Using the ABCDE approach in primary care

I’ve been asked when teaching for a handout on the ABCDE approach in primary care so this is the reason for this blog.  I’m hoping it will also work on its own if you’re interested in learning more about using the ABCDE approach in primary care.

When teaching medical emergencies I always focus on using an ABCDE approach.  This is the generally accepted approach to medical/surgical emergencies and is taught on the majority of courses.  I prefer to teach the ABCDE approach rather than the management of a distinct list of conditions although I do try to base it on a case example to show how it works in practice.

Why do I like it?

The ABCDE approach focuses on the most life threatening problems first.  It provides an easy to remember mnemonic and therefore enhances team work and communication and improves patient care.  It also doesn’t necessarily require the ability to make a diagnosis, only to recognise and treat problems as appropriate.

ABCDE stands for Airway, Breathing, Circulation, Disability and Exposure.  When assessing an ill patient I advocate using a Look, Listen, and Feel and Do approach.  This ensures that most things (if not all) will have been considered and that treatment is based on what is found.

Below is a discussion of things to consider as part of an ABCDE approach.  It’s based on the slides I use when teaching using the ABCDE in Primary Dental Care or General Practice.  I use examples of possible cases to highlight the key components.  In the acute setting where there is a larger skill base and range of equipment other aspects may also be considered.  During assessment each aspect is assessed and managed in turn, as the skills of the assessor and available equipment allow, before moving onto the next.  The aim is to complete your assessment from A to E so that nothing is missed.

Airway

Case example

“Mr Adams is waiting for his appointment –
You go to collect him and find him slumped in the chair and snoring”

What do you think about his airway?

You might look at his position, you can hear snoring, an indication of a partially obstructed airway most likely from his tongue, you might also want to feel for breath.

What will you do?

Try and rouse him, if he responds and becomes alert then he should be able to maintain his own airway.  If he doesn’t rouse and is unconscious then you will need to change his position and obtain urgent help whilst continuing with your assessment.  If he is unconscious and breathing then it’s appropriate to put him into the recovery position.

2nd example

“Miss Anderson has come to have a filling –
You’ve anaesthetised her gum and a minute later she starts to complain of difficulty breathing”

What do you think of her airway?

If you have just given a patient anything then you should consider anaphylaxis.  If you look at her you may see swelling of the lips, tongue, throat, eyes and/or face.  If it is anaphylaxis then you may hear a stridor and she may become hoarse.

What will you do?

For anaphylaxis you are looking for life threatening airway, breathing and circulation signs to then consider your treatment.  Remember your first line treatment is adrenaline

Further airway assessment
Look for:-
  • Conscious level affects ability to control tongue and therefore to maintain own airway
  • Distressed/difficulty breathing
  • Foreign objects
  • Teeth!
  • Vomit/secretions
  • Swelling
  • Seesaw breathing
  • Accessory muscles
Listen for:-
  • Talking
  • Silence
  • Noisy – stridor, wheeze, snoring, gurgling

NB complete silence indicates complete airway obstruction, added noises from the airway indicate partial blockage

Feel for:-
  • Air on the face
Do:-
  • Position – head tilt and chin lift, recovery position
  • Oxygen – high flow through a non-rebreath oxygen mask
  • Suction
  • Adrenaline
  • Nebulisers/Inhalers through a spacer device
  • Remove the foreign object ~ If choking is suspected follow the Choking Algorithm

When satisfied that any airway problems have been managed as effectively as possible progress to assessing breathing.

Breathing

Case example

“Mr Brown arrives for his appointment short of breath”

What do you want to know? What are you going to do?
Always start your assessment with A, therefore:-

A ~ clear, talking in short sentences

What do you think of his breathing?

One of the important aspects to consider is ‘is this normal? Or normal for him?’  Otherwise when assessing someone’s breathing then consider the following…

Look for:-
  • Are they breathing?
  • Distressed
  • Short of breath/fast breathing
  • Very slow breathing
  • Lethargy/decrease in consciousness
  • Increased effort ~ are they becoming tired?
  • Colour – blue/grey
Listen for:-
  • Talking ~ are they able to complete sentences?
  • Confusion/irritability
  • Silent
  • Noisy – wheezing, rattling
Feel for:-
  • Chest movement ~ Hands on the chest?
Do:-
  • Position – sit up, lean forward
  • Oxygen
  • Saturations
  • Suction
  • Adrenaline
  • Inhalers – plastic bottles/cups

Once any breathing problems have been assessed and treated then move onto circulation

Circulation

Case example

“Whilst you’re treating Mr Campbell he complains of chest pain”

What do you want to know? What are you going to do?

As with your breathing assessment it’s important to consider if this is normal or normal for him?

You always start your assessment with A, so:-

A ~ clear, talking in sentences
B ~ slight shortness of breath

You now need to assess Mr Campbell’s circulation

What is the chest pain like? Has he had it before?  If he tells you it’s the same as his normal angina then you might manage this differently than if he tells you he’s never had it like this before and it feels tight and is radiating to his arm.  To complete your assessment then consider….

Look for:-
  • Colour – pale, waxy
  • Capillary refill – normal is <2 seconds
  • Bleeding
  • Diarrhoea
  • Vomiting
Listen for:-
  • Complaints of Chest pain
  • Blood pressure
Feel for:-
  • Radial pulse = BP>70
  • Pulse
  • Temperature ~ consider Sepsis as a cause
Do:-
  • Position – lay them down, legs up, recovery position
  • Chest pain – reclining
  • GTN spray
  • Aspirin
  • Oxygen

Once any circulation problems have been assessed and treated then move onto disability

Disability

I also teach ‘D’ as standing for disorientation; this is the section where anything to do with neurological function is considered.  Therefore any loss of consciousness, stroke, hypoglycaemia, fits or head injury for example.

Case example

“Mrs Dawson arrives for her appointment she appears drunk”

What do you want to know? What are you going to do?
Always begin your assessment with A~

A ~ clear and talking
B ~ breathing slightly fast
C ~ pale and clammy

At this point you might think this is a circulation problem, which would be possible.  However, most commonly someone may appear drunk when they are experiencing a low blood sugar so if you know that the person has not been drinking and they are diabetic then it would be worth considering if hypoglycaemia is the cause.

To complete your assessment…

Look for:-
  • Conscious level/confusion
  • AVPU
  • Pupils
  • Blood sugar
  • Medication history
  • Fitting
  • FAST
Listen for:-
  • Talking coherently
  • Confusion
Feel for:-
  • Able to move all limbs
Do:-
  • Position – recovery position
  • Hypostop, Glucagon
  • Buccal Midazolam


Exposure

Case example

Mrs Evans arrives having fallen outside and has cut her leg

What do you want to know? What are you going to do?
Always start with A…

A ~ clear and talking
B ~ breathing slightly fast
C ~ pale
D ~ feels light-headed

If possible it is best to elevate a bleeding limb and apply direct pressure.  The fact that she also feels light-headed means that she may feel better if she lays flat with her leg up and/or supported on a chair.

Complete your assessment…

Look for:-
  • Head to toe
  • Front to back
  • Pockets
  • Notes/medical history
Listen for:-
  • History
  • Relatives with them?
Feel for:-
  • Calves
Do:-
  • Plan their EXIT!
  • Go back to………………A

If on completion of ‘E’ you have not felt it necessary to request an emergency ambulance then now is an appropriate time to consider their discharge, where do they need to go for further treatment or can they go home?

An ABCDE assessment should take no longer than 5 minutes.  If there is any change then return to A and re-assess, or return to A and monitor closely whilst waiting for any treatment to take effect or for help to arrive.

As mentioned above this list is not exhaustive but is based on my medical emergencies course that I deliver in Primary Dental and General care.  If you have any questions please contact me.  I hope it has been useful.