Assess

rhythm

IMMEDIATELY RESTART CPR

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

CPR for 2 min

CPR for 2 min

During CPR Adrenaline 1 mg IV

Amiodarone 300 mg IV

Deliver 2nd shock

Deliver 3rd shock

Assess

rhythm

Shockable

(VF / Pulseless VT)

Non-Shockable

(PEA / Asystole)

MINIMISE INTERRUPTIONS IN CHEST COMPRESSIONS

Absent ventricular (QRS) activity

Atrial activity (P waves) may persist

Rarely a straight line trace

Adrenaline 1 mg IV then every 3-5 min

Clinical features of cardiac arrest ECG normally associated with an output

Adrenaline 1 mg IV every 3-5 min

Continue chest compression and ventillation

Assesment of rhythm every 2 minutes

Any questions