ABCDE Assessment in Emergency Management

Introduction

The ABCDE approach is a systematic assessment meant to be used for critically unwell patients. It involves five steps: Airway, Breathing, Circulation, Disability, and Exposure. Each stage requires clinical assessment, investigations, and interventions. Issues are addressed and the patient is regularly re-assessed to monitor the effects of treatment.

The intention of the ABCDE approach is to improve the prognosis of unwell patients regardless of diagnosis. This guide is meant to provide a general overview for use in a simulation setting. It is written with final year medical students in mind, listing assessments, investigations, and interventions expected of a junior doctor.

This guide is intended as a study aid for simulation sessions and should not be relied upon for patient care.

General tips

Suggestions for applying the ABCDE approach in an emergency setting:

• Address all problems as they are discovered.
• Regularly re-assess and after each intervention to monitor the patient's response to treatment.
• Delegate tasks when possible.
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
• Clearly communicate how often observations should be relayed.
• Early help should be requested using an appropriate SBARR handover structure.
• Review results as soon as they become available.
• Guidelines and algorithms should be used when managing specific scenarios.
• Any medications or fluids must be prescribed at the time.
• The assessment and management should be documented properly in the notes, though this should not delay initial clinical assessment, investigations, and interventions.

Initial steps

Acute scenarios typically begin with a brief handover from nursing staff including the patient's name, age, background and reason for the review.

Airway Assessment

When reviewing a patient, introduce yourself to the person providing the handover and listen carefully. Introduce yourself to the patient, including your name and role. Ask the patient how they are feeling as this may provide important information regarding symptoms.

Ensure the patient's notes, observational chart, and prescription chart are easily accessible. If possible, ask another clinical member of staff to assist. If the patient is unconscious or unresponsive, initiate basic life support according to resuscitation guidelines.

Clinical Assessment

If the patient can talk, their airway is patent and you can move on to the assessment of breathing. If the patient is unable to talk, look for signs of airway compromise, such as cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds, and additional sounds. Open the mouth and inspect for obstructions such as secretions or foreign objects.

Causes of Airway Compromise

• Inhaled foreign body (sudden onset shortness of breath and stridor)
• Blood in the airway (epistaxis, haematemesis, and trauma)
• Vomit/secretions in the airway (alcohol intoxication, head trauma, dysphagia)
• Soft tissue swelling (anaphylaxis, infection such as quinsy or necrotising fasciitis)
• Local mass effect (tumours and lymphadenopathy such as lymphoma)
• Laryngospasm (asthma, gastro-oesophageal reflux disease, intubation)
• Depressed level of consciousness (opioid overdose, head injury, and stroke)

Regardless of the cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team. While awaiting senior input, you can perform some basic airway manoeuvres to help maintain the airway.

Head-Tilt Chin-Lift Manoeuvre

Open the patient's airway with a head-tilt chin-lift manoeuvre: place one hand on the patient's forehead and the other under the chin, tilt the forehead back while lifting the chin forwards to extend the neck, and inspect the airway for obvious obstruction. If an obstruction is visible, use a finger sweep or suction to remove it.

Jaw Thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw thrust rather than a head-tilt chin-lift manoeuvre: Identify the angle of the mandible, place your index and other fingers behind the angle of the mandible and apply steady upwards and forward pressure to lift the mandible, and use your thumbs to slightly open the mouth by downward displacement of the chin.

Breathing

Clinical Assessment

Observations

Review the patient's respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Bradypnoea may be due to sedation, opioid toxicity, raised intracranial pressure (ICP) or exhaustion in airway obstruction (e.g. COPD).
• Tachypnoea may be due to airway obstruction, asthma, pneumonia, pulmonary embolism (PE), pneumothorax, pulmonary oedema, heart failure, or anxiety.

Review the patient's oxygen saturation (SpO2):

• A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention.
• Hypoxaemia may be seen in pneumothorax, pneumonia, pulmonary embolism or respiratory failure.

Oropharyngeal Airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient's airway. They should be used in conjunction with the manoeuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient's mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient's airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal Airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1. Check the patency of the patient's right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Other Interventions

If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.

Re-assessment

Make sure to re-assess the patient after any intervention.

Acute Respiratory Management: ABCDE Approach

Respiratory conditions can be acute and require swift assessment and management. Some examples include Pulmonary Embolism (PE), Chronic Obstructive Pulmonary Disease (COPD), Asthma and Pulmonary Oedema. See our guide on performing observations/vital signs to determine underlying health issues.

General Inspection

Inspect the patient from the end of the bed while at rest to identify any clinical signs of underlying pathology. These include Cyanosis, Shortness of Breath, Cough, Stridor, Cheyne-Stokes Respiration and Kussmaul's Respiration.

Tracheal Position

Gently assess the position of the trachea. It should be central in healthy individuals. Tracheal deviation away can indicate tension pneumothorax or large pleural effusions while tracheal deviation towards can suggest lobar collapse or pneumonectomy. Palpation of the trachea can be uncomfortable, so warn the patient beforehand and apply a gentle technique.

Chest Expansion

Assess the patient's chest expansion for evidence of reduced chest wall movement. Symmetrical reduction can be associated with pulmonary fibrosis, while asymmetrical reduction can suggest pneumothorax, pneumonia or pleural effusion.

Percussion of the Chest

Percuss the patient's chest, looking to hear a resonant percussion note. Dullness can suggest increased tissue density, such as cardiac dullness, consolidation, tumour or lobar collapse. Stony dullness is usually caused by underlying pleural effusion, while hyper-resonance can indicate decreased tissue density, such as pneumothorax.

Auscultation

Auscultate the patient's chest to identify any abnormalities, such as bronchial breathing, which is associated with consolidation. It is harsh-sounding and has equal inspiration and expiration, with a pause in between.

Assessment of Breathing

During an assessment of breathing, there are several signs to look for. These include:

 
• Quiet/reduced breath sounds: this suggests reduced air entry into that region of the lung, such as a pleural effusion or pneumothorax.
 
• Wheeze: a continuous, coarse, whistling sound often associated with asthma, COPD and bronchiectasis.
 
• Stridor: a high-pitched extra-thoracic breath sound coming from turbulent airflow through narrowed upper airways. Stridor has various causes, including foreign body inhalation and subglottic stenosis.
 
• Coarse crackles: discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis or pulmonary oedema.
 
• Fine end-inspiratory crackles: these sound similar to the noise generated when separating velcro and are associated with pulmonary fibrosis.

Investigations and Procedures

Arterial Blood Gas (ABG)

If necessary, take an ABG (e.g. if the SpO2 is low). For more information on taking and interpreting an ABG, see our guides.

Chest X-Ray

If lung pathology is suspected, order a portable chest X-ray. Consult our chest X-ray interpretation guide for more details.

Interventions

If the patient is short of breath, they should be sat upright in the bed if possible to aid inspiration.

Oxygen

Administer oxygen to all critically unwell patients during the initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. Oxygen levels can then be titrated downwards after the initial assessment. In COPD, target SpO2 levels (88-92%) and consider using a Venturi mask (24%, 4L or 28%, 4L). In acute exacerbations of COPD with evidence of type 2 respiratory failure, discuss non-invasive ventilation with a senior. If the patient is conscious, sit them upright to help with oxygenation.

CPR

If the patient loses consciousness and there are no signs of life on assessment, call for a crash and commence CPR.

Acute Severe Asthma

The acute management of asthma may involve interventions such as oxygen, nebulisers, steroids and other agents (e.g. magnesium sulphate, aminophylline). Consult our guide to the acute management of asthma for more details.

Acute Exacerbation of COPD

The acute management of an exacerbation of COPD may involve interventions such as oxygen, nebulisers, steroids and antibiotics. See our guide to the acute management of COPD for more details.

Other Pathology

Other pathologies which may be identified during the assessment of breathing include pneumonia and pneumothorax. Each problem should be treated as it is identified.

Re-assessment

Always conduct an assessment after any intervention.

Circulation

Clinical Assessment

Observations

Review the patient's heart rate:

 
• A normal resting heart rate (HR) ranges from 60-99 beats per minute.
 
• Potential causes of tachycardia (HR>99) include hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain and drugs (e.g. salbutamol).
 
• Potential causes of bradycardia (HR<60) include acute coronary syndrome (ACS), ischaemic heart disease, electrolyte abnormalities (e.g. hypokalaemia) and drugs (e.g. beta-blockers).

Review the patient's blood pressure:

 
• A normal blood pressure (BP) range is between 90/60mmHg and 140/90mmHg but previous readings should be reviewed to evaluate the patient's usual baseline BP.
 
• Potential causes of hypertension include hypervolaemia, stroke, Conn's syndrome, Cushing's syndrome and pre-eclampsia (in pregnant females). Severe hypertension with confusion, drowsiness, breathlessness, chest pain and visual disturbances may present (systolic BP > 180 mmHg or diastolic BP > 100 mmHg).
 
• Potential causes of hypotension include hypovolaemia, sepsis, adrenal crisis and drugs (e.g. opioids, antihypertensives, diuretics).

Abnormalities in heart rate or blood pressure with other symptoms such as syncope, pre-syncope, shortness of breath or evidence of myocardial ischaemia require urgent senior and/or critical care input.

Fluid Balance Assessment

Calculate the patient's fluid balance:

• Evaluate the patient's current fluid balance using their fluid balance chart to inform resuscitation efforts (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting).
• Reduced urine output (oliguria) in an adult typically is defined as less than 0.5ml/kg/hour.
• Possible causes of oliguria include dehydration, hypovolaemia, reduced cardiac output and acute kidney injury.

General Inspection

Examine the patient from the end of the bed while at rest for clues of underlying pathology:

   
• Pallor may represent anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
 
• Oedema typically causes swelling in limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and may suggest heart failure.

Palpation

Place the dorsal aspect of the hand onto the patient to assess temperature:

 
• Symmetrically warm hands indicate adequate perfusion in healthy individuals.
 
• Cool hands may indicate poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
 
• Cool and sweaty/clammy hands could be associated with acute coronary syndrome.

Measure capillary refill time (CRT):

 
• In healthy individuals, the initial pallor of the area compressed should return to its original colour in less than two seconds.
 
• A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and requires assessment of central capillary refill time.

Pulses and Blood Pressure

Examine the patient's radial and brachial pulses to assess rate, rhythm, volume, and character:

 
• An irregular pulse is associated with arrhythmias such as atrial fibrillation.
 
• A slow-rising pulse is associated with aortic stenosis.
 
• A pounding pulse is associated with aortic regurgitation and CO₂ retention.
 
• A thready pulse is associated with intravascular hypovolaemia (e.g. sepsis).

Jugular Venous Pressure (JVP)

Observe for evidence of a raised JVP which may be caused by:

 
• Right-sided heart failure: commonly caused by left-sided heart failure (e.g. secondary to fluid overload). Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
 
• Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
 
• Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Auscultation

Listen to the patient's precordium to assess heart sounds:

 
• An ejection systolic murmur is associated with aortic stenosis.
 
• An early diastolic murmur is associated with aortic regurgitation.
 
• A mid-diastolic murmur is associated with mitral stenosis.
 
• A pan-systolic murmur is associated with mitral regurgitation.
 
• A murmur of recent onset may suggest recent myocardial infarction (e.g. papillary muscle rupture) or endocarditis.
 
• A pericardial rub or muffled heart sounds may indicate underlying pericarditis.
 
• A third heart sound is typically associated with congestive heart failure.

Ankles and Sacrum

Examine the patient's ankles and sacrum for evidence of oedema which is typically associated with heart failure.

Investigations and Procedures

Intravenous Cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

Blood Tests and Blood Cultures

Request FBC, U&Es and LFTs for all patients regardless of their presentation and consider additional blood tests such as:

 
• Sepsis: CRP, lactate and blood cultures
 
• Haemorrhage or surgical emergency: coagulation and cross-match
 
• Acute coronary syndrome: troponin
 
• Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
 
• Pulmonary embolism: D-dimer (if appropriate based on Well's score)
 
• Overdose: toxicology screen (e.g. paracetamol levels)
 
• Anaphylaxis: consider serial mast cell tryptase levels

ECG

Record a 12-lead ECG if appropriate (e.g. if the patient has chest pain, arrhythmia, a murmur, or suspected electrolyte imbalance).

Investigations and Interventions

In critically unwell patients, such as those with myocardial infarction and severe electrolyte abnormalities requiring replacement, consider continuous ECG monitoring.

Bladder Scan

Conduct a bladder scan if urinary retention or obstruction is suspected.

Urine Pregnancy Test

Perform a urine pregnancy test in any female of childbearing age presenting with clinical evidence of shock, abdominal pain or gynaecological symptoms.

Other Cultures/Swabs

Request that nursing staff collect and send other appropriate cultures (e.g. sputum, urine, line cultures).

Fluid Output/Catheterisation

Ask nursing staff to initiate a strict fluid balance if not already in place. Also consider catheterisation to accurately monitor urine output or to relieve urinary retention when appropriate.

Interventions

Hypovolaemia

Hypovolaemic patients require fluid resuscitation (the following guidelines are for adults):

 
• Administer a 500ml bolus of Hartmann's solution or 0.9% sodium chloride (warmed if available) over fewer than 15 minutes.
 
• Administer 250ml boluses in patients at an increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP). Consider repeating fluid bolus administration up to four times (e.g. 2000ml or more).