Assessment and Management of Patient’s ABCDE Status:

Every patient admitted in the emergency medicine ward should initially be assessed for
his/her ABCDE status and any abnormality found on that assessment should be managed first
before moving to a more detailed assessment and management.
It is important to remember that whatever the underlying condition is, a patient’s ultimate cause
of death is Cardiorespiratory arrest. Thus it is the dysfunction of the patient’s respiratory status
(assessed by evaluating the patient’s Airways and Breathing status) and cardiac status (assessed
by evaluating the patient’s Circulatory status) that will ultimately cause the patient’s death.
Assessment and management of the patient’s D(disability) and E(everything else!) status will
allow further insight into the patient’s condition and allow optimum management. Hence it is
imperative to start assessing the patient via ABCDE assessment and managing any abnormality
noted before moving to a more detailed management. It is also important that throughout the
patient’s stay in the hospital, on follow up assessments, the patient should always be evaluated
for his ABCDE status.

● AIRWAY ASSESSMENT AND MANAGEMENT:

A patient’s airway status is endangered when one of two things happen:
1. The patient’s airway is obstructed and blocked. This may be due to various reasons like:
o Tongue fallback (very likely in the unconscious patient)
o Excessive airway secretions
o Foreign body
o Laryngeal edema due to various causes like anaphylaxis, infection, etc.

2. The patient is unable to protect his/her own airway from aspiration of his/her own
secretions as well as any food eaten. This is likely, for example, if the patient has altered
level of consciousness, has bulbar palsy causing swallowing difficulties, or if there is
excessive airway secretions or excessive vomiting.

Both these conditions are likely to occur if the patient has altered level of consciousness. A
patient with low GCS is likely to suffer from tongue fall back causing airway obstruction and
may also be unable to protect their own airway from their own secretions.
Assessment of patient’s airway safety:

● Look at the oxygen sats. An airway whose safety has been compromised is bound to
be associated with hypoxia and hence if the oxygen sats are normal, the airway is still
safe. However, while every compromised airway safety is bound to be associated with
hypoxia, it does not mean that all cases of hypoxia is associated with a compromised
airway since there are various other reasons which may lead to hypoxia.
● Look for air entry upon auscultation of the lung field: One of the most obvious and
evident manifestation of complete aiway obstruction is evidence of absent air entry
bilaterally on lung field auscultation. This is a very alarming sign needing immediate
action.
● Listen for stridor or any kind of noisy breathing: One of the most alarming features of
partial upper airway obstruction is evidence of stridor which is a harsh, high pitched,
loud sound produced during inspiration due to turbulent airflow through a partially
obstructed larynx or any other partially obstructed structure in the upper respiratory
tract. As upper airway obstruction becomes more prominent and severe, the stridor
sound may be heard through the breathing cycle and not be just limited to the
inspiratory phase. Noisy breathing may also imply airway obstruction.

If there is evidence of airway obstruction through the above two examinations, visually inspect
the oral cavity and deep into it for any evidence of tongue fall back or any visible foreign
body.

Even if the airway is deemed ‘safe’ through the above assessments, identify those who are at
risk of losing the safety of their airways(for e.g those with a low GCS, those having seizures,
those with profuse vomiting, etc).
Management of patient’s airway status:

● Head up chin lift procedure/Jaw thrust procedure and removing any foreign body
obstructing the airway: In any supine unconscious patient presenting to the emergency
ward, the first step is to open the airway by doing a head up chin lift procedure (jaw
thrust procedure in a patient with suspected or confirmed trauma – in order to protect
the cervical spine). This maneuver will prevent tongue fall back causing airway
obstruction. If any foreign body is obstructing the airway, it must be promptly removed
through appropriate means.

● Using airway adjuncts: In any patient who is at risk of tongue fall back causing airway
obstruction, airway adjuncts should be used. This can take the form of an oropharyngeal
airway or nasopharyngeal airway. Nasopharyngeal airway should be used in patients
with intact gag reflex since use of oropharyngeal airway in such patients will not be
tolerated by them and may provoke vomiting with subsequent risks of aspiration.
However, nasopharyngeal airway is contraindicated in patients with head injury causing
suspected basal fractures and in severe facial injury and also relatively contraindicated
in patients with clotting disorders. In the unconscious patient or semi conscious patient
without intact gag reflex, ideally the oropharyngeal airway can be used since it
additionally also protects against tongue bite, specially in patients with chances of
seizure.

Oropharyngeal airways(Image Courtesy: wikipedia)

 Nasopharyngeal airways(image courtesy hitecmed.com)

● Airway protection from aspiration: This is one of the most vital parts of airway
management and is often ignored in the general medicine wards of Bangladesh. We
often think that an unconscious/semiconscious patient kept NPO or fed via NG tube will
have low chances of aspiration whereas actually one of the biggest threats to the
patient is his/her own oral and airway secretions, which if aspirated will be catastrophic
for the patient. Hence, it is imperative that appropriate steps are taken to prevent
aspiration in patients at risk, and in the event that aspiration takes place, prompt
action be taken within seconds via suctioning of the upper airway and consideration of
I/V steroids.
Patients at risk of aspiration are those who have altered level of consciousness or who have
excessive vomiting or airway secretions. Patients who have low GCS (around 8 or below)
are unable to protect their own airway from aspiration and hence may need active airway
management to protect the airway. Unless the low GCS is readily reversible and easily
treatable(for e.g due to hypoglycemia), any patient with a low GCS and at risk of losing
their airway safety needs an urgent discussion with the critical care team for the
appropriateness of actively protecting their airways(for e.g through intubation and
mechanical ventilation). But if intubation is either not possible or not appropriate for the
patient, and the patient has to be kept in the general medicine ward with their airway
unprotected against the risk of aspiration, then the chances of aspiration can somewhat be
reduced by keeping them NPO (or feeding them via NG tube if feeding is a pressing need,
for e.g if the state of unconsciousness is likely to be prolonged by more than a day or two),
nursing them in the propped up position, and regularly suctioning off any oral or airway
secretions.
 ● Management of the underlying condition causing airway compromise is also of
paramount importance. Most of such causes are likely to be prolonged and they can be
sorted out once initial ABCDE assessment and management is complete. But sometimes,
some conditions like hypoglycemia will need immediate management simultaneously and
this must be kept in mind.
It is also noteworthy that a lot of conditions causing decreased level of consciousness and
hence endangering airway safety are likely to be completely reversible and short lasting
(for e.g hypoglycemia, post ictal state, opioid overdose) and hence such cases may avoid
the need for invasive procedures like intubation if strict preventive measures are taken to
prevent aspiration and airway obstruction by tongue fall back during the time their
consciousness level is low.

Emergency cricothyroidotomy will be LIFESAVING in conditions causing

complete upper airway obstruction for e.g due to laryngeal edema(as a result of
anaphylaxis or infection) or foreign body(if it cannot be removed manually or if it
cannot be expelled via maneuvers like abdominal thrust and back thrust).
Sometimes, when there is partial but not complete upper airway obstruction,
emergency cricothyroidotomy may be avoided by taking prompt decision to
intubate. Differentiating between complete and partial upper obstruction is thus
important. In a patient in whom steps have been taken to prevent tongue fall
back, partial upper airway obstruction will be evident in the form of stridor and
presence of cough while complete airway obstruction will be evident in the form
of inability to cough and absent air entry on bilateral lung field auscultation.
 ● ASSESSMENT AND MANAGEMENT PATIENT’S BREATHING STATUS
When assessing and managing the patient’s breathing status, the two most important things to
consider are hypoxia and chances of impending respiratory arrest.
Thus the patient needs to be assessed in a way as to look for these two dangerous signs and if
they are found, all efforts need to be made in tackling them. There are many ways to manage
hypoxia as we can see below but in those in whom respiratory arrest is likely to occur, that will
need urgent ventilation, initially in the form of bag mask ventilation through AMBU bag and, if
respiratory arrest is likely to be prolonged, then provision of mechanical ventilation needs to be
made as early as possible.

Assessment of breathing status:

Oxygen saturation: Measure via the pulse oximeter. Ideally all patients, unless they have
chronic type II respiratory failure, should have an oxygen saturation above 94%. Pulse oximetry
tends to be unreliable when the patient is significantly hypoxic or has inadequate peripheral
circulation and in such cases, oxygen saturation and partial pressure of oxygen in the blood
should be reliably be assessed by Arterial Blood Gas analysis.
Cyanosis: If pulse oximetry is unreliable, and ABG results are yet not available, whether the
patient is hypoxic or not can also be partially assessed by clinically looking for cyanosis,
although this is not a very sensitive method of detecting hypoxia.
ABG analysis: ABG analysis is a vitally important investigation performed in any patient
admitted in the emergency ward in whom clinical assessment have failed to rule out hypoxia or
in whom CO2 intoxication is likely(for e.g chronic type II respiratory failure with acute
exacerbation). ABG analysis will help assess the degree of any hypoxia if present, any CO2
retention(as well as find out whether CO2 retention is chronic/acute/acute on chronic) and
quantify the degree of respiratory acidosis. ABG should be only done after a comprehensive
ABCDE assessment and management of the patient.
Respiratory Rate and Respiratory Pattern: A patient having respiratory distress will likely
have increased respiratory rate which is one of the signs of respiratory distress. This may be due
to a variety of lung and heart conditions but may also be due to metabolic acidosis (for e.g in
DKA, alcohol intoxication and renal failure). Respiratory rate is also increased in sepsis.
Increased respiratory rate is also detrimental for the patient since the hyper active muscles of
breathing consume a lot of oxygen, meaning there is less oxygen for the vital organs. On the
other hand, an abnormally low respiratory rate is even more alarming. This might be due to
brainstem dysfunction caused by various factors (for e.g drug intoxication, brainstem stroke,
brainstem infections, etc) and may be a sign of impending respiratory arrest, which will be
catastrophic. While looking for the respiratory pattern, any irregularity in the respiratory pattern
should be very worrisome. In an unconscious patient, respiratory drive is from the brainstem and
hence any irregularity in the respiratory pattern should alert the physician regarding brainstem
dysfunction (due to the various causes mentioned above) and again may be a sign of impending
respiratory arrest. Patients with gasping are considered to be in respiratory arrest already. A
patient in respiratory arrest will stop breathing altogether and there will be no evidence of any
breathing.
Lung examination: While ABCDE assessment of the patient, a quick lung examination should
be done by percussion and auscultation to rule out the dangerous pathologies like pneumothorax,
pulmonary edema, pneumonia, aspiration pneumonitis, anaphylaxis, acute exacerbation of
asthma or COPD, etc. A formal lung examination should again be carried out after initial
ABCDE assessment and management.
Trachea positioning: This is particularly importantly if a tension pneumothorax or massive
pleural effusion/hemothorax is interfering with breathing. A Tension pneumothorax is an
emergency needing immediate relief and can be diagnosed by absent breath sounds one one side
(with normal to increased percussion note) with trachea deviated to the other side associated with
hypoxia, haemodynamic instability and sometimes raised JVP.
Any evidence of CO2 retention: This should be mainly assessed in those who are at risk(for e.g
COPD patients, those with neuromuscular dysfunction): It can be assessed clinically(although
with low sensitivity) by looking for the triad of warm peripheries, bounding pulse and
flapping tremor. It can be confirmed and quantified by looking at the ABG status. When a
patient has been found to have CO2 retention, it is important to decide if the CO2 retention is
compensated or uncompensated since it will have varying implications on treatment(the simple
way to differentiate between a compensated and uncompensated CO2 retention is by looking at
the arterial blood pH – uncompensated CO2 retention will be associated with a respiratory
acidosis with the pH below 7.35).
Management of Patient’s breathing status:
This will focus initially on correction of any hypoxia, and also deal with the danger of any
impending respiratory arrest. It will also require treatment of the underlying cause causing
breathing dysfunction, which in some cases (for e.g airway obstruction due to any cause as
described above, anaphylaxis, tension pneumothorax, acute severe asthma, severe
exacerbation of COPD, severe pulmonary edema, brainstem dysfunction due to raised ICP or
due to opioid overdose) will need immediate management side by side with ABCDE
resuscitation while in some cases (e.g pneumonia, uncomplicated pneumothorax, etc), can also
be achieved once the initial ABCDE resuscitation is completed. Besides, patients who have been
proven to have CO2 intoxication may need additional treatment to get rid of the excess CO2
inside the body as has been discussed below.
Correction of Hypoxia:
Hypoxia is dangerous, and particularly so since it cause cardiac arrest. So, it must be
aggressively tackled.
There are many methods of correcting hypoxia through oxygen support. This will include nasal
cannula, simple face mask, non-rebreathing mask, High Flow Nasal Cannula, CPAP support or
even consideration of mechanical ventilation.
Any unwell patient who is found to be hypoxic needs to be initially started at 15L/min of
oxygen support through the non rebreathing mask.

The amount of oxygen and the device through which the oxygen is being provided needs to be
then titrated as appropriate to maintain an oxygen sats between 94-96%(88-92% in patients with
long standing COPD or with a history of CO2 retention)
Nasal cannula can only deliver about 4L/min of oxygen and should not be used to deliver
oxygen beyond 4L/min since it causes nasal mucosal irritation. Simple face mask can deliver
upto around 6-7 L/min of oxygen while oxygen support through the use of a non-rebreathing
mask can provide as high as 15L/min of oxygen.
Nasal cannula, simple face mask and the non rebreathing mask are ‘Fixed Flow’ Devices, but
not ‘Fixed Performance’ Devices. What this means is that when these devices are providing a
particular flow rate of oxygen(for e.g say 4L/min), they will keep on providing oxygen at that
particular velocity but the ‘amount’ or ‘concentration’ of oxygen that the patient will receive
from that particular device at that particular flow rate will depend on the patient’s respiratory
rate, with the patient receiving less concentration of oxygen if their respiratory rate is high
and vice versa. Hence, even though the traditional thought is that providing oxygen at 4L/min
automatically equates to giving an oxygen concentration of 28%, this is not actually true with
these ‘fixed flow devices’ since if a nasal cannula is providing oxygen to a patient at a rate of
4L/min, it means that the particular patient will continue to receive oxygen at a fixed flow of
4L/min but the concentration of oxygen that the patient will receive will not be fixed at 28%
but will vary with the respiratory rate of the patient.
This is where the concept and usefulness of Venturi Masks come into play for patients at risk
of CO2 retention. Since these patients require their oxygen sats to be maintained in the tight
range of 88-92% , using ‘fixed flow devices’(which cannot guarantee a constant supply of the
same concentration of oxygen to these patients) for prolonged periods of time is potentially
dangerous since there is a risk of ‘too much’ or ‘too less’ oxygen to these patients depending
on their respiratory rate. On the other hand, Venturi masks are ‘fixed performance’ devices
meaning that, at a particular flow rate of oxygen, these masks will always provide the same
concentration of oxygen to these patients, regardless of their respiratory rate. Venturi masks
are colour coded, with each particular colour representing a particular percentage of oxygen
that can be given at a particular flow rate when we use a venturi mask with that colour
code(please refer to the image below). Hence, if a patient at risk of CO2 retention needs 28%
of oxygen to maintain his/her sats in between 88-92%, that patient must be given oxygen at a
flow rate of 4L/min using a venturi mask which is colour coded as white.
Simple Face Mask(image courtesy: emsstuff.com)

Non-Rebreathing Mask (image courtesy: wikipedia)

 Venturi Mask(image courtesy: oxfordmedicaleducation.com)

Any patient needing oxygen should have an ABG to look specially at pO2, pCO2, and the pH
levels of the blood. If the oxygen sats or the pO2 of a patient remain below normal even with
15L/min of oxygen therapy through the non rebreathing mask, then that patient needs urgent
discussion with the critical care team to decide on the optimum mode of escalation of oxygen
therapy beyond the non rebreathing mask.

This escalation of oxygen therapy may involve one of the following:

a. High Flow Nasal Cannula
b. Positive Pressure Non invasive Oxygenation support through CPAP
c. Intubation and Mechanical Ventilation.

It is of paramount importance to seek the help of the Critical Care Team with regards to which
mode of escalation to involve as this needs complex considerations and is well under the
expertise of the critical care team.
High Flow Nasal Cannula is a powerful means of providing oxygenation and is very well
tolerated by patients. It can provide 100% humidified oxygen at about 60L/min and is not
contraindicated in patients with low GCS. The one disadvantage it has compared to CPAP is the
fact it provides less positive pressure oxygenation support than CPAP.

Positive Pressure Oxygenation Support through CPAP is also a powerful means of oxygenation.
Modern CPAP machines can provide almost 100% oxygen. When a patient is started on CPAP,
the initial settings are usually 5-7.5 cm H20 of PEEP and 60% oxygen. The oxygen percentage
can be titrated up or down as appropriate to maintain an oxygen sat above 94% (88-92% in
patients with long standing COPD or history of CO2 retention). The PEEP from the CPAP can
also be increased gradually upto 15 cm H20. The advantage of positive pressure oxygen support
is that it helps open collapsed alveoli and also reduces the work of breathing and hence decreases
wastage of oxygen by the hyper active respiratory muscles. However, not all patients can tolerate
CPAP and this can often be very distressing for the patients. There are also a number of
contraindications against CPAP, for e.g inability to protect the airway due to low GCS, recent
injury or surgery involving the ENT region, facial traumas, asthma, bowel obstruction,
pneumothorax, etc – please refer to specialist textbooks for a full list of contraindications. If a
patient is started on CPAP, this should always be under the supervision of the Critical Care team,
even if it is done in a ward setting. If either High flow Nasal Cannula or CPAP is not available,
and it is not possible/appropriate to intubate the patient, BiPAP can also be sometimes
considered as a method of providing positive pressure oxygenation.

Dealing with impending (or already occurred) respiratory arrest:

Respiratory arrest is catastrophic and will need urgent bag mask ventilation with AMBU bag
initially, and then, if it is likely to be prolonged, and if it is deemed appropriate to intubate the
patient(based on the patient’s baseline health state), placement of advanced airway (ideally
endotracheal intubation, but if such expertise is not immediately available, then at least
placement of devices like laryngeal mask airway or i-Gel temporarily which does not require
much expertise).
But the ideal thing is to identify the patient at risk of developing respiratory arrest before it
occurs. This will mean understanding which patients are at risk of developing respiratory arrest.
Respiratory arrest occurs in patients with brainstem dysfunction (which may be due to various
reasons like brainstem stroke, massive stroke causing mass effect and putting pressure on the
brainstem, brainstem infection, any cause leading to raised Intracranial pressure, electrolyte
imbalance, drug intoxication, metabolic acidosis, CO2 retention, etc).
It will also require picking up early signs which may warn of impending respiratory arrest. This
is usually evident in the form of an abnormally low respiratory rate or irregular respiratory
pattern in a patient with altered level of consciousness who has no voluntary control over
respiration (in whom the brainstem is supposed to maintain a normal respiratory rate and
pattern).
In patients with impending respiratory arrest, and in whom intubation is considered appropriate
given the patient’s baseline health status, an early decision should be made to use advanced
airway techniques for ventilation like endotracheal intubation (which will require expertise) or
even using devices like laryngeal mask airway or i-Gel(which will not require much expertise
but unfortunately is a temporary measure applicable for a few hours).
These patients should be urgently discussed with the Critical Care Team.

● Managing the underlying cause behind breathing status dysfunction:

This is of paramount importance. As discussed above, for some conditions like tension
pneumothorax, severe pulmonary edema, severe exacerbation of Asthma or COPD, anaphylaxis,
raised ICP causing brainstem dysfunction, etc, it will require urgent management simultaneously
with ABCDE resuscitation (for e.g relieving bronchospasm in a patient with severe asthma with
salbutamol nebulisation while simultaneously giving oxygen support or relieving the tension
pneumothorax with emergency needle insertion into the 2nd intercostal space while
simultaneously giving oxygen support).
In other conditions which are not so catastrophic emergencies, however, this may be focused on
after initial ABCDE resuscitation.
 ● Dealing with CO
2 retention:
This is not always relevant but may assume relevance in those at risk. Such patients include
patients with chronic obstructive lung conditions (like COPD or bronchiectasis) or in patients
with neuromuscular paralysis (e.g GBS) or in patients with obstructive sleep apnoea, etc. If such
patients show evidence of CO2 retention on clinical assessment(as discussed above), then
appropriate steps must be taken to deal with that after the initial ABCDE assessment and
management.
Before dealing with CO2 retention, what is of paramount importance is to understand the
difference between compensated CO2 retention and uncompensated CO2 retention.
Compensated CO2 retention is not harmful and should not be interfered with since it has been
well compensated by renal HCO3 retention(interfering with it will paradoxically lead to
unopposed HCO3 retention in the body and will lead to paradoxic metabolic alkalosis). On the
other hand, any uncompensated retention of CO2 in the body is harmful and must be got rid off.
Regarding how to differentiate between these, one simple and basic way to understand is that, in
patients with chronic CO2 retention compensated well by kidney HCO3 retention, the blood pH
should be normal and there should be no evidence of respiratory acidosis. On the other hand, in
patients with uncompensated CO2 intoxication, the blood pH should reveal evidence of
respiratory acidosis.
In case of uncompensated CO2 retention, the excess CO2 causing intoxication can be driven off
the body by tackling the condition which has led to this (for e.g acute exacerbation of COPD)
and then, if it does not resolve, via BiPAP therapy. But in those in whom BiPAP is
contraindicated (for e.g in patients with low level of consciousness), then such patients will need
urgent discussion with the critical care team for the appropriateness of intubation and mechanical
ventilation.
The goal is not to drive off all the extra CO2 retained in the body rather stabilise the blood pH
value by only driving off the uncompensated CO2 retained in the body.
The underlying cause behind uncompensated CO2 retention must also be dealth with
aggressively as mentioned above (for e.g treatment of acute exacerbation of COPD).

Patients with history of CO2 retention should not have their

oxygen saturation raised above 92% and it should be
maintained at 88-92%(and not below 88%)
ASSESSMENT AND MANAGEMENT OF PATIENT’S CIRCULATORY STATUS
A patient with circulatory insufficiency is usually in shock and the management of shock has
been described in detail in the later chapters.
Circulatory insufficiency may be obvious in the form of hypotension, tachycardia (or
bradycardia), arrhythmia, low urinary output but may be subtle requiring careful recording of
any postural changes in blood pressure, postural changes in pulse, capillary refill time,
temperature of the peripheries, measurement of serum lactate levels, etc. A wide variety of
causes are implicated in causing circulatory insufficiency and a good doctor should be able to
find out the correct cause through proper history, examination and investigations.

Assessment of patient’s circulatory status:

Blood pressure: A patient may have hypotension. When recording for blood pressure, ideally it
should be measured in both the upper arms as any major discrepancy between the two may point
towards pathologies like Aortic Dissection in the presence of suggestive clinical features(for e.g
chest pain). Even without hypotension, there may be still be evidence of circulatory
insufficiency, as evident in the form of postural hypotension (defined as a fall in systolic and
diastolic blood pressure by 20 mm Hg and 10 mm Hg or more upon standing for 2- 3 mins from
lying position) so after the initial ABCDE assessment and management, if there is any suspicion
of postural hypotension, this should be assessed for.
Pulse: A variety of abnormalities may be noted when recording the pulse. There may be
tachycardia (most common in circulatory insufficiency), bradycardia (implicating a defect in the
conduction system of the heart), arrhythmia as well as radio-radial delay or radio-femoral delay
(in conditions like Aortic Dissection). In early hypovolemia, there may be no tachycardia, rather
only postural changes in pulse (postural tachycardia) as defined by a rise in pulse by more than
30/min upon standing for 2-3 mins from lying position. The strength of the pulse volume will
give a good idea about the underlying circulatory state.
Capillary Refill time: It is prolonged in conditions like hypovolemic shock, cardiogenic shock,
etc. It is one of the earliest signs in circulatory insufficiency and should be routinely checked in
all acutely ill patients as part of ABCDE assessment.
Peripheral temperatures: In circulatory insufficiency due to hypovolemia or cardiac
dysfunction, the peripheries are often cold and clammy. On the other hand, in conditions like
early stage of sepsis, the peripheries are warm.
Bedside ECG monitoring: In any patient with circulatory insufficiency, bedside ECG
monitoring is a must. It will point out any arrhythmia if present, can give clues regarding
conditions like MI or pulmonary embolism and may even give clues to diagnosing conditions
like potassium, calcium and magnesium imbalance.
Heart/lung Examination: The precordium should be quickly checked for evidence of any
gallop rhythm (which occurs in acute heart failure), evidence of pulmonary hypertension (which
may occur in pulmonary embolism) and valvular heart disease. The lungs should be checked for
any evidence of pulmonary edema.
JVP: This should be checked as part of ABCDE assessment whenever there is evidence of
shock. This can help differentiate between cardiogenic shock (with raised JVP and engorged
neck veins) and non-cardiogenic shock (e.g hypovolemic shock). However JVP is also expected
to be raised and neck veins engorged in obstructive shock (for e.g due to massive pulmonary
embolism, tension pneumothorax and cardiac tamponade).
Hydration Status: Hydration status can be assessed by looking at the tongue, skin turgor,
eyeballs, urine colour, lungs for evidence of any pulmonary edema, JVP and neck veins as well
as use of bedside USG to look for diameter variation of the lumen of IVC with inspiration and
expiration (for details regarding how to do this, please refer to specialist textbooks on critical
care medicine). A patient may be found overhydrated or dehydrated. Whenever a patient with
shock is also found to be clinically dehydrated, it implicates the need for urgent fluid
resuscitation.
Serum Lactate levels: In any patient with circulatory insufficiency causing tissue
hypoperfusion, serum lactate levels will start going high. Serially following the s. lactate levels
may help assess the efficacy of the measures taken for circulatory resuscitation.
Management of Patient’s circulatory dysfunction:
This has been talked about in details in the chapter in shock later in the book. Managing the
patient’s circulatory dysfunction will concentrate on:

● Correcting the circulatory status

● Treating the underlying cause
Correction of circulatory status will focus on normalizing Blood pressure (including
postural changes), Pulse (including postural changes), Capillary refill time, peripheral
temperatures, JVP, s. lactate levels, correcting any dehydration if present and also
normalizing the urine output. Any pulmonary edema, if present, is a sign of fluid overload
and should be treated. In most cases, circulatory insufficiency will require I/V fluids apart
from the obviously fluid overloaded patient with pulmonary edema due to cardiac
dysfunction or renal failure. Inotropes and Vasopressors may also be needed according to the
clinical context. This has been discussed in details later in the book in the chapter on shock.
In the worst case scenario, if any cardiac arrest occurs, and the patient does not have a DNR
form filled, this will require treatment with Advanced Cardiac Life support (with CPR +/-
D.C shock and I/V Adrenaline, etc).
Treating the underlying cause is of paramount importance. This may be needed to be
corrected immediately if due to life threatening causes like hypoglycemia, hypocalcemia,
hypoxia, tension pneumothorax, MI, hyperkalemia, hyperthermia, hypothermia, pulmonary
embolism, etc.
Lastly, Prevention is better than Cure. So, a good physician is likely to identify conditions
which may lead to circulatory insufficiency and even worse, cardiac arrest and take pre
emptive steps to deal aggressively with such conditions before they cause circulatory
insufficiency and cardiac arrest. Such conditions Include:
Hypoxia MI
Hypovolemia Pulmonary embolism
Tension pneumothorax Potassium imbalance (do not correct
hypokalemia too
rapidly by giving more than 40mmol/hr of
potassium)
Cardiac tamponade Calcium imbalance
Hypoglycemia Magnesium imbalance, etc.
Assessment and Management of Disability(D):
Check the following and make immediate corrections where relevant:

Capillary blood sugar

GCS
Any obvious focal neurology or lateralizing signs(look at any obvious signs of limb paralysis,
the planter response, any gross evidence of cranial nerve palsies)
Pupils, their symmetry and their reaction to light
Signs of meningism

Assessment and Management of Everything Else(E):

Check for any other emergency abnormalities and correct promptly where relevant:

Temperature
Anaemia
Jaundice
Flapping Tremor
Abdominal examination
Urine output
General skin survey
Limb examination
TO CONCLUDE, WHEN ASSESSING AND MANAGING A PATIENT’S ABCDE STATUS,
IT IS OF PARAMOUNT IMPORTANCE TO CORRECT EACH ABNORMALITY THAT YOU
NOTICE BEFORE MOVING ON TO THE NEXT COMPONENT OF THE ABCDE
PARAMETERS(UNLESS THAT ABNORMALITY CANNOT BE IMMEDIATELY
CORRECTED). FOR EXAMPLE, WHEN ASSESSING THE AIRWAYS, IF YOU NOTICE
ANY ABNORMALITY THAT CAN BE IMMEDIATELY CORRECTED, CORRECT THAT
FIRST BEFORE MOVING ON TO BREATHING STATUS. WHEN ASSESSING THE
BREATHING STATUS, CORRECT ANY IMMEDIATELY CORRECTABLE
ABNORMALITIES FOUND BEFORE MOVING ON TO CIRCULATION.
A Summary of the ABCDE approach:

In any unwell patient, follow the following ABCDE approach:

A(airway):

a. Ask yourself, is the patient at risk of obstructing his/her airway or aspirating(for e.g due to low
GCS)?
b. Is the Airway patent(a patient with obstructed airway will have a low oxygen sats; patients with
partially obstructed airways will have noisy breathing and stridor while patients with completely
obstructed airway will have no air entry into the lungs)
c. Has the patient aspirated? If so, do immediate suction
d. If the patient is either at risk of obstructing the airway(due to low GCS) consider putting a
Nasopharyngeal or Oropharyngeal airway in place as appropriate
e. If the patient already has an obstructed airway due to tongue fall back open up the airway by
head up chin lift or jaw thrust procedure as appropriate
f. In cases where there is obstructed airway but there is no tongue fall back, think of other causes,
for e.g foreign body, laryngeal spasm, etc
g. If patient is at risk of aspirating due to low GCS, formulate a definite plan for protecting the
airway(for e.g consider the appropriateness of intubation/nurse in the left lateral position and
do regular suctioning of any excessive secretions if not suitable for intubation). If intubation is
an appropriate option but will take time to arrange and the patient is at significant risk of losing
control over the airway, I-Gel or laryngeal airway may be a suitable stop-gap solution and
discuss with seniors having appropriate experience over using it.

B(Breathing):

a. Oxygen sats? If hypoxic, immediately start oxygen at 15L/min via the nonrebreather mask and
then down titrate as appropriate(patients with history of long standing COPD and history of CO2
retention will ultimately need to have an oxygen sats target of 88-92% by giving them
appropriate amount of oxygen through the venturi mask but in the acute settings all hypoxic
patients must be started at 15L/min oxygen via the non rebreather mask)
b. Respiratory Rate?
c. Respiratory Pattern?
d. Tracheal position?
e. Quick auscultation of the lungs. Any bronchospasm needing nebulisation? Any obvious evidence
of pleural effusion or consolidation or LRTI?
f. Consider need for escalating oxygen therapy(if patient still remaining hypoxic at 15L/min via non
rebreather mask, further escalations are needed for oxygen administration. This may take the
form of administering oxygen through High Flow Nasal Cannula, CPAP, BIPAP or even
mechanical ventilation – discuss with the seniors and the critical care team)
g. Is there any carbon dioxide retention? If so, why? How do we treat it? Is BiPAP needed?
C(Circulation):

a. Pulse(including postural changes if relevant): rate, rhythm, nature of the pulse

b. BP(including BP in both arms and postural changes if relevant)
c. Temperature of the peripheries
d. Capillary Refill Time
e. Quick precordial examination
f. JVP
g. Any evidence of pulmonary oedema on lung examination in B? Treat as appropriate if present.
h. Hydration status
i. Optimise hypotension through considering appropriateness of I/V fluids or vasopressors or
inotropes as needed(please refer to the chapter on shock)
j. Bedside ECG
k. Correction of any dangerous arrhythmias as needed
l. Take bloods for emergency investigations including blood gas analysis(arterial if any respiratory
condition or hypoxia, otherwise venous blood gas will suffice). Blood gas analysis is an extremely
important investigation in the acute setting for any unwell patient, and a lot of blood gas
analysers also provide an accurate lactate and electrolyte levels(please check your local
facilities)
m. Insert a cannula line(or two lines if hypovolemic)

D(Disability):

a. Capillary Blood Sugar! Correct any hypoglycemia immediately

b. Any lateralizing or focal neurological signs?
c. Pupils and their reaction to light
d. Planter response
e. Any obvious cranial nerve palsy?
f. GCS and orientation
g. Any signs of meningism
h. Fundoscopy in selected cases(only after a comprehensive ABCDE assessment and management
has been done)

E(everything else!):

a. Temperature
b. Abdomen: any evidence of ‘surgical’ abdomen, for e.g any localised severe tenderness, any
generalised tenderness, any guarding, any rigidity, bowel sounds, any obvious mass, any obvious
ascites, any palpable bladder suggestive of urinary retention?
c. Limbs: any DVT or cellulitis? Any pedal oedema?
d. General skin survey
e. Anemia
f. Jaundice
g. Urine output
h. Any flapping tremor?