ABCDE assessment

Question 1

What is A?

Answer 1

• Airway
• Look for signs of obstruction
• Is the patient talking?
• Check airway is clear and patent

Question 2

What is B?

Answer 2

• Breathing
• Look for chest movement
• Colour (cyanosis - blue)
• Sounds
• Depth (equal of both sides)
• Respiratory rates (normal 12-20)
• O2 sats (>96% or 88-92% for patients with COPD)
• Use of accessory muscles and abdominal breathing

Question 3

What is C?

Answer 3

• Circulation
• Colour (blue, pink, pale or mottled)
• Temperature
• Heart rate
• Blood pressure
• Capillary refill time (normal <2 seconds)
• Urine output

Question 4

What is D?

Answer 4

• Disability
• Level of consciousness
• AVPU (Alert, verbal, pain, unresponsive)
• GCS (Glasgow Coma Scale)
• Pupil size and reaction to light

Question 5

What is E?

Answer 5

• Exposure
• Skin (rash, bruises, abrasions)
• Core temperature
• Blood glucose

Question 6

What does the C stand for in AcVPU?

Answer 6

• Confusion
• Confusion that is not normal for that person, could be caused by abnormal blood levels, head injury, sepsis and infection

Question 7

What does airway obstruction cause?

Answer 7

• Paradoxical chest (Breathing movements in which the chest wall moves in on inspiration and out on expiration, in reverse of the normal movements)
• Abdominal movements (‘see-saw’ respirations)
• The use of the accessory muscles of respiration

Question 8

What is a high respiratory rate?

Answer 8

• > 25 breaths per minute
• Known as tachypnea
• Is a marker of illness and is a warning that the patient may deteriorate

Question 9

What does a prolonged CRT suggest?

Answer 9

• Poor peripheral perfusion
• Other factors include cold surroundings, poor lighting, old age