Assignment 2 - ABCDE Assessment PDF

Preview

Summary

Assignment 2 - ABCDE Assessment...

Description

Table of Contents

Introduction............................................................................................................................ 1 Initial Management Priorities – The Early Warning Score.......................................................1 Management Priorities: The ABCDE Assessment..................................................................2 Management Priorities: Primary Causes for Deterioration......................................................5 Clinical Implications of Current Management Practices..........................................................9 Conclusion........................................................................................................................... 10 References........................................................................................................................... 12

1 Introduction

The assessment and management of the critically unwell patient has remained a global health priority for almost two decades, with sub-optimal management potentially resulting in increased intensive care admission, and higher inpatient mortality (D. Smith & Bowden, 2017). The implementation of an Early Warning Score (EWS), to support the recognition of physiological abnormalities has become standard, though its strong evidence in prediction patient deterioration (Smith, Prytherch, Meredith, Schmidt, & Featherstone, 2013). The ABCDE assessment approach of Airway, Breathing, Circulation, Disability and Exposure, and ‘4Hs 4Ts’ pneumonic of Hypovolaemia, Hypoxia, Hypothermia, Hyper/Hypokalaemia, Tension Pneumothorax, Thromboembolism, Toxins and Tamponade are considered current best practice in Australia when assessing and managing the critically unwell patient (Australian Resuscitation Council, 2016a). The EWS observations, ABCDE assessment and ‘4Hs 4Ts’ will be discussed, measuring Australian standards against international best practice. The clinical implications of these management systems will be discussed in terms of patient outcomes, and healthcare resources with recommendations for further research made.

Initial Management Priorities – The Early Warning Score Accurately monitoring and documenting physiological observations is a key component of the initial management of the deteriorating patient (Australian Commission on Safety and Quality in Health Care (ACSQHS), 2011). The ACSQHC Standard, Recognising and Responding to Clinical Deterioration, mandates the use of observation and response charts within Australia (ACSQHS, 2017). These charts promote the identification and recognition of acute deteriorating, and subsequently guide the appropriate escalation of care and management (ACSQHS, 2017). The use of an Early Warning Score (EWS) is promoted, with a score being attributed to each clinical observation parameter, based on the degree of

2 physiological abnormality further mandating the appropriate escalation of care (Queensland Health, 2012). Evidence suggests, an improvement in patient outcomes, with a reduced cardiac arrest rate, and reduction of inpatient mortality from 13.8 to 11 deaths per 1000 rapid response initiations (Mullany, Ziegenfuss, Goleby, & Ward, 2016) . However, McGaughey, O'Halloran, Porter, and Blackwood (2017) argue whilst these principles generally achieved desired patient outcomes, hierarchical referral systems, ward culture, workload and staffing resources had a negative impact of the implantation of these initiatives. Therefore, further attention needs to be focused on educational, cultural and organisational factors in order to improve the successful implementation of the EWS management priorities (McGaughey et al., 2017).

Evidence suggests despite geographical differences; the characteristics of the deteriorating patient remain the same. Suggesting the deteriorating patient is a global issue, with a high inpatient mortality rate. Other than the United Kingdom (UK), most other international countries do not utilise national initiatives in healthcare, and are mandated by local governments, or individual healthcare organisations. Similar to Australian standards, the UK’s National Early Warning Score (NEWS), represents the national standardised approach to assessment and escalation of the deteriorating patient (Day & Oxton, 2014). Much like Australia, NEWS is based on the allocation of scores to physiological parameters, to demonstrate their deviation from acceptable norms, with subsequent standards for escalation of care (Day & Oxton, 2014). In 2014, a Finnish university hospital compared their current escalation criteria against the UK’s NEWS, and evidenced that the use of an early warning score highlights high risk patients within the ward population, whereas the previous conventional criteria, were not able to (Tirkkonen, Olkkola, Huhtala, Tenhunen, & Hoppu, 2014).

Management Priorities: The ABCDE Assessment

3 With a strong history, the ABCDE Assessment of: Airway, Breathing, Circulation, Disability, and Exposure, was first coined in the 1950s, as ABC with further development in the 1970s, to what is known as the ABCDE Assessment (Thim, Krarup, Grove, Rohde, & Løfgren, 2012). Within Australia and New Zealand, guidelines for the management of a critically unwell patient are governed by the Australian and New Zealand Committee on Resuscitation (ANZCOR), with Australia further governed by the Australian Resuscitation Council (ARC). According to the ANZCOR Guidelines, the ABCDE approach to managing the critically unwell patient, is current best practice within Australia (Australian Resuscitation Council, 2016a). The ABCDE approach oversees assessment and management performed both concurrently and continuously (Thim et al., 2012). Thim et al. (2012) argues managing the critically unwell patient, the causative factor may be unknown, therefore management must be implemented prior to a definitive diagnosis. Through using a structured pneumonic, such as ABCDE, life-threatening issues are quickly addressed, therefore appropriate management are able to commenced (Thim et al., 2012).

Comparatively, guidelines within the UK are governed by the Resuscitation Council UK, and promote the ABCDE approach for inpatient assessment and subsequent management (Gwinnutt, Davies, & Soar, 2015). The ABCDE assessment within the UK, will only take place is signs of life have been established, if there are no signs of life – immediate cardiopulmonary resuscitation is commenced (Gwinnutt et al., 2015). Similarly, Australian resuscitation guidelines state that if a patient shows no signs of life, or is not breathing normally, to immediately commence cardiopulmonary resuscitation (ANZCOR, 2016).

Airway management, is an essential component for critically unwell patients, including the roles of patency assessment and suctioning (Sole & Bennett, 2014). The current method of assessment within Australia is to look and listen, look for unusual respiratory movements, and listen for signs of airway obstruction (Smith & Bowden, 2017).

4 Smith and Bowden (2017) identify common causes of airway obstruction as: fluids, secretions, central nervous system depression, trauma, foreign objects or inflammation. According to the American Heart Association (AHA) (2015) guideline updates, oxygen delivery and ventilation should be through either an advanced airway or bag-mask device within the inpatient setting. This practice, is also reflected within the UK, however the use of supplemental oxygen is supported during airway management, suggesting to maintain an oxygen saturation of 94 to 98 percent, with hypercapnia risk patients at 88 to 92 percent (Resuscitation Council UK, 2015). Within Australia, supplemental oxygenation is not considered until the breathing assessment in the ABCDE algorithm, with airway management purely focusing on maintaining a patent airway.

Abnormal observations during a breathing assessment, can be due to both acute or chronic respiratory conditions (Smith & Bowden, 2017). Smith & Bowden (2017) further argue a comprehensive breathing assessment is required to ascertain the adequacy of pulmonary ventilation, and effectiveness of pulmonary gas exchange. As previously stated, Australian guidelines recommend the look, listen and feel approach with two rescue breaths administered prior to resuscitation if the patient is not breathing (ANZCOR, 2016). As per international standards, Australian guidelines recommend the use of supplemental oxygen when oxygen saturation falls below 94 percent, with oxygen saturations titrated for patients at risk of hypercapnic respiratory failure to 88 to 92 percent (ANZCOR, 2016). Differentiating from the UK’s guidelines, Australian guidelines suggest that in patients with suspected acute coronary syndromes, and normal oxygen saturation, that oxygen therapy is not required, and could be potentially harmful (ANZCOR, 2016).

Abnormal physiological observations within the circulation assessment are secondary to acute or chronic cardiac conditions such as: insufficient circulating volume, arrhythmias, cardiac failure, tension pneumothorax or cardiac tamponade (Smith & Bowden,

5 2017). Within Australia, the recommended compression-to-ventilation ratio is 30:2, regardless of age at approximately 100-120 compressions/min (ANZCOR, 2016). This reflects on the UK’s 30:2 cardiopulmonary resuscitation ratio with a rate of 100-120 compressions/min (Gwinnutt et al., 2015). Prior to 2015, it was recommended to perform chest compressions at a minimum of 100/ min, however clinical evidence suggests that as the rate of compressions increase, compression depth decreases in a dose-dependent manner (American Heart Association (AHA), 2015). Therefore, by restricting the maximum dose ensures adequate depth during compressions is achieved. Following successful resuscitation, circulation management should be focuses on: volume replacement, restoration of tissue perfusion and haemorrhage control with causative life-threatening factors requiring immediate management (Thim et al., 2012).

Upon successful ABC assessment, UK guidelines recommend the review and management of the ABC assessment, prior to focus disability and exposure (Resuscitation Council UK, 2015). Disability and exposure, within Australia focuses on assessing consciousness level, pupils, blood glucose levels, temperature and skin inspection (Australian Resuscitation Council, 2016a). This is reflected within the UK guidelines for disability and assessment, however the UK recommend addressing pharmacological causes for decreased consciousness, as a part of the assessment (Resuscitation Council UK, 2015). No evidence on best practice was obtainable from the AHA resuscitation guidelines.

Management Priorities: Primary Causes for Deterioration

The Australian guidelines recommend treating the reversible causes for clinical deterioration during the ABCDE assessment, or during resuscitation (Australian Resuscitation Council, 2016a). Current Australian Resuscitation Council (ARC) teaching, identified the ‘4Hs and 4Ts’ pneumonic, as best practice for recalling the reversible causes

6 (Australian Resuscitation Council, 2010) . According to the ARC, the 4Hs are: Hypovolaemia, Hypoxia, Hypothermia, Hyper/Hypokalaemia (2010). Whereas the 4Ts are: Tension Pneumothorax, Thromboembolism, Toxins and Tamponade (ARC, 2010).

Management of hypovolaemia involves maintaining tissue perfusion and blood pressure until the cause for fluid loss is rectified (Mann, 2017). Causes of hypovolaemia most commonly are due to haemorrhage or shock, however fluid replacement management is dependent on the causative factor (ARC, 2016). According to Mann (2017), best practice for the management of haemorrhagic hypovolaemia is the early identification of bleeding sources, minimisation of blood loss, tissue perfusion restoration and achieving haemodynamic stability, which can be identified during the ABC and E portions of the ABCDE assessment algorithm. The ARC recommends restoration with fluid resuscitation and blood transfusions, as best practice within Australia (ARC, 2016). However, according to Mann (2017), further evidence Is required to establish the most effective fluid resuscitation strategy.

Hypoxia is defined as poor tissue oxygenation secondary to failure in any physiological system that circulates oxygen throughout the body (Olive, 2016). Current Australian guidelines state the risk of hypoxia can be minimised through ensuring adequate lung ventilation with 100 percent oxygen during cardiopulmonary resuscitation (Australian Resuscitation Council, 2016b). Management principles of hypoxia, are in line with airway management, as described in the ABCDE assessment algorithm.

Hypothermia is defined when a patient’s core body temperature is below 35 degrees Celsius and is potentially life-threatening as a precursor for cardiac arrhythmias (ARC, 2016). Current inpatient practice involves the use of both warm intravenous fluids, and

7 external warm air ventilation (ARC, 2016), however management differs dependant on patient condition and severity of hypothermia, when assessed with other parameters as per the ABCDE assessment (ARC, 2016). Best practice guidelines argue careful management of the hypothermic patient should take place, as sudden movement may trigger an arrhythmia (Chu, 2016). Chu’s (2016) evidence-based practice recommendations are concurrent with current Australian standards, involving a mixture of advanced life support management with external warming. However, Chu (2016) only recommends the use of warmed intravenous saline in patients whom are hemodynamically unstable.

Electrolytes are essential for maintaining bodily function and good health, with deviations from the norm resulting in potentially life threating problems (Crawford, 2014). Hyperkalaemia is defined as a serum potassium level above 5.0mmol/L, with causative factors resulting from excessive intake of potassium containing substances, impaired elimination, cellular injury or altered fluid shift from intracellular to extracellular spaces (Crawford, 2014). As per the ARC guidelines, the initial management of hyperkalaemia is to antagonise the myocardial effects of potassium through stabilising the cell membrane (ARC, 2016). Best practice, is to administer intravenous calcium, such as Calcium Chloride, or Calcium Gluconate before considering other management options, such as dialysis or pharmaceutical means to restore homeostasis (ARC, 2016). Current evidence-based practice, recommends the administration of salbutamol, and intravenous insulin-dextrose to be the most effective at reducing serum potassium (Batterink, Cessford, & Taylor, 2015). However, there is little evidence to suggest a reduction in adverse patient outcomes with current management practices (Batterink et al., 2015).

A tension pneumothorax is defined at the progressive accumulation of air within the pleural space, in which atmospheric pressure is exceeded by intrapleural pressure though inspiration and expiration (Byrd, 2017). Australian guidelines recommend rapid

8 decompression through thoracostomy or needle thoracentesis, using a 14-gauge intravenous catheter in the affected site, followed by chest drain insertion when appropriate, one clinically identified through chest x-ray, however when haemodynamically unstable, may be performed prior to chest x-ray (ARC, 2016). Best practice guidelines, support the use of a 14-gauge intravenous catheter, however state that in approximately one-third of patients, the chest wall thickness may be greater than the length of the cannula; therefore it is also appropriate to use the fourth-fifth intercostal space (Byrd, 2017). Byrd (2017), supports the Australian standards, stating that interventions to treat a pneumothorax should not be delayed through awaiting radiographic confirmation.

According to the ARC (2016), thrombosis is a common cause of cardiac arrest, with the ability to induce arrhythmias or ‘primary pump’ failure. The primary cause, is often a pulmonary embolism, and the ARC recommends administering a fibrinolytic drug immediately with evidence suggesting fibrinolysis during cardiopulmonary resuscitation demonstrates good survivability and neurological outcomes (ARC, 2016). Best practice evidence supports airway and oxygenation management as a first-line pulmonary embolism management, in conjunction with fluid restoration and anticoagulation, as per the ABCDE assessment algorithm (Merli, Eraso L. H., Galanis T., & Ouma G., 2017).

The ARC states, that in the event of an unobtainable history, toxins through therapeutic or toxic substances must be considered as a part of a comprehensive assessment – whether accidental or deliberate (ARC, 2016). However, these can often be difficult to detect without diagnostic investigations, and there is little evidence to suggest specific treatment will improve patient mortality during a resuscitation event (ARC, 2016).

Cardiac tamponade is a life-threatening compression of the heart secondary to pericardial accumulation of fluids or gas; usually the result of trauma, effusion or rupture

9 (Bella, 2017). However, as per the ARC, cardiac tamponade can often be difficult to diagnose during cardiac arrest, compared with pre-arrest phase patients (ARC, 2016). Australian guidelines recommend the use of a focused cardiac ultrasound to formally diagnose tamponade, as this diagnostic procedure can be performed intra-cardiopulmonary resuscitation (ARC, 2016). Australian guidelines recommend management through resuscitative thoracotomy or pericardiocentesis (ARC, 2016). However, the ARC, further stipulates that emergency pericardiocentesis, is difficult during resuscitation, therefore a subxiphoid or apical approach have reportedly been associated with good outcomes; however, a blind approach without image guidance is associated with poor patient outcomes (2016). Best practice recommendations suggest, when a patient is haemodynamically unstable, pericardiocentesis is best first line management of cardiac tamponade (Bella, 2017). Australian guidelines for best-practice management of cardiac tamponade in the emergency setting are in line with international standards. International best-practice guidelines, do not stipulate a preferred method to completing pericardiocentesis, unlike the Australian guidelines. Clinical Implications of Current Management Practices Evidence suggests most in-patients who suffer a cardiorespiratory arrest demonstrate physiological abnormalities preceding the arrest (Goldhill, McNarry, Mandersloot, & McGinley, 2005). Whilst the clinical effectiveness of the Early Warning Score (EWS) is widely documented, there is little information regarding hospital resource utilisation and cost effectiveness (Murphy et al., 2018). Murphy et al. (2018) suggest further research is required analysing the cost effectiveness of EWS.

The ABCDE assessment approach remains a vital clinical tool in the initial assessment and management of the critically unwell patient through aiding in the identification and prioritisation of clinical interventions (Thim et al., 2012). Widespread, global use of the ABCDE assessment approach will ensure succinct team management, and

10 therefore improve patient outcomes (Thim et al., 2012). Thim et al. (2012) further states, evidence reinforcing the ABCDE assessment approach, is expert consensus. However, evidence suggests that a majority of physical assessment skills taught in pre-workplace education, such as university training, are not used in practice (Sunaryo, 2015). An Australian study supports this, evidencing that of 126 skills taught to nursing students, only five were used consistently in clinical practice (Douglas, Windsor, & Lewis, 2015). Furthermore, Douglas et al. (2015) suggest a lack of confidence as an important barrier to the use of physical assessment skills. Therefore, it could be concluded that whilst the ABCDE assessment approach is generally considered as evidence-based practice for the management of the cr...