A B C D an overview

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History, examination, differential diagnosis and treatment will not help someone who is critically ill. Diagnosis is

Table 1.1 An example early warning scoring system.

Score

3

2

1

0

1

2

3

Heart rate

< 40

41-50

51-100

101-110

111-130

> 130

Systolic BP

< 70

71-80

81-100

101-179

180-199

200-220

> 220

Respiratory rate

< 8

8-11

12-20

21-25

26-30

> 30

Conscious level

Confused

A

V

P

U

Urine (ml/4 h)

< 80

80-120

120-200

> 800

02 saturations

< 85%

86-89%

90-94%

> 95%

02 therapy

NIV

> 60%

02 therapy

or CPAP

oxygen

Each observation has a score. If the total score is 4 or more (the cut-off varies between institutions), a doctor is called to assess the patient.

NIV, non-invasive ventilation; CPAP, non-invasive continuous positive airway pressure; A, alert; V, responds to verbal commands; P, responds to painful stimuli; U, unresponsive.

50 45 40 35 30

20 15 10

CPR before ICU ICU mortality

Figure 1.2 Impact of PART in a London hospital. Abbreviations: CPR, cardiopulmonary resuscitation; ICU, intensive care unit; PART, patient at risk team. Reproduced with permission from Theta Press Ltd (Goldhill D. Medical Emergency Teams. Care of the Critically III. 2000;16:209-12

irrelevant when the things that kill first are literally A (airway compromise), B (breathing problems), and C (circulation problems) - in that order. What the patient needs is resuscitation not deliberation. Patients can be alert and "look" well from the end of the bed, but the clue is often in the vital signs. A common theme in studies is the inability of hospital staff to recognise when a patient is at risk. Even when the vital signs are documented, there is a failure to appreciate that serious abnormal physiology is an emergency.

The most common abnormalities before cardiac arrest are hypoxaemia with an increased respiratory rate and hypotension leading to hypoperfusion with an accompanying metabolic acidosis and tissue hypoxia. Hypoperfusion is common in hospital. If this is left untreated, a downward physiological spiral ensues. With time the hypoperfusion may become resistant to treatment with fluids and drugs. Therefore early action is vital. The following chapters teach the theory behind A, B, C, D in detail. Practical courses also exist that use scenario-based teaching on how to manage patients at risk. These are recommended because the A, B, C approach described below requires practical skills (for example, assessment and management of the airway), which cannot be learned adequately from a book.

A, B, C, D, E is the initial approach to any patient who is acutely ill:

• A - assess airway and treat if needed

• B - assess breathing and treat if needed

• C - assess circulation (that is, pulse, blood pressure, and skin perfusion) and treat if needed

• D - assess disability (the simple AVPU scale can be used (alert, responds to voice, responds to pain, unresponsive)

• E - expose and examine patient fully once A, B, and C are stable. Arterial blood gases and a bedside glucose measurement are the first investigations in any critically ill patient. Further information gathering can be done at this stage - for example, further history and details from notes and charts.

If there is one thing in medicine which is evidence-based, it is that patients with serious abnormal physiology are an emergency. The management of such patients requires pro-activity, a sense of urgency, and the continuous presence of the attending doctor. For example, if a patient is hypotensive and hypoxaemic from pneumonia, it is not acceptable for oxygen, fluids, and antibiotics simply to be prescribed. The oxygen concentration may need to be changed several times before the PaO2 is acceptable. More than one fluid challenge may be required to get an acceptable blood pressure - and even then, vasopressors may be needed if the patient remains hypotensive because of severe sepsis. Intravenous antibiotics need to be given immediately. ICU and CPR decisions need to be made at this time - not later. The emphasis is on both rapid and effective intervention.

Integral to the management of the acutely ill patient is the administration of effective analgesia. This is not discussed further in subsequent chapters but it is extremely important. Suffice to say that titrated intravenous analgesia is the method of choice in critically ill patients who suffer from delayed gastric emptying and reduced skin and muscle perfusion, making oral, subcutaneous, or intramuscular drugs less reliable.

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