ABCDE Approach

SpO2 Scale 2 = for use in patients at risk of hypercapnic failure (COPD)

recommended saturations of 88-92%

Addition of New Confusion = ACVPU 

NEWS Scores:

• 0 = minimum 12 hourly obs
• 1-4 = minimum 4-6 hourly obs, may need to escalate care
• 3 in a single parameter = 1 hourly, may need escalation
• 5 or more = needs urgent clinical assessment
• 7 or more = continuous monitoring, needs emergency assessment, may need trasnfered to higher level of care

• can the patient speak in complete sentences?
• what sounds? wheeze/gurgling/stridor
• what colour are the lips?
• is there swelling of the lips?

Treatment/Action

• open the airway
• maintain airway using simple adjuncts (guedel airway, nasopharyngeal airway) advanced techniques (laryngeal mask ariway or endotracheal tube)
• give 100% oxygen on non-rebreather mask 

RATES approach

• Respiratory rate
• Auscultate chest
• Trachea (is it central? if not could be tension pnuemothorax)
• Effort of breathing
• SpO2

Treatment:

• give high flow oxygen
• support breathing
• treat underlying cause

Recognition of circulation problems:

• Shortness of breath
• syncope (passing out)
• capillary refill time longer than 2 seconds
• pulse
• blood pressure
• bleeding/fluid loss

Treatment:

• MOVE = monitor, oxygen, venous access, ECG

MONA = morphine, oxygen, nitrates, aspirin (for treatment of heart attack)

Recognition:

A.G.E.D = 

• AVCPU score then GCS
• Glucose 
• Eyes
• Drugs

Treatment:

• give oxygen if appropriate
• achieve normoglycaemia
• treat underlying cause
• consider lateral position

Head to Toe assessment

Avoid heat loss (check temp.)

Maintain dignity

Check for...

• skin integrity
• wounds
• rashes
• swelling 
• bleeding