The Systematic Approach to the Seriously Ill Patient

Calling 9-1-1 activates the emergency response system.

BLS Assessment: Know your DRS ABCD

The following is an outline of the systematic approach to assisting the cardiac arrest patient. The BLS assessment is the foundation of all life support activities in emergency situations where the patient is unconscious. 

The BLS assessment is composed of six steps:

STEP 1: Ensure scene safety (no danger).

STEP 2: Check for a response.

STEP 3: Shout for help and activate the emergency response system.

STEP 4: Check for abnormal breathing or no breathing. Check for a pulse. No pulse and abnormal breathing indicate a cardiac arrest. Retrieve the automated external defibrillator (AED) or the crash cart with a defibrillator (or ask a bystander or colleague to do so).

STEP 5. Begin high-quality cardiopulmonary resuscitation (CPR) (starting with compressions). Apply the AED or defibrillator pads and use it as soon as it is ready.

STEP 6. As soon as an additional rescuer arrives, provide two-person CPR. Utilize the AED or defibrillator.

DRS ABCD Mnemonic

These six easy steps can be remembered by the mnemonic: DRS ABCD (danger, response, shout for help, airway, breathing, circulation, and defibrillation).

Read: Bradycardia with a Pulse Algorithm Explained

The Systematic Approach

Primary Assessment

For the conscious patient, the provider should perform the primary assessment: know the ABCDE mnemonic. For the unconscious patient, the primary assessment is performed after the BLS assessment.¹

Related Video – Understanding the Steps of the Primary Assessment

If the patient is conscious or has regained consciousness after performing high-quality CPR, then the advanced cardiovascular life support (ACLS) provider performs the primary assessment, which comprises the ABCDE mnemonic.

A = airway: Maintain airway patency, especially in the unconscious patient. 

Use maneuvers such as the head tilt-chin lift or jaw-thrust.² Use an airway, such as an oropharyngeal airway, for unconscious patients or a nasopharyngeal airway for conscious or semiconscious patients with an active gag reflex. Insert an advanced airway (endotracheal tube, laryngeal mask, laryngeal tube, or an esophageal-tracheal tube) as soon as possible if hypoxic arrest is suspected.

B = breathing: Give supplementary oxygen — 100% for cardiac arrest patients or titrate to achieve 94% or higher for others. Avoid excessive ventilation.³ Monitor for adequate ventilations (chest rise, capnography, O₂ saturation, and auscultation).

C = circulation: Monitor CPR quality: capnography (partial pressure of end tidal CO₂ [PETCO₂]) must be > 10 mm Hg and intra-arterial pressure must be > 20 mm Hg. If these parameters are low, improve CPR quality. Monitor cardiac rhythm with a cardiac monitor or defibrillator. Provide shocks as indicated, depending on rhythm. Obtain intravenous (IV) or intraosseous (IO) access and give fluids as necessary.

D = disability: Check neurologic function (Glasgow Coma Scale [GCS], neurologic examination) and observe pupillary dilatation and level of consciousness using the AVPU mnemonic: alert, verbal, pupils, and unresponsive. Check glucose, temperature, and perfusion issues.

E = exposure: Perform a quick physical examination to look for obvious reasons for cardiac arrest, such as trauma, burns, hemorrhaging, and other unusual findings. Some patients may be wearing medical bracelets. It may be necessary to remove some of the patient’s clothing. Keep the patient warm and remember to examine the patient’s posterior surfaces as well.

The ABCDE mnemonic is a way to help memorize the primary assessment.

Secondary Assessment

The secondary assessment includes obtaining a focused medical history to identify potential causes of cardiac arrest. After identifying the cause, the provider performs necessary interventions. To rule out possible diagnoses, use the mnemonic SAMPLE: signs and symptoms, allergies, medications, past medical history, last meal consumed, and events that led up to the present illness.

Related Video – Understanding the Secondary Assessment Steps

The Hs and Ts mnemonic is part of the secondary assessment.

Hs include hypovolemia, hypoxia, hydrogen ion (acidosis), hypo- or hyperkalemia, and hypothermia. 

Ts include tension pneumothorax, tamponade, toxins, and thrombosis (pulmonary and coronary). 

The Hs and Ts mnemonic is an invaluable tool to help determine the possible causes of cardiac arrest.

Related Video – One Quick Question: What are Hs and Ts?

The mnemonics presented in this article help the healthcare provider care for the acutely or seriously ill patient in a systematic approach.