Continuing from last week’s post on cABCDE we’ll be starting with B, Breathing. In the previous post we discussed catastrophic bleeding and opening the airway, this will take a matter of seconds.
B – Breathing
The initial step to take is to listen, see and feel if the patient is breathing. This is done by opening the airway either by a jaw thrust or a head tilt chin lift and then placing you cheek near the patients mouth so you can feel their breath against your cheek. This also allows you to look down their chest to see if their chest is rising equally. This is done for 10 seconds, if no breath is noted then CPR (cardiopulmonary resuscitation) needs to be commenced and help needs to be on its way, preferably with an AED. If a breath is noted within the 10 seconds then a full assessment of the patients breathing can be carried out.
A respiratory rate can be counted, how many times the patient breaths in a minute, the normal range for this is 10-20. An oxygen saturation probe can be attached to the patient’s finger if there is one available, this should be above 94%, so 88%-92% if the patient has a history of COPD. The trachea in the neck needs to be checked to make sure it is central, if it’s deviated to one side then that indicates a tension pneumothorax, where air gets between the layer of pleura that coats the inside of the chest wall and the layer of pleura that covers the lung. When so much air gets in between these layers the pressure pushes the thoracic content to the other side of the chest. Checking that both sides of the chest are expanding equally and if possible use a stethoscope to assess if there are breath sounds on both sides of the chest and if there is any added sounds like wheeze, which could indicate asthma attack or crackles which could indicate an infection.
C – circulation
This is an assessment of how the heart is pumping blood around the body. A basic assessment is the colour of the patient, if they are pale or well perfused. A blood pressure reading can tell you a lot about the condition of the patient. However, if a blood pressure cuff is not available then a rough estimate can be achieved from the pulses that are present. If a radial pulse is present then the systolic pressure is at least 90mmHg, if a femoral pulse is present then systolic is at least 60mmHg. A heart rate can also be established from the pulse and if this is regular or irregular. An irregular pulse can indicate atrial fibrillation which if this of new onset can indicate a variety of thing such as infection.
D – disability
This usually refers to a neurological issue. The Glasgow Coma Scale is used to assess the conscious level of a patient. This is based on 3 criteria, eye, verbal and motor response. The maximum score is 15 whereas the minimum score is 3. Any patient that scores an 8 or below should be intubated.
A few checks that can be easy to do are to look at the patients’ pupils to see if they are of equal size. The pupils can also be checked to see if they are reactive, this can be achieved with the torch on your phone. Due to the pupil light reaction when light is passed into a pupil the pupil will constrict due to a reflex the other pupil will also constrict even if light isn’t passed into the other pupil. If one of the pupils doesn’t constrict this can signify a problem with the reflex pathway within the brain.
Another important assessment is to test the patients’ blood sugars. This needs a BM kit in order to test. A level below 3.0mmol/L is called hypoglycaemia and hyperglycaemia is above 11mmol/L. These conditions can cause neurological symptoms such as drowsiness and blurred vision. Hypoglycaemia can be easily corrected with glycogel or if that isn’t available a sugary drink can help with symptoms.
E – exposure
This assessment is to check everything else that might initially distract you from the patient’s condition as a whole, such as an open fracture. Gloved hands are used to pat down the patient to check for pain and blood that might not be immediately obvious. Don’t forget to check the back of the patient.
Don’t forget to think about temperature at this point too. If you are unable to check temperature using a probe then just consider the environment. If the patients core body temperature drops below 34 degrees Celsius then they have an increased risk of mortality, despite minimal injuries.