The Main Principles:

 Use the Airway, Breathing, Circulation, Disability, and Exposure, to assess and treat
 Do complete initial assessment and re-assess regularly
 Call for appropriate help early
 Ensure personal safety (wear glasses, apron, gloves)
 If the patient is awake, ask “How are you?” and hold his hands.
 If the patient appears unconscious or has collapsed, shake him and ask “Are you alright?”.
o If the patient responds by talking normally, he has a patent airway, breathing, and has
brain perfusion.
o If he speaks only in short sentences, he may have breathing problems.
o If he does not respond, he is likely to be critically ill.
 If you have any doubts about the diagnosis of cardiac arrest, start CPR until expert help arrives.
 If they are present, monitor the vital signs as early as possible (Pulse Oximetry, ECG monitoring,
Blood Pressure measurement)
o Insert IV cannula as soon as possible
o Take blood for investigation when inserting the IV cannula.

(A) Airway
(airway obstruction is an emergency)

1. Look for the signs of airway obstruction:

 In the critically ill patient, depressed consciousness often leads to airway obstruction.
 Airway obstruction causes paradoxical chest and abdominal movements (‘see- saw’ respirations) and
the use of the accessory muscles of respiration.
 In complete airway obstruction, there are no breath sounds at the mouth or nose.
 In partial obstruction, air entry is diminished and often noisy.
 Central cyanosis is a late sign of airway obstruction.
2. Treat airway obstruction as an emergency:
 In most cases, only simple methods of airway clearance are required (e.g. airway opening manoeuvres,
suction, insertion of an oropharyngeal or nasopharyngeal airway).
 Tracheal intubation by an expert may be required when these fail.
3. Give oxygen at high concentration:
 Give high-concentration oxygen using a mask with an oxygen reservoir. Ensure that the oxygen flow is
sufficient (usually 15 l min-1) to prevent collapse of the reservoir during inspiration.
 If the patient’s trachea is intubated, give high- concentration oxygen with a self-inflating bag.
 Aim to maintain an oxygen saturation of 94-98 %. In patients at risk of hypercapnic respiratory failure
aim for an oxygen saturation of 88-92 %.

(B) Breathing
Evaluate:
Frequency and rate
Volume: amplitude of tidal volume and symmetry
Work: respiratory pattern, accessory muscles, noises
Oxygen
It is vital to diagnose and treat immediately life-threatening conditions, e.g. acute severe asthma, pulmonary oedema,
tension pneumothorax, massive haemothorax.

1. Look, listen and feel for the general signs of respiratory distress (sweating, central cyanosis, use of the accessory
muscles of respiration, abdominal breathing.)
2. Listen to the patient’s breath sounds a short distance from his face: rattling airway noises indicate the presence of
airway secretions, usually because the patient cannot cough or take a deep breath. Stridor or wheeze suggests
partial, but important, airway obstruction.
3. Count the respiratory rate. (The normal rate is 12-20 breaths min-1. A high (> 25 min-1), or increasing,
respiratory rate is a marker of illness and a warning that the patient may deteriorate suddenly.)
4. Assess the depth of each breath, the pattern (rhythm) of respiration and whether chest expansion is equal and
normal on both sides.
5. If the patient’s depth or rate of breathing is judged to be inadequate, or absent, use pocket mask or two-person
bag-mask ventilation to improve oxygenation and ventilation, whilst calling immediately for expert help. In
cooperative patients without airway obstruction consider the use of non-invasive ventilation (NIV). In patients
with an acute exacerbation of COPD, the use of NIV is often helpful and prevents the need for tracheal intubation
and invasive ventilation.
6. Record the inspired oxygen concentration (%) and the SpO2 reading of the pulse oximeter. The pulse oximeter
does not detect hypercapnia. If the patient is receiving supplemental oxygen, the SpO2 may be normal in the
presence of a very high PaCO2.
7. Percuss the chest if you are trained to do so: hyper resonance suggests a pneumothorax; dullness suggests
consolidation or pleural fluid.
8. Auscultate the chest with a stethoscope if you are trained to do so: bronchial breathing indicates lung
consolidation with patent airways; absent or reduced sounds suggest a pneumothorax or pleural fluid or lung
consolidation caused by complete bronchial obstruction.\
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. Feel the chest wall to detect surgical emphysema or crepitus (suggesting a pneumothorax until proven
otherwise).
11. Note any chest deformity (this may increase the risk of deterioration in the ability to breathe normally) and the
presence and patency of any chest drains. Remember that abdominal distension may limit diaphragmatic
movement, thereby worsening respiratory distress.
12. The specific treatment of breathing problems depends on the cause. Critically ill patients should be given oxygen.
In some patients with chronic obstructive pulmonary disease (COPD), high concentrations of oxygen may depress
breathing (i.e. they are at risk of hypercapnic respiratory failure – often referred to as type 2 respiratory failure).
Nevertheless, these patients will also sustain organ damage or cardiac arrest if their blood oxygen levels are
allowed to decrease. In this group, aim for a lower than normal oxygen saturation. Give oxygen via a Venturi 28 %
mask (4 l min-1) or a 24 % Venturi mask (4 l min-1) initially and reassess. Aim for target SpO2 range of 88-92 %
in most COPD patients, but evaluate the target for each patient based on the patient’s arterial blood gas
measurements during previous exacerbations (if available). Some patients with chronic lung disease carry an
oxygen alert card (that documents their target saturation) and their own appropriate Venturi mask.

(C) Circulation
Evaluate
Frequency and rate
Pulses (Peripheral and central)
Peripheral perfusion (CRT, skin aspect and temperature, urine output)
Pre-charge (Blood Volume)
Pressure (Arterial)

In almost all medical and surgical emergencies, consider hypovolaemia to be the likeliest cause of shock, until proven
otherwise. Unless there are obvious signs of a cardiac cause (e.g. chest pain, heart failure), give intravenous fluid to any
patient with cool peripheries and a fast heart rate.

In surgical patients, rapidly exclude bleeding (overt or hidden).

Remember that breathing problems, such as a tension pneumothorax, can also compromise a patient’s circulatory state.
This should have been treated earlier on in the assessment
 1. Look at the colour of the hands and fingers: are they blue, pink, pale or mottled?
2. Hold the patient’s hand: is it cool or warm?
3. Measure the capillary refill time. Apply pressure for 5 seconds on a fingertip held at heart level (or just above)
with enough pressure to cause blanching. Time how long it takes for the skin to return to the colour of the
surrounding skin after releasing the pressure. The normal refill time is usually less than 2 seconds. A prolonged
time suggests poor peripheral perfusion. Other factors (e.g. cold surroundings, poor lighting, old age) can prolong
the time.
4. Count the patient’s pulse rate (or heart rate by listening to the heart with a stethoscope).
5. Palpate peripheral and central pulses, assessing for presence, rate, quality, regularity and equality. Barely
palpable central pulses suggest a poor cardiac output, whilst a bounding pulse may indicate sepsis.
6. Measure the patient’s blood pressure. Even in shock, the blood pressure may be normal, because compensatory
mechanisms increase peripheral resistance in response to reduced cardiac output. A low diastolic blood pressure
suggests arterial vasodilation (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).
7. Auscultate the heart with a stethoscope if you are trained to do so. Is there a murmur or pericardial rub? Are the
heart sounds difficult to hear? Does the audible heart rate correspond to the pulse rate?
8. Look for other signs of a poor cardiac output, such as reduced conscious level and, if the patient has a urinary
catheter, oliguria (urine volume less than 0.5 ml kg-1 hour-1).
9. Look thoroughly for external bleeding from wounds or drains or evidence of concealed haemorrhage (e.g. thoracic,
intra-peritoneal, retroperitoneal or into gut). Intra-thoracic, intra-abdominal or pelvic blood loss may be
significant, even if drains are empty.
10. The treatment of cardiovascular collapse depends on the cause, but should be directed at fluid replacement,
control of bleeding and restoration of tissue perfusion. Seek the signs of conditions that are immediately life
threatening, e.g. cardiac tamponade, massive or continuing haemorrhage, septicaemic shock, and treat them
urgently.
11. Insert one or more large (14 or 16 G) intravenous cannulae. Use short, wide-bore cannulae, because they enable
the highest flow.
12. Take blood from the cannula for routine haematological, biochemical, coagulation and microbiological
investigations, and cross-matching, before infusing intravenous fluid.
13. Give a rapid fluid challenge (over 5-10 minutes) of 500 ml of warmed crystalloid solution (e.g. Hartmann’s
solution or 0.9 % sodium chloride) if the patient is normotensive. Give one 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 crackles after each bolus, consider a central venous pressure (CVP) line). Follow your local protocols for
liquid resuscitation in trauma and surgical patients.
14. Reassess the heart rate and BP regularly (every 5 minutes), aiming for the patient‘s normal BP or, if this is
unknown, a systolic pressure greater than 100 mmHg.
15. If the patient does not improve, repeat the fluid challenge.
16. If symptoms and signs of heart failure (shortness of breath, increased heart rate, raised JVP, a third heart sound
and pulmonary crackles on auscultation) occur, decrease the fluid infusion rate or stop the fluids altogether. Ask
for expert help as other treatments to improve tissue perfusion (e.g. inotropes or vasopressors) may be needed.
17. If the patient has primary chest pain and a suspected ACS, record a 12-lead ECG early, and treat initially with
aspirin, nitroglycerine and oxygen if appropriate, and morphine.
18. Immediate general treatment for ACS includes:
 Aspirin 300 mg, orally, crushed or chewed, as soon as possible.
 Nitroglycerine, as sublingual glyceryl trinitrate (tablet or spray).
 Oxygen, aiming at a SpO2 of 94-98 %; do not give supplementary oxygen if the patient’s SpO2 is within
this range when breathing air alone.
 Morphine (or diamorphine) titrated intravenously to avoid sedation and respiratory depression.

(D) Disability
Common causes of unconsciousness or altered consciousness level include hypoxia, hypercapnia, cerebral hypoperfusion,
hypoglycaemia or the recent administration of sedatives or analgesic drugs.

1. Review and treat the ABCs: exclude or treat hypoxia and hypotension.
2. Check the patient’s drug chart for reversible drug-induced causes of depressed consciousness. Give an antagonist
where appropriate (e.g. naloxone for opioid toxicity).
3. Examine the pupils (size, equality and reaction to light).
 4. Make a rapid initial assessment of the patient’s conscious level using the AVPU method: Alert, responds to Vocal
stimuli, responds to Painful stimuli or Unresponsive to all stimuli. Alternatively, use the Glasgow Coma Scale
score.
5. Measure the blood glucose to exclude hypoglycaemia using a rapid finger-prick bedside testing method. If the
blood sugar is below 4.0 mmol l-1, give an initial dose of 50 ml of 10 % glucose solution intravenously. If
necessary, give further doses of intravenous 10 % glucose every minute until the patient has fully regained
consciousness, or a total of 250 ml of 10 % glucose has been given. Repeat blood glucose measurements to
monitor the effects of treatment. If there is no improvement consider further doses of 10 % glucose and call for
expert help. Other concentrations of intravenous glucose are available and can be used according to local policy.
6. Nurse unconscious patients in the lateral position if their airway is not protected.

(E) Exposure
To examine the patient properly full exposure of the body may be necessary.
Respect the patient’s dignity and minimise heat loss.

Additional information
History
Signs and symptoms
Allergy Medicines
Pertinent medical history
Last meal
Events
Risk factors

1. Take a full clinical history from the patient, any relatives or friends, and other staff.
2. Review the patient’s notes and charts:
o Study both absolute and trended values of vital signs
o Check that important routine medications are prescribed and being given
2. Review the results of laboratory or radiological investigations.
3. Consider which level of care is required by the patient (e.g. ward, HDU, ICU).
4. Make complete entries in the patient’s notes of your findings, assessment and treatment. Where necessary, hand
over the patient to your colleagues using SBAR or RSVP.
5. Record the patient’s response to therapy.
6. Consider definitive treatment of the patient’s underlying condition.