ABCDE Approach to Emergency Examination

Table of Contents

ABCDE Approach to Emergency Examination & Secondary Survey

Why this matters: The ABCDE approach gives the EMT a repeatable method for finding and treating immediate threats to life. It is not a one-time checklist and it is not a substitute for clinical judgement. Assess the patient in order, treat a life-threatening problem as soon as it is found, call for help early, measure the response, and return to the beginning when the patient's condition changes. Once the primary survey is completed and immediate threats are controlled, the secondary survey searches systematically for injuries and illness that could otherwise be missed.

Learning outcomes

After studying this lesson, the emergency medical care student should be able to:

Explain the purpose, sequence and limitations of the ABCDE approach.
Recognise when a trauma patient requires a C-ABCDE sequence because catastrophic external haemorrhage is present.
Assess and manage immediate threats to the airway while protecting the cervical spine when indicated.
Identify respiratory distress, respiratory failure and life-threatening chest conditions during the breathing assessment.
Assess circulation, control external haemorrhage, recognise shock and obtain appropriate monitoring.
Assess disability using response, pupils, glucose, seizures and neurological trends.
Expose enough of the patient to find hidden injury while preventing hypothermia and preserving dignity.
Perform a methodical secondary head-to-toe survey and focused history when the patient is stable enough.
Reassess, document, communicate and hand over findings in a way that another clinician can act on.

What the ABCDE approach is—and what it is not

ABCDE stands for Airway, Breathing, Circulation, Disability and Exposure. It is an initial assessment and treatment framework for an acutely ill or injured person. The order reflects the fact that an obstructed airway, absent breathing or catastrophic circulatory failure can kill within minutes. The framework is used for adults, children and pregnant patients, with age-appropriate equipment and modifications.

ABCDE is not a race to collect every vital sign before helping the patient. It is also not a diagnosis. It identifies physiological threats and buys time for a complete history, examination, investigations and definitive treatment.

Core principles of ABCDE

Principle	What it means in practice
Assess in sequence	Move from A to E, but stop and treat immediately when a life-threatening abnormality is found.
Treat as you find	Open/maintain the airway, support breathing, control haemorrhage and correct reversible threats before completing later steps.
Call for help early	Use the team, summon advanced support and prepare transport before the patient deteriorates further.
Reassess repeatedly	Repeat the primary survey after each intervention, whenever the patient worsens and during transfer.
Use objective data	Combine appearance, examination, respiratory rate, pulse, blood pressure, SpO₂, temperature, glucose and consciousness.
Look for causes	Correct immediate threats while considering trauma, illness, poisoning, pregnancy, infection and environmental causes.
Communicate	Give a clear time-stamped handover; use closed-loop communication when working with a team.

Preparation before touching the patient

Protect yourself and the team: use gloves, eye protection, mask/apron as indicated, and avoid exposure to blood, vomit, chemicals or violence.
Make the scene safe: look for traffic, electricity, fire, weapons, collapsed structures, gas, body fluids and ongoing violence.
Estimate the number of patients: request additional resources early during mass-casualty events.
Identify the mechanism or complaint: ask bystanders what happened while approaching, without delaying the first look.
Introduce yourself and obtain cooperation: explain what you will do and ask the patient to stay still when spinal injury or major trauma is possible.
Bring the right equipment: suction, oxygen, bag-mask device, airway adjuncts, monitoring, glucose meter, bleeding-control supplies, splints, blankets and communication tools.

First-look question: Does the patient look critically ill, injured or unable to protect the airway? If yes, shout for help and begin the primary survey immediately. Do not allow a long history, paperwork or a crowded scene to delay life-saving care.

C-ABCDE: catastrophic haemorrhage before airway

When major external bleeding is obvious or suspected, some trauma systems use C-ABCDE: first identify and control catastrophic haemorrhage, then continue with Airway, Breathing, Circulation, Disability and Exposure. This does not mean ignoring the airway; it recognises that a rapidly exsanguinating patient can die before an airway problem is reached.

Visible problem	Immediate action within training and protocol	Reassessment
Heavy limb bleeding	Apply firm direct pressure; use a tourniquet for life-threatening extremity bleeding if trained and local protocol permits.	Check whether bleeding has stopped, distal circulation where appropriate and time of application.
Junctional wound or groin/axilla bleeding	Pack and compress the wound when trained; maintain pressure and call for advanced help.	Look for continued blood loss and signs of shock.
Scalp or body wound	Direct pressure unless an impaled object or skull injury makes pressure unsafe; protect the wound.	Monitor dressings, mental status, perfusion and blood loss.
Amputation	Control bleeding, preserve the amputated part in clean moist covering inside a sealed bag placed cool—not directly on ice.	Repeat ABCDE; document time and mechanism.

A — Airway

The airway assessment asks whether air can move freely from the mouth and nose to the lungs, and whether the patient can protect that passage. Airway compromise can be caused by the tongue, vomit, blood, secretions, a foreign body, facial trauma, swelling, burns, infection, reduced consciousness or a cervical spine injury.

Airway: visual and auditory clues

Finding	What it may indicate	Priority
Unable to speak, silent chest or no air movement	Complete obstruction or respiratory arrest.	Call for help and begin the appropriate airway/resuscitation algorithm immediately.
Snoring	Tongue or soft-tissue obstruction in reduced consciousness.	Open the airway and consider an appropriate adjunct within scope.
Gurgling or bubbling	Blood, vomit or secretions in the airway.	Position/suction as trained; protect against aspiration.
Stridor or harsh inspiratory noise	Upper-airway narrowing, swelling or foreign body.	Keep the patient calm and upright if appropriate; request urgent advanced airway support.
Hoarse or muffled voice, drooling	Airway oedema, anaphylaxis, burns or deep neck infection.	Anticipate rapid deterioration; do not delay escalation.
Gasping, abnormal snoring or irregular breaths	Agonal breathing in an unresponsive patient.	Treat as ineffective breathing and follow the resuscitation protocol.

Airway assessment steps

Look into the mouth only as much as is safe: identify vomit, blood, secretions, loose teeth, dentures or an obvious foreign body.
Speak to the patient. A clear answer demonstrates that the airway is currently patent, but does not guarantee it will remain so.
Listen for snoring, gurgling, stridor, hoarseness or silence.
Look for facial swelling, burns, trauma, trismus, tongue swelling and increasing work of breathing.
If trauma is possible, manually stabilise the head and neck and use a jaw-thrust approach when trained; avoid unnecessary neck movement.
Remove only visible, easily accessible material; never perform a blind finger sweep.
Use suction and airway adjuncts according to training, age, gag reflex and local protocol.

Airway adjuncts: principles for EMT students

Adjunct/technique	Key principle	Important caution
Head-tilt/chin-lift	Opens the airway when trauma is not suspected.	Avoid or modify when cervical spine injury is possible.
Jaw thrust	Moves the mandible forward while limiting neck movement.	Can be difficult and painful; maintain spinal precautions when indicated.
Oropharyngeal airway	Helps prevent the tongue from obstructing the airway in an unconscious patient without a gag reflex.	Do not use in an awake patient with an intact gag reflex; choose the correct size.
Nasopharyngeal airway	May help a partially conscious patient who cannot tolerate an oral airway.	Avoid with major facial trauma or suspected basal skull injury and follow local policy.
Suction	Removes blood, vomit or secretions that obstruct ventilation.	Use brief, controlled suction; monitor oxygenation and avoid unnecessary trauma.
Bag-mask ventilation	Provides assisted ventilation when breathing is absent or inadequate.	Requires a good mask seal, airway opening and team coordination.

Airway memory cue: “LOOK, LISTEN, SPEAK, OPEN, SUCTION, SUPPORT.”
Look for obstruction and swelling; listen for abnormal sounds; speak to test patency; open with the correct manoeuvre; suction visible fluids; support with adjuncts/ventilation and advanced help.

B — Breathing

Breathing assessment determines whether the patient is ventilating and oxygenating adequately. Start with the look-listen-feel approach, then measure respiratory rate, oxygen saturation and other observations. A patient may have a normal-looking airway but still be in respiratory failure.

Breathing: look, listen and feel

Action	What to assess	Concerning finding
Look	Rate, rhythm, depth, chest movement, effort, colour, posture and ability to speak.	Very fast/slow breathing, pauses, shallow breaths, asymmetry, cyanosis, exhaustion or inability to speak.
Listen	Breath sounds and upper-airway noise without delaying treatment.	Wheeze, crackles, stridor, gurgling, silence, grunting or markedly reduced air entry.
Feel	Chest expansion, air movement, tracheal position and tenderness when appropriate.	Absent/asymmetric expansion, surgical emphysema, severe tenderness or tracheal deviation.
Measure	Respiratory rate, SpO₂, pulse, temperature and response to oxygen/positioning.	Falling saturation, increasing effort, altered response or worsening trend.

Respiratory rate and pattern

Count for a full minute when rhythm is irregular, and observe without announcing that you are counting because patients may unconsciously change their breathing.
Record rate, rhythm, depth and effort—not only the number.
Rapid shallow breathing may represent pain, fever, metabolic acidosis, shock or lung disease.
Slow, irregular or shallow breathing may reflect opioid toxicity, head injury, exhaustion or severe neurological disease.
Periodic breathing, apnoeic pauses or gasping are abnormal and require immediate escalation.

Work of breathing and fatigue

Look for nasal flaring, intercostal or suprasternal recession, accessory-muscle use, abdominal paradox, pursed lips, tripod posture and head bobbing in infants. Watch whether the patient can speak a full sentence. A patient who becomes quieter, drowsier or less effortful after severe respiratory distress may be tiring and losing the ability to ventilate.

Danger pattern: increasing effort + altered mental status + falling oxygen saturation is respiratory failure until proven otherwise. Reassess the airway, summon advanced help and support ventilation according to local protocol.

Oxygen saturation: useful but not sufficient

Apply the correct probe and check a good signal; cold fingers, movement, nail products and poor perfusion can reduce reliability.
Interpret SpO₂ alongside respiratory effort, mental status, skin colour and the patient's baseline.
A reassuring number does not exclude carbon monoxide exposure, hypoventilation or a deteriorating patient.
Follow local oxygen targets and protocol; do not delay airway or ventilation support while waiting for a reading.

Life-threatening breathing problems to recognise

Pattern	Appearance and examination clues	EMT priority
Severe asthma/bronchospasm	Wheeze, prolonged expiration, accessory muscles, inability to speak, exhaustion or a silent chest.	Position for comfort, oxygen/bronchodilator support within protocol and urgent escalation.
Pulmonary oedema	Breathlessness, orthopnoea, crackles, frothy sputum, sweating and anxiety.	Sit upright if tolerated, support oxygenation and seek urgent advanced care.
Tension pneumothorax	Sudden severe distress, unilateral absent breath sounds, hypotension, distended neck veins or tracheal deviation late.	Immediate advanced trauma/airway response; do not delay transport for a complete routine examination.
Massive haemothorax	Trauma, severe breathlessness, dull/absent breath sounds, pallor and shock signs.	Support breathing and circulation, control bleeding and expedite definitive care.
Airway obstruction	Stridor, inability to speak or cough effectively, cyanosis, silent chest or collapse.	Use the appropriate choking/airway algorithm immediately.

C — Circulation

Circulation assessment asks whether blood is moving effectively to the brain and organs. Examine pulses, skin, capillary refill, blood pressure, bleeding, urine history and mental status. Remember that shock can exist with a normal blood pressure during early compensation.

Circulation assessment sequence

Identify and control external haemorrhage.
Check central and peripheral pulse for rate, rhythm, strength and equality where clinically appropriate.
Inspect colour, temperature, moisture, mottling and capillary refill, considering skin tone and ambient temperature.
Measure blood pressure using the correct cuff; interpret a trend rather than one isolated number.
Look for signs of poor perfusion: confusion, restlessness, pallor/grey colour, cold clammy skin, weakness, faintness and reduced urine output history.
Consider cardiac monitoring, oxygen saturation, glucose and vascular access according to scope and protocol.

External haemorrhage control

Step	Action	Safety/documentation point
1. Expose enough	Find the source without unnecessary exposure; use gloves and eye protection.	Record location, approximate severity and mechanism.
2. Direct pressure	Apply firm continuous pressure with gauze or a clean dressing.	Do not keep lifting the dressing to look; add material over it if soaked.
3. Pack when indicated	Pack deep wounds such as groin, axilla or junctional areas when trained.	Maintain pressure and note the time.
4. Tourniquet when indicated	Use for life-threatening extremity bleeding when direct pressure is ineffective or impractical and protocol allows.	Record exact application time; do not loosen intermittently.
5. Reassess	Check bleeding control, distal findings where relevant, mental status and shock signs.	Handover the intervention and trend to the receiving team.

Pulse, perfusion and capillary refill

Assess the radial pulse in a conscious stable adult, but use a central pulse when the patient is collapsed or the peripheral pulse is absent.
Record fast/slow, regular/irregular, weak/bounding and equal/unequal—not merely “pulse present.”
Capillary refill is affected by temperature, age, lighting, pressure and skin tone; use it as one part of perfusion assessment, not a stand-alone diagnosis.
In dark skin, inspect conjunctivae, lips, tongue, palms, soles and nail beds and use the whole clinical picture.

Shock patterns

Shock pattern	Possible causes	Appearance clues
Hypovolaemic	Trauma, gastrointestinal loss, dehydration, burns or obstetric bleeding.	Pale, cool, sweaty, thirsty, restless, weak pulse and later reduced response.
Distributive/septic	Severe infection and systemic vasodilation.	Fever or low temperature, warm flushed skin early or cool mottled skin late, confusion and weakness.
Anaphylactic	Severe allergic reaction.	Hives, facial/tongue swelling, wheeze/stridor, flushing, hypotension or collapse.
Cardiogenic	Acute myocardial dysfunction or severe arrhythmia.	Breathlessness, chest discomfort, sweating, pallor, crackles, weak pulse and altered response.
Obstructive	Tension pneumothorax, tamponade or massive pulmonary embolism.	Severe breathlessness, distended neck veins, hypotension, unequal breath sounds or sudden collapse.

D — Disability

Disability is the rapid neurological assessment. It does not mean disability as a personal identity; it means detecting impaired brain function, seizures, hypoglycaemia and other reversible threats. A change in responsiveness can be caused by hypoxia, shock, glucose abnormality, stroke, head injury, infection, poisoning or postictal state.

Disability assessment components

Component	What to assess	Important question
Response	AVPU/ACVPU, GCS if trained, orientation, speech and ability to follow commands.	Is this new, and what is the patient's baseline?
Pupils	Size, equality, reaction to light and obvious abnormality.	Is there a new unequal or non-reactive pupil after trauma or neurological change?
Glucose	Point-of-care blood glucose when altered, confused, fitting, weak or diabetic.	Could a rapidly reversible glucose problem explain the presentation?
Seizure	Active convulsions, eye deviation, tonic-clonic movement, postictal drowsiness or injuries.	When did it start, how long, and did the patient return to baseline?
Focal deficit	Facial droop, arm/leg weakness, abnormal speech, gaze deviation or unequal coordination.	When was the patient last known well?
Temperature/medicines	Fever, hypothermia, sedatives, opioids, insulin, alcohol or toxins.	Could infection, exposure or medication cause the altered state?

Consciousness: trend is more important than one score

Record the patient's best response and repeat it. A drop from alert to voice, or from voice to pain, is significant even if the patient later improves. Use the same tool and stimulus each time. A GCS score may be required by local protocol, but a score must never delay airway and breathing support.

Finding	Immediate considerations
New confusion or agitation	Hypoxia, hypoglycaemia, shock, sepsis, stroke, head injury, intoxication or withdrawal.
Increasing drowsiness	Respiratory failure, opioid/sedative effect, intracranial injury, seizure or severe metabolic illness.
Unresponsive with normal breathing	Protect airway, place safely according to trauma risk, monitor continuously and seek advanced help.
Unresponsive with abnormal breathing	Immediate resuscitation response; treat gasping as ineffective breathing.

Glucose and altered mental status

Check glucose early in an unexplained altered mental state, seizure, weakness, collapse or diabetic patient.
Confirm the meter, strip, sample and units; record the value and time.
Follow local treatment protocol and reassess response after treatment.
Never give oral food or drink to a patient who cannot protect the airway.
Consider other causes even when glucose is abnormal; one finding does not exclude head injury, infection or poisoning.

E — Exposure and environment

Exposure means looking for hidden injury, rashes, bleeding, burns, swelling, medical devices and environmental clues while preventing heat loss. Uncover only what is necessary, maintain privacy and replace wet or soiled clothing with dry coverings. Hypothermia worsens coagulopathy and shock, particularly after major trauma.

Exposure sequence

Cut or remove clothing carefully when needed, taking account of mechanism, dignity, cultural preference and possible spinal injury.
Inspect front, sides and back for bleeding, wounds, burns, deformity, swelling, bruising, rash, needle marks and medical alert information.
Palpate only when appropriate and trained; look for tenderness, instability, crepitus, pulses and sensation.
Check temperature and protect from rain, wind, cold floors and wet clothing.
Cover the patient, preserve evidence when assault or crime is suspected, and document what was exposed and why.

Exposure findings that change urgency

Finding	Potential threat	Next priority
Hidden bleeding under clothing	Major haemorrhage.	Expose, control bleeding, prevent heat loss and repeat circulation assessment.
Burns to face, chest or circumferential limb	Airway inhalation injury, restricted ventilation or impaired perfusion.	Assess airway/breathing early and request advanced care.
Deformity, open fracture or absent distal pulse	Fracture, vascular injury or compartment threat.	Control bleeding, immobilise according to protocol and reassess neurovascular status.
Non-blanching rash with fever/toxicity	Serious infection or sepsis.	Escalate immediately and use infection precautions.
Wet/cold patient with altered response	Hypothermia, exposure or drowning.	Remove from hazard, dry/insulate, reassess ABCDE and prevent further heat loss.

Treat-before-diagnosis examples

Finding during ABCDE	Do not wait for	Act now
Airway obstruction with stridor	A complete history or definitive diagnosis.	Position, airway support, oxygen/ventilation as trained and urgent advanced help.
Severe respiratory distress	A chest X-ray or full secondary survey.	Support breathing, monitor and prepare rapid transfer.
Uncontrolled external bleeding	Blood pressure to “prove” shock.	Direct pressure/packing/tourniquet as indicated.
Altered patient with low glucose	A full neurological diagnosis.	Follow glucose treatment protocol and reassess consciousness.
Facial swelling and wheeze	Laboratory allergy testing.	Follow anaphylaxis protocol and anticipate airway deterioration.

Reassessment after ABCDE

ABCDE is a loop. After an intervention, return to A and repeat through E. Reassessment is essential after oxygen, suction, airway adjuncts, bleeding control, glucose treatment, seizure treatment, movement, analgesia, splinting or any change in the patient's appearance.

“ABCDE → TREAT → ABCDE AGAIN.”
Record what was found, what was done, the time, the response and the next plan. A patient who improves still requires observation because deterioration can recur.

When to stop the primary survey and call for advanced help

Airway cannot be maintained with basic manoeuvres or the patient is rapidly swelling.
Breathing is absent, inadequate, exhausting or associated with persistent severe hypoxia.
Catastrophic haemorrhage continues despite appropriate first-line control.
Shock signs are worsening, the patient collapses or mental status falls.
Seizure is prolonged/recurrent, glucose remains dangerously abnormal or a focal neurological deficit is new.
There is major trauma, suspected spinal injury, burns, drowning, poisoning or pregnancy-related collapse beyond the EMT's resources.

What is a secondary survey?

The secondary survey is a systematic, more detailed examination performed after the primary survey has identified and treated immediate threats. It is appropriate when the patient is stable enough to tolerate it. It may be used for trauma, medical illness, collapse, poisoning and unexplained symptoms. Continuous ABCD observation continues during the secondary survey; if the patient deteriorates, stop and return to ABCDE.

Conditions before beginning the secondary survey

Check	Question	Action if not satisfactory
Primary survey	Have immediate airway, breathing and circulation threats been addressed?	Continue primary treatment; do not begin a long examination.
Stability	Are the patient's vital signs, mental status and appearance stable or improving?	Reassess ABCDE and expedite transport/advanced support.
Analgesia/comfort	Has pain been recognised and managed within scope?	Provide appropriate comfort measures and avoid unnecessary movement.
Privacy/warmth	Can the patient be exposed safely and respectfully?	Use sheets, screens and a warm environment; expose only one region at a time.
Team and equipment	Are monitoring, suction, oxygen and transport resources ready?	Ask for assistance before turning, log-rolling or moving the patient.

History during the secondary survey: SAMPLE and AMPLE

Use a structured history while examining, without allowing questions to delay emergency treatment. SAMPLE is useful for medical emergencies; AMPLE is commonly used in trauma. Use the patient's own words when possible and confirm information with relatives, witnesses, medication packets or referral notes.

Letter	SAMPLE	Questions
S	Signs and symptoms	What is happening now? Where is the pain? What makes it better or worse? What has changed?
A	Allergies	Any medicine, food, latex or environmental allergies? What reaction occurs?
M	Medications	Prescribed, over-the-counter, herbal, contraceptive, insulin, anticoagulant or recreational substances?
P	Past history/pregnancy	Medical and surgical conditions, previous episodes, pregnancy possibility and last menstrual period where relevant.
L	Last oral intake	When and what did the patient last eat, drink or take?
E	Events/environment	What happened before the illness or injury? Mechanism, time, witnesses and treatment already given?

AMPLE trauma history	Key information
Allergies	Medication, latex, food and other reactions.
Medications	Especially anticoagulants, insulin, antiplatelets and sedatives.
Past medical history	Heart/lung disease, diabetes, epilepsy, pregnancy and previous surgery.
Last meal	Time and amount of food/drink; relevant for anaesthesia and aspiration risk.
Events/environment	Mechanism, speed, height, restraint use, ejection, fall surface, violence or blast.

Head-to-toe secondary survey sequence

Head and scalp.
Face, eyes, ears, nose and mouth.
Neck and cervical spine.
Chest and axillae.
Abdomen and flanks.
Pelvis and perineum when indicated.
Back and posterior surfaces.
Upper limbs, hands and neurovascular status.
Lower limbs, feet and neurovascular status.
Repeat vital signs, pain, neurological status and all abnormal findings.

Head and scalp examination

Inspect/palpate	Findings to record	Clinical significance
Scalp	Bleeding, lacerations, swelling, tenderness, depression or foreign body.	Scalp wounds can hide significant blood loss; a depression may suggest fracture.
Face	Symmetry, bruising, swelling, deformity, burns and tenderness.	Facial injury may threaten airway, vision or neurological function.
Eyes	Pupil equality/reactivity, vision complaint, orbital swelling, bleeding or foreign body.	May indicate head injury, orbital trauma or neurological deficit.
Ears/nose	Bleeding, clear fluid, bruising, deformity and obstruction.	May indicate facial/skull trauma or airway compromise.
Mouth	Loose teeth, blood, burns, tongue injury, dentures and secretions.	Important for airway protection and aspiration risk.

Neck and cervical spine

Maintain manual stabilisation and spinal motion restriction when mechanism, symptoms or examination indicate risk.
Inspect for wounds, swelling, bruising, tracheal deviation, distended neck veins and surgical scars.
Ask about midline neck pain, tingling, weakness or inability to move; do not force movement to “test” the spine.
Look for airway swelling, hoarseness, subcutaneous emphysema and penetrating injury.
Palpate only according to training and protocol, and stop if severe pain or neurological symptoms occur.

Chest examination

Area	Inspect	Palpate/assess when appropriate
Front and sides	Wounds, bruising, burns, sucking chest wound, asymmetry and paradoxical movement.	Tenderness, crepitus, chest expansion and air entry.
Back	Posterior wounds, bruising, deformity and pressure injury.	Only during a coordinated turn/log-roll with spinal precautions.
Breathing pattern	Rate, effort, posture, cyanosis and speech.	Repeat SpO₂, respiratory rate and auscultation if trained.
Cardiac clues	Chest pain, sweating, pallor, distress and collapse.	Pulse, blood pressure, rhythm monitoring and 12-lead ECG when available and within service scope.

Abdomen and flanks

Inspect for distension, bruising, seatbelt marks, penetrating wounds, evisceration, pregnancy, surgical scars and visible pulsation. Ask about pain location, onset, radiation and movement. Palpate gently and systematically only when trained, noting tenderness, guarding, rigidity or a palpable mass. Do not repeatedly press an open wound or push protruding organs back inside.

Pelvis and perineum

Look for bruising, bleeding, open wounds, deformity, incontinence or blood at the urethral opening when relevant.
Ask about pelvic pain, inability to stand, numbness, pregnancy and vaginal bleeding in a sensitive, private manner.
Do not repeatedly rock or compress the pelvis; unnecessary movement can worsen haemorrhage.
Cover the patient promptly and use a chaperone or second clinician according to local policy.

Back and posterior surfaces

Inspect the back for wounds, bruising, burns, deformity, tenderness, pressure injuries and objects trapped beneath the patient. A log-roll should be coordinated by enough trained staff, with spinal alignment maintained when indicated. Check the bed or ground for blood and note any object that may have caused injury.

Limbs and neurovascular assessment

Check	What to assess	Document
Look	Deformity, swelling, open wound, bruising, burns, abnormal rotation and colour.	Side, location, size, skin condition and visible blood loss.
Feel	Tenderness, temperature, pulses and sensation.	Exact site, distal pulse and comparison with the other side.
Move	Active movement if safe; do not force an injured limb.	Strength, pain, limitation and patient cooperation.
Circulation	Colour, warmth, capillary refill and distal pulse.	Before and after splinting or repositioning.
Sensation	Numbness, tingling or altered sensation.	Patient's words, distribution and trend.

Special situations and adaptations

Trauma

Use the mechanism of injury to predict hidden problems, but do not allow the mechanism to replace examination.
Consider C-ABCDE when catastrophic haemorrhage is present.
Protect the cervical spine when the mechanism or symptoms suggest risk; avoid unnecessary movement.
Search the entire patient, including the back and areas hidden by clothing or equipment.
Prevent hypothermia and reassess after every movement, dressing, splint or airway intervention.

Medical emergencies

In medical patients, the secondary survey may focus more on symptoms and systems than on trauma. Continue to use ABCDE, then examine the region suggested by the complaint. For chest pain, assess heart and breathing clues; for abdominal pain, assess shock, pregnancy and bleeding; for fever, search for infection and altered mental status; for poisoning, protect the team and identify the agent without delaying supportive care.

Pregnancy and postpartum emergencies

Ask about gestational age, bleeding, abdominal pain, contractions, fetal movement, severe headache, visual symptoms and seizures.
Position to reduce aortocaval compression where appropriate while maintaining airway and breathing support.
Do not dismiss shock, breathlessness, facial swelling or altered response as normal pregnancy changes.
Protect privacy, use a chaperone and follow local obstetric emergency protocols.

Children and infants

Use age-appropriate airway equipment and normal ranges; the child's appearance, interaction with the caregiver, tone, feeding and work of breathing are important.
Calculate or confirm weight when medication or equipment selection requires it, using local protocols.
Do not separate a frightened child from a caregiver unnecessarily; observe while the caregiver comforts them.
Remember that hypotension can be a late sign of paediatric shock; treat worsening appearance, perfusion and response seriously.

Older adults and frail patients

Ask about baseline cognition, mobility, communication, medication and recent functional change.
Look for subtle deterioration: new confusion, reduced appetite, a fall, weakness, drowsiness or inability to perform a usual task.
Prevent hypothermia and skin injury during exposure and movement.
Review anticoagulants, antiplatelets, insulin, sedatives and multiple medicines during the history.

Low-resource and pre-hospital considerations

When monitors, oxygen, suction or advanced clinicians are limited, careful observation and repeated basic measurements become even more important. Use a watch for respiratory rate, manual pulse and blood pressure when available, a thermometer, a glucose meter and direct patient/witness history. Make early transport decisions, communicate with the receiving facility and improvise only within training and approved local protocols.

Clinical scenarios

Scenario 1: Severe asthma with a silent chest

A 24-year-old patient is sitting forward, exhausted, unable to speak and has very little audible wheeze. The respiratory rate is high and the patient is becoming drowsy.

Reasoning: Less wheeze is not improvement when air movement is falling. Treat as impending respiratory failure: airway/breathing support, emergency escalation, monitoring and rapid transport.

Scenario 2: Road-crash haemorrhage

A motorcyclist has heavy bleeding from the thigh, pale clammy skin and increasing restlessness. He has a noisy airway but is still answering.

Reasoning: Use C-ABCDE. Control catastrophic bleeding while another team member manages airway and spinal protection. Reassess after the haemorrhage intervention.

Scenario 3: Confusion after a missed meal

A diabetic patient is sweaty, irritable and unable to answer appropriately. There is no obvious trauma and breathing is adequate.

Reasoning: Disability comes early: check glucose, protect the airway, treat according to protocol and repeat consciousness/glucose assessment. Do not give oral sugar to a patient who cannot swallow safely.

Scenario 4: Hidden posterior injury

A patient who fell from a roof has a normal-looking front examination but severe back pain and tingling in both legs.

Reasoning: Maintain spinal precautions, perform a coordinated log-roll only when necessary, inspect the back and document motor/sensory findings. The secondary survey can reveal threats not visible from the front.

Scenario 5: Anaphylaxis with a “normal” blood pressure

A patient develops hives, facial swelling, wheeze and hoarseness after an injection. The first blood pressure is normal.

Reasoning: Do not wait for hypotension. The combination of airway and breathing signs is high risk; activate the anaphylaxis pathway, call for help and reassess continuously.

Scenario 6: Stable enough for secondary survey—then deterioration

After a primary survey, a trauma patient is talking and has improving vital signs. During the abdominal examination, the patient becomes pale, sweaty and less responsive.

Reasoning: Stop the secondary survey and return immediately to ABCDE. Look for haemorrhage or another new threat; the secondary survey is never more important than a deteriorating primary survey.

Common mistakes in ABCDE and secondary survey

Mistake	Why it is dangerous	Correct approach
Completing A–E without treating abnormalities	Life-threatening problems remain untreated while the examiner continues.	Stop, treat, call for help and then continue.
Taking a long history before looking at breathing	Respiratory failure can progress during questioning.	First look, primary survey, then focused history.
Ignoring catastrophic bleeding because the patient is talking	Compensated shock can deteriorate suddenly.	Control severe haemorrhage first when present.
Relying on one SpO₂ or blood-pressure value	Technical error and compensated shock can mislead.	Assess trends and the full clinical picture.
Forcing a breathless patient flat	May worsen ventilation and distress.	Use the position of comfort unless contraindicated.
Repeated pelvic rocking or unnecessary spinal movement	May worsen bleeding or neurological injury.	Move only with a clear indication and a coordinated team.
Exposing the patient and leaving them cold	Hypothermia worsens trauma and shock.	Expose one area at a time, cover promptly and monitor temperature.
Failing to repeat the examination after treatment	Response and deterioration are missed.	Use the ABCDE loop and document the trend.

Documentation and handover template

Section	Record
Time and context	Time found/first assessed, location, mechanism or chief complaint, number of patients and scene hazards.
Primary survey	Catastrophic haemorrhage, airway, breathing, circulation, disability and exposure findings in order.
Interventions	What was done, by whom, exact time, equipment/size when relevant and response.
Vital trends	Respiratory rate, SpO₂, pulse, blood pressure, temperature, glucose, pain and consciousness over time.
Secondary survey	Head-to-toe findings, SAMPLE/AMPLE history, injuries found, neurovascular status and negative findings that matter.
Handover	Patient identification, situation, background, assessment, treatment, response, concerns and recommended next action.

Example handover: “This is a 36-year-old male, motorcycle crash at 14:10. On arrival he had uncontrolled right-thigh bleeding, noisy airway and pale clammy skin. C-ABCDE completed: bleeding controlled with tourniquet at 14:14; airway now patent after suction; respirations 30 with right-sided reduced air entry; pulse 124 weak, BP 92/58; ACVPU A but increasingly restless. Secondary survey not completed because perfusion is worsening. Advanced trauma support and urgent transfer requested.”

Practical ABCDE checklist

Scene safe, PPE applied and help requested early.
Catastrophic haemorrhage identified and controlled when present.
Airway open, sounds assessed, suction/adjuncts available and spinal precautions considered.
Breathing rate, effort, chest movement, sounds, colour and SpO₂ assessed.
Circulation: bleeding, pulse, skin, blood pressure, perfusion and shock trend assessed.
Disability: AVPU/ACVPU or GCS, pupils, glucose, seizures and focal deficits assessed.
Exposure completed safely with warmth, privacy and a search for hidden injury.
Life threats treated immediately, then ABCDE repeated.
Secondary survey begun only when stable enough and stopped if deterioration occurs.
History, findings, interventions, times and trends documented and handed over.

Revision questions

What does ABCDE stand for, and why is the sequence important?
When should a C-ABCDE sequence be used?
List five signs of upper-airway obstruction.
Why can a clear spoken answer fail to guarantee a safe airway?
What is the difference between a head-tilt/chin-lift and jaw thrust?
List six findings that indicate severe breathing compromise.
Why can a “silent chest” in severe asthma be dangerous?
Describe the steps for assessing circulation in a shocked patient.
Why can shock be present before hypotension develops?
What are the main components of the disability assessment?
Why should glucose be checked in altered mental status?
What does exposure involve, and how do you prevent hypothermia?
State the conditions that should be met before beginning a secondary survey.
Write out SAMPLE and AMPLE and give one question for each letter.
List the regions covered by a head-to-toe secondary survey.
Why should the pelvis not be repeatedly rocked?
What neurovascular findings should be recorded after a limb injury or splint?
Give four reasons to stop a secondary survey and return to ABCDE.
Explain why the ABCDE approach is a loop rather than a single checklist.
Write a concise handover for a deteriorating trauma patient using objective findings.

Key takeaways

ABCDE identifies and treats physiological threats before a definitive diagnosis is available.
Treat life-threatening abnormalities as soon as they are found, call for help and reassess after every intervention.
C-ABCDE gives catastrophic haemorrhage priority in major trauma.
The secondary survey is a detailed head-to-toe examination and focused history performed only after immediate threats are controlled.
Exposure must balance finding hidden injuries with privacy, warmth and dignity.
A changing trend is often more important than one reassuring measurement.
Clear documentation and handover are clinical safety interventions.

References and further study

Clinical note: This page is for emergency medical care education. Perform procedures only within your training and scope of practice, and follow current Uganda Ministry of Health, ambulance-service and receiving-facility protocols.