Prepared by: TIM Makara,AD_KSFH
ABCDE Approach: Key Principles, Summary, and Best Practices in Anesthesia
The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) is a systematic
framework for assessing and managing critically ill patients, including those undergoing
anesthesia. Originally developed for trauma resuscitation, it is now universally applied in
perioperative and critical care settings to prioritize life-threatening conditions [1][5]. This
review synthesizes its key principles, anesthesia-specific applications, and evidence-based best
practices.
1. Key Principles and Rationale
• Universal Applicability: Applicable to all critically ill patients regardless of etiology
(e.g., trauma, medical emergencies, perioperative crises) or age [1][12].
• Sequential Prioritization: Addresses threats in order of physiological precedence:
Airway compromise kills before breathing failure, which kills before circulatory
collapse [2][5].
• Dynamic Reassessment: Mandates continuous reevaluation after each intervention
(e.g., recheck airway after intubation before assessing breathing) [1][4].
• Interprofessional Standardization: Creates a shared mental model for teams,
improving communication and reducing errors during crises [2][12].
• Intervention Before Diagnosis: Emphasizes stabilization before definitive
diagnosis (e.g., decompress tension pneumothorax empirically based on signs) [5].
2. Step-by-Step Summary with Anesthesia-Specific Considerations
A: Airway
• Assessment:
o Patency: Voice quality (normal speech = patent), stridor, gurgling, silence [14].
o Obstruction Risks: Depressed consciousness (Guedel’s Stage 2 anesthesia),
edema, secretions, blood, or vomit [8][14].
• Interventions:
o Basic: Head-tilt chin-lift (non-trauma), jaw-thrust (suspected cervical spine
injury) [1][5].
o Advanced: Oropharyngeal/nasopharyngeal airways, rapid sequence intubation
(RSI), surgical airway (cricothyroidotomy) [5][14].
o Anesthesia Focus: Laryngospasm management during Stage 2 (Excitement
phase), suctioning under deep anesthesia (Stage 3, Plane 1) [8].
B: Breathing
• Assessment:
o Rate/Pattern: Tachypnea (>25/min), bradypnea (<12/min), Cheyne-Stokes,
Kussmaul [4].
o Effort: Accessory muscle use, tracheal deviation, paradoxical breathing [2][5].
o Auscultation: Unilateral absent sounds (pneumothorax), wheeze
(bronchospasm) [4].
o Monitoring: SpO₂ (target 94–98%; 88–92% in severe COPD), end-tidal
CO₂ (detect hypercapnia) [2][14].
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Prepared by: TIM Makara,AD_KSFH
• Interventions:
o Oxygen: High-flow via non-rebreather mask (15 L/min) [1].
o Life-Threats: Needle decompression (tension
pneumothorax), bronchodilators (status asthmaticus), positive pressure
ventilation [5].
o Anesthesia Focus: Bag-mask ventilation during difficult intubation, NIV for post-
extubation support [1][4].
C: Circulation
• Assessment:
o Perfusion: Capillary refill >2 sec, mottling, cool extremities [2][9].
o Hemodynamics: Hypotension (SBP <90 mmHg), tachycardia, narrowed pulse
pressure (<35 mmHg) in hypovolemia [5].
o Bleeding: Revealed (external) vs. concealed (thoracic, abdominal, pelvic) [5][9].
• Interventions:
o Hemorrhage Control: Direct pressure, tourniquets, surgical control [5].
o Fluid Resuscitation: Isotonic crystalloids (1–2 L) → blood products (massive
transfusion protocol) [5][9].
o Anesthesia Focus: Vasopressors for septic/distributive shock, tranexamic acid for
surgical bleeding [1][2].
D: Disability (Neurological)
• Assessment:
o Consciousness: AVPU scale (Alert, Voice, Pain, Unresponsive) or GCS [1][5].
o Pupils: Size, reactivity, asymmetry (signifying herniation) [4][10].
o Glucose: Point-of-care testing (hypoglycemia mimics coma) [4].
• Interventions:
o Airway Protection: Intubate if GCS ≤8 [5].
o Specific Treatments: Glucose (D50W for hypoglycemia), naloxone (opioid
overdose), mannitol (raised ICP) [4].
o Anesthesia Focus: Depth monitoring (BIS) to avoid Stage 4 (Overdose) [8].
E: Exposure/Environment
• Assessment:
o Full Examination: Log-roll to inspect posterior surfaces for wounds, rashes,
bleeding [4][5].
o Temperature: Hypothermia (<36°C) common post-resuscitation/OR [1][2].
• Interventions:
o Warmth: Forced-air warmers, fluid warmers, ambient temperature control [1][2].
o Remove Hazards: Wet clothing, cold surfaces [4].
o Anesthesia Focus: Normothermia maintenance to prevent coagulopathy and
arrhythmias [1][2].
Table: Key Anesthesia-Specific ABCDE Considerations
Component Anesthesia Risk Factors Critical Interventions
Airway Laryngospasm (Stage 2), aspiration RSI, video laryngoscopy, suction
Breathing Opioid-induced apnea, atelectasis Naloxone, PEEP, recruitment
maneuvers
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Prepared by: TIM Makara,AD_KSFH
Circulation Anesthetic-induced vasodilation Vasopressors, goal-directed fluid
therapy
Disability Delayed emergence, intra-op EEG monitoring, reversal agents
awareness
Exposure Impaired thermoregulation Forced-air warming, warmed IV fluids
3. Best Practices in Anesthesia
• Team Training: Simulation-based drills improve adherence from 29–35% pre-training
to 65–97% post-training [3][12]. Assign clear roles (e.g., team leader, airway manager,
circulator) [5][12].
• Cognitive Aids: Use checklists for crises (e.g., malignant hyperthermia,
anaphylaxis) [10][12].
• Monitoring Integration: Combine ABCDE with multimodal monitoring (e.g., SpO₂,
EtCO₂, arterial line, BIS) [8][14].
• Tailored Oxygenation: Avoid hyperoxia in COPD; use Venturi masks for precise FiO₂
control [2][4].
• Temperature Management: Active warming for all cases >30 minutes; monitor core
temperature [12][14].
• Postoperative Vigilance: Apply ABCDE in PACU for extubation readiness assessment
and post-extubation care [14].
• Knowledge Maintenance: Annual reassessment of ABCDE knowledge; deficits are
common among non-critical care specialists [3][9][10].
Table: Adherence to ABCDE Approach by Provider Factors
Factor Impact on Adherence/Knowledge Evidence
Specialty ICU/ED > Anesthesiology/Cardiology Schoeber et al.
2022 [3][10]
Experience >10 years > <5 years Alqahtani et al. 2024 [9]
Simulation Training 65–97% post-training vs. 29–35% Scoping Review [12]
baseline
Team Leader 84% adherence vs. 33% without leader Koko et al. 2023 [12]
Presence
4. Evidence Base and Limitations
• Effectiveness: Associated with earlier threat identification, improved team
communication, and reduced omission of critical steps [1][12].
• Gaps: Direct mortality impact remains understudied; adherence varies widely (18–84%
clinically) [1][23].
• Barriers: Algorithm complexity, time pressure, and inconsistent training limit
adherence [3][10].
5. Conclusion
The ABCDE approach is the cornerstone of managing critical events in anesthesia. Its power
lies in standardization, prioritization, and team alignment. Best practices include simulation
training, integrated monitoring, and temperature management. Future efforts should focus on
simplifying tools, linking adherence to patient outcomes, and specialty-specific training (e.g.,
for cardiothoracic anesthesiologists) [9][12].
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Prepared by: TIM Makara,AD_KSFH
References (Vancouver Style)
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Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med.
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approach: a cross-sectional study. BMC Emerg Med. 2022;22(1):202.
doi:10.1186/s12873-022-00753-y [3][10]
4. Geeky Medics. ABCDE Assessment - OSCE Guide. Accessed July 1,
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