The ABCDE assessment
The A-E assessment is one of those things that just keeps coming back. Whether you’re a medical student, student Nurse, student Physician Associate (PA) or working clinically, you cannot escape the A-E! Download the ABCDE cheat sheet below.
Depending on the stage in training you are, you have the opportunity to practice (and perform) an A-E on simulated dummies, role-plays, and real patients. These can be in group or individual activities, exam situations, or real-life assessment of acutely unwell patients.
Thinking back to when I first started practicing the A-E assessment in medical school, well let’s not beat around the bush, I hated it. This is mostly because I was nervous and underconfident, a feeling that I’m sure many students can relate to.
Any kind of ‘performance’ can be really stressful, and that feeling of “ahhh, I don’t know what I’m doing!” (even though you probably do know what you are doing) is made so much worse by knowing you are being watched and about to receive feedback, but also the patient or simulated patient may be reactive, shouting out in pain, confused, scared… Overall there’s just so much to think about, which all increases our cognitive load.
Experiencing heavy cognitive load (from all these factors going on around you and the situation you are in) typically negatively influences your mental processing, leading to errors.
Fortunately, we can follow the ABCDE process to break down these complex clinical scenarios into more manageable procedural and problem-solving tasks. It’s structure is logical and easy to follow to bring situational awareness among the whole multiple disciplinary team working on assessing the patient.
The ABCDE approach is essentially an assessment and treatment algorithm to provide lifesaving treatment, and to buy time to establish diagnosis and treatment – WOW!
The stages of the assessment are:
Airway
Breathing
Circulation
Disability
Exposure
Within each stage, you perform clinical examinations, investigations and interventions. As you work though your assessment you may come across problems, which you can address and treat as you find them, reassessing regularly and following any intervention to assess response to treatments or identify new problems.
If you feel the patient has no immediately life-threatening needs and you want more information from the patient, you can ask them. Taking a brief history and collecting information can be done while simultaneously doing ABCDE, or on finishing E before reassessing.
If at any point you need help or are concerned about the patient, call for help! The SBAR structure for handover and communication can help you in calling your senior for help.
How to perform the ABCDE assessment (for Students)
Starting the assessment
You will usually be given a brief, with a little bit of background about the patient and their presentation. In on OSCE or MOSLER exam, you will then have a short amount of time outside the station where you can read this information carefully, gather your thoughts, get in the A-E zone!
When you enter the station, don’t be alarmed if there are other people in the room. There may be someone to assist you in the assessment and someone actually examining.
Wash your hands, introduce yourself to the patient and other team members (clarifying roles if necessary). If there is no-one there assisting you, you can ask for assistance if possible.
Confirm the patient details.
Note: If the patient is unconscious/unresponsive, basic life support (BLS) should be the more appropriate algorithm, with resuscitation if needed. (https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines)
Airway
You can ask the patient for information including identification details, “how are you feeling?”… If they can talk, and have no additional strange sounds (snoring, gurgling, stridor…) you can be confident that the airway is clear. For completeness you can use a pen torch to look in the mouth for any airway obstruction/foreign body (including vomit and secretions, and consider if suction is safe) .
Airway compromise can be devastating (remember that episode of Grey’s Anatomy where April gets fired! Dramatic). Signs of this can include added breathing sounds, see-saw breathing, observed difficulty breathing, inflammation/narrowing at the back of the throat.
If you have concerns about airway, perform airway maneuvers (head- tilt chin-lift/jaw thrust), use airway adjuncts (Oropharyngeal/Nasopharyngeal airway) as tolerated and call for help- specifically an anesthetist/crash team plus intubation.
Breathing
This is a respiratory examination with extra spice, you may already be familiar with a respiratory examination, but the ‘spice’ here is interpreting your findings as you go and responding to them.
Look
End of the bed observations (a few examples of things you might note)
Are they short of breath?
Is there increased work of breathing?
Are they breathing deeply and rapidly? (Kussmaul’s respiration)
Are they cyanosed (bluish tint)?
Are they coughing? What are they coughing?
Are there extra sounds of breathing? (https://www.youtube.com/watch?v=KRtAqeEGq2Q)
Are there any visible chest abnormalities or scars?
Feel
Position of the Trachea, is it central?
Chest Expansion, is there reduced chest wall movement? Is this symmetrical or asymmetrical?
Listen
Percuss the chest wall, does it sound resonant (normal), dull (or stony dull), or hyper-resonant? Is this symmetrical or asymmetrical?
Auscultate (use your stethoscope) and listen for any abnormalities. This could include crackles, wheeze, reduced breathing sounds…
Monitoring
Oxygen saturations
Respiratory rate
Investigations
Chest X-ray
Arterial blood gas ABG
Interventions/Treatment
It may be that you identify a problem in “B”, if so… What are you going to do about it?
Can the patient sit up? The patients position can affect oxygenation.
Does the patient need oxygen? Give 15L via non-rebreathe mask (standard in acute settings if not contraindicated by COPD/other, where you can consider lower % oxygen) this can be reduced with target saturations later.
Is there evidence of type 2 respiratory failure on your ABG results? Are you considering non-invasive ventilation?
Do you need to prescribe any nebulizers? Steroids? Antibiotics?
Can you see air or fluid in the pleural cavity? Are you considering a procedure to address this? Are you competent in chest drain or thoracocentesis? Do you need to call your senior?
Circulation
Similarly to “B”, This is a cardiovascular examination with extra spice, you may already be familiar with a cardio examination, but the ‘spice’ here is the added investigations, interpreting the findings as you go, and responding to them.
Look
End of the bed observations (a few examples of things you might note)
Is the patient pale (pallor)?
Is the patient flushed/sweaty/clammy?
Is there visible oedema?
Does the patient have a catheter?
Is there an available fluid balance chart?
Are there fluids currently running?
Feel
Are they warm or cool? You can feel their hands/feet and work upward to assess for peripheral temperature (Can you feel anything else? Sweaty? Clammy?)
Capillary refill time
Pulse, what is the rate? What’s the volume? Is it regular? What’s the character?
Assess the Jugular Venous Pressure (JVP)
Can you feel any heaves or thrills?
Is the apex beat as expected?
Is there pitting oedema?
Listen
Auscultate (use your stethoscope) and listen for any abnormalities in the heart sounds.
Monitoring
Heart Rate
Blood Pressure
Continuous ECG
Fluid balance (this could be asking the patient is they have been passing urine/vomiting/loose stools… or measuring fluid input and output +/- catheter)
Investigations
12 lead ECG
Interventions/Treatment
Can you achieve intravenous access? Try to achieve at least one wide bore cannula for access, two would be even better!
While you are sticking the patient with a needle, why not strike two birds with one stone and collect your blood samples to send to the lab at the same time as inserting IV access. This could include cultures if required.
Is the patient hypovolemic, needing fluid resuscitation? Prescribe and provide a bolus of 0.9% NaCl (500-250ml) see NICE fluid resuscitation guidelines-(https://www.nice.org.uk/guidance/cg174/resources/intravenous-fluid-therapy-in-adults-in-hospital-algorithm-poster-set-191627821)
Is the patient overloaded? Are you considering furosemide and fluid restriction?
Does the patient have an arrhythmia? Consider rate and rhythm control
Are there signs of acute coronary syndrome? Do you need to treat as ACS?
Is the patient peri-arrest? Call the Crash Team.
Disability
Assess the patient’s consciousness using AVPU (or GCS if more detail is required)
Assess the patients’ pupils
Are there any visible signs of a head injury?
Review the drugs chart- could anything here result in neurological abnormalities? (this could include opioids, sedatives and anticoagulants)
Is the patient confused? Why are they confused?
Consider a gross neurological assessment. Can you wiggle your toes? Can you squeeze my fingers? Can you feel that (peripheral sensation)?
Monitoring
Are neurological observations required?
Investigations
Is a formal cognitive assessment required?
Capillary blood glucose (+/- ketones)
Is imaging required eg. CT Head
Interventions/Treatment
Depending on what you find, do you need to treat this?
Is the GCS so low you are concerned about the patient’s airway and you need to commence airway management?
Is there a toxicity which needs reversal? (Opioids or other drugs)
Is the blood glucose too low or too high? Do you need tom commence treatment for DKA or hypoglycemia?
Exposure, or “Everything Else”
This involves everything we haven’t already assessed.
This can include:
Assessing the patient’s pain (are they in any pain you haven’t already assessed?)
Abdominal examination
Skin inspection for rashes/wounds/injuries
Inspecting for bleeding (including PR bleeding, this may be seen on the sheets surrounding the patient)
Do they have any drains or -ostomies which need inspecting or examining?
Monitoring
Temperature
Investigations
Swabs for culture
Urine for culture
PR
Bladder scan
X-ray (various)
Ultrasound (various)
Interventions/Treatment
Treat what you see!
Do you need to manage hemorrhage? Would this include the major hemorrhage protocol?
Is the patient septic? Start the sepsis six.
Is there a source of infection? Do you need to use the BNF/local guidance to select the most appropriate antimicrobial therapy.
Is there a concern about a limb? DVT, Acute limb ischemia? Fracture? Commence management for these findings.
This is obviously not an exhaustive list of possible findings and actions – but hopefully gives you a flavor of the approach to the ABCDE and the many many possibilities of where it may take you.
The crux of the ABCDE is to assess A,B,C,D, and E to stabilize the patient and address their immediate needs. You do not need to jump to conclusions of diagnosis, continue to assess ABCDE, and reassess.
My top tips for ABCDE Assessment:
Introduce yourself to the team and establish roles
Communicate with the team throughout your ABCDE, this may be summarizing your findings or relaying the advice from your senior.
Be ready to put your hands on the patient. I see a lot of students with their hands behind their back the whole ABCDE, they never touch the patient, they ask the nurse or other team member to take all the blood, attach all the monitoring equipment, give the oxygen. If YOU are doing the ABCDE, YOU should be getting stuck in and examining the patient, not just relying on the HR, BP, RR…
If in doubt, reassess! Reassess, reassess, and reassess.
Treat problems as you find them
Remember to investigate within each stage of your ABCDE
Take a systematic approach
Prescribe as you go (fluids and medications)
Use the BNF and other local guidelines to help inform your management
If you are worried about your patient or if you feel out of your depth… Call for help.
And finally,
Take deep breaths, remain calm, and remember help is never far away.