Lesson 6.5 : ABCDE: Emergency Assessment and the SimMan Station

Lesson 6.5: ABCDE — Emergency Assessment and the SimMan Station

The SimMan emergency station presents an acutely unwell manikin. You are expected to perform a structured ABCDE assessment, initiate management at each step, and escalate appropriately using SBAR. The manikin can display programmable clinical signs, unlike the healthy actors in examination stations.

Staying calm, systematic, and talking out loud is what the examiner wants to see. Saying 'I am concerned about this patient and would like to call my registrar now' is a mark-scorer, not an admission of failure.

Step	Assessment	Management
A — AIRWAY	Is the airway patent? Talking = patent. Signs of obstruction: gurgling (secretions), stridor (partial obstruction), snoring (tongue), silent chest (complete obstruction).	Head-tilt chin-lift. Jaw thrust if C-spine concern. Suction if secretions. Airway adjunct (nasopharyngeal or oropharyngeal). Call anaesthetics early if compromised. High-flow O2 via non-rebreather mask (15 L/min) unless COPD with known CO2 retention.
B — BREATHING	RR (normal 12–20 bpm). SpO2 (target 94–98%; 88–92% in COPD). Inspect chest: symmetry, accessory muscles, deformity. Percuss: dull = effusion or consolidation; hyper-resonant = pneumothorax. Auscultate: absent breath sounds, wheeze, crackles.	Optimise O2. Nebulised salbutamol for wheeze. Needle decompression for tension pneumothorax (2nd ICS midclavicular line). Escalate early.
C — CIRCULATION	Pulse: rate, rhythm, volume. BP. CRT (>2 sec = poor perfusion). Skin: pale, mottled, clammy. ECG. IV access x2.	Two wide-bore cannulae. Take bloods (FBC, U&E, LFT, CRP, blood cultures, glucose, coagulation, crossmatch). IV fluid bolus if hypotensive (see below). Catheterise for urine output monitoring (target >0.5 mL/kg/hour). Adrenaline 500 micrograms IM for anaphylaxis.
D — DISABILITY	GCS (Eyes 1–4, Verbal 1–5, Motor 1–6). ACVPU: Alert / Confusion (new) / Voice / Pain / Unresponsive. Pupils: size, symmetry, reactivity (fixed dilated = herniation). Fingerprick blood glucose: always.	BM <4 mmol/L: 150–200 mL 10% glucose IV or glucagon 1 mg IM. Suspected opioid toxicity (pinpoint pupils + respiratory depression): naloxone 400 mcg IV or IM.
E — EXPOSURE	Fully expose the patient (maintain dignity). Rash (meningococcal — non-blanching petechiae; urticaria in anaphylaxis). Temperature: fever suggests sepsis; hypothermia is equally dangerous. Check drug chart: causative medication? Missed dose? Calculate NEWS2 score.	Treat the underlying cause. Reassess from A to E after each intervention — does the patient look better or worse?

NEWS2 — The Escalation Scoring Tool

NEWS2 aggregates 7 physiological parameters. An unacceptable deviation in any single parameter triggers escalation regardless of the total aggregate score.

Parameter	Score 0	Score 1	Score 2	Score 3
Respiratory rate (breaths/min)	12–20	9–11 or 21–24	—	≤8 or ≥25
SpO2 Scale 1 (%)	≥96	94–95	92–93	≤91
Supplemental O2	No	—	Yes	—
Systolic BP (mmHg)	111–219	101–110	91–100	≤90 or ≥220
Heart rate (beats/min)	51–90	41–50 or 91–110	111–130	≤40 or ≥131
Consciousness (ACVPU)	Alert	—	—	New Confusion / Voice / Pain / Unresponsive
Temperature (°C)	36.1–38.0	35.1–36.0 or 38.1–39.0	≥39.1	≤35.0

NEWS2 Score	Risk Level	Response Required
1–4	Low	Minimum 12-hourly observations. Nurse to assess if escalation needed.
Any single parameter = 3	Low-medium	Urgent assessment by a clinician competent to manage acutely unwell patients.
5–6	Medium	Urgent assessment. Increase monitoring frequency.
≥7 or 3 in one parameter	High	Continuous monitoring. Emergency response. Consider critical care.

ACVPU (not AVPU): the 'C' for Confusion was added in NEWS2 because new-onset confusion is a significant indicator of deterioration, it scores 3 even if the patient is still responding verbally.

SBAR — How to Escalate

	Example
S — Situation	"This is Dr [X], FY2 on Ward 6. I'm calling about Mr Ahmed in Bed 4. I'm very concerned — he is acutely unwell."
B — Background	"He is 72, admitted two days ago with right lower lobe pneumonia. Background of COPD and Type 2 diabetes."
A — Assessment	"Obs: RR 28, SpO2 88% on 4L O2, HR 115, BP 88/54, temperature 38.9, GCS 13. NEWS2 score is 14. I believe he is in septic shock."
R — Recommendation	"I have given O2, taken bloods and cultures, and established IV access. I need senior review now and consideration of the Sepsis Six bundle. Can you come immediately, please?"

High-Yield SimMan Scenarios — Management Summaries

Anaphylaxis

Step	Action
1. Recognition	Urticaria/angioedema + wheeze or hypotension + allergen exposure. Diagnosis is clinical.
2. Most important step	Adrenaline 500 micrograms (0.5 mg) 1:1000 IM into outer thigh. Repeat after 5 minutes if no improvement.
3. Position	Lay flat with legs elevated unless the patient has breathing difficulty (sit up) or is in cardiac arrest (CPR).
4. Oxygen	High-flow O2.
5. IV access	500–1000 mL 0.9% NaCl fluid challenge (anaphylaxis can cause distributive shock).
6. Secondary	Chlorphenamine 10 mg IV. Hydrocortisone 200 mg IV. Salbutamol nebuliser for bronchospasm. Do not delay adrenaline for these.
7. Monitoring	Observe minimum 6 hours after resolution. Prescribe adrenaline auto-injector (EpiPen) on discharge. Refer to allergy clinic.

Sepsis — Sepsis Six Bundle (NICE NG253, 2024–2025)

Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Suspect it when a patient with infection appears deteriorating or has a NEWS2 ≥5.

Priority	Action	Time Target
1. Oxygen	Target SpO2 >94% (88–92% if known COPD).	Immediately
2. Blood cultures	Take before antibiotics if possible — do not delay antibiotics waiting for cultures.	Before antibiotics
3. IV antibiotics	Broad-spectrum as per local protocol (e.g. piperacillin/tazobactam 4.5g IV TDS).	Within 1 hour (high risk)
4. IV fluids	Initial bolus 250 mL 0.9% NaCl over 10–15 minutes if signs of hypoperfusion. Reassess after each bolus. (NICE NG253, updated 2025)	Within 1 hour
5. Blood lactate	Venous lactate — >2 mmol/L is a danger sign; >4 mmol/L indicates septic shock.	Urgently
6. Urine output	Catheterise and monitor strictly. Target >0.5 mL/kg/hour.	As soon as possible

High-risk patients (NEWS2 ≥7 or meeting high-risk criteria) should receive antibiotics within 1 hour. Moderate-risk patients: within 1–3 hours, with time to investigate before giving antibiotics.

Acute Severe Asthma (NICE/BTS/SIGN)

Severity	Features	Management
Acute severe	PEF 33–50% best. RR >25. HR >110. Unable to complete sentences.	O2 to maintain SpO2 94–98%. Salbutamol 5 mg nebulised. Add ipratropium 0.5 mg nebulised. Prednisolone 40–50 mg oral (or hydrocortisone 100 mg IV if unable to swallow).
Life-threatening	PEF <33% best. SpO2 <92%. Silent chest. Cyanosis. Bradycardia. Exhaustion. Altered consciousness.	All of the above + IV magnesium sulphate 1.2–2 g over 20 min (single dose). Escalate to ITU. Senior review immediately.

Diabetic Ketoacidosis (JBDS Guidelines)

Element	Detail
Diagnosis	BM >11 mmol/L (or known T1DM) + ketones >3 mmol/L or 2+ ketonuria + pH <7.3 or HCO3 <15 mmol/L.
IV fluids	0.9% NaCl — 1L over first hour, then titrate per DKA protocol based on Na and clinical status.
Insulin	Fixed-rate IV insulin infusion (FRIII) 0.1 units/kg/hour. Do not stop background long-acting insulin.
Potassium	Check K before starting insulin. Insulin drives K into cells — aggressive replacement is essential. Target 4.0–5.5 mmol/L.
Monitoring	Hourly BM and ketones. 2-hourly venous blood gas. Strict fluid balance.
Key target	Ketone fall >0.5 mmol/L/hour. BM fall approximately 3 mmol/L/hour. pH improving. Add 10% glucose when BM falls below 14 mmol/L.

Acute Pulmonary Oedema

Action	Detail
Position	Sit upright. High-flow O2.
IV furosemide	40–80 mg IV (or higher if already on regular furosemide). Produces immediate venodilation and subsequent diuresis.
GTN spray	400 micrograms sublingual if SBP >100 mmHg — reduces preload. Titrate carefully; watch BP.
Do NOT give IV fluids	Cardiogenic pulmonary oedema is a fluid overload state — adding IV fluids worsens it.
Escalation	CPAP/NIV if SpO2 does not improve with O2. Involves respiratory/ITU team. Identify and treat precipitant: new AF, ACS, hypertensive emergency, medication non-compliance.

Status Epilepticus (≥5 minutes or two seizures without regaining consciousness)

Time	Action
0–5 min	ABCDE. Airway: recovery position if possible. High-flow O2. Call for help. IV access.
First medication	Lorazepam 4 mg IV. If no IV access: buccal midazolam 10 mg or rectal diazepam 10 mg.
>10 min (if still seizing)	Repeat lorazepam 4 mg IV.
>30 min (refractory)	Levetiracetam 60 mg/kg IV (max 4,500 mg), sodium valproate, or phenytoin. Requires ITU involvement.
Throughout	Fingerprick glucose — correct hypoglycaemia if present. Bloods: glucose, U&E, FBC, Ca2+, AEDs levels. Consider LP if meningitis possible after status controlled — give ceftriaxone empirically first.