1. Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess and treat the patient
2. Treat life-threatening problems before moving to the next part of assessment
3. Recognise when you need extra help and call for help early
4. Use all members of the team – this allows interventions to be undertaken simultaneously
5. Communicate effectively – we suggest the Situation, Background, Assessment, Recommendation (SBAR) approach

First steps

• Wear apron and gloves as appropriate
• If the patient appears unconscious or has collapsed, shake them and ask “Are you alright?”
  • If there is a normal response, the patient has a patent airway, is breathing and has brain perfusion. Failure to respond is a clear marker of critical illness

Is this a cardiac arrest?

• The first step is to decide whether this is a cardiac arrest
• If the patient is unconscious, look listen and feel for normal breathing (occasional gasps are not normal); simultaneously feel for a carotid pulse
•  If there are any doubts about the presence of a pulse then start CPR, call the arrest team and follow the Advanced Life Support algorithm
• If this is not a cardiac arrest, proceed to ABCDE

Airway (A)

• Look: inside the mouth, remove obvious objects/dentures
• Listen: stridor, snoring, gurgling imply airway compromise
• Do: Suction under direct vision if secretions present
• Do: Jaw thrust/head tilt/chin lift (with cervical spine control in trauma)
• Do: Insert and oropharyngeal or nasopharyngeal airway as tolerated
• If airway still compromised call arrest team
• Do: Give oxygen
  • Maintain an oxygen saturation of 94–98% – always give oxygen initially in the acutely unwell patient
• Ask nurse to put monitoring on now – this will speed things up
• Extra: if the patient is peri-arrest ask for the crash trolley now

Breathing (B)

Circulation (C)

• If no pulse call cardiac arrest team
• Look: for pallor, cyanosis, distended neck veins
• Feel: for a central pulse (carotid/femoral) rate and rhythm; check for capillary refill time
• Monitoring: defibrillator ECG leads and blood pressure if not already done
• Do: Get venous access (x2 large bore) and send bloods if time allows
  • FBC, U&E, LFT, coagulation, group and screen, troponin if appropriate
• Do: Get VBG with the bloods and/or ABG if sats under 95%
• Do: Give fluids
  • If low blood pressure or high pulse give a fluid challenge now (500ml saline stat) unless the patient is in overt heart failure
  • Hypovolaemia is a more likely cause of acute deterioration than overload; you can always stop the fluids and diurese after ABCDE is over if necessary

Disability (D)

• Assess AVPU (and GCS if you have time)
• Check fingerprick glucose
• Do: Give glucose if under 4mmol/l (give 50ml of 50% glucose [or 100ml 20%] IV)
• Look: for pupil size and reaction to light; unusual posturing
• Feel: for tone in all four limbs and plantar reflexes

Actions after ABCDE

• After doing the ABCDE assessment you can now move on to a fuller assessment and management strategy:

Click here for a huge ABCDEFGHIJKLMNOPQ assessment!

Another way of looking at this is to:

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