Core Concept Assessment Treatment

A – Airways Is the airway patent/open?

Voice (normal voice=patent airway) Breath sounds (noisy breathing, increased

breathing effort, or no respirations despite great effort)

Head tilt and chin lift Oxygen (15 L/min) Suction

B – Breathing Is their breathing sufficient? Ability to get O2 in and out

Respiratory rate (12–20 min) Chest wall movements (symmetry, use of

accessory muscles) Chest percussion (unilateral dullness or

resonance) Cyanosis, distended neck veins,

lateralization of trachea Lung auscultation Pulse oximetry (97%–100%)

Seat comfortably Rescue breaths (assisted ventilation) Inhaled medications Bag-mask ventilation Decompress tension pneumothorax

C – Circulation Is their blood circulation sufficient? (perfusion)

Skin color, sweating Capillary refill time (<2 s) Pulse rate (60–100 min) Heart auscultation BP (hypotension & hypovolemia=impaired

circulation) ECG monitoring LOC (decreased)

Stop bleeding Elevate legs Intravenous access ASAP Infuse saline

D – Disability What is their LOC and functional abilities?

AVPU Method: Grades/Rates LOCo Alerto Voice responsiveo Pain responsiveo Unresponsive

Glasgow Coma Score –alternative to AVUP Limb movements (evaluate potential signs of

lateralization) Pupillary light reflexes Blood glucose (↓ BG can lead to ↓ LOC)

Treat Airway, Breathing, and Circulation problems (especially in patients only pain responsive or unresponsive with a primary cerebral condition)

Recovery position (ensures airway patency; call for HCP –intubation may be required)

Glucose for hypoglycemia

E – Exposure Expose skin for physical exam

Expose Skin (examine for signs of trauma, bleeding, skin reactions [rashes], needle marks, etc.)

Check Temperature

Treat suspected cause