The ABCDE approach is used for performing an initial systematic assessment of any critically unwell or deteriorating patient, and intervening as necessary. Getting called to see unwell patients is part of the job of a junior doctor so it’s worth having a system in place! This method involves ordered examination, investigation and intervention, focusing on each major body system in turn. Any problems are addressed as they are identified with the patient being regularly re-assessed.
The aim of the ABCDE approach is to improve the clinical outcome of the unwell patient, with or without a definitive diagnosis.
The below guide is a general overview that can be used for any unwell patient in a simulationsetting; it may seem intimidating at first, but remember your patient is unlikely to need all of the investigations or interventions mentioned! More specific cases can be found in the emergency section of the site and are linked to throughout. This guide is written with final year medical students in mind– the assessments, investigations, and interventions included may generally be expected to be within the competencies of a junior doctor.
This guide has been created to assist students in preparing for emergency simulationsessions as part of their training, it is not intended to be relied upon for patient care.
Tips before you begin
Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management is effective
Make use of the team around you to delegate tasks where appropriate – is another clinical member of staff available to help you?
All critically unwell patients should have continuous monitoring equipment attached for accurate observations and if necessary ECG readings – this will save you time! Communicate how often would you like these readings to be relayed to you
If you need senior input for your patient, call for help early using an appropriate SBARR handover structure (check out the guide here)
Review results (e.g. laboratory investigations) as they become available
Make use of medical school/hospital guidelines and algorithms in managing specific situations such as haematemesis
Any medications or fluids will need to be prescribed
Your assessment and management should be documented in the notes (however this should not delay initial clinical assessment and management)
You are likely to see this patient after a brief handover from another member of staff.
Introduce yourself to whoever has requested a review of the patient.
Perform a quick general inspection of the patient to get a sense of how unwell they are:
Check consciousness level using AVPU
How do they look? Are they pale?
How is their breathing?
Are there obvious signs of bleeding?
What is around the bedside? (look for IV lines, monitoring equipment etc)
Introduce yourself to the patient
Ask the patient how they are doing – in what way are they feeling unwell?
Are they in pain?
Make sure the patient notes, observation chart and prescription chart are on hand
Ask for another clinical member of staff to assist you if possible
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Can the patient talk?
The airway is patent; move on to Breathing assessment
Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles, diminished breath sounds, added sounds)
Is the patient cyanosed?
Open the mouth and inspect: Is there anything obviously compromising the airway (e.g. secretions)?
Possible causes of airway compromise:
Inhaled foreign body (acute onset, may be unilateral, classically stridor)
Secretions, blood, vomit (often obvious, may have gurgling breath sounds)
Depressed level of consciousness (e.g. opioid overdose, head injury)
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain the airway.
Maintain the airway whilst awaiting senior input
1. Perform head tilt, chin lift manoeuvre.
2. If noisy breathing persists try a jaw thrust.
3. If airway still appears compromised use an airway adjunct:
Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise may gag/aspirate)
Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially conscious)
Check for central cyanosis: hypoxia can have CNS, respiratory, cardiac and haematological causes
Listen to the breath sounds- rattling suggests secretions
Expose the chest
Jugular venous pressure (JVP): raised in acute severe asthma, heart failure, fluid overload
Signs of respiratory distress: sweating, use of accessory muscles, abdominal breathing
Deformity affecting breathing
Rhythm and depth of inspiration:
Cheyne-Stokes respiration (cyclical apnoeas, then varying depth of inspiration/rate of breathing) may be due to stroke, raised intracranial pressure, pulmonary oedema, opioid toxicity, hyponatraemia, or carbon monoxide poisoning
Kussmaul’s respiration (deep, sighing) can be seen in metabolic acidosis (e.g. DKA)
Trachea: Is there a mediastinal shift? (e.g. tension pneumothorax)
Extremes of heart rate or blood pressure with any worrying features such as shock, new heart failure, syncope or myocardial ischaemia suggest the patient may be peri-arrest. Seek immediate senior help and alert the crash team as appropriate.
Is the patient septic?
You have enough information to identify SIRS at this point. Perform the sepsis 6 immediately in suspected sepsis.
Take blood cultures
Give IV antibiotics
Give IV fluids
Check serial lactates
Measure urine output
Check peripheries: warm/cold/cyanosed
Measure central cap refill time: CRT>2 seconds may suggest shock or dehydration
JVP (if not already assessed) – raised in fluid overload, sunken in dehydration
Central and peripheral pulse for rate, rhythm, volume, and quality:
A bounding pulse suggests sepsis or fluid overload, a weak pulse suggests poor cardiac output
An irregular pulse may be due to atrial fibrillation (AF)
Check ankles/sacrum for oedema
Is the patient in heart failure?
Are they overloaded with fluid?
Does the patient have a new murmur suggestive of endocarditis?
Is there a pericardial rub or muffled heart sounds? (e.g. pericarditis)
A third heart sound may indicate heart failure
What is the patient’s fluid output?
Oliguria may suggest hypovolaemia, poor cardiac output, acute kidney injury (AKI) or dehydration. Suspect retention or obstruction if the patient is otherwise stable.
The output may be high in fluid overload.
Insert at least one wide-bore IV cannula (14G or 16G) and take bloods as below.
In suspected DVT, calculate a Well’s score and manage appropriately.
Seek senior advice.
Re-assess after any intervention
Re-assessment and seeking help
Re-assess the patient in the same systematic manner as above. Your aim is to improve the clinical outcome of the patient.
React to any changes and evaluate the effectiveness of your interventions.
Deterioration should be recognised quickly and acted upon immediately.
Seek help if the patient shows no signs of improvement or if you have any concerns.
Who can help?
You should have another member of the clinical team aiding you in your ABCDE assessment, such as the patient’s nurse, who can perform observations, take samples to the lab, catheterise if appropriate etc.
You may need further help or advice from a senior staff member.
Do not delay seeking help if you have concerns about your patient.
Additionally, make sure to check the medications you have just prescribed and what they are normally taking. It might be that their current regime is inappropriate for them
Document your ABCDE assessment clearly, including examination, observations, investigations, interventions, and patient response/changing condition. Write down any pertinent details from your history taking.
If a senior doctor hasn’t already been involved, it is important to contact them and make them aware of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Should they be referred for a review by a speciality doctor?
Should any changes be made to the management of their underlying conditions?
The next team of doctors on shift should be made aware of any patient in their department who has become acutely unwell.