ABCDE

OBSERVATIONS & ASSESSMENTS

AIRWAY
Look
• Is the chest moving?
• Are there any visible obstructions?

Listen
• For stridor, gurgling, snoring etc.
• Is the patient talking, crying?

Feel
• Breath on face for at least 10 seconds
• Misting on an O2 mask
AIRWAY
Possible causes of an obstructed airway
• Swelling
• Secretions, vomit, mucus, blood
• Foreign body
• Drug induced
• Congenital
AIRWAY
Interventions
• Airway reposition – chin lift, jaw thrust
• Suction
• Medication
BREATHING
Effort
• Assess respiratory rate, regularity and depth
• Accessory muscle use
• Recession
Effectiveness
• Degree of chest expansion
• Breathing sounds and symmetry
• SpO2 in air
Effects
• Skin colour
• Mental status
• Sympathetic nervous system
BREATHING
Interventions
• Administer high flow oxygen
• Continually assess effectiveness of oxygen
• Elevate patient if possible
• Rescue breaths – BVM
• Medication
CIRCULATION
Look
• Capillary refill
• Skin appearance
• Urine output
• Visual Infusion Phlebitis

Feel
• Temperature gradient
• Pulse volume
• Heart rate
• Heart rhythm
CIRCULATION
Possible causes of a circulation problem
• Hypovolaemia
• Sepsis
• Anaphylaxis
• Primary cardiac problem
• Blood flow obstruction
• Anaemia
CIRCULATION
Interventions
• Establish IV access
• Fluid bolus
• IV antibiotics
DISABILITY
Consciousness
• Alert – GCS 15
• Voice – GCS 12
• Pain – GCS 8
• Unresponsive – GCS 3
Posture
• Hypertonia
• Decerebrate
• Decorticate
• Responsive to pain
Pupils
• Equal and reactive to light
EXPOSURE
Skin appearance
• Evidence of blood, lesions, rashes etc.
• Temperature
 Don’t
Ever
Forget
Glucose