A to E Assessment

Question 1

Airways

Answer 1

Look, for rise and fall of the chest and obvious obstructions in the mouth
Listen, for upper airway sounds - stridor (swelling), snoring (obstruction) and gurgling (fluid)
Feel, for breath on the cheek

Question 2

Breathing

Answer 2

Respiratory rate, oxygen saturations
Use of accessory muscles: head bobbing, nasal flaring or shoulder shrugging
Recession: tracheal, sternal, subcostal or intercostal
Airway sounds: stridor on inspiration, wheeze on expiration, grunting and gasping
Chest expansion: equal and bilateral
Colour

Question 3

Circulation

Answer 3

Capillary refill time peripherally and centrally (less than two seconds)
Temperature peripherally and centrally
Pulse peripherally and centrally (thready/bounding/weak)
Blood pressure
Heart rate and rhythm
Urine output (mls/kg/hour)

Question 4

Disability

Answer 4

AVPU/GCS: 15/15 alert, 12/15 responds to voice, 8/15 responds to pain and 3/15 unresponsive
Pupils equal and reactive to light
Posture: hypotonia
Blood glucose: 4-7mmols

Question 5

E

Answer 5

Rashes: blanching or non blanching
Bruises and wounds: accidental or non accidental injuries
Allergic reactions