ABCDE Assessment in Trauma

The ABCDE assessment is typically used when a patient presents with a traumatic injury. It stands for Airway, Breathing, Circulation, Disability & Exposure. Thinking about clinical scenarios in a systematic way like this can help rapidly identify life-threatening traumatic pathology while minimizing cognitive strain on the provider by providing a “checklist” to help guide clinical decision making.

Airway

Speak to the patient. Does the patient know where they are, what happened, what day it is? This is the first step in understanding the patient’s level of consciousness. Next, note the quality of the patient’s speech (How many words can they get out? Are they struggling to say a full sentence?). Next inspect the airway by checking for any obstruction, missing teeth, burns, blood, vomit, or any secretions. In cases where there is a concern for unstable cervical spine injuries, appropriate inline cervical spinal precautions should be practiced while performing a physical exam (C3, 4, 5 keeps the diaphragm alive).

Observe and make note of abnormal breath sounds, snoring, or gurgling. Look for any swelling of the airway (hematoma, edema, crepitus). If there is bleeding in the airway this can cause aspiration. If there is a concern for a patient’s ability to protect or maintain their airway, endotracheal intubation, and mechanical ventilation may be necessary.

Breathing

Inspect the chest by looking at the rate, depth, and pattern of your patient. Are the chest rise and fall symmetrical? Is the patient belly breathing? Check for equal breath sounds bilaterally. Then listen to the chest. Note lung sounds and if the patient is experiencing any difficulty breathing. Check oxygen saturation (SpO2). Initiate supplemental oxygen if needed.

Life threats: Tension pneumothorax, open pneumothorax, flail chest, massive hemothorax.

Circulation

Obtaining vital signs quickly and placing your patient on a continuous cardiac monitor is important to monitor some of the earliest signs of shock - tachycardia may manifest first, followed by hypotension.

Get adequate IV access. Two large-bore peripheral IVs or if you can’t get peripheral IV access you can get an intraosseous line or central line. Initiate isotonic crystalloid (NS or LR) or in cases of shock or impending cardiovascular collapse secondary to hemorrhage, blood should be given instead.

Next, feel and examine your patient’s skin and extremities. Cool extremities is another telltale sign of shock secondary to hypoperfusion of peripheral tissues. You may also want to note external cutaneous finds such as the color of the patient’s skin. Is it mottled? Does their face look flushed, pale, blue? Finally, palpate a pulse.

Pro Tip: Pulse checks (adequacy of perfusion):

• Carotids - SBP > 60
• Femoral - SBP >70
• Radial - SBP > 80
• Dorsalis Pedis - SBP >90

Life threats: hemorrhagic shock (rapid blood loss), tension pneumothorax, and cardiac tamponade (obstructive shocks).

Disability

Determine the patient’s alertness and neurological status. There are various clinical scores you can use to help aid with this determination, AVPU (alert, verbal, pain, unresponsive) and the Glasgow Coma Scale (GCS) are popular options.

In addition to checking to see if the patient is conscious, check pupils for reactivity and size. Discrepancies in pupillary size unilaterally could suggest intracranial pathologies such as herniation or intracranial hemorrhage.

Also, don’t forget to check a blood glucose level as this could cause a patient’s depressed or altered mental status.

Life threats: penetrating cranial injury, intracranial hemorrhage (subdural hematoma, epidural hematoma, subarachnoid hemorrhage, intraparenchymal and intraventricular hemorrhage), diffuse axonal injury, high spinal cord injury.

Exposure/Environment

Remove all clothing or coverings, expose, and examine the patient for any underlying external injuries. For example, areas of ecchymosis might reveal the site of deeper or internal injuries. Avoid hypothermia (cover the patient with warm blankets, bair hugger, warm IV fluids). Be thorough and don’t forget to examine the entire patient, this includes the axilla and perineum. Roll the patient to examine the back for cutaneous injuries or midline spinal injuries or bony step-offs. Finally, during rolling maneuvers, don’t forget to maintain C-spine immobilization.

Alexander Tataryn

As a Medical-Surgical/Telemetry Nurse, Alex enjoys every single moment of what he does - whether it's as simple as putting a warm blanket on a patient to lifesaving procedures like CPR, he takes pride in all of it. Based in Portland, Oregon, he enjoys hiking, weightlifting and video games.