ABCDE APPROACH - Trauma Assessment and Immediate Management - Adult Vital Signs

Q: What actions are recommended for an unconscious patient with limited or no air movement when trauma is not suspected?

Use head-tilt and chin-lift, keep the airway open with OPA or NPA, and place the patient in the recovery position or position of comfort. If possible, continue ongoing monitoring while following the ABCDE sequence.

Q: How should stridor and signs of anaphylaxis or hypoxia be managed?

Keep the patient calm and allow a position of comfort, then treat anaphylaxis with IM adrenaline and treat hypoxia with oxygen.

Q: What are key special considerations and danger signs to check in children during ABCDE assessment?

Children may have bigger heads and shorter, softer necks, may not report trauma, and can present serious internal injury with few external signs. Danger signs include airway obstruction, increased work of breathing, cyanosis, altered mental status, poor feeding or inability to drink, seizures/convulsions, and low body temperature.

Sep 20, 2026

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ABCDE APPROACH for rapid assessment and immediate management, starting with Airway, Breathing, Circulation, Disability, and Exposure, with clear decision points based on the presence or absence of trauma. Includes guidance for foreign body, gurgling, stridor, wheeze, tension pneumothorax, opiate overdose, shock and bleeding, pericardial tamponade, seizures, hypoglycaemia, and temperature control. Provides normal adult vital sign ranges, estimation of systolic blood pressure, SAMPLE history elements, and special considerations for children including danger signs and weight estimation.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages14

Reading Time35 min

AccessFree to download

ABCDE Approach

Airway

Breathing

Circulation

Disability

Exposure

Special Considerations in the Assessment of Children

Danger Signs in Children

Normal Adult Vital Signs

SAMPLE History

Approach to the Patient With Trauma

ABCDE APPROACH REMEMBER... Always check for signs of trauma [see also TRAUMA card] ASSESSMENT FINDINGS IMMEDIATE MANAGEMENT Airway | | A | | --- | --- | Unconscious with limited or no air movement If NO TRAUMA: head-tilt and chin-lift, use OPA or NPA to keep airway open, place in recovery position or position of comfort. If possible TRAUMA: use jaw thrust with c-spine protection and place OPA to keep the airway open (no NPA if facial trauma) . | Foreign body in airway Remove visible foreign body. Encourage coughing.
• If unable to cough: chest/abdominal thrusts/back blows as indicated
• If patient becomes unconscious: CPR | | --- | | Gurgling Open airway as above, suction (avoid gagging) . | Stridor Keep patient calm and allow position of comfort. • For signs of anaphylaxis: give IM adrenaline • For hypoxia: give oxygen Breathing | | B | | --- | --- | Signs of abnormal breathing or hypoxia Give oxygen. Assist ventilation with BVM if breathing NOT adequate. | Wheeze | Give salbutamol. For signs of anaphylaxis: give IM adrenaline. | | --- | --- | | Signs of tension pneumothorax (absent sounds / hyperresonance on one side WITH hypotension, distended neck veins) | Perform needle decompression, give oxygen and IV uids. Will need chest tube | Signs of opiate overdose (AMS and slow breathing with small pupils) Give naloxone. Circulation | | C | | --- | --- | Signs of poor perfusion/shock If no pulse, follow relevant CPR protocols. Give oxygen and IV uids. Signs of internal or external bleeding Control external bleeding. Give IV uids. Signs of pericardial tamponade (poor perfusion with distended neck veins and mu􀀞ed heart sounds) Give IV ﬂuids, oxygen. Will need rapid pericardial drainage Disability D Altered mental status (AMS) If NO TRAUMA, place in recovery position. | Seizure | Give benzodiazepine. | | --- | --- | | Seizure in pregnancy (or after recent delivery) | Give magnesium sulphate. | | Hypoglycaemia | Give glucose if <3.5 mmol/L or unknown. | | Signs of opiate overdose (AMS with slow breathing with small pupils) | Give naloxone. | Signs of life-threatening brain mass or Raise head of bed, monitor airway. bleed (AMS with unequal pupils) Will need rapid transfer for neurosurgical services Exposure | | E | | --- | --- | Remove wet clothing and dry skin thoroughly. | Remove jewelry, watches and constrictive
clothing | | --- | | Prevent hypothermia and protect
modesty. | Snake bite Immobilize extremity. Send picture of snake with patient. Call for anti-venom if relevant. | If cause unknown, remember trauma: Examine the entire body and always consider hidden injuries [see also TRAUMA card] | | --- | | REMEMBER: PATIENTS WITH ABNORMAL ABCDE FINDINGS MAY NEED RAPID HANDOVER/TRANSFER. PLAN EARLY. | NORMAL ADULT VITAL SIGNS Pulse rate: 60–100 beats per minute Respiratory rate: 10–20 breaths per minute Systolic blood pressure >90 mmHg Oxygen Saturation > 92% Estimating systolic blood pressure (not reliable in children and the elderly): Carotid (neck) pulse 􀃆 SBP ≥ 60 mmHg Femoral (groin) pulse 􀃆 SBP ≥ 70 mmHg Radial (wrist) pulse 􀃆 SBP ≥80 mmHg SAMPLE History Signs & Symptoms Allergies Medications PMH Last oral intake Events | SPECIAL CONSIDERATIONS IN THE ASSESSMENT OF CHILDREN | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | • Children have bigger heads and tongues, and shorter, softer necks than adults. Position airway as appropriate for age.
• Always consider foreign bodies. | | | | | | A | | | | | | | | | | | | | | | | | | | | • Look for signs of increased work of breathing (e.g. chest indrawing, retractions, nasal aring) .
• Listen for abnormal breath sounds (e.g. grunting, stridor, or silent chest) .
AGE RESPIRATORY RATE (breaths per minute) <2 months 40–60 2–12 months 25–50 1–5 years 20–40 | | | | | | | B | | | | | | | | | | | | |

FAQs

What actions are recommended for an unconscious patient with limited or no air movement when trauma is not suspected?

Use head-tilt and chin-lift, keep the airway open with OPA or NPA, and place the patient in the recovery position or position of comfort. If possible, continue ongoing monitoring while following the ABCDE sequence.

How should stridor and signs of anaphylaxis or hypoxia be managed?

Keep the patient calm and allow a position of comfort, then treat anaphylaxis with IM adrenaline and treat hypoxia with oxygen.

What are key special considerations and danger signs to check in children during ABCDE assessment?

Children may have bigger heads and shorter, softer necks, may not report trauma, and can present serious internal injury with few external signs. Danger signs include airway obstruction, increased work of breathing, cyanosis, altered mental status, poor feeding or inability to drink, seizures/convulsions, and low body temperature.

Sep 20, 2026

Upload by Well Done