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Now that we have looked at the basics of patient care and introduced the ABCDE approach, we are now going to look at the steps in greater detail. All these steps are as laid down by the UK Resuscitation Council in their latest guidelines for anaphylaxis care by healthcare professionals. Links to the full document are available in the student download area, starting with 'A', which stands for airway. Any airway obstruction is an emergency, so you must get expert help immediately.

Look for the signs of an airway obstruction or abdominal movements sometimes referred to as ‘see-saw’ respirations. Look for the use of the accessory muscles in respiration. Central cyanosis, the bluish discoloration of the skin, nail beds or mucous membranes, is a late sign of airway obstruction. In complete airway obstruction, there are no breath sounds from the mouth or nose. In partial obstruction, air entry is diminished and often noisy.

In most cases, airway obstruction is caused by the tongue falling to the back of the throat. One simple method of airway clearance is to open the airway through a head-tilt chin-lift maneuver. With correct training you could also use suction or the insertion of an artificial airway. Anaphylaxis can cause airway swelling. Overcoming this obstruction may be very difficult and early tracheal intubation is often required. This requires expert help and should only attempted with correct training.

You should give high concentration oxygen using a mask with an oxygen reservoir. Or, if delivering breaths, use 100 percent oxygen and a bag valve mask with an oxygen reservoir. In the absence of arterial blood gas values, use pulse oximetry to guide oxygen therapy. Aim for an oxygen saturation of 94-98%. In the sickest patients this is not always possible, so you may have to accept lower values. For example, 90-92% oxygen saturation on a pulse oximeter.

The B in the ABCDE's stands for breathing.

During the immediate assessment of breathing, it is vital to diagnose and treat immediately life-threatening conditions such as when a patient is not breathing. Look, listen, and feel for the general signs of respiratory distress: sweating, central cyanosis, use of the accessory muscles in respiration, subcostal and sternal recession in children, and abdominal breathing. Count the respiratory rate (normal adult rate is 12 - 20 breaths per minute). A high, or increasing, respiratory rate is a mark of illness and a warning that the patient may deteriorate suddenly.

Assess the depth of each breath, the pattern or rhythm of respiration, and whether chest expansion is equal and normal on both sides. Listen to the patient's breath sounds a short distance from his face. Rattling airway noises indicate airway secretions, usually because the patient cannot cough or take a deep breath. A wheeze suggests partial but important airway obstruction. Listen to the chest with a stethoscope if you are trained to do so. The specific treatment of breathing disorders depends upon the cause. Note that bronchospasm, which causes wheezing is common in anaphylaxis. Regardless of their conditions, all critically ill patients should be given oxygen.

Initially give the highest possible concentration of inspired oxygen using a mask with an oxygen reservoir. Ensure a high flow of oxygen (usually greater than 10 litres min-1) to prevent collapse of the reservoir during inspiration. If the patient's trachea is intubated, give high concentration oxygen with a self-inflating bag. If the patient's depth or rate of breathing is inadequate or the patient has stopped breathing, use a pocket mask or two person bag-mask ventilation while calling urgently for expert help. In an anaphylactic reaction, upper airway obstruction or bronchospasms may make bag mask ventilation difficult or impossible. Early tracheal intubation should be considered by someone experienced in the technique.

The C stands for Circulation.

In almost all medical emergencies, including an anaphylactic reaction, consider hypovolaemia as the likeliest cause of shock until proven otherwise. In anaphylaxis, the shock is usually caused by vasodilation and fluid leaking from capillary blood vessels. Unless there are obvious signs of a cardiac cause like chest pain or heart failure, give intravenous fluid to any patient with low blood pressure and a high heart rate. Remember that breathing problems, which should have been treated earlier on in the breathing assessment, can also compromise a patient’s circulatory state.

Look at the colour of the hands and digits: are they blue, pink, pale or mottled? Assess the limb temperature by feeling the patient’s hands; are they cool or warm? Measure the capillary refill time. Apply pressure for five seconds on a fingertip held at heart level with enough pressure to cause blanching. Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure. The normal refill time is less than two seconds. A prolonged time suggests poor peripheral perfusion. Other factors the prolong the refill time could be cold surroundings, poor lighting and/or old age. Assess the state of the veins; they may be under-filled or collapsed when hypovolaemia is present. Determine the patient’s heart rate and compare to the normal rate for their age.

Palpate peripheral and central pulses, assessing for presence, rate, quality, regularity and equality. Barely palpable central pulses suggest a poor cardiac output. Measure the patient’s blood pressure. Even in shock, the blood pressure may be normal. In anaphylaxis, vasodilation is common and the blood pressure may fall very early on.

Listen to the heart with a stethoscope, if you are trained to do so. Look for other signs of a poor cardiac output, such as a reduced consciousness level. The treatment of cardiovascular collapse depends on the cause, but should be directed at fluid replacement and restoration of tissue perfusion. Seek out signs of conditions that are immediately life-threatening, for example massive or continuing bleeding, or anaphylactic reaction, and treat them urgently.

A simple measure to improve the patient’s circulation is to lie the person flat and raise the legs. This must be done with care as it may worsen a breathing problem.

The D stands for Disability.

Common causes of unconsciousness include profound hypoxia, hypercapnia, cerebral hypoperfusion due to hypotension, or the recent administration of sedative or analgesic drugs.

Review and treat the ABCs: exclude hypoxia and hypotension, then examine the pupils, looking at the size, equality, and reaction to light.
Assess the patient’s conscious level rapidly using the AVPU method:
A = Alert;
V = Responds to vocal stimuli;
P = Responds to painful stimuli;
or U = Unresponsive to all stimuli.
You can also use the Glasgow Coma Scale.
Where possible measure the blood glucose, using a glucose meter or stick method, to exclude hypoglycaemia.

Finally, E stands for exposure.
To examine the patient properly, full exposure of the body is necessary. Skin and other changes after anaphylaxis can be subtle. Minimise heat loss where possible and always respect the patient’s dignity.
Take a full clinical history from the patient, relatives, friends, and other staff. If you can, review the patient’s notes and charts to get a better picture of the the situation you are dealing with.

Check that important routine medications are prescribed and being given correctly. Where possible, review the results of laboratory or radiological investigations and consider what level of care is required. For example, transport to a hospital if in the community.  Make complete entries in the patient’s notes of your findings, assessment and treatment. Record the patient’s response to therapy, and finally, consider definitive treatment of the patient’s underlying condition.

So to summarise: there are many steps within the ABCDE approach. With what we have discussed, we have applied it to Anaphylaxis care. It is important to always get help and ensure you stay within your training and do not attempt any procedure unless you are qualified and allowed to do so. These recommendations are from the UK Resuscitation Councils latest guidelines on anaphylaxis care. Remember, you can find a link to the full document from the student download area of this course.