Assessment of the Airway (WHO Basic Emergency Care - "A" in ABCDE)

1. Quick Safety Check First

2. Determine if the Airway is Patent

• If they answer normally in a clear voice -> the airway is patent (open) for now, and you move on to assess Breathing.
• If they cannot speak, speak only in a whisper, or make abnormal sounds -> suspect airway compromise and act immediately.

3. Look, Listen, and Feel for Obstruction

• Look: for chest/abdominal movement (see-saw or paradoxical breathing suggests obstruction), accessory muscle use, agitation or confusion (a sign of hypoxia), cyanosis (lips/tongue), visible blood, vomitus, secretions, swelling, or a foreign object in the mouth.
• Listen: put your ear close to the patient's mouth/nose and listen for:
  • Snoring - tongue falling back and partially obstructing the pharynx (common in reduced consciousness)
  • Gurgling - liquid (blood, vomit, secretions) in the airway
  • Stridor (high-pitched sound, usually on inspiration) - obstruction at or above the larynx (e.g. croup, anaphylaxis, foreign body, epiglottitis)
  • Wheeze - lower airway narrowing
  • Hoarse voice - laryngeal involvement
  • Silence with chest movement - complete obstruction (a true emergency)
• Feel: air movement at the nose/mouth on your cheek; feel for tracheal position and any crepitus or swelling in the neck.

4. Classify What You Find

• Patent airway - talking normally, no added sounds.
• Partial obstruction - some air movement but noisy (snoring, gurgling, stridor, wheeze); patient may be agitated or drowsy.
• Complete obstruction - no air movement, no sound, often with paradoxical chest/abdomen movement and rapidly progressing cyanosis. This is immediately life-threatening.

5. Common Causes to Keep in Mind

6. Immediate Actions if the Airway is Not Clear

1. Open the airway: head-tilt/chin-lift in a patient with no suspected spinal injury, or jaw thrust if trauma/C-spine injury is suspected.
2. Clear it: finger sweep or suction visible blood, vomit, or secretions; remove a visible foreign body carefully (do not blind finger-sweep in children if the object isn't visible, to avoid pushing it deeper).
3. Position: recovery (lateral) position in an unconscious, breathing patient without trauma, to let secretions drain and the tongue fall forward off the pharynx.
4. Adjuncts: insert an oropharyngeal (Guedel) airway in the unconscious patient without a gag reflex, or a nasopharyngeal airway if the patient is semi-conscious with an intact gag reflex.
5. Oxygen: give supplemental oxygen to any patient with actual or threatened airway compromise.
6. Call for help early - anaphylaxis, epiglottitis, expanding hematoma, or major facial trauma may need advanced airway management (bag-valve-mask, supraglottic airway, intubation, or surgical airway) that is beyond basic measures.
7. Reassess continuously - after every intervention, go back and re-check airway patency using the same look/listen/feel approach before moving to Breathing.

Key Teaching Point for BEC

Step-by-Step Airway Management (WHO BEC Approach)

Step 1: Assess for Obstruction (Look, Listen, Feel)

• Ask the patient a question - normal speech = patent airway.
• Look for chest/abdominal movement, cyanosis, agitation.
• Listen for snoring, gurgling, stridor, wheeze, or silence with chest movement.
• Feel for air movement at the nose/mouth.

Step 2: Position the Patient

• Place the patient supine on a firm, flat surface.
• No trauma suspected: use the sniffing position - slight neck flexion with head extension (ear canal aligned with the sternal notch). A folded towel under the occiput helps in adults.
• Trauma suspected / C-spine injury possible: keep the head, neck, and trunk in a neutral line. Do NOT extend or flex the neck.

Step 3: Open the Airway (Manual Maneuvers)

1. Place one hand on the forehead, the other under the bony part of the chin.
2. Tilt the head back gently while lifting the chin upward and forward.
3. Continue until the teeth almost touch - this pulls the tongue and epiglottis off the posterior pharyngeal wall.

1. Kneel at the top of the patient's head.
2. Place fingers behind the angles of the mandible on both sides.
3. Push the jaw forward (anteriorly) without tilting the head or neck.
4. Use thumbs to open the lips slightly if needed.

Step 4: Inspect and Clear the Mouth/Oropharynx

• Look inside the mouth for secretions, blood, vomitus, loose dentures, broken teeth, or a visible foreign body.
• Suction any liquid material with a rigid or flexible suction catheter.
• If a foreign body is visible, remove it with a finger sweep or forceps.
• Never do a blind finger sweep - it can push an unseen object deeper and worsen obstruction (current teaching explicitly warns against this, a change from older recommendations).
• Leave well-fitted dentures in place - they improve the seal for bag-mask ventilation later.

Step 5: Reassess

• Improved air entry, normalized sound = maneuver worked, maintain position.
• Still obstructed = move to airway adjuncts.

Step 6: Insert an Airway Adjunct if Needed

1. Size it: measure from the corner of the mouth to the angle of the jaw (or earlobe).
2. Insert "upside down" (curve facing up toward the palate) and rotate 180 degrees as it passes the tongue, OR insert right-side-up using a tongue depressor to hold the tongue down.
3. Reassess air movement.
   • Wrong size risk: too long can trigger vomiting or push the epiglottis into the larynx; too short can push the tongue back and worsen obstruction.

1. Size it: measure from the nostril to the earlobe (or angle of jaw).
2. Lubricate generously with water-soluble gel.
3. Insert into the larger, less obstructed nostril, directed straight back (posteriorly along the floor of the nasal cavity), not upward.
4. Avoid in suspected basilar skull fracture or significant mid-face trauma (risk of intracranial placement, epistaxis).

Step 7: Positioning for Ongoing Protection

• Unconscious, breathing adequately, no trauma: place in the recovery (lateral) position so secretions drain away from the airway and gravity keeps the tongue forward.
• If trauma is suspected, maintain spinal precautions and use suction/jaw thrust rather than repositioning.

Step 8: Give Oxygen

• Apply supplemental oxygen as soon as any airway compromise is identified, even before the airway is fully secured - it extends the time to hypoxia while you work.

Step 9: Escalate if Basic Measures Fail

• Call for advanced help immediately.
• Prepare for bag-valve-mask ventilation with adjuncts in place, a supraglottic airway (e.g. laryngeal mask airway), or definitive airway (endotracheal intubation / surgical airway) by trained personnel.

Step 10: Continuous Reassessment

Assessment of Breathing ("B" in ABCDE)

Step 1: Confirm Breathing is Present

• Look, listen, and feel for about 10 seconds:
  • Look: chest/upper abdomen rising and falling.
  • Listen: air escaping from the nose/mouth.
  • Feel: air movement on your cheek near the patient's mouth/nose.
• If not breathing, or only gasping (agonal breathing) in an unresponsive patient - this is a respiratory/cardiac arrest. Start CPR immediately per resuscitation guidelines; do not spend more time assessing.

Step 2: General Look for Respiratory Distress

• Sweating, central cyanosis (lips, tongue)
• Use of accessory muscles (neck, intercostal, abdominal muscles working)
• Nasal flaring, tracheal tug
• Abnormal chest wall movement: see-saw/paradoxical breathing (chest falls while abdomen rises - a sign of severe obstruction or fatigue)
• Agitation or confusion (an early sign of hypoxia); drowsiness or reduced consciousness (a late, ominous sign of hypercapnia/hypoxia)
• Position the patient adopts (e.g. tripod position in severe distress)

Step 3: Count and Characterize the Respiratory Rate

• Count for a full 30-60 seconds if possible.
• Normal adult range: roughly 12-20 breaths/min.
• Tachypnea (>20-25/min) or a rising trend is an early warning sign that the patient may deteriorate suddenly - even before oxygen saturation drops.
• Bradypnea (<10-12/min) or irregular gasping suggests fatigue, CNS depression, or impending arrest.
• Note the depth (shallow vs deep) and rhythm (regular vs irregular, e.g. Cheyne-Stokes).

Step 4: Inspect the Chest

• Symmetry: is chest expansion equal on both sides? Asymmetry suggests pneumothorax, hemothorax, flail chest, or main-stem bronchial obstruction.
• Wounds/deformity: open chest wounds, flail segments, bruising, distended neck veins, tracheal deviation (tension pneumothorax pushes trachea away from the affected side).
• Work of breathing: accessory muscle use, intercostal/subcostal retractions (especially prominent in children).

Step 5: Listen (Auscultate) and Percuss if Equipment Available

• Auscultate both lung fields: normal vesicular sounds vs absent/decreased breath sounds (pneumothorax, hemothorax, consolidation), crackles (pulmonary edema, pneumonia), wheeze (bronchospasm), or stridor (upper airway - reassess Airway if present).
• Percuss the chest:
  • Hyper-resonance -> may suggest pneumothorax
  • Dullness -> may suggest consolidation or pleural fluid
• Listen for rattling airway noises close to the face - suggests secretions the patient cannot clear (an airway issue that overlaps with breathing).

Step 6: Measure Oxygenation

• Apply a pulse oximeter if available - target SpO2 is generally >94% in most acute patients (individualized in COPD).
• Falling or persistently low SpO2 despite oxygen is a red flag for immediate escalation.
• If available and indicated, an arterial blood gas can clarify hypoxia vs hypercapnia (type 1 vs type 2 respiratory failure), though this should never delay treatment.

Step 7: Identify and Treat Life-Threats Immediately (Don't Wait to Finish the Exam)

Step 8: Give Oxygen and Support Ventilation as Needed

• Give supplemental oxygen to any patient with respiratory distress or low SpO2.
• If breathing is inadequate (very slow, very shallow, or absent), assist with bag-valve-mask ventilation, with airway adjuncts (OPA/NPA) in place, while arranging for advanced airway support if needed.
• Consider non-invasive positive-pressure ventilation (NIPPV/BiPAP) for conditions like pulmonary edema or COPD exacerbation if the patient is conscious and cooperative, with frequent reassessment of work of breathing, heart rate, respiratory rate, and SpO2.

Step 9: Reassess Continuously

• Breathing status can change quickly. Recheck rate, effort, sounds, and SpO2 after every intervention and at regular intervals.
• If the patient becomes unresponsive and stops breathing normally at any point, escalate immediately to resuscitation (CPR/advanced airway).

Quick Summary (BEC-style mental checklist)

Assessment of Circulation ("C" in ABCDE)

Step 1: Look for Signs of Circulatory Compromise

• Skin color and temperature: pale, cool, clammy, mottled skin suggests poor perfusion; warm, flushed skin with bounding pulses can suggest early/distributive shock (e.g. sepsis, anaphylaxis).
• Sweating (diaphoresis) - a sympathetic response to shock.
• Level of consciousness - agitation, confusion, or reduced responsiveness reflects cerebral hypoperfusion.
• Visible external bleeding - obvious hemorrhage from wounds, or blood-soaked clothing/dressings.
• Distended neck veins vs flat neck veins - helps distinguish obstructive/cardiogenic shock from hypovolemic shock.

Step 2: Check the Pulse

• Rate: tachycardia is often the earliest compensatory sign of shock (may occur before blood pressure falls); bradycardia in a shocked patient is an ominous late sign.
• Character: weak/thready pulse suggests hypovolemia; bounding pulse suggests sepsis/distributive states.
• Location as a rough BP guide (useful when no equipment available):
  • Radial pulse palpable -> systolic BP roughly >80-90 mmHg
  • Femoral pulse palpable but not radial -> roughly >70 mmHg
  • Carotid pulse palpable only -> roughly >60 mmHg
• Regularity - irregular pulse may indicate arrhythmia contributing to poor perfusion.

Step 3: Measure Capillary Refill Time (CRT)

1. Apply firm pressure on a fingertip (held at or above heart level) for 5 seconds to cause blanching.
2. Release and time how long the skin takes to return to normal color.
3. Normal: less than 2 seconds. A prolonged CRT suggests poor peripheral perfusion.
4. Note confounders: cold environment, poor lighting, and old age can prolong CRT even without shock.

Step 4: Measure Blood Pressure and Look for Pulse Pressure Changes

• Hypotension is an important, though sometimes late, sign of shock - compensatory mechanisms can maintain BP until they suddenly fail.
• Narrowing pulse pressure (systolic minus diastolic) is an earlier warning sign than a falling systolic pressure alone, because pulse pressure widens early in shock and narrows as compensation fails.

Step 5: Auscultate the Heart and Assess Perfusion Further

• Listen for heart sounds, murmurs, or muffled sounds (consider cardiac tamponade if muffled + hypotension + distended neck veins).
• If available, attach an ECG monitor and check for arrhythmias.
• Check urine output if catheterized/measurable over time - a marker of end-organ perfusion (target >0.5 mL/kg/hr in adults).

Step 6: Identify and Immediately Control Hemorrhage

• External bleeding: apply firm direct pressure; use a pressure dressing; apply a tourniquet proximal to the wound if direct pressure fails to control severe limb hemorrhage.
• Internal/hidden bleeding: consider chest, abdomen, pelvis, and long bones as sources - look for distension, bruising, deformity, and pelvic instability.
• In trauma, "in almost all medical and surgical emergencies, consider hypovolemia the primary cause of shock until proven otherwise" and actively exclude hemorrhage.
• Remember that a breathing problem treated earlier (e.g. tension pneumothorax) can itself cause circulatory collapse - if circulation doesn't improve, re-check Airway and Breathing.

Step 7: Gain IV/IO Access and Begin Resuscitation

• Insert one or two large-bore IV cannulas (or IO access if IV access is difficult, especially in children or profound shock).
• Send blood for cross-match/type and relevant labs if available.
• Fluid resuscitation: give IV crystalloid fluid to any patient with cool peripheries and a fast heart rate, unless there's an obvious cardiac cause of shock (e.g. cardiogenic shock from myocardial infarction, where fluid must be given cautiously).
• For hemorrhagic shock, prioritize blood products over large volumes of crystalloid where available, alongside definitive hemorrhage control.

Step 8: Reassess the Response to Treatment

• Level of consciousness
• Heart rate (improving tachycardia)
• Skin temperature and color
• Capillary refill time
• Blood pressure
• Urine output over time

Quick Summary (BEC-style checklist)

Assessment of Disability (D) and Exposure (E) in the ABCDE Sequence

D - DISABILITY (Neurological Assessment)

Step 1: Assess Level of Consciousness - AVPU

• A - Alert: spontaneously awake and aware
• V - Voice responsive: responds only when spoken to
• P - Pain responsive: responds only to a painful stimulus
• U - Unresponsive: no response to voice or pain

Step 2: Glasgow Coma Scale (GCS) - if more detail needed

Step 3: Check Pupils

• Size, equality, and reaction to light.
• Unequal or non-reactive pupils can indicate raised intracranial pressure, herniation, or focal brain injury.

Step 4: Check Limb Movements for Lateralization

• Compare movement/strength on both sides.
• Asymmetric weakness (hemiparesis) suggests a focal neurological lesion (e.g. stroke, intracranial bleed, spinal injury).

Step 5: Check Blood Glucose - Always

• A critical, easily-reversible cause of altered consciousness. Never skip this step.
• Hypoglycemia can mimic stroke, seizure, or intoxication - treat immediately with oral or IV/IO glucose if low.

Step 6: Consider Other Reversible Causes

• Hypoxia or hypercapnia (recheck Airway/Breathing)
• Hypoperfusion of the brain (recheck Circulation - shock)
• Hypoglycemia
• Drugs/toxins, alcohol
• Seizure (post-ictal state)
• Head injury, stroke, CNS infection

Step 7: Check for Pain

• Ask about pain if the patient can respond - untreated pain worsens physiological stress and should be managed appropriately (analgesia) once life-threats are controlled.

E - EXPOSURE (Full Body Examination and Environmental Control)

Step 1: Expose the Patient Fully

• Remove clothing as needed to perform a head-to-toe examination, looking for injuries, rashes, bleeding sources, medical alert bracelets, track marks, or other clues not visible on initial assessment.
• In trauma, this includes logrolling the patient (with spinal precautions if indicated) to inspect the back, buttocks, and posterior surfaces for wounds or bleeding.
• Look specifically for things easily missed: penetrating wounds, burns, petechiae/purpura (suggesting coagulopathy or meningococcemia), needle marks, medical tags.

Step 2: Protect Dignity and Temperature

• Expose only as much as necessary at a time; cover the patient promptly after examination.
• Prevent hypothermia - use blankets, warm IV fluids if available, and remove wet clothing. Hypothermia worsens coagulopathy and outcomes, especially in trauma/shock.

Step 3: Look for Environmental/Toxicological Clues

• Any signs of exposure to toxins, chemicals, or contamination that require decontamination before further handling.
• Check for signs of self-harm, abuse, or non-accidental injury where relevant.

Step 4: Complete Vital Signs and Temperature

• Record a full set of vital signs including core temperature - fever can point to sepsis/infection as the underlying cause of the presentation; hypothermia needs active rewarming.

Putting It All Together

1. Reassess from A again - the primary survey is a loop, not a single pass. Any deterioration means starting over from Airway.
2. Gather a focused history (e.g. AMPLE: Allergies, Medications, Past medical history, Last meal, Events leading to presentation) once the patient is stabilized.
3. Decide on disposition - further investigations, definitive treatment, or transfer/referral as appropriate to the level of care needed.

Assessment of the Airway (WHO Basic Emergency Care - "A" in ABCDE)

1. Quick Safety Check First

2. Determine if the Airway is Patent

• If they answer normally in a clear voice -> the airway is patent (open) for now, and you move on to assess Breathing.
• If they cannot speak, speak only in a whisper, or make abnormal sounds -> suspect airway compromise and act immediately.

3. Look, Listen, and Feel for Obstruction

• Look: for chest/abdominal movement (see-saw or paradoxical breathing suggests obstruction), accessory muscle use, agitation or confusion (a sign of hypoxia), cyanosis (lips/tongue), visible blood, vomitus, secretions, swelling, or a foreign object in the mouth.
• Listen: put your ear close to the patient's mouth/nose and listen for:
  • Snoring - tongue falling back and partially obstructing the pharynx (common in reduced consciousness)
  • Gurgling - liquid (blood, vomit, secretions) in the airway
  • Stridor (high-pitched sound, usually on inspiration) - obstruction at or above the larynx (e.g. croup, anaphylaxis, foreign body, epiglottitis)
  • Wheeze - lower airway narrowing
  • Hoarse voice - laryngeal involvement
  • Silence with chest movement - complete obstruction (a true emergency)
• Feel: air movement at the nose/mouth on your cheek; feel for tracheal position and any crepitus or swelling in the neck.

4. Classify What You Find

• Patent airway - talking normally, no added sounds.
• Partial obstruction - some air movement but noisy (snoring, gurgling, stridor, wheeze); patient may be agitated or drowsy.
• Complete obstruction - no air movement, no sound, often with paradoxical chest/abdomen movement and rapidly progressing cyanosis. This is immediately life-threatening.

5. Common Causes to Keep in Mind

6. Immediate Actions if the Airway is Not Clear

1. Open the airway: head-tilt/chin-lift in a patient with no suspected spinal injury, or jaw thrust if trauma/C-spine injury is suspected.
2. Clear it: finger sweep or suction visible blood, vomit, or secretions; remove a visible foreign body carefully (do not blind finger-sweep in children if the object isn't visible, to avoid pushing it deeper).
3. Position: recovery (lateral) position in an unconscious, breathing patient without trauma, to let secretions drain and the tongue fall forward off the pharynx.
4. Adjuncts: insert an oropharyngeal (Guedel) airway in the unconscious patient without a gag reflex, or a nasopharyngeal airway if the patient is semi-conscious with an intact gag reflex.
5. Oxygen: give supplemental oxygen to any patient with actual or threatened airway compromise.
6. Call for help early - anaphylaxis, epiglottitis, expanding hematoma, or major facial trauma may need advanced airway management (bag-valve-mask, supraglottic airway, intubation, or surgical airway) that is beyond basic measures.
7. Reassess continuously - after every intervention, go back and re-check airway patency using the same look/listen/feel approach before moving to Breathing.

Key Teaching Point for BEC

Step-by-Step Airway Management (WHO BEC Approach)

Step 1: Assess for Obstruction (Look, Listen, Feel)

• Ask the patient a question - normal speech = patent airway.
• Look for chest/abdominal movement, cyanosis, agitation.
• Listen for snoring, gurgling, stridor, wheeze, or silence with chest movement.
• Feel for air movement at the nose/mouth.

Step 2: Position the Patient

• Place the patient supine on a firm, flat surface.
• No trauma suspected: use the sniffing position - slight neck flexion with head extension (ear canal aligned with the sternal notch). A folded towel under the occiput helps in adults.
• Trauma suspected / C-spine injury possible: keep the head, neck, and trunk in a neutral line. Do NOT extend or flex the neck.

Step 3: Open the Airway (Manual Maneuvers)

1. Place one hand on the forehead, the other under the bony part of the chin.
2. Tilt the head back gently while lifting the chin upward and forward.
3. Continue until the teeth almost touch - this pulls the tongue and epiglottis off the posterior pharyngeal wall.

1. Kneel at the top of the patient's head.
2. Place fingers behind the angles of the mandible on both sides.
3. Push the jaw forward (anteriorly) without tilting the head or neck.
4. Use thumbs to open the lips slightly if needed.

Step 4: Inspect and Clear the Mouth/Oropharynx

• Look inside the mouth for secretions, blood, vomitus, loose dentures, broken teeth, or a visible foreign body.
• Suction any liquid material with a rigid or flexible suction catheter.
• If a foreign body is visible, remove it with a finger sweep or forceps.
• Never do a blind finger sweep - it can push an unseen object deeper and worsen obstruction (current teaching explicitly warns against this, a change from older recommendations).
• Leave well-fitted dentures in place - they improve the seal for bag-mask ventilation later.

Step 5: Reassess

• Improved air entry, normalized sound = maneuver worked, maintain position.
• Still obstructed = move to airway adjuncts.

Step 6: Insert an Airway Adjunct if Needed

1. Size it: measure from the corner of the mouth to the angle of the jaw (or earlobe).
2. Insert "upside down" (curve facing up toward the palate) and rotate 180 degrees as it passes the tongue, OR insert right-side-up using a tongue depressor to hold the tongue down.
3. Reassess air movement.
   • Wrong size risk: too long can trigger vomiting or push the epiglottis into the larynx; too short can push the tongue back and worsen obstruction.

1. Size it: measure from the nostril to the earlobe (or angle of jaw).
2. Lubricate generously with water-soluble gel.
3. Insert into the larger, less obstructed nostril, directed straight back (posteriorly along the floor of the nasal cavity), not upward.
4. Avoid in suspected basilar skull fracture or significant mid-face trauma (risk of intracranial placement, epistaxis).

Step 7: Positioning for Ongoing Protection

• Unconscious, breathing adequately, no trauma: place in the recovery (lateral) position so secretions drain away from the airway and gravity keeps the tongue forward.
• If trauma is suspected, maintain spinal precautions and use suction/jaw thrust rather than repositioning.

Step 8: Give Oxygen

• Apply supplemental oxygen as soon as any airway compromise is identified, even before the airway is fully secured - it extends the time to hypoxia while you work.

Step 9: Escalate if Basic Measures Fail

• Call for advanced help immediately.
• Prepare for bag-valve-mask ventilation with adjuncts in place, a supraglottic airway (e.g. laryngeal mask airway), or definitive airway (endotracheal intubation / surgical airway) by trained personnel.

Step 10: Continuous Reassessment

Step 1: Confirm Breathing is Present

• Look, listen, and feel for about 10 seconds:
  • Look: chest/upper abdomen rising and falling.
  • Listen: air escaping from the nose/mouth.
  • Feel: air movement on your cheek near the patient's mouth/nose.
• If not breathing, or only gasping (agonal breathing) in an unresponsive patient - this is a respiratory/cardiac arrest. Start CPR immediately per resuscitation guidelines; do not spend more time assessing.

Step 2: General Look for Respiratory Distress

• Sweating, central cyanosis (lips, tongue)
• Use of accessory muscles (neck, intercostal, abdominal muscles working)
• Nasal flaring, tracheal tug
• Abnormal chest wall movement: see-saw/paradoxical breathing (chest falls while abdomen rises - a sign of severe obstruction or fatigue)
• Agitation or confusion (an early sign of hypoxia); drowsiness or reduced consciousness (a late, ominous sign of hypercapnia/hypoxia)
• Position the patient adopts (e.g. tripod position in severe distress)

Step 3: Count and Characterize the Respiratory Rate

• Count for a full 30-60 seconds if possible.
• Normal adult range: roughly 12-20 breaths/min.
• Tachypnea (>20-25/min) or a rising trend is an early warning sign that the patient may deteriorate suddenly - even before oxygen saturation drops.
• Bradypnea (<10-12/min) or irregular gasping suggests fatigue, CNS depression, or impending arrest.
• Note the depth (shallow vs deep) and rhythm (regular vs irregular, e.g. Cheyne-Stokes).

Step 4: Inspect the Chest

• Symmetry: is chest expansion equal on both sides? Asymmetry suggests pneumothorax, hemothorax, flail chest, or main-stem bronchial obstruction.
• Wounds/deformity: open chest wounds, flail segments, bruising, distended neck veins, tracheal deviation (tension pneumothorax pushes trachea away from the affected side).
• Work of breathing: accessory muscle use, intercostal/subcostal retractions (especially prominent in children).

Step 5: Listen (Auscultate) and Percuss if Equipment Available

• Auscultate both lung fields: normal vesicular sounds vs absent/decreased breath sounds (pneumothorax, hemothorax, consolidation), crackles (pulmonary edema, pneumonia), wheeze (bronchospasm), or stridor (upper airway - reassess Airway if present).
• Percuss the chest:
  • Hyper-resonance -> may suggest pneumothorax
  • Dullness -> may suggest consolidation or pleural fluid
• Listen for rattling airway noises close to the face - suggests secretions the patient cannot clear (an airway issue that overlaps with breathing).

Step 6: Measure Oxygenation

• Apply a pulse oximeter if available - target SpO2 is generally >94% in most acute patients (individualized in COPD).
• Falling or persistently low SpO2 despite oxygen is a red flag for immediate escalation.
• If available and indicated, an arterial blood gas can clarify hypoxia vs hypercapnia (type 1 vs type 2 respiratory failure), though this should never delay treatment.

Step 7: Identify and Treat Life-Threats Immediately (Don't Wait to Finish the Exam)

Step 8: Give Oxygen and Support Ventilation as Needed

• Give supplemental oxygen to any patient with respiratory distress or low SpO2.
• If breathing is inadequate (very slow, very shallow, or absent), assist with bag-valve-mask ventilation, with airway adjuncts (OPA/NPA) in place, while arranging for advanced airway support if needed.
• Consider non-invasive positive-pressure ventilation (NIPPV/BiPAP) for conditions like pulmonary edema or COPD exacerbation if the patient is conscious and cooperative, with frequent reassessment of work of breathing, heart rate, respiratory rate, and SpO2.

Step 9: Reassess Continuously

• Breathing status can change quickly. Recheck rate, effort, sounds, and SpO2 after every intervention and at regular intervals.
• If the patient becomes unresponsive and stops breathing normally at any point, escalate immediately to resuscitation (CPR/advanced airway).

Quick Summary (BEC-style mental checklist)

Step 1: Look for Signs of Circulatory Compromise

• Skin color and temperature: pale, cool, clammy, mottled skin suggests poor perfusion; warm, flushed skin with bounding pulses can suggest early/distributive shock (e.g. sepsis, anaphylaxis).
• Sweating (diaphoresis) - a sympathetic response to shock.
• Level of consciousness - agitation, confusion, or reduced responsiveness reflects cerebral hypoperfusion.
• Visible external bleeding - obvious hemorrhage from wounds, or blood-soaked clothing/dressings.
• Distended neck veins vs flat neck veins - helps distinguish obstructive/cardiogenic shock from hypovolemic shock.

Step 2: Check the Pulse

• Rate: tachycardia is often the earliest compensatory sign of shock (may occur before blood pressure falls); bradycardia in a shocked patient is an ominous late sign.
• Character: weak/thready pulse suggests hypovolemia; bounding pulse suggests sepsis/distributive states.
• Location as a rough BP guide (useful when no equipment available):
  • Radial pulse palpable -> systolic BP roughly >80-90 mmHg
  • Femoral pulse palpable but not radial -> roughly >70 mmHg
  • Carotid pulse palpable only -> roughly >60 mmHg
• Regularity - irregular pulse may indicate arrhythmia contributing to poor perfusion.

Step 3: Measure Capillary Refill Time (CRT)

1. Apply firm pressure on a fingertip (held at or above heart level) for 5 seconds to cause blanching.
2. Release and time how long the skin takes to return to normal color.
3. Normal: less than 2 seconds. A prolonged CRT suggests poor peripheral perfusion.
4. Note confounders: cold environment, poor lighting, and old age can prolong CRT even without shock.

Step 4: Measure Blood Pressure and Look for Pulse Pressure Changes

• Hypotension is an important, though sometimes late, sign of shock - compensatory mechanisms can maintain BP until they suddenly fail.
• Narrowing pulse pressure (systolic minus diastolic) is an earlier warning sign than a falling systolic pressure alone, because pulse pressure widens early in shock and narrows as compensation fails.

Step 5: Auscultate the Heart and Assess Perfusion Further

• Listen for heart sounds, murmurs, or muffled sounds (consider cardiac tamponade if muffled + hypotension + distended neck veins).
• If available, attach an ECG monitor and check for arrhythmias.
• Check urine output if catheterized/measurable over time - a marker of end-organ perfusion (target >0.5 mL/kg/hr in adults).

Step 6: Identify and Immediately Control Hemorrhage

• External bleeding: apply firm direct pressure; use a pressure dressing; apply a tourniquet proximal to the wound if direct pressure fails to control severe limb hemorrhage.
• Internal/hidden bleeding: consider chest, abdomen, pelvis, and long bones as sources - look for distension, bruising, deformity, and pelvic instability.
• In trauma, "in almost all medical and surgical emergencies, consider hypovolemia the primary cause of shock until proven otherwise" and actively exclude hemorrhage.
• Remember that a breathing problem treated earlier (e.g. tension pneumothorax) can itself cause circulatory collapse - if circulation doesn't improve, re-check Airway and Breathing.

Step 7: Gain IV/IO Access and Begin Resuscitation

• Insert one or two large-bore IV cannulas (or IO access if IV access is difficult, especially in children or profound shock).
• Send blood for cross-match/type and relevant labs if available.
• Fluid resuscitation: give IV crystalloid fluid to any patient with cool peripheries and a fast heart rate, unless there's an obvious cardiac cause of shock (e.g. cardiogenic shock from myocardial infarction, where fluid must be given cautiously).
• For hemorrhagic shock, prioritize blood products over large volumes of crystalloid where available, alongside definitive hemorrhage control.

Step 8: Reassess the Response to Treatment

• Level of consciousness
• Heart rate (improving tachycardia)
• Skin temperature and color
• Capillary refill time
• Blood pressure
• Urine output over time

Quick Summary (BEC-style checklist)

D - DISABILITY (Neurological Assessment)

Step 1: Assess Level of Consciousness - AVPU

• A - Alert: spontaneously awake and aware
• V - Voice responsive: responds only when spoken to
• P - Pain responsive: responds only to a painful stimulus
• U - Unresponsive: no response to voice or pain

Step 2: Glasgow Coma Scale (GCS) - if more detail needed

Step 3: Check Pupils

• Size, equality, and reaction to light.
• Unequal or non-reactive pupils can indicate raised intracranial pressure, herniation, or focal brain injury.

Step 4: Check Limb Movements for Lateralization

• Compare movement/strength on both sides.
• Asymmetric weakness (hemiparesis) suggests a focal neurological lesion (e.g. stroke, intracranial bleed, spinal injury).

Step 5: Check Blood Glucose - Always

• A critical, easily-reversible cause of altered consciousness. Never skip this step.
• Hypoglycemia can mimic stroke, seizure, or intoxication - treat immediately with oral or IV/IO glucose if low.

Step 6: Consider Other Reversible Causes

• Hypoxia or hypercapnia (recheck Airway/Breathing)
• Hypoperfusion of the brain (recheck Circulation - shock)
• Hypoglycemia
• Drugs/toxins, alcohol
• Seizure (post-ictal state)
• Head injury, stroke, CNS infection

Step 7: Check for Pain

• Ask about pain if the patient can respond - untreated pain worsens physiological stress and should be managed appropriately (analgesia) once life-threats are controlled.

E - EXPOSURE (Full Body Examination and Environmental Control)

Step 1: Expose the Patient Fully

• Remove clothing as needed to perform a head-to-toe examination, looking for injuries, rashes, bleeding sources, medical alert bracelets, track marks, or other clues not visible on initial assessment.
• In trauma, this includes logrolling the patient (with spinal precautions if indicated) to inspect the back, buttocks, and posterior surfaces for wounds or bleeding.
• Look specifically for things easily missed: penetrating wounds, burns, petechiae/purpura (suggesting coagulopathy or meningococcemia), needle marks, medical tags.

Step 2: Protect Dignity and Temperature

• Expose only as much as necessary at a time; cover the patient promptly after examination.
• Prevent hypothermia - use blankets, warm IV fluids if available, and remove wet clothing. Hypothermia worsens coagulopathy and outcomes, especially in trauma/shock.

Step 3: Look for Environmental/Toxicological Clues

• Any signs of exposure to toxins, chemicals, or contamination that require decontamination before further handling.
• Check for signs of self-harm, abuse, or non-accidental injury where relevant.

Step 4: Complete Vital Signs and Temperature

• Record a full set of vital signs including core temperature - fever can point to sepsis/infection as the underlying cause of the presentation; hypothermia needs active rewarming.

Putting It All Together

1. Reassess from A again - the primary survey is a loop, not a single pass. Any deterioration means starting over from Airway.
2. Gather a focused history (e.g. AMPLE: Allergies, Medications, Past medical history, Last meal, Events leading to presentation) once the patient is stabilized.
3. Decide on disposition - further investigations, definitive treatment, or transfer/referral as appropriate to the level of care needed.

🚨 SIMULATION CASE: Road Traffic Accident

• Time since injury: ~15 minutes
• No history available yet (patient can't give it)
• He is lying supine on the trolley now, helmet already removed by bystanders (unknown how it was removed)

• Patient is making noisy, gurgling sounds
• There is blood around his mouth and a laceration on his forehead
• His right leg looks deformed at the mid-thigh, with an obvious bone fragment area but no active spurting bleeding
• He groans when you shout his name but does not open his eyes or speak words
• Skin looks pale

Your Task

1. What you'd look/listen/feel for
2. What you suspect is happening with this airway
3. What immediate action you'd take

• Look: There's blood pooling around his lips and inside his mouth. You don't see a foreign body, but his mouth is bloody and he hasn't cleared it himself. His chest is moving, but you notice some see-saw type effort.
• Listen: You hear that gurgling sound clearly when you put your ear close to his mouth - a wet, bubbling noise on each breath.
• Feel: You feel warm, moist air on your cheek with each breath, so air is moving, just noisily.

• The gurgling sound is gone.
• You now hear quieter, clearer breath sounds - but there's a faint snoring quality on inspiration.
• Chest still moving, rate looks fast.

• Insert the OPA (sized from corner of mouth to angle of jaw/earlobe).
• If he tolerates it without gagging or coughing - confirms he's deeply unconscious enough, leave it in.
• If he gags, retches, or tries to bite down - remove it immediately (risk of vomiting/aspiration) and consider a nasopharyngeal airway instead, since you correctly noted there's no facial/basilar skull trauma making NPA unsafe.

Moving to Breathing

• Look: His chest is moving, but you notice the right side of his chest is not rising as much as the left - there's visible asymmetry. He's using his neck and shoulder (accessory) muscles to breathe. There's bruising over the right lateral chest wall, likely from the impact.
• Count: Respiratory rate is 32/min, shallow.
• Feel: You place your hands on both sides of his chest for expansion - the right side lags behind the left.
• A colleague hands you a pulse oximeter: reading is SpO2 88% on room air (you haven't given oxygen yet).
• You have a stethoscope. If you auscultate the chest, and if you percuss it - what would you specifically be listening/feeling for, and what are you worried this could be given the mechanism (motorbike vs pedestrian, chest wall bruising, asymmetry, low SpO2)?

• Auscultation: Breath sounds are markedly decreased to absent on the right side, normal on the left.
• Percussion: Right side is hyper-resonant compared to the left.
• You also notice his trachea feels slightly deviated toward the left on palpation, and his neck veins look distended.
• Someone calls out his BP: 88/54 mmHg, HR 128.

Two accepted landmarks (guidelines differ)

Completing the action

• Cannula: large-bore, 14-16 gauge angiocatheter, ideally long (5-8 cm) since a meta-analysis shows a high failure rate with standard-length needles failing to reach the pleura.
• Before/alongside decompression: give high-flow oxygen immediately, keep the pulse oximeter on, and have suction/chest tube equipment ready since needle decompression is a temporizing measure - he'll need a chest tube (tube thoracostomy) placed definitively afterward.