A-B-C-D-E

Tri Wahyu Murni

march/2016

TWMS-IDI BDG

INTRODUCTION

march/2016

TWMS-IDI BDG

ABCDE description
Airway-Breathing-Circulation-DisabilityExposure approach is applicable in all clinical
emergencies to immediate assessment and
treatment of critically ill or injured patients
This approach is applicable in all clinical
emergencies (prehospital wthout any
equipment, in emergency rooms, in general
wards of hospital or in intensive care).
march/2016

TWMS-IDI BDG

History of the ABCDE approach

In the 1950s, Peter Safar described methods to safe
guard the airway and deliver rescue breaths (A-B)
Kouwhoven and colleagues described closed chest
cardiac massage (adding the letter C). Dr P. Safar first
described the techniques in combination (A-B-C)
Styner in 1976 crashed in a smaal aircraft with his
familly , he observed inadequacy of the emergency
care provided . The systematic approach to the
critically injured patient he formed the A-B-C-D-E
approach is an extention of the initially ABC approach
(tha basis of the ATLS courses)
march/2016

TWMS-IDI BDG

ABCDE approach

The evidence supporting the systematic ABCDE

approach to critically ill (septic shock) or injured
patients is expert consensus

The approach is widely accepted and used by

emergency technicians, critical specialist and
traumatologits

The ABCDE approach is applicable for all

patients (adults or children)

march/2016

TWMS-IDI BDG

ABCDE which patients need

1. The clinical signs of critical conditions are
similar regardles of undelying cause
2. The ABCDE approach should be used
whenever critical illness or injury suspected

march/2016

TWMS-IDI BDG

ABCDE which patients need

3. Cardiac arrest is often preceded by adverse
clinical signs and these can be recognized
and treated with the ABCDE approach
potentially prevent cardiac arrest
4. The ABCDE approach is also recommended
as a first step in post resuscitation care upon
the return of spontaneous circulation
march/2016

TWMS-IDI BDG

ABCDE principles

The initial assessment and treatment are

performed simultaneously and continously

Life saving treatment must be instituted before a

defenitive diagnosis has been obtained.

Early recognition and effective initial treatment

prevents deteoration and shorter time for a
definitive diagnosis to be made

march/2016

TWMS-IDI BDG

ABCDE principles

The ABCDE approach using the structural

approach the aims quickly identify life
threatening problems and intitute treatment to
correct them

The ABCDE approach helps to rapidly recognize

the need for assistance (first responders pre
hospital should call for help, emergency room in
hoaspital need to call a specialist ( hospital
response team/ medical emergency team/
cardiac arrest team)

march/2016

TWMS-IDI BDG

ABCDE principles
The ABCDE approach, on completition of the
initial assessment should be repeated until
the patients stable.
In case of deteriation, reassessment should
be performed

march/2016

TWMS-IDI BDG

10

ABCDE approach

First one s Own safety must be ensured

Then in general impression is obtained by simply
looking at the patient ( skin collors, sweating,
surrounding etc)

The systematic approach described :

1.
2.
3.
4.
5.

march/2016

A = airway patent ?
B = is the brething sufficient ?
C = is the circulation sufficient ?
D = Disability , what is the level of consciousness?
E = Exposure, any clue to explain the patients condition
TWMS-IDI BDG

11

ABCDE approach

Guidelines and guidance Resuscitation council (UK)

Critical patient
Medical/ Surgical

1.
2.
3.
4.
5.
6.

ABCDE Approach
Complete initial assessment and re asses regularly
Treat life threatening problem
Access efeect of treament
Recognize if need extra help (call appropriate help)
This enables interventions (eg assessment, attaching monitors,
intravenous access, to be undertaken simultaneously)

march/2016

TWMS-IDI BDG

12

ABCDE approach

Guidelines and guidance Resuscitation council (UK)

Critical patient
Medical/ Surgical

7. Communicate effectively use the situation , background,

assessment, recommendation (SBAR) or reason, story, vital sign,
plan (RSVP) approach.
8. to keep the patient alive, and achieve some clinical improvement.
This will buy time for further treatment and making the diagnosis.
9. Remember it can take a few minutes for treatments to work, so
wait a short while before reassessing the patient after an
march/2016
TWMS-IDI BDG
13
intervention

No respond

Call for help

Look, listen, Feel

unconscious,
call for help &
start CPR
march/2016

TWMS-IDI BDG

14

ABCDE approach

Guidelines and guidance Resuscitation council (UK)

FIRST STEP.

march/2016

1.

Ensure personal safety. Wear apron and gloves as

appropriate

2.

First look at the patient in general to see ithe patient

appears unwell

3.

If the patient is awake ask how are you if the patient

appears unconcious or his collaped, shake him and ask
are you alright. If the responds normally he has a patent
airway, is breathing and has brain perfusion. If he speaks
only in short sentences, he have may breathing problems.
Failure of the patient to respond is a clear marker of criticl
illness
TWMS-IDI BDG

15

ABCDE approach

Guidelines and guidance Resuscitation council (UK)

FIRST STEP.
4. This first rapid Look, Listen and Feel (LLF) should
take about 30 s, and will often indicate a patient is
critically ill , there ia a need for urgent help. Ask
colleague to ensure appropriate help coming.
5. If the patient is unconcious, unresponsive and is not
breathing normally (occasional gasps are not
normal) start CPR according to the resuscitation
guidelines. If you are confident and trained to do so,
feel for a pulse to determine if the patient has a
respiratory arrest if there are any doubts about the
presence of a pulse start CPR
march/2016

TWMS-IDI BDG

16

ABCDE approach

Guidelines and guidance Resuscitation council (UK)

FIRST STEP.
6. Monitor the vital signs early. Attach a pulse
oximeter. ECG monitor and a on invasive blood
pressure monitor to all critically ill patients as
soon as possible
7. Insert an intravenous cannula as soon as
possible. Take bloods fo investigation when
inserting the intravenous cannula
march/2016

TWMS-IDI BDG

17

ABCDE approach
Critical patient
Medical/ Surgical

1.
2.
3.
4.
5.

A = airway patent ?
B = is the brething sufficient ?
C = is the circulation sufficient ?
D = Disability , what is the level of consciousness?
E = Exposure, any clue to explain the patients
condition

march/2016

TWMS-IDI BDG

18

A = AIRWAY

march/2016

TWMS-IDI BDG

19

AIRWAY assessment
THE AIRWAY IS PATENT if ;
Patient responds in a normal voice
PARTIALLY OBSTRUCTED AIRWAY IF
A changed voice
A noisy breathing (stridor etc)
Incereased breathing effort (paradox
respiration, see saw sign)
A reduced level of conciousness
march/2016

TWMS-IDI BDG

20

AIRWAY assessment & management

(resuscitation council UK)

Airway obstruction is an emergency. Get expert

help immediately. Untreated airway obstruction
cause hypoxia, and risk damaged to the brain,
kidneys and heart, cardiac arrest and death
1. Look for signs of airway obstruction
2. Treat airway obstruction as a medical
emergency
3. Give oxygen as a high concentration

march/2016

TWMS-IDI BDG

21

AIRWAY assessment & management

(resuscitation council UK)

Look for signs of airway obstruction

a) Paradoxical chest and abdominal movements (seesaw respiration)

b) Use of the accessory muscles of respiration.
c) Central cyanosis is a late sign of airway obstruction.
d) In complete airway obstruction , no breath sound at
the mouth or nose.
e) In partial obstruction , air entry is diminished and
often noisy
f) In the critically ill patient, deppresed consiousness
often leads to airway obstruction

march/2016

TWMS-IDI BDG

22

AIRWAY assessment & management

(resuscitation council UK)

Treat airway obstruction as a medical emergency

In most cases only simple methode
1. Airway clearance are required (airway opening)
manouvres. Use a head tilt and chin lift maneuver to
open the airway.
2. Airway suction , to remove obstructions (blood, vomits)
3. insertion OPA (oropharyneal tube) or NPA
(nasopharyneal tube).
4. Tracheal intubation may be required when these fall
High flow O2 should be provided to all citically ill
march/2016

TWMS-IDI BDG

23

 Pasien tidak sadar

Pangkal lidah jatuh kebelakang

Head tilt
Chin lift

march/2016

TWMS-IDI BDG

24

AIRWAY assessment & management

(resuscitation council UK)

Give oxygen as a high concentration

1. Provide high consetration O2, using a mask with O2
reservoir. Ensure that the O2 flow is sufficient
(ussualy 15 l/min) to prevent the collapse of the
reservoir during inspiration. If the patients trachea is
intubated, give high consentrattion O2 with a selfinlating bag
2. In acute respiratory failure , aim to mantain an O2
saturation of 94-96%. mantain an O2 saturation of 9496% In patient at risk of hypercapnic respiratory
failure , the aim for an O2 saturation of 88-92%
march/2016

TWMS-IDI BDG

25

B=BREATHING

march/2016

TWMS-IDI BDG

26

BREATHING assessment
Determine : LLF respiratory distress
Assess Resp rate, the depth of each breath, the pattern
(rhytm) of respiration and whether chest expansion is
equal on both slides.

march/2016

Respiratory rate (normal 12-20 breath/min)

Inspect movement of the thoracic wall for symetry
Respiratory use of auxillary muscle
Percuss the chest for unilateral dullness or resonance
Cyanosis or distended neck vein or laterization of the trachea
Lung auscultation should be performed
If possible a pulse oxymeter should be applied

TWMS-IDI BDG

27

BREATHING assessment
(resuscitation council UK)

During the immediate asessment of breathing. It is

vital to diagnose and treat immediately lifethreatening conditions
1.
2.
3.
4.
march/2016

Acute severe asthma,

Pulmonary edema,
Tension pneumothorax
Massive hematothorax.
TWMS-IDI BDG

28

ASYMETRY CHEST WALL

Tension
peneumothorax

Flail chest
Paradox movement

march/2016

Hematothorax

TWMS-IDI BDG

29

BREATHING management
Tension pneumothorax must be relieved
immediately (needle thoracostomy). Drain
for hematothorax and fluid replacement th/
(hemorhagic shock)
Bronchospasm should be treated with
inhalation
If breathing is insufficiet, assisted ventilation
must be performed. Trained personnel
should use a bag mask (if available)
march/2016

TWMS-IDI BDG

30

Needle
Thoracosentesis

Oro phanryngeal
airway tube

Assisted ventilation
intubation

Inhalation

31

BREATHING assessment & management

(resuscitation council UK)

Note any chest deformity (this may increase the risk

of deteriation in the ability to breathe normal
Look for raised jugular venous pulse (JVP) in acute
severe asthma or a tension pneomothorax,

note the presence and patency of any chest

drains, remember that abdominal distention
may limit diafragma movement, thereby
worsening respiratory distress
march/2016

TWMS-IDI BDG

32

C = CIRCULATORY

march/2016

TWMS-IDI BDG

33

CIRCULATORY assessment
Is the circulation sufficient ?
1. The capillary refil time
2. Pulse rate
3. Inspection : color change, sweating, decreased
level of consiousnes
4. If stethoscpe available : auscultation, blood
pressure measurement
5. If ECG monitor available , blood presure
measurement, heart rhytm
march/2016

TWMS-IDI BDG

34

CIRCULATORY management
Hypovolemia is an important adverse clinical
sign
Placing the patient in the supine position
and elevating the patients legs
Intravenous access should be obtained is
soon as possible and cristaloid should be
infused
march/2016

TWMS-IDI BDG

35

CIRCULATORY assessment
(resuscitation council UK)

This shoud have been treated earlier on in the

assessment?

1. Look at the color of the hand and digits

2. Assess the limb temperature by feeling (cool or
warm)
3. Measure the capillary refil time (normal <2 s)
4. Assess the state of vein (underfilled/ collapsed
when hypovolemia)
5. Count the Pulse rate (preferable HR listening with
stetoscope)
6. Palpate peripheral or central pulses (rate, quality,
regularity, equality)
march/2016

TWMS-IDI BDG

36

CIRCULATORY assessment
(resuscitation council UK)

7. Measure Blood pressure (even shock BP may be

normal because compensatory mecahanism).
Low diastolic BP suggest arterial vasodilation
(anaphylactic shock or septic) .A narrowed pulse
pressure (difference systolic and diastolic < 35
mmHg) suggest arterial vasoconstriction
(cardiogenic or hypovolemic shock).
8. Auscultate the heart (murmur, pericardial rubs,
difficult to hear,) coorespond to pulse rate.
9. Look other sign s
march/2016

TWMS-IDI BDG

37

CIRCULATORY assessment & management

(resuscitation council UK)

10. Look external hemmorhage from wound or drain (

intra thoracic, intra abdominal, intra pelvic be
significant even drain empty)
11. The specific treatment . Seek the signs of
immediately life threatening (cardiac tamponade,
,assive or continuing bleeding, septicemia shock)
12. Insert one or more large iv cannulae (14-16 G), use
short and high flow
13. Take blood for hemological, biochemical,
coagulation, microbiological, or cross matching.
march/2016

TWMS-IDI BDG

38

CIRCULATORY assessment & management

(resuscitation council UK)

14. Give bolus of 500 ml of warmed crystalloid

solution (Hartman so, 0,9% Na Cl) over less than
15 min. If hypotensive . Use 250 ml for patient
with cardiac failure or trauma use closser
monitoring ( listen to the chest for crackles).
15. Reasses the HR and BP regurlary (every 5 min)
targets > 100 mmHg systolic.
16. If does not improve repeat the fluid challeng,
seek expert help
march/2016

TWMS-IDI BDG

39

CIRCULATORY assessment & management

(resuscitation council UK)

17. If symptom and sign of cardiac faillura (dyspnoe,

increase HR, raised JVP, a third heat sound,
pulmonary crackles) decrease or stop fluid infusion,
seek alternative of improving tissue perfusion
(inotropes or vasopressors)
18. If the patient has primary chest pain and suspected
ACS record a 12 lead ECG
19. Immediate general treatment of ACS :

march/2016

Aspirin 500 mg orally

Nitrogycerine or NTG sublinual (tablet or spray)
O2 if Sat < 94%
Morphine (diamorphine) titrated i.v (avoid sedation or resp
depression)
TWMS-IDI BDG

40

i.v access
Intraosseous
access

march/2016

TWMS-IDI BDG

41

D = DISABILITY

march/2016

TWMS-IDI BDG

42

DISABILITY assessment
What is level Is level of consiousness ?
Rapidly assessment using the AVPU method
(A=Allert, V= voice response, P=Pain responsive ,
U=Unresponsive)
GCS (Glasgow Coma Score) can be used : Eye
movement, Voice , Limb movements. Limbs
movements should be inspected to evaluate
potential signs of laterization.
march/2016

TWMS-IDI BDG

43

DISABILITY management
The best immediate treatment for patient
with primary cerebral coditions is
stabilization of the A-B-C.
When the patient is only pain unresponsive
or unresponsive , airway patency may be
ensured ( placing in recovery position or
intubation)
march/2016

TWMS-IDI BDG

44

DISABILITY management
Pupillary light reflexes should be evaluated
and blood glucose measured
If the hypoglycemi corrected quickly with oral
or infused glucose.

march/2016

TWMS-IDI BDG

45

DISABILITY assessment & management

(Resuscitation council UK)

Common cause of unconciousness

1.
2.
3.
4.

march/2016

Profound hypoxia
Hypercapnia
Cerebral hypoperfusion
Recent administration of sedatives or analgesic
drug

TWMS-IDI BDG

46

DISABILITY assessment & management

(Resuscitation council UK)

1. Review and treat ABCs , treat hypoxia and

hypotension.
2. Check the patients drug used (drug induced
causes of depressed conciousness) Give an
antogonist ( eg naloxone for opiod toxicity)
3. Examine the pupils (size , equality, reaction
to light).
4. Make rapid initial assessment a conscious
level using AVPU or GCS
march/2016

TWMS-IDI BDG

47

DISABILITY assessment & management

(Resuscitation council UK)

5. Measure blood glucose to exlude

hyperglycemia use rapid finger prick bedside
test. Follow protocol for management
hypoglycemia . If < 4.0 mmol/L unconscious
patient , give initial dose of 50 ml of 10% glucose
sol i.v. Or give every minute untill the patient has
fully regained consciousness (total 250 ml).
Specific managementfor DM patients
6. In the lateral postion if their airway is nor
protected
march/2016

TWMS-IDI BDG

48

E = EXPOSURE

march/2016

TWMS-IDI BDG

49

EXPOSURE assessment
Any clues to explain the patient condition.

march/2016

Sign of trauma
Bleeding
Skin rashes (skin reacition)
Must be observed

TWMS-IDI BDG

50

EXPOSURE management

Clothing should be removed to allow a thorough

physical examination to be performed

Body temperature can be estimated by feeling

the skin or using a thermometer when available

Respect the dignity and minimize heat loss

march/2016

TWMS-IDI BDG

51

ADDITIONAL INFORMATION
(RESUSCITATION CONCIL UK

march/2016

TWMS-IDI BDG

52

ADDITIONAL INFORMATION
1. Take a full clinical history (from friend, relatives, other
staf)
2. Review the notes and charts (trended vital signs), check
routine medications.
3. Review the results of laboratory or radiological
investigations
4. Consider which level of care required (ward, HCU,ICU)
5. Make complete entries in the patients note or findings
6. Records the patients theraphy
7. Consider definitive treatment of the patients underlying
condition

march/2016

TWMS-IDI BDG

53

HOW TO IMPLEMENT IN

SUDDEN CARDIAC ARREST

march/2016

TWMS-IDI BDG

54

SUDDEN CARDIAC ARREST (SCA)

Adalah keadaan terjadinya henti denyut
jantung secara tiba tiba tanpa diduga.
Hal ini menyebabkan berhentinya aliran
darah ke otak dan ke organ penting
lainnya dalam tubuh kita

CARDIAC ARREST
Bila sistem listrik yg iritatif ini terganggu
menyebabkan kegagalan pengiriman arus listrik ,shg
jantung tidak berdenyut terjadi kegagalan pompa
darah keseluruh tubuh .
Fibrilasi ventrikel (VF) adalah yg paling sering
menyebabkan kematian tiba2 (sudden death),
dengan tidak terkoordinasi nya sinyal listrik , bilik
jantung (ventrikel) berhenti kontraksi.

CARDIAC ARREST
Penanganan fibrilasi hanya dengan kejut listrik
(electrical shock) .
Tindakan harus segera karena > 6 menit otak tidak
mendapat darh akan terjadi kerusakan otak karena
tdk adanya oksigen ke otak.
Dengan adanya AED di tempat layanan publik , akan
membantu penyelamatan korban.

Rantai bertahan hidup

Mengenal kasus
Henti jantung
Henti nafas

Resusitasi
jantung
Paru
(RJP/CPR)

Defibrilasi

Bantuan
hidup lanjut

1
2
3

NEW CPR
PIJAT JANTUNG/ KOMPRESI DADA)
Untuk Dewasa, kedalaman kompresi
jantung minimal 5 cm -> 6 cm

Kompresi pada
pertengahan
sternum diantara
kedua puting susu
Kompresi dengan
menggunakan
tumit/ pangkal
telapak tangan
Kecepatan
kompresi minimal
100x/menit -> 120
x/m

Automated external defbrillator (AED)

1. Buka AED,
nyalakan (ada yang
otomatis menyala
begitu dibuka)

2. Tempelkan
pads, pada
dinding dada

3. Analisa irama
jantung; jangan
sentuh pasien

4. Tetap jaga jarak

dengan pasien ...
Beri kejutan listrik

PENYEBAB CARDIAC ARREST

5 H dan 5T
5H

Hipoksia
Hipovolemia
Hipotermia
Hipo/Hierkalemia
Hidrogen ion (asidosis)

5T

Tension pneumothorax
Tamponade jantung
Toxins
Thrombosis Koroner
Thrombosis Pulmonal

Semoga bermanfaat
april 2011

TWMS