The ABCDE Approach
- Approach the patient, noting their general appearance and any dangers, donning PPE if indicated.
- Talk and touch the patient, checking for a response.
- Consider your options for additional help in the local context and ensure that help is on its way.
Airway
- If the patient is talking then airway patent at present.
- You may need to consider the potential for airway management in future, such as with falling Glasgow Coma Scale (GCS) score, airway burns, etc.
- If the patient is not talking, then open the airway with an appropriate manoeuvre and place adjuncts if needed.
- Apply oxygen via bag valve mask if not breathing or 15L non-rebreather mask if they are.
- If the patient is likely to require intubation, call for help, position the patient, prepare the intubation trolley and difficult airway plan, and run through the checklist.
- Aim to run through the rest of the A-E exam while preparing for intubation.
Breathing
- Assess breathing effort and efficacy.
- You may find a RATES approach helpful:
- R – respiratory rate
- A – auscultation
- T – tracheal position
- E – effort of breathing
- S – oxygen saturation
- If a problem with breathing is identified, then oxygen is applied, and treatment is instituted as needed.
- This may include medications such as salbutamol, adrenaline, antibiotics, or procedures such as decompression of pneumothorax or placement of chest drain.
Circulation
- Assess the circulation by feeling the pulses, skin temperature, central cap refill and looking for any bleeding.
- Place an IV or IO line and take bloods as needed.
- Place on cardiac monitoring and cycle the NIBP every 5 minutes or more often if very unwell.
- Take a 12-lead ECG when able.
- Management of a C problem may include IV fluids, blood transfusion/massive transfusion protocol, vasoactive substances (eg GTN, noradrenaline, dobutamine), amiodarone, aspirin or thrombolysis, and depending on the issue may also include cardioversion, pacing, antibiotics, tourniquet or emergency surgery.
Disability
- Take a blood glucose.
- Assess the conscious state using AVPU, pupil response and whether the patient is moving all 4 limbs.
- Look for signs of head injury.
- Assess pain and provide analgesia if required.
- Check documentation for background history, medications, drugs, allergies and any recent change in condition.
Exposure
- Everything else!
- Palpate the abdomen, looks for rashes or skin changes, roll the patient if needed, place IDC if indicated and check urine, take temperature and institute warming/cooling if needed.
Once the A-E exam is complete, it is helpful to summarise your findings to the team, along with the next steps of your plan, which may include further resuscitation, investigations, imaging, transfer, review with yourself or other specialty teams or a discussion around the ceiling of care.
If the patient’s condition changes, then go back immediately to A and reassess.
In reality, many of the interventions will happen at the same time, especially if working in a large enough team to delegate tasks such as attaching monitoring and gaining IV/IO access. However, it is still helpful to think and talk through the A-E approach, as it helps to maintain structure and prevent you from missing things. The focus of the A-E approach is on identifying and treating life-threatening problems, not history and exam, so you are not aiming to diagnose the underlying condition immediately, but to buy time to start the correct investigations and treatment.