Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach

Department of Cardiology, Aarhus University Hospital, Aarhus.
International Journal of General Medicine 01/2012; 5:117-21. DOI: 10.2147/IJGM.S28478
Source: PubMed
ABSTRACT
The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is applicable in all clinical emergencies for immediate assessment and treatment. The approach is widely accepted by experts in emergency medicine and likely improves outcomes by helping health care professionals focusing on the most life-threatening clinical problems. In an acute setting, high-quality ABCDE skills among all treating team members can save valuable time and improve team performance. Dissemination of knowledge and skills related to the ABCDE approach are therefore needed. This paper offers a practical "how-to" description of the ABCDE approach.

Full-text

Available from: Erik Lerkevang Grove, Jun 05, 2014
© 2012 Thim et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article
which permits unrestricted noncommercial use, provided the original work is properly cited.
International Journal of General Medicine 2012:5 117–121
International Journal of General Medicine
Initial assessment and treatment with the Airway,
Breathing, Circulation, Disability, Exposure
(ABCDE) approach
Troels Thim
1,2
Niels Henrik Vinther
Krarup
1,4
Erik Lerkevang Grove
1
Claus Valter Rohde
3
Bo Løfgren
1,4
1
Department of Cardiology,
Aarhus University Hospital, Aarhus,
2
Department of Internal Medicine,
Regional Hospital of Randers, Randers,
3
Department of Anestesiology, Aarhus
University Hospital, Aarhus,
4
Research
Center for Emergency Medicine,
Aarhus University Hospital, Aarhus,
Denmark
Correspondence: Troels Thim
Department of Cardiology, Aarhus
University Hospital, Brendstrupgaardsvej
100, 8200 Aarhus N, Denmark
Tel +45 7845 9001
Fax +45 7845 9010
Email troels.thim@ki.au.dk
Abstract: The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is
applicable in all clinical emergencies for immediate assessment and treatment. The approach
is widely accepted by experts in emergency medicine and likely improves outcomes by helping
health care professionals focusing on the most life-threatening clinical problems. In an acute
setting, high-quality ABCDE skills among all treating team members can save valuable time
and improve team performance. Dissemination of knowledge and skills related to the ABCDE
approach are therefore needed. This paper offers a practical “how-to” description of the ABCDE
approach.
Keywords: emergency medicine, general medicine, internal medicine, multiple trauma,
multiple injury
Introduction
The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a
systematic approach to the immediate assessment and treatment of critically ill or
injured patients. The approach is applicable in all clinical emergencies. It can be
used in the street without any equipment (Figure 1) or, in a more advanced form,
upon arrival of emergency medical services, in emergency rooms, in general wards
of hospitals, or in intensive care units.
1
The aim of this paper is to offer a practical
“how-to” description of the ABCDE approach.
The aims of the ABCDE approach are:
• to provide life-saving treatment
• to break down complex clinical situations into more manageable parts
• to serve as an assessment and treatment algorithm
• to establish common situational awareness among all treatment providers
• to buy time to establish a final diagnosis and treatment.
Evidence supporting the ABCDE approach
The evidence supporting the systematic ABCDE approach to critically ill or injured
patients is expert consensus. The approach is widely accepted and used by emergency
technicians, critical care specialists, and traumatologists. In analogy, algorithms for
resuscitation are applied to improve the speed and quality of treatment. The authors
believe that a generally accepted algorithm for the ABCDE approach taught to health
care professionals may improve treatment of the critically ill and injured, whereas
differences in the interpretation of the algorithm may lead to confusion.
2
A uniform
Dovepress
submit your manuscript | www.dovepress.com
Dovepress
117
REVIEW
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/IJGM.S28478
Number of times this article has been viewed
This article was published in the following Dove Press journal:
International Journal of General Medicine
30 January 2012
Page 1
International Journal of General Medicine 2012:5
adoption of the ABCDE approach among members of a
treatment team is likely to improve team performance.
Training health care professionals for recognition and
management of critically ill patients increases confidence and
reduces concerns about being responsible for the severely ill.
3
Resuscitation algorithm training and the use of algorithms in
treatment of septic patients impact outcome.
4,5
Which patients need ABCDE?
The ABCDE approach is applicable for all patients, both
adults and children. The clinical signs of critical conditions
are similar regardless of the underlying cause. This makes
exact knowledge of the underlying cause unnecessary when
performing the initial assessment and treatment. The ABCDE
approach should be used whenever critical illness or injury
is suspected. It is a valuable tool for identifying or ruling
out critical conditions in daily practice. Cardiac arrest is
often preceded by adverse clinical signs and these can be
recognized and treated with the ABCDE approach to poten-
tially prevent cardiac arrest.
6–8
The ABCDE approach is also
recommended as the first step in postresuscitation care upon
the return of spontaneous circulation.
9
The ABCDE approach is not recommended in cardiac
arrest. When confronted with a collapsed patient, first ensure
the safety of yourself, bystanders, and the victim. Then check
for cardiac arrest (unresponsive, abnormal or absent breath-
ing, and, if trained, pulse-check lack of carotid artery pulse).
If the victim is in cardiac arrest, call for help and start
cardiopulmonary resuscitation according to guidelines.
9
If
the patient is not in cardiac arrest, use the ABCDE approach.
Which physicians need ABCDE?
All health care professionals can encounter critically ill or
injured persons, either at work or in private life, and may
therefore benefit from knowing the ABCDE approach. The
lay public expects health care professionals to act when
confronted with illness or injury, whether it occurs in the
street with no equipment at hand or in the hospital. These
expectations can be met by instituting life-saving treatment
using the ABCDE approach. Assessment and treatment can
be initiated without equipment and more advanced interven-
tions can be applied on arrival of emergency medical services,
in a clinic, or at the hospital.
Medical emergencies, including pediatric emergencies,
occur in the general practitioners office more often than
expected.
10–14
Patients turn to their general practitioner even
when it would be more appropriate to call emergency medical
services for immediate hospital admission. Unfortunately,
the general practitioner’s office is not always sufficiently
prepared.
10–15
ABCDE principles
With the ABCDE approach, the initial assessment and
treatment are performed simultaneously and continuously.
Alert
Voice responsive
Pain responsive
Unresponsive
Remove clothing
Heart rate
Look, listen and feel
Head tilt and chin lift
Capillary refill time
E xposure
D isability
C irculation
B reathing
A irway
Figure 1 The ABCDE approach without the use of equipment.
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
118
Thim et al
Page 2
International Journal of General Medicine 2012:5
Even when a critical condition is evident, the cause may be
elusive; in such situations, life-saving treatment must be
instituted before a definitive diagnosis has been obtained.
Early recognition and effective initial treatment prevents
deterioration and buys time for a definitive diagnosis to be
made. Causally focused treatment can then be instituted.
The mnemonic ABCDE” stands for Airway, Breathing,
Circulation, Disability, and Exposure. First, life-threatening air-
way problems are assessed and treated; second, life-threatening
breathing problems are assessed and treated; and so on. Using
this structured approach, the aim is to quickly identify life-
threatening problems and institute treatment to correct them.
Often, assistance will be required from emergency
medical services, a specialist, or a hospital response team
(eg, medical emergency team or cardiac arrest team). The
ABCDE approach helps to rapidly recognize the need
for assistance. Responders should call for help as soon as
possible and exploit the resources of all persons present
to increase the speed of both assessment and treatment.
Improved outcome is most often based on a team effort.
On completion of the initial ABCDE assessment, assess-
ments should be repeated until the patient is stable. It must
be remembered that it may take a few minutes before the
effect of an intervention is evident. In case of deterioration,
reassessment should be performed.
Table 1 gives important summary points of the ABCDE
approach.
The ABCDE approach
First, one’s own safety must be ensured. Then, a general
impression is obtained by simply looking at the patient (skin
color, sweating, surroundings, and so on). Although this is
valuable, the critical clinical situation is frequently complex
and the systematic approach described below helps break it
down into manageable parts (Table 2).
A – Airway: is the airway patent?
If the patient responds in a normal voice, then the airway
is patent. Airway obstruction can be partial or complete.
Signs of a partially obstructed airway include a changed voice,
noisy breathing (eg, stridor), and an increased breathing effort.
With a completely obstructed airway, there is no respiration
despite great effort (ie, paradox respiration, or “see-saw” sign).
A reduced level of consciousness is a common cause of airway
obstruction, partial or complete. A common sign of partial
airway obstruction in the unconscious state is snoring.
Untreated airway obstruction can rapidly lead to cardiac
arrest. All health care professionals, regardless of the set-
ting, can assess the airway as described and use a head-tilt
and chin-lift maneuver to open the airway (Figure 2). With
the proper equipment, suction of the airways to remove
obstructions, for example, blood or vomit, is recommended.
If possible, foreign bodies causing airway obstruction should
be removed. In the event of a complete airway obstruction,
treatment should be given according to current guidelines.
9
In
brief, to conscious patients give five back blows alternating
Table 2 The ABCDE approach with important assessment points
and examples of treatment options
Assessment Treatment
A – Airways Voice
Breath sounds
Head tilt and chin lift
Oxygen (15 l min
-1
)
Suction
B – Breathing Respiratory rate
(12–20 min
-1
)
Chest wall movements
Chest percussion
Lung auscultation
Pulse oximetry (97%–100%)
Seat comfortably
Rescue breaths
Inhaled medications
Bag-mask ventilation
Decompress tension
pneumothorax
C – Circulation Skin color, sweating
Capillary rell time
(,2 s)
Palpate pulse rate
(60–100 min
-1
)
Heart auscultation
Blood pressure (systolic
100–140 mmHg)
Electrocardiography
monitoring
Stop bleeding
Elevate legs
Intravenous access
Infuse saline
D – Disability Level of consciousness –
AVPU
•Alert
•Voice responsive
•Pain responsive
•Unresponsive
Limb movements
Pupillary light reexes
Blood glucose
Treat Airway,
Breathing, and
Circulation
problems
Recovery position
Glucose for
hypoglycemia
E – Exposure Expose skin
Temperature
Treat suspected
cause
Notes: Normal adult ranges are given in parentheses. Importantly, a patient with
values within the given ranges may still be critically ill. Assessment and treatment
points in italics require equipment. The approach described in this table is primarily
aimed at the nonspecialist and is not exhaustive.
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
119
ABCDE approach
Table 1 Summary points of the ABCDE approach
Airway, Breathing, Circulation, Disability, Exposure
Universal principles for all patients
Apply when critical illness or injury is suspected or evident
Assess and treat continuously and simultaneously
Treat life-threatening signs immediately
Life-saving treatment does not require a denitive diagnosis
Reassess regularly and at any sign of deterioration
Page 3
International Journal of General Medicine 2012:5
circulatory problems. Color changes, sweating, and a
decreased level of consciousness are signs of decreased
perfusion. If a stethoscope is available, heart auscultation
should be performed. Electrocardiography monitoring and
blood pressure measurements should also be performed as
soon as possible. Hypotension is an important adverse clinical
sign. The effects of hypovolemia can be alleviated by placing
the patient in the supine position and elevating the patient’s
legs. An intravenous access should be obtained as soon as
possible and saline should be infused.
D – Disability: what is the level
of consciousness?
The level of consciousness can be rapidly assessed using the
AVPU method, where the patient is graded as alert (A), voice
responsive (V), pain responsive (P), or unresponsive (U).
Alternatively, the Glasgow Coma Score can be used.
16
Limb
movements should be inspected to evaluate potential signs of
lateralization. The best immediate treatment for patients with
a primary cerebral condition is stabilization of the airway,
breathing, and circulation. In particular, when the patient is
only pain responsive or unresponsive, airway patency must be
ensured, by placing the patient in the recovery position, and
summoning personnel qualified to secure the airway. Ulti-
mately, intubation may be required. Pupillary light reflexes
should be evaluated and blood glucose measured. A decreased
level of consciousness due to low blood glucose can be cor-
rected quickly with oral or infused glucose.
E – Exposure: any clues to explain
the patient’s condition?
Signs of trauma, bleeding, skin reactions (rashes), needle
marks, etc, must be observed. Bearing the dignity of the
patient in mind, clothing should be removed to allow a
thorough physical examination to be performed. Body
temperature can be estimated by feeling the skin or using a
thermometer when available.
History of the ABCDE approach
The formulation of the mnemonic ABC has its roots in the
1950s. Safar described methods to safe-guard the airway
and deliver rescue breaths, thereby giving rise to the first
two letters of the mnemonic, A and B.
17
Kouwenhoven and
colleagues described closed-chest cardiac massage, add-
ing the letter C.
18
Dr Safar first described the techniques in
combination.
19
The further development and dissemination of the
ABCDE approach has been attributed to Styner. In 1976,
with five abdominal thrusts until the obstruction is relieved.
If the victim becomes unconscious, call for help and start
cardiopulmonary resuscitation according to guidelines.
9
Importantly, high-flow oxygen should be provided to all
critically ill persons as soon as possible.
B – Breathing: is the breathing sufcient?
In all settings, it is possible to determine the respiratory rate,
inspect movements of the thoracic wall for symmetry and use
of auxiliary respiratory muscles, and percuss the chest for
unilateral dullness or resonance. Cyanosis, distended neck
veins, and lateralization of the trachea can be identified. If
a stethoscope is available, lung auscultation should be per-
formed and, if possible, a pulse oximeter should be applied.
Tension pneumothorax must be relieved immediately
by inserting a cannula where the second intercostal space
crosses the midclavicular line (needle thoracocentesis).
Bronchospasm should be treated with inhalations.
If breathing is insufficient, assisted ventilation must be
performed by giving rescue breaths with or without a barrier
device. Trained personnel should use a bag mask if available.
C – Circulation: is the circulation
sufcient?
The capillary refill time and pulse rate can be assessed
in any setting. Inspection of the skin gives clues to
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
120
Thim et al
Figure 2 Head-tilt and chin-lift to open the airway.
Page 4
International Journal of General Medicine
Publish your work in this journal
Submit your manuscript here: http://www.dovepress.com/international-journal-of-general-medicine-journal
The International Journal of General Medicine is an international,
peer-reviewed open-access journal that focuses on general and internal
medicine, pathogenesis, epidemiology, diagnosis, monitoring and treat-
ment protocols. The journal is characterized by the rapid reporting of
reviews, original research and clinical studies across all disease areas.
A key focus is the elucidation of disease processes and management
protocols resulting in improved outcomes for the patient.The manu-
script management system is completely online and includes a very
quick and fair peer-review system. Visit http://www.dovepress.com/
testimonials.php to read real quotes from published authors.
International Journal of General Medicine 2012:5
Styner crashed in a small aircraft with his family, and they
were admitted to the local hospital. Here, he observed an
inadequacy of the emergency care provided. Emphasizing
the systematic approach to the critically injured patient,
he formed the basis of the Advanced Trauma Life Support
courses. Accordingly, the ABCDE approach is an extension
of the initially described ABC approach for patients in car-
diac arrest to patients experiencing all medical and surgical
emergencies.
Conclusion
The ABCDE approach is a strong clinical tool for the initial
assessment and treatment of patients in acute medical and
surgical emergencies, including both prehospital first-aid and
in-hospital treatment. It aids in determining the seriousness
of a condition and to prioritize initial clinical interventions.
Widespread knowledge of and skills in the ABCDE approach
are likely to enhance team efforts and thereby improve patient
outcome.
Acknowledgment
The authors would like to thank Gitte Skovgård Jensen for
expert assistance in preparation of the figures.
Disclosure
The authors report no conflicts of interest related to this
work.
References
1. Thim T, Krarup NH, Grove EL, Lofgren B. ABCDE a systematic approach
to critically ill patients. Ugeskr Laeger. 2010;172(47):3264–3266.
2. Guly HR. ABCDEs. Emerg Med J. 2003;20(4):358.
3. Featherstone P, Smith GB, Linnell M, Easton S, Osgood VM. Impact of a
one-day inter-professional course (ALERT) on attitudes and confidence
in managing critically ill adult patients. Resuscitation. 2005;65(3):
329–336.
4. Moretti MA, Cesar LA, Nusbacher A, Kern KB, Timerman S, Ramires JA.
Advanced cardiac life support training improves long-term survival from
in-hospital cardiac arrest. Resuscitation. 2007;72(3):458–465.
5. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy
in the treatment of severe sepsis and septic shock. N Engl J Med.
2001;345(19):1368–1377.
6. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council
Guidelines for Resuscitation 2010. Section 1. Executive summary.
Resuscitation. 2010;81(10):1219–1276.
7. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council
Guidelines for Resuscitation 2010. Section 4. Adult advanced life
support. Resuscitation. 2010;81(10):1305–1352.
8. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council
Guidelines for Resuscitation 2010. Section 8. Cardiac arrest in special
circumstances: Electrolyte abnormalities, poisoning, drowning,
accidental hypothermia, hyperthermia, asthma, anaphylaxis,
cardiac surgery, trauma, pregnancy, electrocution. Resuscitation.
2010;81(10):1400–1433.
9. Koster RW, Baubin MA, Bossaert LL, et al. European Resuscitation
Council Guidelines for Resuscitation 2010. Section 2. Adult basic life
support and use of automated external defibrillators. Resuscitation.
2010;81(10):1277–1292.
10. Mansfield CJ, Price J, Frush KS, Dallara J. Pediatric emergencies in
the office: are family physicians as prepared as pediatricians? J Fam
Pract. 2001;50(9):757–761.
11. Sempowski IP, Brison RJ. Dealing with office emergencies. Step-
wise approach for family physicians. Can Fam Physician. 2002;48:
1464–1472.
12. Wheeler DS, Kiefer ML, Poss WB. Pediatric emergency preparedness
in the office. Am Fam Physician. 2000;61(11):3333–3342.
13. Toback SL. Medical emergency preparedness in off ice practice.
Am Fam Physician. 2007;75(11):1679–1684.
14. Dick ML, Schluter P, Johnston C, Coulthard M. GPs’ perceived
competence and comfort in managing medical emergencies in southeast
Queensland. Aust Fam Physician. 2002;31(9):870–875.
15. Fuchs S, Jaffe DM, Christoffel KK. Pediatric emergencies in office
practices: prevalence and office preparedness. Pediatrics. 1989;83(6):
931–939.
16. Lockey A, Balance J, Domanovits H, et al, eds. Advanced Life Sup-
port. ERC Guidelines 2010 Edition. Belgium: European Resuscitation
Council; 2011.
17. Safar P, McMahon M. Mouth-to-airway emergency artificial respiration.
J Am Med Assoc. 1958;166(12):1459–1460.
18. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac
massage. JAMA. 1960;173:1064–1067.
19. Safar P, Brown TC, Holtey WJ, Wilder RJ. Ventilation and circulation
with closed-chest cardiac massage in man. JAMA. 1961;176:574–576.
submit your manuscript | www.dovepress.com
Dovepress
Dovepress
Dovepress
121
ABCDE approach
Page 5
  • Source
    • "Nevertheless, it would inevitably have led to a huge bias due to memory retention and creation of automatisms. So the variety of scenarios—none of them were identical—were created to develop MDT management with the same technical skills for IO access and ABCDE approach [104] as well as nontechnical skills for CRM and leadership, and to generate stress in different ways. Authors' contributions AG and DO: has made substantial contributions to conception and design; will perform acquisition of data, analysis and interpretation of data, and will be involved in drafting the manuscript or revising it critically for important intellectual content. "
    [Show abstract] [Hide abstract] ABSTRACT: Human error and system failures continue to play a substantial role in adverse outcomes in healthcare. Simulation improves management of patients in critical condition, especially if it is undertaken by a multidisciplinary team. It covers technical skills (technical and therapeutic procedures) and non-technical skills, known as Crisis Resource Management. The relationship between stress and performance is theoretically described by the Yerkes-Dodson law as an inverted U-shaped curve. Performance is very low for a low level of stress and increases with an increased level of stress, up to a point, after which performance decreases and becomes severely impaired. The objectives of this randomized trial are to study the effect of stress on performance and the effect of repeated simulation sessions on performance and stress. This study is a single-center, investigator-initiated randomized controlled trial including 48 participants distributed in 12 multidisciplinary teams. Each team is made up of 4 persons: an emergency physician, a resident, a nurse, and an ambulance driver who usually constitute a French Emergency Medical Service team. Six multidisciplinary teams are planning to undergo 9 simulation sessions over 1 year (experimental group), and 6 multidisciplinary teams are planning to undergo 3 simulation sessions over 1 year (control group). Evidence of the existence of stress will be assessed according to 3 criteria: biological, electrophysiological, and psychological stress. The impact of stress on overall team performance, technical procedure and teamwork will be evaluated. Participant self-assessment of the perceived impact of simulations on clinical practice will be collected. Detection of post-traumatic stress disorder will be performed by self-assessment questionnaire on the 7 th day and after 1 month. We will concomitantly evaluate technical and non-technical performance, and the impact of stress on both. This is the first randomized trial studying repetition of simulation sessions and its impact on both clinical performance and stress, which is explored by objective and subjective assessments. We expect that stress decreases team performance and that repeated simulation will increase it. We expect no variation of stress parameters regardless of the level of performance. Trial registration ClinicalTrials.gov registration number NCT02424890
    Full-text · Article · Dec 2016 · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine
  • Source
    • "Generally, SABC requires that injury judgments must be accurate, measures must be quick and everyone must do their best to make the casualty stable [23]. The airway, breathing, circulation, disability and exposure (ABCDE) approach still plays a classic and practical role in the immediate assessment and treatment of the critical casualty [24]. "
    [Show abstract] [Hide abstract] ABSTRACT: There has been no large-scale naval combat in the last 30 years. With the rapid development of battleships, weapons manufacturing and electronic technology, naval combat will present some new characteristics. Additionally, naval combat is facing unprecedented challenges. In this paper, we discuss the topic of medical rescue at sea: what challenges we face and what we could do. The contents discussed in this paper contain battlefield self-aid buddy care, clinical skills, organized health services, medical training and future medical research programs. We also discuss the characteristics of modern naval combat, medical rescue challenges, medical treatment highlights and future developments of medical rescue at sea.
    Full-text · Article · Dec 2015 · Military Medical Research
  • Source
    • "Hence, it is desirable to prepare final year medical students for the initial management of emergency situations. Systematic assessment of critically ill patients using the simple ABCDE mnemonic is widely accepted as a clinical working tool [4]. The ABCDE acronym stands for airway, breathing, circulation, disability, and exposure/environment, describing the order in which the problems associated with acute illness should be addressed. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction. The aim of this study was to explore the learning effect of engaging trainees by assessing peer performance during simulation-based training. Methods. Eighty-four final year medical students participated in the study. The intervention involved trainees assessing peer performance during training. Outcome measures were in-training performance and performance, both of which were measured two weeks after the course. Trainees' performances were videotaped and assessed by two expert raters using a checklist that included a global rating. Trainees' satisfaction with the training was also evaluated. Results. The intervention group obtained a significantly higher overall in-training performance score than the control group: mean checklist score 20.87 (SD 2.51) versus 19.14 (SD 2.65) P = 0.003 and mean global rating 3.25 SD (0.99) versus 2.95 (SD 1.09) P = 0.014. Postcourse performance did not show any significant difference between the two groups. Trainees who assessed peer performance were more satisfied with the training than those who did not: mean 6.36 (SD 1.00) versus 5.74 (SD 1.33) P = 0.025. Conclusion. Engaging trainees in the assessment of peer performance had an immediate effect on in-training performance, but not on the learning outcome measured two weeks later. Trainees had a positive attitude towards the training format.
    Full-text · Article · May 2014 · BioMed Research International
Show more