A-E assessment

If in doubt - OXYGEN, 2 CANNULAE, BLOODS

This is basically how you approach the sick patient but is also a useful way of examining any patient. It's probably not that useful for your exams (nobody's going to physically give you a pneumonic 50 year-old in type I respiratory failure) but you will eventually be a doctor. Plus it might come up.

Initially, out-of-hospital basic life support approached patients with an ABC approach. Over time, this has been expanded, particularly for the treatment of medical emergencies, because broadly, the problems should be prioritised in alphabetical order (A problems trump C problems) because they're the things that will kill your patient most quickly.

The mnemonic strictly is DR ABC (Danger, Response ABC...).

D is for Danger, R is for Response

In real life, look around and make sure there's nothing that's going to endanger you. Running into a road that's on fire to save somebody is very brave but also very stupid. If you die or are hurt, your patient is definitely dead.

Check for a response using shout and shake. Be careful. Usually shaking a patient's hand and shouting in their ear is sufficient. Then you need to do two simultaneously things.

• Breathing
  • Look for chest movement
  • Listen and feel for breath sounds at the mouth
• Circulation
  • Feel for a central pulse (either carotid or femoral)

If there's no response for 10 seconds, confirm, call (999 or 2222 depending on where you are), compress. Then go to BLS or ALS depending on your location

A is for Airway

Examination

WARNING - take care of the C-spine in trauma patients

A talking patient has a patent airway. You regularly see "A Patent" in the notes. They're not talking about copyright law - it's true for the majority of patients. And is the first part of examination of any acutely ill patient.

• Look for obstruction (secretions, vomitus, angry man with pillow) or an obviously reduced GCS (<8 needs ventilation)
• Listen for snoring or gurgling if there's airway compromise.
• Feel for breath sounds using your cheek (you should have already done this)
• Oxygen whenever there is any doubt. 15L (100%) through a non-rebreathe mask (aka trauma mask).

Management

Manoeuvre

The following airway manoeuvres are listed in order of difficulty and invasiveness. Well, to be honest, LMAs are really easy. But definitely invasiveness.

• Jaw thrust or head-tilt, chin-lift (NOT in C-spine injury)
• Bag-and-mask - ventilate the patient manually. Unless you're an anaesthetist, this is a two-person technique. Additional adjuncts are:
• Guedel - a small plastic tube, inserted upside-down into the mouth and twisted 180 degrees to move the tongues out of the way OR
  • Nasopharyngeal airway - longer plastic tube that is pushed through the nose
• Laryngeal mask airway (LMA)/iGel - cuffed tube which sits just above the larynx. With an LMA, you need to inflate the cuff. An iGel doesn't need inflating - it's just flexible plastic.
• Intubation - should only be performed by somebody who is trained. A definite airway is a "cuffed tube in the trachea".

Ventilation

This is intubated and ventilated, non-invasive ventilation or breathing for himself.

B is for Breathing

Examination

Five things

• Observations
  • Saturations (including supplemental oxygen)
  • Respiratory rate
• Look for symmetrical chest movement, fogging of the mask, obvious wounds
• Feel for tracheal deviation and chest expansion
• Listen to the chest (auscultation)

Management

• Oxygen (watch out in COPD)
• Treat anything reversible (like a tension pneumothorax)
• Think about an ABG
• Order a CXR if there is an indication

C is for Circulation

Examination

Five things

• Observations
  • Blood pressure
  • Heart rate
• Look for signs of shutdown centrally (blue tongue or lips) and peripherally (blue fingers and toes) or signs of obvious bleeding (melaena, haematemesis or traumatic)
• Feel for capillary refill time at the sternum, apex beat, pulse and temperature of peripheries
• Listen for heart sounds

Management

• Two large-bore cannulae in the ante-cubital fossae. If this fails, intraosseus or central access.
• Bloods - FBC, U+E, CRP. Consider G+S or cross-match
• Start fluids (colloid or crystalloid - no sugar) as fast as possible (watch out in heart failure)

D is for Disability

This is a focussed neurological examination

Examination

Unfortunately, it doesn't quite fit into the "five things" and "obs, look, listen, feel" of the previous ones.

• Pupils - equal and responsive to light. Ensure no RAPD
• GCS/AVPU - sudden drops are bad. Less than 8 requires airway support
• BM - hypoglycaemia is the most important cause of a drop in GCS

Management

If they're hypoglycaemic, give them sugar (10% dextrose stat). If there's any other sudden change and they're stable enough, get a CT head.

E is Exposure

Examination

• Temperature - a sign of sepsis
• Abdomen - Look for obvious swelling, wounds, distention; feel for tenderness, masses, guarding' listen for the presence of bowel sounds
• Limbs (legs first) - look for swelling (unilateral/bilateral), colour (limb ischaemia) or obvious abnormality (fractures); feel for pitting oedema, pain; move (ha! gotcha! not listen!) to ensure all limbs are able to move.

Management

Paracetamol can be given for the temperature along with cooling measures. Blood cultures should be taken in any pyrexial patient. And AXR or CT abdomen may be appropriate if acute abdominal pathology is suspected. With a DVT, start treatment-dose enoxaparin and if you suspect acute heart failure, start high-dose furosemide.