ABC assessment

Introduction
The bread and butter of clinical assessment, the
ABC approach gives a rapid analysis of the
patient’s vital physiological parameters. The panic
induced by being faced with the unfamiliar is a
remarkable way of losing one’s train of thought—
this checklist ensures all necessary first-line
assessments are made and should not be
dismissed as one purely for managing trauma.
This guide is no substitute for hands-on training;
there is now a wealth of courses such as
Advanced Life Support or Care of the Critically Ill
Surgical Patient. These will give much greater
confidence in handling medical emergencies and
should be viewed as essential for the first few
years of clinical practice.

A simple premise…
 Airway—oxygen (either as a constituent of
room air or as medical gas) must be able to
get to the bronchial tree for ventilation to
occur
 Breathing—gas exchange will not occur
without some kind of ventilatory movement
and the right gases being supplied
 Circulation—the overall goal of oxygenating
blood is to perfuse the body’s organs
 Disability—central nervous system
problems cause multiple sequelae:
unprotected airways, Cushing’s response
and status epilepticus are but a few
 Everything else—once the above have been
covered, it’s time to begin thorough
secondary assessment
Airway
 Start talking to the patient now—one
doctor’s obstructed airway is another
doctor’s snoring, sleepy patient!
 Is the patient talking without any other
abnormal noises?
o If yes, the airway is patent—proceed
to breathing assessment
 Head tilt, chin lift and jaw thrust to open
the airway
o Simple and effective manoeuvres
which will give a surprisingly high
degree of control
 Is there obstruction evident?
o Suction any vomit or excess
secretions (and file it in the back of
your mind that the patient has likely
aspirated)
o Magill forceps carry greater 5-year
survival for doctors’ fingers in
removal of solid objects! (Think of
status epilepticus)
 Airway adjuncts can help you now
o In the absence of basal skull trauma,
nasopharyngeal airways can be
tolerated by patients with a relatively
high GCS. Size by using the patient’s
little finger as a diameter guide,
lubricate, pass directly pos- terior via
right nostril, ensuring that safety pin
is in place at flared end of tube to
avoid misplacement
o A Guedel airway will likely only be
tolerated by a patient with lowered
consciousness, and carries its own
risk of causing airway obstruction by
posterior displacement of the
 tongue. Size from the distance
between the angle of the mouth and
the earlobe, and insert flat over the
tongue with the curve upwards. On
reaching the back of the tongue,
rotate through 180° so the curve is
downwards (minimizing chances of
taking the tongue back with the
airway). It has a useful secondary
function as a bite block for an
intubated patient
o Remember that adjuncts primarily
aid oxygenation by holding airways
open—this also renders them highly
susceptible to aspiration. Manual
control is always desirable until the
airway is either self-managed or
secured by intubation.

Breathing
oxygenation
 15 l/min oxygen via a non-rebreathing face
mask (giving around 85% FiO2)
o In a medical emergency, this is
almost always indicated in the initial
management
o Use caution in patients in type 2
respiratory failure (i.e. with a hypoxic
respiratory drive) owing to the risk of
CO2 retention.
o In this situation, it is advisable to use
a Venturi mask and to titrate FiO2 to
the patient’s condition
o Remember that hypoxia kills before
hypercapnia—ensure that
oxygenation is adequate. Non-
invasive ventilation (e.g. BIPAP) may
 be required if a balance between
oxygenation and CO2 retention
cannot be found.
Assess breathing
 How effective is the breathing?
o Respiratory rate, in the context of
clinical condition. For example, the
severely asthmatic patient with a
normal respiratory rate but poor
chest movements after 20 minutes is
not improving but tiring.
o Monitor SpO2, again in the context of
clinical condition. If peripherally
poorly perfused, the oximetry probe
will not give useful information and
an ABG is far more appropriate.
o Work of breathing (accessory muscle
use, subcostal/intercostal recessions,
tracheal tug)
o Auscultate chest (assess air entry,
any added sounds?)
 Have a very low threshold for taking ABG
sample
 Augment breathing if required, by use of
bag and mask.

Circulation
Assessment of circulatory state
 Does the patient have a pulse? If no,
initiate basic life support. If yes, what is its
character?
 Blood pressure
 What does the combination of blood
pressure and pulse tell you? (think about
high vs. low output cardiac failure, etc.)
 Is there evidence of overfilling?—chest
creps, pedal and sacral oedema, raised JVP
  Is there evidence of underfilling?—dry
mucous membranes, skin turgor, sunken
eyes, thirst
 Does the patient have a fluid balance chart
to help with your assessment?
 Better still, do they have a urinary
catheter? If so, what is urine volume and
colour?
 Further guidance on fluid balance and what
to do about it is in the next section.
Haemorrhage
 Is there any history of trauma or bleeding
conditions?
 Abdominal examination should always be
performed as part of circulatory
assessment—in the absence of trauma, this
is the most likely site of concealed blood
loss.
Points of access
 Now is the time to take stock of the
situation. What access does the patient
have, and do they need more?
 If regular fluid and drug administration is
required, more than one IV cannula is
desirable as it enables intercurrent
administration (and offers a small degree of
redundancy)
 Is invasive monitoring going to be required?
 Arterial lines offer beat-on-beat blood
pressure monitoring and mean arterial
pressure, as well as a portal for repeated
ABG sampling
 Central venous lines normally have four
lumens, allowing rapid fluid administration,
greater electrolyte replacement rates and
monitoring CVP (a more direct means of
ascertaining the patient’s intravascular
 filling)
 As well as the individual competence
required for line insertion, nursing and
management must be considered. A patient
with this much access will normally be in a
higher dependency environment than the
ward, and so should be discussed at an
early stage with the critical care team.
Cardiac monitoring and ECGs
 As a first line, cardiac monitoring offers
continual visualization (normally of lead II)
pending a formal ECG
 Although monitors are often in short
supply, modern defibrillators normally offer
monitoring either through separate leads or
via the main electrodes if adhesive.

Disability
Assess GCS
Although only strictly validated for head injury,
the GCS is now almost universally used as a
means of expressing level of consciousness
across three domains:
o Eyes (also take this opportunity to note
pupillary size and reflexes)
 1—not opening
 2—opens in response to pain
 3—opens on command
 4—spontaneously opening
o Voice
 1—no vocalization
 2—noises
 3—incoherent speech
 4—confused speech
 5—talking and oriented
o Movement
  1—no movement
 2—extension
 3—abnormal flexion
 4—withdrawal from pain
 5—localizes to pain
 6—movement on command
If there is no neurological history and a normal
GCS, there is little to justify further neurological
examination. Weakness, headache, back pain,
new retention of urine or altered sensation should
all prompt full neuro- logical assessment.
Everything else
If corrective management has been instituted
throughout this process, you should now be in a
position to find out more information from nursing
staff and clinical notes.
Will imaging help your management? If not sought
already, is senior review required? Continuous
reassessment is also a key principle here—check
your measures are still working frequently.

Don’t struggle out of your depth with this

approach. Almost all encounters with the seriously
sick are frightening—if you can’t manage, seek
help. Most crucially, don’t be afraid to put out an
arrest call—a patient in 3rd degree AV block, for
example, hasn’t arrested but you will not be
faulted for calling the team. Early escalation of
care for seriously ill patients is associated with
better outcome, and there is little more
frustrating than for a critical care team to see a
potentially salvageable patient through the
retrospectoscope 3 hours later.