6)
Biochemical
Metabolic (lactic) acidosis
High or low white cell count
Low platelet count
High creatinine
High C‐reactive protein (CRP)
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. If this is left untreated, a downward physiological spiral ensues. With time, these abnormalities may become resistant to treatment with fluids and drugs. Therefore, early action is vital. The following chapters teach the theory behind ABCDE in more detail. Practical courses also exist which use scenario‐based teaching on how to manage patients at risk (see further resources). These are recommended because the ABCDE approach described below requires practical skills (e.g. assessment and management of the airway) which cannot be learned adequately from a book.
ABCDE 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 and treat if needed
D – assess disability and treat if needed
E – expose and examine patient fully once A, B, C, and D are stable. Further information gathering and tests can be done at this stage
Do not move on without treating an abnormality. For example, there is no point in doing an arterial blood gas on a patient with an airway obstruction
A more detailed version of the ABCDE system is shown in Box 1.3.
Box 1.3 The ABCDE System
Airway
Examine for signs of upper airway obstruction
If necessary, do a head tilt‐chin lift manoeuvre
Suction (only what you can see)
Simple airway adjuncts may be needed
Give oxygen if needed (see Chapter 2 for more details)
Breathing
Look at the chest
Assess rate, depth, and symmetry of movement
Measure SpO2
Quickly listen with a stethoscope (for air entry, wheeze, crackles)
You may need to use a bag and mask if the patient has inadequate ventilation
Treat wheeze, pneumothorax, fluid, collapse, infection, etc. (is a physiotherapist needed?)
Circulation
Assess limb temperature, capillary refill time, blood pressure, pulse, urine output
Insert a large bore cannula and send blood for tests
Give a fluid challenge if needed (see Chapter 5 for more details)
Disability
Make a note of the AVPU scale (alert, responds to voice, responds to pain, unresponsive)
Check pupil size and reactivity
Measure capillary glucose
Examination and Planning
Are ABCD stable? If not, go back to the top and call for help
Complete any relevant examination e.g. heart sounds, abdomen, full neurological exam
Treat pain
Gather information from notes, charts, and eyewitnesses
Do tests e.g. arterial blood gases, X‐rays, ECG
Do not move an unstable patient without the right monitoring equipment and staff
Make ICU and CPR decisions
You should have called a senior colleague by now, if you have not done so already.
Patients with serious abnormal vital signs are an emergency. The management of such patients requires proactivity, 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 due to septic shock. 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 extremely important to the patient but also has a range of physiological benefits and is discussed further in Chapter 10.
Special Considerations in the Geriatric Population
The proportion of older people in the population is increasing. Around 80% of people aged over 80 years function well and relatively independently and only 13.7% of people aged over 85 years live in institutions in the UK.20 However, there are important physiological differences in this age group which are important for healthcare staff to understand. The interpretation of symptoms and signs and the management of acute illnesses may be different in the elderly population.
The following are important physiological differences in older people:
Reduced homeostatic reserve: ageing is associated with a decline in organ function with a reduced ability to compensate. The following are reduced – normal PaO2, cerebral blood flow, maximum heart rate and cardiac reserve, maximum oxygen consumption, renal blood flow, maximum urinary concentration, and sodium and water homeostasis
Impaired immunity: older patients commonly do not have a fever or raised white cell count in infection. Hypothermia may occur instead. A rigid abdomen is uncommon in the older people with an acute abdomen – they are likely to have a soft, but generally tender abdomen despite perforation, ischaemia, or peritonitis. A
