The ABCDE

Assessment
• The ABCDE approach is intended as a rapid bedside
assessment of a deteriorating/ critically ill patient, and it is
designed to provide the initial management of life-
threatening conditions in order of priority, using a structured
method to keep the patient alive and to achieve the first steps
to improvement, rather than making a definitive diagnosis
(Smith 2003).
• A- airway
• B- breathing
• C- circulation
• D- disability
• E- exposure
Airway (A)
The aim of the airway assessment is to establish the patency of the airway
and assess the risk of deterioration in the patient’s ability to protect their
airways.
The patient’s airway can be clear (if the patient is talking), partially
obstructed (if air entry is diminished and often noisy) or completely
obstructed (if there are no breath sounds at the mouth or nose)
(Resuscitation Council 2011).
 Causes of Airway Obstruction

• Patient’s tongue
• Foreign body
• Vomit, blood and secretions
• Local swelling
 Assessing the Airway

• Observe patient for signs of airway obstruction: such as

paradoxical chest and abdominal movements. This refers to
a state whereby the chest and abdomen rise and fall
alternatively and vigorously to attempt to overcome the
obstruction (Resuscitation Council 2011).
• Look to identify whether skin colour is blue or mottled.
• Listen for signs of airway obstruction: certain sounds will assist you in localising
the level of the obstruction (Smith 2003). For example, noises such as snoring,
expiratory wheezing, or gurgling may indicate a sign of a partially obstructed
airway (Resuscitation Council 2011).
• Listen and feel for airway obstruction: If the breath sounds are quiet, then air
entry should be confirmed by placing your face or hand in front of the patient’s
mouth and nose to determine airflow, by observing the chest and abdomen for
symmetrical chest expansion, or listening for breath sounds with a stethoscope
(Resuscitation Council 2011).
 Airway Obstruction Treatment

• According to Resuscitation Council (2011), airway obstruction is a

medical emergency. Expert help should be called immediately as
untreated airway obstruction can rapidly lead to cardiac arrest, hypoxia,
damage to the brain, heart, kidneys and even death.
• Once airway obstruction has been identified, treat appropriately. For
example: suction if required, administration of oxygen as appropriate, and
moving the patient into a lateral position (Jevon 2012).
Breathing (B)
• Breathing function should only be assessed and
managed after the airway has been judged as
adequate.
• Assessment of breathing is designed to detect signs of
respiratory distress or inadequate ventilation (Smith
2003).
steps that can be used to assess breathing:
• Look for the general signs of respiratory distress such as sweating, the
effort needed to breathe, abdominal breathing and central cyanosis.
• Count patient’s respiratory rate: the normal respiratory rate in adults is
between 12 – 20 breaths/minute (Prytherch 2010). The respiratory rate
should be measured by counting the number of breaths that a patient takes
over one minute through observing the rise and fall of the chest. A high
respiratory rate is a marker of illness or an early warning sign that the
patient may be deteriorating (Resuscitation Council 2011).
• Assess the depth of each breath the patient takes, the rhythm of
breathing and whether chest movement is equal on both sides.
• Measure patient’s peripheral oxygen saturation using pulse oximeter
applied to the end of the patient’s finger. The British Thoracic Society
(O’Driscoll et al. 2008), recommends a target oxygen saturation of
between 94%-98%, with a minimum level of 88%. However, the pulse
oximeter does not detect hypercapnia (carbon dioxide retention)
(Resuscitation Council UK 2011).
• Blood gas analysis: This test provides a valuable respiratory assessment
about the levels of oxygen, carbon dioxide in the blood and the blood PH.
The test provides more in-depth information about the effectiveness of
respiratory function than pulse oximetry (Mallet 2013).
• Assess air entry using a stethoscope to confirm whether air is entering
the lungs, whether both lungs have equal air entry and whether there are
any additional abnormal breath sounds such as wheezing and crackles
(Mallet 2013).
 Treatment

• The specific treatment of respiratory disorders depends upon the cause.

However, regardless of the cause, expert help should be called
immediately (Resuscitation Council 2011).
• If the patient’s breathing is compromised, position patient appropriately
(usually in an upright position).
Circulation (C)
• Assessment of circulation should be undertaken only once the airway and
breathing have been assessed and appropriately treated.
• The aim of assessing the circulatory system is to determine the
effectiveness of the cardiac output. Cardiac output is the volume of
blood ejected from the heart each minute (Mallet 2013).
 Causes of Poor Circulation

• Shock (including hypovolaemia, septic, or anaphylactic

shock)
• Cardiac arrhythmias
• Heart failure
• Pulmonary embolism
 Assessing Circulation

• Blood pressure (BP): is an indication of the effectiveness of the cardiac

output. Measure the patient’s blood pressure as soon as possible; low
blood pressure (relative to the normal blood pressure of the patient) is
often a late sign in the deteriorating patient and can be an adverse clinical
sign (Mallet 2013).
• Gauge the patient’s peripheral skin temperature by feeling their hands
to determine whether they are warm or cool.
• Feel and measure the patient’s heart rate: assess the patient’s heart rate
relative to their normal physiological condition. Heart rate is usually felt
by palpating the pulse from an artery that lies near the surface of the skin,
such as the radial artery in the wrist. The pulse should be felt for presence,
rate, quality and regularity (Smith 2003). If there are any abnormalities
detected such as thread pulse, then a 12 lead electrocardiogram (ECG)
should be undertaken (Mallet 2013).
• Patient’s temperature: normal temperatures range from 36.8Oc to
37.9Oc. If a patient has a raised temperature, it is important to understand
the reason for this, as the treatment will vary depending on the cause
(Mallet 2013).
• Capillary refill time (CRT): a simple measure of peripheral circulation.
The patient’s hand should be at the level of their heart. Press the top of the
patient’s finger for 5 seconds to blanch the skin, and then release
(Mangione 2000). The normal value for CRT is usually < 2 seconds. A
prolonged CRT could indicate poor peripheral perfusion (Resuscitation
Council UK 2011).
• Look for other signs of a poor cardiac output such as a decreased level
of consciousness. If the patient has a urinary catheter, check for reduced
urine output (urine output of < 0.5 mL kg/hr) and assess for any signs of
external bleeding from wounds or drains (Resuscitation Council UK
2011).
 Treatment

• According to the Resuscitation Council 2011, the specific treatment for

circulation problems depends on the cause, however, fluid replacement,
restoration of tissue perfusion and haemorrhage control will usually be
necessary.
• Ensure that the patient has an intravenous cannula so that emergency
fluids and medicines can be administered more efficiently.
• Remember to continuously reassess the patient’s heart rate and blood
pressure, with the target of restoring them to the patient’s normal
physiological state, or, if this is not known, aim for >100mmHg systolic
(Resuscitation Council 2011).
• Seek help from more experienced practitioners.
Disability (D)
• This assessment involves reviewing the patient’s neurological status,
and its assessment should only be undertaken once A, B and C above have
been optimised, as these parameters can all affect the patient’s
neurological condition.
 Assessing Neurological Function

• Level of consciousness: conduct a rapid assessment of the patient’s level

of consciousness using the AVPU system (Smith 2003).
• Awake (A): observe if the patient can open his/her eyes, takes interest and responds
normally to his/her environment. This would be assessed as ‘awake’.
• Responding to voice (V): if the patient has his/her eyes closed and only opens them when
spoken to, this would be assessed as ‘voice’. However, a judgement should be made
when a patient is naturally sleeping, as physiologically this is not considered an altered
level of consciousness.
• Responding to pain (P): the patient who doesn’t respond to voice should be shaken
gently to try to elicit a response. If there is still no response, then painful stimuli should
be applied. If the patient responds to painful stimuli, then the level of consciousness is
assessed as ‘responds to pain’. Examples of painful stimuli include the ‘trapezius
squeeze’.
• Unresponsive (U): a patient not responding to pain is ‘unresponsive’.
• If you’re concerned about the patient’s level of consciousness, then use a more
in-depth assessment, such as the Glasgow Coma Scale (GCS), and seek
further help (Resuscitation Council 2011).
• Pupil reaction: examine the patient’s pupils for size, shape and reaction to
light.
• Blood glucose levels: a blood glucose measurement should be taken to exclude
hypoglycaemia using a rapid finger-prick bedside testing method. Follow local
protocols for management of hypoglycaemia (Resuscitation Council UK 2011).
 Treatment of Altered Conscious Level

• The priority is to assess airway, breathing and circulation to exclude

hypoxia and hypotension.
• Check the patient’s medicine chart for reversible medicine-induced causes
of an altered level of consciousness, and remember to call for expert help
(Thim T et al. 2012).
• Unconscious patients whose airways are not protected should be nursed in
the lateral position (Resuscitation Council 2011).
Exposure (E)
 Assessing Exposure

• Conduct a thorough examination of the patient’s body for

abnormalities, checking the patient’s skin for the presence of rashes,
swelling, bleeding or any excessive losses from drains. Respect the
patient’s dignity at all times and minimise heat loss.
• Look at the patient’s medical notes, medicine charts, observation charts
and results from investigations for any additional evidence that can inform
the assessment and ongoing plan of care for the patient.
• Remember to document all the assessments, treatments and responses
to treatment in the patient’s clinical notes.
• Always seek help from more senior or experienced practitioners if the
patient is continuing to deteriorate.
• The ABCDE approach is a robust clinical tool that enables healthcare
professionals to determine the seriousness of the patient’s condition and
prioritize clinical interventions.
• Your facility’s policies and procedures should always be followed
when responding to/managing a critically ill or deteriorating patient.