CLINICAL I Systematic

Using the ABCDE

approach for all critically
unwell patients
Ian Peate, Principal, School of Health Studies, Gibraltar, and David Brent, Critical Care Staff Nurse, Rhyl

AdobeStock/Monkey Business
Abstract
The ABCDE approach is a systematic
approach that must be used for all critically
unwell or/and deteriorating patients.
This article provides an overview of the
underlying principles with a general overview
that may be used for any unwell adult
patient. Understanding the key issues
discussed can assist the healthcare worker
in preparing for emergency situations.
Assessing and identifying quickly those
patients whose condition is deteriorating
and prioritising interventions is a key
component of safe healthcare. The ABCDE
assessment should only be undertaken by
suitably educated and trained staff.
Key words
● Emergency
● Deteriorating
● Critically ill
● Systematic approach
When a patient is critically ill, the ABCDE approach helps tackle their health problems systematically.
The involvement of family can be crucial.

T
he approach to all deteriorating or
critically ill patients is the same,
regardless of patient or setting.
The aim of the ABCDE assessment is
to keep the patient alive and achieve
the first steps to improvement. This
approach will buy time in order to
make a diagnosis and instigate further
treatment. The aim of the assessment is
to identify and stabilise the patient’s most
life-threatening problems first, prior to
moving on to the next vital system, so as
to achieve some clinical improvement so
a diagnosis can be made and appropriate
treatment instigated. Attend to the
most critical interventions first, before
moving on.
Once a completed ABCDE assessment
has been undertaken, the steps of the
assessment are reassessed, determining
if clinical features are improving or
deteriorating. ABCDE prioritises life-
saving interventions, allowing healthcare
workers to identify any subtle changes in
a person’s condition.  See Figure 1: the ABCDE approach.
The ABCDE approach requires
healthcare workers to use their senses
and their clinical judgement, with the
focus on the whole of the patient. If
undertaken correctly, this is a quick,
yet detailed assessment, that can be
completed in fewer than five minutes.
The earlier any deterioration in the
patient can be recognised, the quicker
the issues can be addressed and escalated,
resulting in positive patient outcomes.
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Safe environment
“The ABCDE approach requires healthcare workers to use It is essential when making the initial
approach to undertaking the ABCDE
their senses and their clinical judgement, with the focus assessment that healthcare staff are safe.
on the whole of the patient” When outside of a clinical area (ie a

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Components of the ABCDE approach
Airway
A patent airway is a priority  education and training.
Breathing
Effective breathing is essential
Circulation
Adequate oxygenation is crucial  normal brain perfusion. However, if the
Disability
Level of consciousness
Environment
Signs of concern on and around the patient’s body
World Health Organization, 2018
Figure 1. The ABCDE approach
hospital), you must ensure scene safety,
be aware of any scene hazards, being
alert, for example, to fire, any dangers
associated with a road traffic collision,
the possibility of a building collapsing
or a chemical spill. Be aware and do not
put yourself at risk if there is any violent
activity. This is also known as a general
or preliminary assessment of the patient
and their surroundings, identifying any
immediate environmental hazard. This
may include the healthcare practitioner
introducing themselves and stating their
role and performing a risk assessment of
their personal safety.
If there is risk of infection
transmission, you must assess and
wear appropriate personal protective
equipment (PPE). Consider the most
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appropriate PPE for the situation,
for example:
● Gloves
● Gown 
● Mask
British Journal of Healthcare Assistants March 2021 Vol 15 No 2
● Goggles
● Hand washing.
Use PPE and wash your hands (or
use alcohol gel cleanser) before and
after every patient contact. Adhere to
local decontamination protocols and
procedures. Seek help from colleagues at
the earliest opportunity if needed. Report
and document according to local policy
and procedure.
Initial response
The Resuscitation Council UK (RCUK)
(2015) suggests a range of activities (first
steps) that should be taken before the
ABCDE assessment is commenced. These
“Airway obstruction is an emergency: get expert help
immediately. If left untreated, airway obstruction results
in hypoxia and can cause damage to the brain, kidneys and
heart, lead to cardiac arrest and death can ensue”
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Systematic I CLINICAL
activities should only be undertaken
within your scope of practice and
for which you have received specific
Introduce yourself to the patient,
stating your role. Observe the patient in
general (including skin colour, posture,
facial expression) to see if they appear
unwell. If the patient is awake, use open-
ended questions such as, ‘How are you?’
If the patient seems to be unconscious
or has collapsed, then shake the person
and ask, ‘Are you alright?’ If they respond
normally, then the airway is patent
(open); if the patient is breathing, there is
response is in short sentences, there could
be breathing problems. If the patient fails
to respond, this is an obvious indication
of critical illness. If indicated, call for help
immediately: ask a colleague to do this. If
the patient is unconscious, unresponsive
and is not breathing normally, start
cardiopulmonary resuscitation (CPR),
according to local guidelines. 
In all critically ill patients, monitor vital
signs early. Attach a pulse oximeter, ECG
monitor and a blood pressure monitor as
soon as possible. An intravenous cannula
should be inserted as quickly as possible
and at the same time bloods are taken
for investigation when the intravenous
cannula is being inserted. 
A detailed examination
of the ABCDE system
Airway
The airway is located between the lips
and the trachea (Steen, 2010). Airway
obstruction is an emergency: get expert
help immediately. If left untreated, airway
obstruction results in hypoxia and can
cause damage to the brain, kidneys and
heart, lead to cardiac arrest and death
can ensue.
085
CLINICAL I Systematic

musical breathing sound), this may be

AdobeStock/LeeSensei
anaphylaxis (see Glossary) and the patient
may require intramuscular
adrenaline. Make arrangements for
handover or transfer for advanced
airway management.
If there are any abnormal airway
sounds, frequently reassess the airway.
Partial obstruction might worsen, leading
to a complete obstruction of the airway.

Breathing

While undertaking the immediate

Figure 2. Using a clinical dummy to demonstrate the chin lift manouevre to save the airway during
first aid procedure.
If the patient is able to speak normally,
move on to assessing the other ABCDEs.
If they are able to speak, but this is not
normal, listen for abnormal sounds that
could indicate obstruction, look and
listen for any fluid in the airway, see if
there are any foreign bodies, swelling
assessment of breathing, it is essential
to diagnose and treat immediately any
life-threatening conditions, such as,
acute severe asthma, pulmonary oedema,
tension pneumothorax and haemothorax. 
Count respiratory rate: normal
suction the airway. If the rest of the respiratory rate is 12–20 breaths per
ABCDE is normal and there is no minute. A high (above 25 breaths per
trauma, the recovery position may be minute) or increasing respiratory rate
considered. If there is swelling, hives, is an indicator of illness and a warning
or stridor (abnormal, high-pitched, sign that the patient may deteriorate

AdobeStock/rdrgraphe
around the airway or altered cognitive
status. Check to determine if the patient
is able to swallow saliva.
If the patient is unconscious and not
breathing normally (if there is concern
of trauma), then open the airway using
the head tilt/chin lift manoeuvre (see
Figure 2).
Consideration should be given to
placing an airway device (for example,
oropharyngeal or nasopharyngeal airway)
to maintain the airway. If the patient is
unable to talk, observe the chest wall and
determine if it is moving up and down,
listen for air movement from the mouth
and nose.
If there is a suspicion of choking and
a foreign body is visible, remove it. If
the patient is able to cough, encourage
them to cough, and keep the patient
calm. If the patient is choking, unable to
cough/make sounds, use chest thrusts/
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abdominal thrust (see Figure 3), or

back blows. If the patient becomes
unconscious while choking, commence
CPR according to local guidelines.  Figure 3. If the patient is choking, unable to cough/make sounds, use chest thrusts/abdominal thrust, or
If there are secretions present, back blows.

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 Systematic I CLINICAL

suddenly. You must look, listen and feel

AdobeStock/Leonid Smirnov
to determine if the patient is breathing.
● Is the patient diaphoretic (with
excessive, abnormal sweating)?
● Any signs of central cyanosis
(see Glossary)?
● Assess if the breathing is very fast, very
slow or very shallow 
● Observe for increased work of
breathing: are the accessory muscles
of respiration being used?
● Is there nasal flaring?
● Observe chest wall movement: are
there any abnormalities?
● Listen and note abnormal breath
sounds (with severe wheeze, there may
be no audible breath sounds due to
severe airway narrowing)
● Listen to the chest: are the breath
sounds equal?
● Check for the absence of breath sounds
on one side (unilaterally).
If there is a dull sound with percussion Figure 4. If the patient is unconscious, with abnormal breathing, perform (if trained to do so) bag-valve-
to the same side of the chest, this may mask ventilation (pocket mask ventilation) with oxygen and commence CPR.
be a pleural effusion or haemothroax. If
hypotensive, with distended neck veins Circulation Capillary refill
or tracheal shift, this may be a tension Measurement of peripheral capillary refill
pneumothorax. Check and record the time is undertaken by compressing a
patient’s oxygen saturation. fingertip for five seconds at heart level, or
If the patient is unconscious with just above, with sufficient firm pressure
abnormal breathing, perform (if trained to cause blanching (Jevon and Gallier,
to do so) bag-valve-mask ventilation 2020). You must time how long it takes
(pocket mask ventilation, see Figure 4) In nearly all medical and surgical for the skin to return to the colour of
with oxygen and commence CPR emergencies, hypovolaemia (loss of blood the surrounding skin after releasing the
according to local guidelines.  or fluid) is considered the primary cause pressure. The normal time is less than
If the person is not breathing of shock, until this is proven otherwise. two seconds. A central capillary refill
adequately (for example, their Shock is defined as an impaired delivery time can also be measured; this involves
respirations are too slow or too shallow), of oxygen and nutrients to the tissues the upper sternum, assessing whether any
then begin performing (if trained to (Garretson and Malberti, 2007). peripheral compromise is also systemic. 
do so) bag-valve-mask ventilation Shock is a life-threatening condition: if Assess, report and document heart
with oxygen. If oxygen is not available untreated, it leads to organ dysfunction. rate and blood pressure to ascertain
immediately, do not delay ventilation. It should be remembered that breathing if they are within the normal range.
Make arrangements for immediate problems, for example, a tension Observe for external haemorrhage
transfer for airway management. pneumothorax, can also compromise a from wounds or drains, or evidence of
The patient may need oxygen, patient’s circulatory state. Look, listen and concealed haemorrhage (haemorrhage
prescribed salbutamol, adrenaline feel for signs of poor perfusion: that is concealed in a body cavity i.e.
needle decompression, chest tubes/ ● Cool, moist extremities  intra-abdominal, intra-thoracic, pelvis). If
drains and intravenous fluids for other ● Delayed capillary refill severe haemorrhage is not controlled, this
breathing-related conditions (such as ● Diaphoresis can lead to shock.
hypoxia, anaphylaxis, tension/haemo ● Low blood pressure The treatment of cardiovascular
pneumothorax). The specific treatment ● Tachypnoea collapse will depend on the cause; this
of respiratory disorders will depend upon ● Tachycardia should focus on the administration of
the cause; all critically ill patients should ● Absent pulses prescribed intravenous fluid replacement
be given oxygen.  ● Oliguria (if a urinary catheter is in situ). (in the context of any pre-existing cardiac
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condition), control of haemorrhage and

restoration of tissue perfusion. Assess
“Shock is a life-threatening condition: if untreated, and reassess heart rate and pulse every
five minutes. Undertake a 12-lead ECG.
it leads to organ dysfunction” Seek urgent expert help early on. In

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CLINICAL I Systematic
While ensuring dignity and respect for the patient, undertake an overall examination. Observe for any
clinical signs that could be suggestive of deep vein thrombosis (DVT); these include a hot, painful,
swollen calf.
“An acute change in a person’s level of consciousness
may be the first indication of a significant acute change
in health status, particularly in older patients. Acute
confusion is becoming an increasingly important sign
of clinical deterioration as populations age”
cardiac arrest, commence CPR according
to local guidelines.
Disability
There are a number of common causes
of unconsciousness and these include
profound hypoxia, hypercapnia,
cerebral hypoperfusion, or the recent
administration of sedatives or analgesic
drugs. Review ABC, so as to exclude
and if needed to treat hypoxia and
hypotension. Undertake a rapid
assessment of the patient’s level of
consciousness using the ACVPU scale
(see Table 1).
An acute change in a person’s level
of consciousness may be the first
indication of a significant acute change
in health status, particularly in older
patients. Acute confusion is becoming
an increasingly important sign of
088
scale (Table 1), where ‘C’ indicates the
AdobeStock/Solarisys
patient is presenting with new confusion
or delirium. To undertake assessment of
disability, the GAP acronym (Table 2) can
be used:
Glucose: measure the patient’s blood
glucose for abnormalities. If blood
glucose levels are low, oral or intravenous
glucose can be given. If the blood glucose
is elevated, check ketone levels which if
also elevated may suggest a diagnosis of
diabetic ketoacidosis (DKA).
ACVPU: use the ACVPU scale (Table 1)
to rapidly undertake the patient’s level
of consciousness. If a more detailed
assessment of the patient’s level of
consciousness is required, use the
Glasgow Coma Scale. 
Pupils: assess the size and symmetry
of the pupils. Examine the pupillary
reaction to light. 
See Table 2 regarding using GAP to
assess disability.
The Glasgow Coma Scale (www.
glasgowcomascale.org) may also be
used. This is a common scoring system
that is used to describe the level of
consciousness in a person after traumatic
brain injury.
Check the patient’s drug chart, looking
for the recent administration of reversible
drug-induced causes of reduced
A Patient is alert consciousness, and assess pupillary
response to light. Measure blood glucose
C New confusion or delirium using a rapid finger-prick bedside testing
V Patient is responding to verbal stimulus
method, so as to exclude hypo- or
hyperglycaemia (see Glossary).
P Patient responds to painful stimulus If the patient is unconscious, there is
no trauma, the ABCDEs are otherwise
U Patient is unresponsive
normal, nurse them in the lateral position
Table 1. The ACVPU scale to measure a patient’s (the recovery position), protecting
level of consciousness. their airway. 
clinical deterioration as populations age Exposure
(Williams, 2019). Given acute confusion
is a compelling marker of clinical risk
and acute illness severity, Williams (2019)
noted that this could be missed by the
simple recording of the AVPU scale,
unless the possibility of new confusion is
routinely considered. This has prompted Take a full clinical history from the
the addition of ‘C’ to the now ACVPU patient, any relatives or friends and other
Glucose Measure blood glucose for abnormalities
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ACVPU Use ACVPU scale (Table 1) to rapidly determine patient's level of consciousness
Pupils Assess the size and symmetry of the patient's pupils.
Table 2. Using GAP to assess disability.
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 Systematic I CLINICAL

S Signs and symptoms
A Allergies
M Medications
P Past medical history
L Last oral intake
E Events surrounding
the injury/illness
Table 3. The elements of a SAMPLE history (Source: Adapted World Health Organization (WHO), 2018).
“Take a full clinical history from the patient, any relatives
or friends and other staff”
staff. The six elements of the SAMPLE
model for taking a patient history are
found in Table 3.
Review and assist with reviewing the
patient’s notes and charts. Check on the
medication chart that any important
routine medications are prescribed and
have been administered. Any laboratory
or radiological investigations should
be made available for review.  Measure
and record the patient’s temperature. An
Glossary
Anaphylaxis
Central cyanosis
Diaphoresis
Haemothorax
Hypercapnia
Hypoperfusion
Hypoxia
Oliguria
Perfusion
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Patient/family, other members of staff report of signs
and symptoms
Important to prevent harm; may also suggest anaphylaxis
Obtain a full list of current and most recent medications or any
dose changes
Obtaining a past medical history can help in understanding
the illness
Take note of the patient’s last oral intake, whether solid or
liquid; it may indicate a risk of vomiting or choking if the
patient needs to be sedated, intubated or to undergo any
surgical procedure
Helpful cues/clues can help to determine progression
and severity of illness.
abnormal temperature can be a common
finding in patients with infections and
inflammatory processes. A temperature
above 38˚C or below 36˚C might raise
concern regarding sepsis.
While ensuring dignity and respect for
the patient and ensuring minimum heat
loss (preventing hypothermia, an acutely
ill patient may be unable to regulate
body temperature), undertake an overall
examination. Examine the entire body
A severe, life-threatening, generalised or systemic
hypersensitivity reaction
Abnormal blue discolouration of the skin and mucous
membranes caused by inadequate oxygenation
The excretion of moisture through the pores of the skin
A collection of blood between the chest wall and the lung
A condition that arises from having too much carbon dioxide
in the blood
A reduced amount of blood flow
A condition in which tissues of the body receive insufficient
amounts of oxygen
The production of abnormally small amounts of urine
The process of oxygenated blood being delivered to the tissues
of the body
Key points
● Use the ABCDE approach in all critically or
deteriorating patients, regardless of setting
● Undertake the initial assessment and
regularly re-assess
● Treat any life-threatening problems prior to
moving on to the next part of the assessment 
● Recognise and call for appropriate help early
● The aim is to keep the patient alive, buying
time for further treatment and to make
a diagnosis.
for any hidden injuries, such as rashes,
bites or other lesions; finding these could
indicate an allergic reaction or infection.
Observe for any clinical signs that
could be suggestive of deep vein
thrombosis (DVT), which include a hot,
painful, swollen calf. If there is limb
deformity, this may indicate a fracture. 
Document all findings and all
interventions in the patient’s notes and be
prepared to undertake a handover of the
patient to other colleagues.
Conclusion
The ABCDE approach has been designed
to ensure that life-threatening conditions
are identified and treated early, and that
there is an order of priority. If a problem
is discovered as this stepwise approach is
being implemented, this problem must be
addressed immediately, before moving on
to the next step. BJHCA
References
Garretson S, Malberti S. Understanding
hypovolaemic, cardiogenic and septic shock.
Nurs Stand. 2007 Aug 22-28;21(50):46–55;
quiz 58. doi: 10.7748/ns2007.08.21.50.46.c4608
Jevon P, Gallier H. How to measure capillary
refill time in patients who are acutely ill. Nurs
Times. 2020;116(8):29–30
Resuscitation Council UK. The ABCDE
approach. 2015. www.resus.org.uk/
library/2015-resuscitation-guidelines/abcde-
approach (accessed 7 January 2021)
Steen C. Prevention of deterioration in
acutely ill patients in hospital. Nurs Stand
2010;24(49):49–57
Williams B. The National Early Warning Score
and the acutely confused patient. Clin Med
(Lond). 2019 Mar; 19(2): 190–191. doi:
10.7861/clinmedicine.19-2-190

World Health Organization. The ABCDE and

Pneumothorax A collection of air between the chest wall and the lung
SAMPLE History Approach. 2018. https://
Tachycardia An abnormally fast heart rate www.who.int/emergencycare/publications/
BEC_ABCDE_Approach_2018a.pdf (accessed
Tachypnoea A condition that refers to rapid breathing.
7 January 2021)

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