08/12/2022, 17:04 ABCDE Assessment - Lecturio

ABCDE Assessment
The airway, breathing, and circulation, disability and exposure (ABCDE) assessment is the
mainstay management approach used in managing critically ill patients. The ABCDEs are
the essential 1st steps to perform in many situations including unresponsive patients,
cardiac arrests, and critical medical or trauma patients. For the trauma patient, ABCDE is
included in the primary survey, the initial evaluation, and management of injuries.

Last updated: July 5, 2022

CONTENTS

Primary Survey
Airway
Breathing
Circulation
Disability and Exposure
Secondary Survey
Clinical Relevance
References

Primary Survey
A primary survey is the initial evaluation used to identify and manage life-threatening
injuries in a trauma patient.

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The components of the primary survey are:

Airway

Breathing

Circulation

Disability

Exposure

Airway
Purpose
Establish airway patency.
Assess the patient’s ability to protect the airway.
Manage the airway.
Spinal immobilization: using a backboard and rigid cervical collar

Causes of airway compromise

Traumatic injury
Patient’s tongue
Foreign body 
Vomit, blood, and secretions
Localized swelling due to infection or anaphylaxis

Airway assessment
If the patient can speak normally → airway is intact.
Signs of an unprotected airway:
Paradoxical chest and abdominal movements
Cyanosis
Abnormal breathing sounds:
Snoring
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Stridor
Expiratory wheezing
Gurgling
Presence of an expanding hematoma
Presence of subcutaneous emphysema
Glasgow Coma Scale (GCS) < 9

Airway management
Adequate ventilation with 100% oxygen using a bag and mask
Pulse oximetry to monitor oxygen levels
Airway suctioning (with a suction catheter) can help remove secretions in an
effort to clear the airway.
Special maneuvers:
Chin lift, jaw thrust
Oral (oropharyngeal tube) or nasal (nasopharyngeal tube) airways can
be used to temporarily maintain the airway 
If maneuvers fail, establish a definitive airway:
Endotracheal (orotracheal) intubation 
Insertion of a tube into the trachea through the mouth (less
commonly the nose)
1st-line procedure
Cricothyrotomy
Incision of the membrane between the thyroid cartilage and
cricoid cartilage
Used if endotracheal in severe traumatic injuries, if intubation fails,
or if airway is severely swollen (anaphylaxis!) 
Easier to perform than tracheostomy
Temporary procedure
Tracheotomy 
Incision to the trachea with insertion of a tracheal tube
Preferred in pediatric patients (age < 8) as the cricoid is much
smaller

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Breathing
Breathing is the next step after the airway has been deemed adequate.

Purpose
Detect signs of respiratory distress.
Maintain sufficient oxygenation and ventilation.
At this step, if breathing problems are found, it may be necessary to perform
procedures (i.e., thoracostomy) to correct breathing issues found.

Breathing assessment
Listen to breath sounds.
Count respiratory rate:
12–20/min is normal.
If respiratory rate is ↓ or ↑, consider airway assistance.
40% of cardiac arrest patients may have agonal breathing (series of noisy
gasps).

Signs of respiratory distress

Inspection: 
Central cyanosis
Jugular venous distention
↑ effort needed to breathe
Use of accessory muscles
Abdominal breathing
Percussion: hyperresonance (pneumothorax) or dullness (hemothorax)
Palpation: tracheal shift, subcutaneous emphysema, flail segments
Auscultation: ↓ air entry during auscultation
Oxygen saturation < 88%

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↓ end-tidal CO₂ (capnography)

Breathing management
Depends on the cause
Return to A (airway) to establish definitive airway if there is respiratory
distress.
Procedures for management of life-threatening breathing conditions:
Tube thoracostomy (small incision of the chest wall is made and a chest
tube is inserted) is needed in:
Tension pneumothorax, open pneumothorax
Flail chest
Massive hemothorax
Pericardiocentesis (a needle and small catheter are inserted into the
pericardial sac to drain excess fluid) is needed in cardiac tamponade.

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Thoracostomy:
A primary skin incision is made superiorly to the rib to avoid the neurovascular supply that runs inferiorly to
the rib. The surgeon tunnels through the subcutaneous tissue and muscle to enter the pleural cavity.
Entrance into the pleural cavity is confirmed and the chest tube is placed.
Image by Lecturio.

Circulation
Performed after the airway and breathing have been judged as normal and adequate.

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Purpose
Determine the effectiveness of the cardiac output.
Secure adequate tissue perfusion.
Treatment of external bleeding

Causes of poor circulation

Shock (including hypovolemia, septic, or anaphylactic shock)
Traumatic injury to arteries (compartment syndrome, arterial lacerations,
crush injury)
Cardiac arrhythmias 
Heart failure 
Pulmonary embolism

Circulation assessment
Non-breathing (apneic) patients:
CPR (cardiopulmonary resuscitation) (function as artificial circulation)
Protect the spinal cord with cervical collar
Breathing patients:
Blood pressure assessment: indication of the effectiveness of the
cardiac output, considered ↓ if systolic < 90 mm Hg
Measure heart rate by palpating the following arteries:
If carotid pulse is palpable → systolic pressure likely ≥ 60 mm Hg
If femoral pulse is palpable → systolic pressure likely ≥ 70 mm Hg
If radial pulse is palpable → systolic pressure likely ≥ 80 mm Hg
If dorsalis pedis pulse is palpable → systolic pressure likely ≥ 90
mm Hg
Check skin (cold, clammy skin is an indication of hypovolemia).
Check capillary refill time (abnormal greater than 2 seconds).
Check urinary output (< 0.5 ml/kg/h considered low).

Circulation management
Di l lh h
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Direct pressure
2 large-bore to control
IV lines to beany external
placed in all hemorrhage
patients; if not possible, alternatives
include:
Central access into femoral, jugular, subclavian veins
Intraosseous access
Percutaneous and cutdown catheters in the lower limb saphenous vein
(less common)
Consider mass transfusion blood protocol.

Disability and Exposure

Disability assessment
The goal of disability assessment is to determine and manage the presence of
neurologic injury.
Examine pupils → pupil dilation suggests ipsilateral brain mass or blood
collection, causing compression on the 3rd cranial nerve 
Motor and sensory examination
Assess level of consciousness and mental status through GCS:
Patient receives score for best response in each area.
Scores in each area are combined to reach a total score of 3–15.
↑ the number → the better the prognosis
Score ≤ 9 indicates coma and patient needs endotracheal intubation.
Life-threatening neurological injuries include:
Penetrating cranial injury
Intracranial hemorrhage:
Subdural hematomas
Epidural hematomas
Traumatic subarachnoid hemorrhage
Intraparenchymal or intraventricular bleeding
Diffuse axonal injury
High spinal cord injury

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Table: Glasgow Coma Scale

Feature Response Score

Eye opening Open spontaneously 4

Open to verbal command 3

Open to pain 2

No eye opening 1

Verbal response Oriented and appropriate 5

Disoriented but conversant 4

Nonsensical words 3

Moaning 2

Silent 1

Motor response Follows commands 6

Localizes pain 5

Withdraws to pain 4

Flexor posturing 3

Extensor posturing 2

Flaccid 1

Exposure

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The goal of this step is to evaluate and manage negative environmental effects:
Completely undress the patient and carry out a full physical exam.
Keep the patient in a warm environment (hypothermia can trigger
coagulopathies).

Secondary Survey
The goal of the secondary survey is to rapidly and thoroughly examine the patient from
head to toe to identify all potentially significant injuries.
Performed after the primary survey and initial stabilization are completed
Examine patient from head to toe, including all orifices (ears, nose, mouth,
vagina, rectum).
Order imaging as needed.
Go back to primary survey for reassessment frequently!

Clinical Relevance
The following are conditions that can cause acutely and severely impaired
cardiovascular function in a patient:
Cardiac arrest: the loss of cardiac function in a person with or without known
cardiac disease. The 4 cardiac rhythms that are known to produce a
pulseless cardiac arrest are ventricular fibrillation, rapid
ventricular tachycardia, pulseless electrical activity, and asystole. Treatment
is with advanced cardiac life support (ACLS), which includes CPR and giving
epinephrine. 
Flail chest: a condition that occurs when 3 or more contiguous ribs are
fractured in 2 or more different locations. Marked by chest pain, tachypnea,
hypoxemia, and paradoxical thoracic wall movement. Often, tube
thoracostomy is needed, as the condition is associated with pneumothorax.
Management includes oxygen supplementation, pain control, and positive
pressure ventilation if respiratory failure presents.
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Hemothorax: a collection of blood in the pleural cavity. The condition usually

occurs following chest trauma, which leads to lung laceration or damage to
intercostal arteries. Symptoms include shortness of breath and chest pain.
Signs include hypotension, tachycardia, decreased air entry,
tracheal deviation, and dullness on percussion. Management is by chest tube
insertion.
Pulmonary contusion: a traumatic parenchymal lung injury. Patients present
with tachypnea, tachycardia, and hypoxemia. Computed tomography scan
shows patchy alveolar infiltrates not restricted by anatomical borders (non-
lobar opacification). Management involves oxygen administration, pain
control, chest physiotherapy, and mechanical ventilation in severe cases.
Pneumothorax: an abnormal collection of air in the pleural space. Physical
exam findings include decreased breath sounds, hyperresonance on
percussion, tracheal deviation, mediastinal shift (away from tension
pneumothorax), decreased tactile vocal fremitus, and distended jugular veins
. Chest X-ray, ultrasound of chest, and CT all can identify pneumothoraces.
Treatment includes emergent needle decompression and thoracotomy.
Cardiac tamponade: an accumulation of fluid in the pericardial space,
resulting in reduced ventricular filling and subsequent hemodynamic
compromise. Cardiac tamponade is a severe form of pericardial effusion. In
the setting of trauma, the effusion is blood. Physical examination findings
include Beck's triad (hypotension, jugular venous distention, and muffled
heart sounds). Treatment is emergent pericardiocentesis.

References

1. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013
May;74(5):1363-6. doi: 10.1097/TA. 0b013e31828b82f5.
2. Sivilotti, M. Initial management of the critically ill adult with an unknown overdose. (2019).
UpToDate. Retrieved November 22, 2020 from: https://www.uptodate.com/contents/initial-
management-of-the-critically-ill-adult-with-an-unknown-overdose
3. Thim, T., Krarup, N. H., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and
treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.
International journal of general medicine, 5, 117–121. https://doi.org/10.2147/IJGM.S28478

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