Emergency Medicine - All About the "ABCs"
Friday, November 17, 2006
Robert L. Norris, MD, FACEP
Whenever we assess any patient in the Emergency Department, Emergency Physicians make a determination regarding that person’s “ABCs”. Often it is clear that the “ABCs” are intact, as when the patient is able to give us a history concerning their visit to the E.D. for, say, their injured ankle. They have an open airway and intact breathing – otherwise they would be unable to speak – and they have an intact circulation – a circulation adequate to pump oxygen rich blood to the brain, feeding those neurologic centers that allow the patient to recall their history and to perform the mechanics of speaking. At other times, it is clear that the “ABCs” are NOT intact, and require immediate intervention. A common example is the victim of cardiac arrest – lying on the ground, unconscious, blue, without any breathing or pulse. This victim needs someone to quickly step up and open his Airway, provide rescue Breathing, and then do cardiac compressions (providing artificial Circulation). This is, of course, the basic, yet critical, sequence of Cardiopulmonary Resuscitation (CPR) as advocated by the American Red Cross and the American Heart Association.
It is just as important for laypeople who are attempting to provide emergency care to a person in the prehospital environment (first aid) to recall and assess the proper sequence of the “ABCs”. Is the person’s airway open and patent – allowing air to move in and out? Is the patient breathing effectively – exchanging enough air with each breath? Is the victim’s circulation adequate to perfuse the brain and other vital organs with enough oxygen rich blood? If the answer is “no” to any one of these questions, then the rescuer must act immediately, addressing the issues in sequence. There is no use to try to provide artificial Breathing if the Airway is not open, as there will be no way for the air to enter the breathing tubes. Likewise, providing external chest compressions is unlikely to be of great benefit if the victim lacks an intact airway and breathing.
So, if called into action to handle any apparent emergency in the street or in the woods, start by assessing the Airway, the Breathing and the Circulation. A basic CPR class (through the American Red Cross or the American Heart Associate) is an excellent way to get the basics on the “ABCs”.
Stay alert and stay safe,
Dr. Bob
10 Comments:
At Wed Nov 29, 03:15:00 PM 2006,
socal patient said…
How often do you open an airway and how do you do it? Howzit done in the field? I really enjoy your blog. It's so ... calm and mellow I think maybe I should move to your city if I need an ER!
socal.patient@yahoo.com
At Thu Nov 30, 09:30:00 PM 2006,
Robert L. Norris, MD, FACEP said…
Dear "socal patient",
Opening a patient's airway in the ER can mean anything from lifting the unconscious patient's chin to get his/her tongue (which, with gravity, is laying in the back of the mouth & throat) up out of the way, to making an incision into the throat (just below the larynx) with a scalpel. When we have a very sick patient we tend to resort to “intubation." This means placing a plastic tube through the mouth and into the trachea. Often we will use medications to help relax the patient. Then we use a special device (a laryngoscope) to lift the tongue up out of the way so we can see the vocal cords. Then we pass the tube between the cords and this gives us a secure airway - an airway we can use to breathe for the patient and an airway that helps reduce the risk that the patient will aspirate (inhale stuff into the lungs that shouldn't be there). It's something we do routinely in our busy ER.
In the field, the technique varies based on the skills of the rescuer. If it's a lay person with CPR training, then the airway is usually opened using the "chin-lift" or "jaw-thrust" technique. If, on the other hand, the rescuer is a paramedic, he/she has special airway skills that will allow "intubation" in similar fashion to what we do in the ER.
I hope you NEVER need an ER, but if you do, I hope your experience is positive in every way!
Best wishes,
Dr. Bob
At Tue Dec 19, 07:41:00 AM 2006,
Anonymous said…
When in a noncontrolled environment, don't forget to consider your own safety before addressing the ABCs.
At Tue Dec 19, 03:09:00 PM 2006,
Cal said…
Ok, I'm a medstudent, we also follow ATLS protocol in the UK.
One thing I don't get though. (I'm only a third year so please don't be too horrified at my ignorance!) You should never intubate a patient without RSIs, right?
... or wrong? What if, in an emergency emergency emergency situation, you had no RSIs? Would you go ahead and intubate anyway?
Hmm.
By the way, I really like your blog. I'll definitely be checking back!
At Wed Jan 17, 03:54:00 PM 2007,
Robert L. Norris, MD, FACEP said…
Dear "Calavera",
Sorry for the delay in responding... been a bit under the weather (I know, "physician heal thyself!", and "catching up after the Holidays"...
Your question is a great one!... no ignorance there!
RSI stands (in Emergency Medicine) for "Rapid Sequence Intubation." It involves quickly giving a patient who needs a protected airway a drug to put him to sleep and a drug to paralyze him so that we can QUICKLY gain control of the airway with minimal risk of his aspirating stomach contents into his lungs.
The vast majority of intubations in a state-of-the-art ER will be done via RSI, but not necessarily all. For example, if a victim comes in in full cardiopulmonary arrest, he needs no sedation or paralysis because he is already unconscious and his muscles are (usually) fully relaxed, so we can just proceed with intubation. Another time we would not do RSI was if we predicted the patient was going to be a "difficult airway case" - a situation in which we might not be able to get control of the airway or ventilate the patient with a resuscitation bag (e.g., a person with rapidly progressive upper airway swelling due to an acute allergic reaction). In such a situation, it would be better to do an "awake intubation" - sedating the patient a little (while she continues to breathe on her own), using some topical anesthesia to the mouth and upper airway, and carefully take a look and intubate.
Hope this is helpful and answers your questions.
Best wishes,
Dr. Bob
At Thu Jan 25, 03:13:00 PM 2007,
Cal said…
It does indeed, thanks so much for replying! You haven't updated the blog in ages, I thought you might have been ill, it's good to see some signs of life from you!
At Mon Jan 29, 11:28:00 AM 2007,
Robert L. Norris, MD, FACEP said…
Sorry for the "gap" in postings... we are considering taking the Blog in a little bit different direction... exciting, informative, at times funny, at times heart-wrenching...
Stay tuned for more details soon!
Best wishes,
Dr. Bob
At Mon Mar 26, 05:49:00 PM 2007,
Harry said…
What determines when intubation is necessary during an MVI,suspected TBI,seizering ,posturing,unconcious etc.
At Tue Apr 03, 01:28:00 PM 2007,
Robert L. Norris, MD, FACEP said…
Dear Harry,
We generally intubate a patient (trauma or otherwise) when we need to accomplish any of the following:
- protect the airway from aspiration of stomach contents
- provide oxygenation and ventilation for patients when their efforts are ineffective
- provide positive airway pressure when needed (e.g., when needed to keep the distal airways open and functioning, as in a near-drowning)
- provide gentle hyperventilation (may buy a bit of time in a victim with bad head injury)
- put the patient at rest (e.g., in a victim in shock who needs every molecule of oxygen for vital organs, we can save some of that oxygen by taking over the work of breathing for him)
- sometimes we intubate because we anticipate things may get worse for the patient over the ensuing minutes or hours (e.g., a victim of smoke inhalation that may develop delayed airway swelling and breathing insufficiency), or we want a controlled situation as a poly-trauma victim goes to multiple hospital departments for diagnostic studies
- sometimes we just intubate because we get the sense "this patient needs it"... that's part of the "art" of medicine!
Best wishes,
Dr. Bob
At Wed Jun 27, 07:03:00 AM 2007,
ahmed abbas said…
dear friend iam from egypr and this branche is new established
i dont know exactly the nature of ER please help me
and tell me if ER doctor can do emergency operation or its jop is to stabilize case until call surgeon
thank you
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