In this lesson, we'll cover the primary patient assessment by thoroughly checking the ABCDE's in ACLS for unconscious patients who are in full arrest that are either cardiac or respiratory in nature.
However, all ACLS healthcare providers should conduct a primary assessment after first completing a basic life support assessment.
This BLS assessment includes checking for responsiveness with taps and shouts, and if the patient is found to be unresponsive, calling 911 or calling in a code depending on the area in which you work. Also check the patient for breathing and a pulse and attach the defibrillator and possibly defibrillate if there is no pulse.
However, for conscious patients who may need more advanced assessment and management techniques, the healthcare professional will conduct the primary assessment first. During your primary assessment, continue to assess and perform all actions appropriately until the patient is transferred to the next level of care.
Pro Tip #1: Oftentimes, members of a high-performance team will perform the assessment and actions in ACLS simultaneously. However, if this isn't the case, it's important to remember, per the latest guidelines, to assess the patient first then perform the appropriate actions.
Keep in mind, when you get into the scenario-based testing part of this course with ProACLS, it's formatted in a linear fashion to simplify and clarify the vital skills needed to successfully pass the test. However, real-life ACLS codes have many working parts, many of which will happen dynamically and simultaneously to expedite important assessments, treatments, and therapies in order to successfully save the patient's life.
The following is a breakdown of the primary ACLS primary assessment by using the ABCDE method.
Airway
It's vital to maintain an open airway in an unconscious patient. The ways in which you'll accomplish this include:
- Head tilt, chin lift
- Basic airway adjuncts like:
• Oropharyngeal airway (OPA)
• Nasopharyngeal airway (NPA)
The advanced practitioner can use an advanced airway if a basic airway is not sufficient or if capnography is vital to the success of the resuscitation.
The different types of advanced airways include, but are not limited to:
- Endotracheal tubes
- Esophageal tracheal tubes
- Laryngeal tube or laryngeal masks
Pro Tip #2: It's important to weigh the costs vs. the benefits of early advanced airway placements compared to interrupting chest compressions. If bag-mask ventilation is adequate, the healthcare provider may wait to insert an advanced airway until the patient does not respond to initial resuscitation attempts with CPR and defibrillation, or until ROSC occurs. Advanced airway devices such as an LMA, laryngeal tube, or an i-gel can be placed while chest compressions continue.
It's important to confirm the proper placement of any advanced airway once it is placed. This can be done by a physical examination of the airway or a quantitative waveform from capnography readings. And CPR should be properly integrated with ventilations after intubation is done to optimize pulse pressures and oxygenation of vital organs and cells.
Pro Tip #3: Because movements from CPR and transportation can alter or dislodge an advanced airway, it's important to use a securing device to hold the advanced airway in place. And remember to monitor airway placement with continuous quantitative waveform capnography.
Also, make note of your organization's protocols and operating procedures when using prescribed devices for tube immobilization.
Breathing
When assessing a patient's breathing, it's important to ask yourself, are ventilations and oxygenation adequate?
Adequate ventilations will show the patient breathing a rate between 12 and 20 breaths per minute with visible chest rise and fall. A normal pulse oximetry for a patient is between 96% and 99%. Certain patients, such patients with COPD, may have a normal oxygen saturation for them around 90%. Their skin should not appear cyanotic or blue at all and there should be no abnormal breathing noises, such as snoring, stridor, gurgling, etc.
When do patients need supplemental oxygen? Well, keep in mind every patient is unique and has their own specific needs, so treat every person based on that. There are some guidelines to start with though. For cardiac arrest patients, administer 100% oxygen. Once ROSC is achieved, titrate to minimally needed oxygen for a reliable pulse ox reading of at least 90%. Administering oxygen to a post cardiac arrest patient with a pulse oximetry reading of over 98% is not indicated. For stroke or hypoxemia patients, SpO2 of greater than or equal to 94%. For ACS patients as low as 90% is appropriate.
Now since we treat all patients uniquely, we can start most patients on supplemental oxygen, but we need to closely monitor their condition and ensure reliable pulse oximetry readings and if possible use capnography as well. Oxygenation has been a significant focus over the last several guidelines as we learn more about oxygen toxicity and the negative effects it may have to just give to every patient. Use oxygen when needed, but ensure appropriate use.
Circulation
It's vital to assess and reassess the quality of CPR by monitoring the quantitative waveform capnography. And if PETCO2 is less than 10 mmHg, this may be a sign that you should work to improve CPR quality.
Pro Tip #4: If you're able to monitor intra-arterial pressures, and the relaxation phase or diastolic pressure is less than 20 mmHg, attempt to improve CPR quality by assessing compression depth, rate, and hand placement.
Attach a monitor and defibrillator to check for arrhythmias or cardiac arrest rhythms like:
- Ventricular fibrillation
- Pulseless ventricular tachycardia
- Asystole
- Pulseless electrical activity
Lastly, be sure to provide defibrillation/cardioversion as needed. Obtain IV or IO access to deliver adequate fluid replacement and medications, and give appropriate drugs to manage rhythm and blood pressure. Then, give IV or IO fluids if needed. Later, check glucose levels, temperature, and check and correct, if possible, the perfusion.
Disability
When it comes to disability, evaluate the following: check the patient for neurologic function and quickly assess for responsiveness, levels of consciousness, and check for pupil dilation, which may indicate brain death or viability, but not in every case.
Lastly, use the acronym AVPU to assess the patient:
A - Is the patient Alert?
V - Does the patient respond to your Voice?
P - Does the patient respond to Painful stimulus?
U - Is the patient completely Unresponsive?
Exposure
Exposure reminds the healthcare professional to remove the patient's clothing and perform a good physical examination. While doing so, look for obvious and not-so-obvious signs of trauma, such as:
- Bleeding
- Burns
- Unusual markings
- Medical alert bracelets