Econdary ABCD (Airway, Breathing, Circulation, Differential Diagnosis)
Econdary ABCD (Airway, Breathing, Circulation, Differential Diagnosis)
Econdary ABCD (Airway, Breathing, Circulation, Differential Diagnosis)
If the patient is not ventilating well or if there is a presumed risk of aspiration, insert an
advanced airway device when prudent:
Endotreacheal Intubation is the preferred method.
(View the advanced airway section)
Breathing
Confirm correct placement of the advanced airway device:
If incorrect placement:
Remove the airway device, ventilate the patient using the ambu bag for a short period of time,
and then reattempt placement.
If correct placement:
Continue to monitor:
Circulation
Obtain IV or IO access.
Monitors (ECG, BP cuff, pulse oximeter, et CO2 monitor)
Identify:
heart rhythm
Obtain a 12 lead ECG if possible.
Initiate therapy of ACLS algorithm corresponding with the identified heart rhythm. (Drug
therapy, Electrical therapy, Pacing, etc.)
Differential Diagnosis
(needed for successful treatment of some patients)
Consider reversible causes of rhythm/arrhythmia.
Differential Diagnosis Chart:
Patent/obstructed
If the airway is patent there should be noticeable chest rise/expansion with either spontaneous
respirations or with rescue breaths. The provider may also be able to hear or feel the
movement of air from the patient.
A completely obstructed airway will be silent. An awake patient will lose their ability to speak,
while both a conscious or unconscious patient will not have breath sounds on evaluation. If the
patient is attempting spontaneous breaths without success, there may be noticeable effort of
intercostal muscles, diaphram, or other accessory muscles without significant chest
rise/expansion. The provider will also not feel or hear the movement of air. If the airway is
partially obstructed snoring or stridor may be heard.
Brain Injury?
The breathing center that controls respirations is found within the pons and medulla of the
brain stem. If trauma, hypoxia, stroke, or any other form of injury affects this area, changes in
respiratory function may occur. Some possible changes are apnea (cessation of breathing),
irregular breathing patterns, or poor inspiratory volumes. If the breathing pattern or inspiratory
volumes are inadequate to sustain life, rescue breathing will be required, and an advanced
airway should be placed.
Oral Airway:
Assure the artificial airway is the appropriate size for the patient.
The airway should be easily inserted with a tongue blade.
Avoid use in patients with an active gag reflex.
When you are unable to open airway using head tilt-chin lift or jaw thrust maneuvers.
If you have difficulty forming a seal with the face mask.
If the patient requiring continued ventilatory support.
When the patient has a high risk for aspiration (provide an ETT or Combitube).
Remember, a patient should be unconscious or sedated without an active gag reflex before
instrumentation of the airway occurs with an ETT, Combitube, or LMA.
Gently advance the combitube into the mouth midline along the base of the tongue.
Assure tube rotation of the combitube is following the curvature of the pharynx.
Cease advancement of the tube once the heavy black rings reach the patient’s teeth.
The Combitube is blindly placed into the esophagus 80% of the time and into the trachea 20%
of the time.
The combitube provides ventilatory access irregardless of tracheal or esophageal intubation.
Inflate the pharangeal cuff with 100ml of air. Prevents leak through the nose and mouth. Helps
secure placement.
Inflate the tracheal cuff with 15ml of air. Prevents ventilation of stomach. Reduces risk of
aspiration of stomach content.
First attempt confirmation of esophageal intubation by ventilating through the esophageal tube.
(See “Secondary ABCD” section regarding placement confirmation)
Attempt confirmation of tracheal intubation by ventilating through the tracheal tube. (See
“Secondary ABCD” section regarding placement confirmation)
Once placement has been confirmed:
Positive pressure ventilation is generally kept under 20 CmH2O to prevent inflation of the
stomach. LMA’s are contraindicated for the morbidly obese patient.
The patient is still at high risk of aspiration, even with an appropriately placed LMA. LMA’s are
contraindicated in patients with GERD, full stomachs, and pregnant women.
Cardiac/Electrical Therapy
Transcutaneous Pacemaker (External Pacemaker):
Used to treat unstable bradycardias not responding to drug therapy. Provides temporary
pacing through the skin in emergency situations.
Place pads and electrodes in correct position to assure an appropriate ECG reading.
Set the pacer 10-20 beats per min above the patient’s intrinsic heart rate or 60 beats per min if
there is no intrinsic heart rate.
Start at O mA and work energy level up until you have capture (heart pulsation).
Assure the patient is sedated and comfortable during pacer delivery.
Cardioversion:
Defibrilation:
Supraventricular Tachycardia
Atrial Fibrillation
Atrial Flutter
Sinus Bradycardia
1° Atrioventricular Block
Asystole
Tachycardias
ACLS Adult Tachycardia with a Pulse
Determine if the patient is Stable or Unstable.
Initiate CABD and Secondary ABCD.
Adenosine 1st dose: 6mg IV then 2nd and 3rd doses: 12mg IV.
Irregular:
Atrial Fibrillation with Aberrancy:
Toursades de Pointes:
CABD, ABCD
Using defibrillator:
Verify presence of VF: Defibrillate the patient at 360j using monophasic or at the factory
recommended joules for a biphasic.
CABD, ABCD
Determine if the patient is stable or unstable.
Stable:
Unstable:
Give epinephrine 1mg IV every 3-5min until transcutaneous pacing can be initiated.
Initiate transcutaneous pacing until transvenous pacing can be initiated.
If TCP fails or intravenous pacing is delayed consider Epinephrine (2-10 mcg/min IV),
Dopamine (5-20 mcg/kg/min), or Isoproterenol (3-20 mcg/mim).
Treat causes (atropine 0.5-1mg IV may be used if vagal mechanism is suspected).
Asystole
CABD, ABCD
(if lead II is asystolic, confirm rhythm in leads avL and III.)
Drug therapy:
Drug Therapy:
Acute Stroke
Initiated treatment within 10 min of arrival to the ER:
CABD, ABCD
Appropriate Action:
Initiate CABD.
Have one onlooker call for help.
Have another onlooker retrieve the AED.
Look, listen, and feel for breathing.
2) You are just returning from lunch to the ER and you hear a code blue being initiated in bay
2. You run to the bay to find a patient confused, obtunded, and lethargic in the bed. Oxygen by
NC, ECG, and IV access are already established. The nurse is unable to cycle a blood
pressure. When assessing the ECG you see:
[Patient is breathing.]
[Faint pulse is felt approximately 35 times a minute.]
3) You enter your friends house to find their elderly grandmother staring at the wall and leaning
to their side.