The ABCDE assessment forms part of Phase 1 of the Triage Consultation Model.
ABCDE and the Clinical Presentation
Assessing the ABCDE and the patient’s clinical presentation is a mandatory part of every triage consultation.
The time of symptom onset is an important factor in determining the urgency level. Ask focused questions, explore the answers in more detail where necessary, and consider whether each question is relevant. Applying contextual thinking is often one of the most challenging aspects of triage.
Important questions include:
- What are the patient’s symptoms, or what has happened?
- When did the symptoms begin?
- Is the patient alert and able to speak on the telephone?
- How is the patient’s breathing?
- Is there any bleeding?
- Have you noticed any changes in skin colour?
- Is the patient passing urine?
- Is the patient nauseated, dizzy, sweating or anxious?
- How unwell does the patient appear? For example, do they have a fever?
- What is the patient still able to do independently?
- Are there any other symptoms?
- Is this a new complaint or a recurring problem?
- Has the patient already taken any medication or tried any treatment?
Always determine whether the symptoms started suddenly or developed gradually, and whether the patient’s condition is stable, improving, or deteriorating.
In high-urgency situations, rapid assessment takes priority over following the consultation model step by step. Continuously consider whether the patient’s vital functions are at risk.
Airway (A)
Assess whether the airway is open and unobstructed.
Pay attention to:
- Airway noises
- Shortness of breath
- Signs of an allergic reaction
If the airway is compromised, take immediate action.
Breathing (B)
Assess the patient’s breathing.
Pay attention to:
- Breathing rate
- Shortness of breath
- Whether the patient is able to speak in full sentences
Severe respiratory distress is a sign of a high-urgency situation.
Circulation (C)
Assess the patient’s circulation.
Pay attention to:
- Bleeding
- Skin colour
- Signs of shock, such as sweating, a rapid pulse, or reduced responsiveness
Disability (D)
Assess the patient’s level of consciousness.
Any alteration in consciousness requires prompt assessment and action. Consider possible causes such as hypoglycaemia or an acute neurological condition.
Exposure and Environment (E)
Assess factors that may influence the patient’s condition, including:
- Body temperature
- Pain
- Environmental factors
Always consider the patient’s overall clinical presentation when determining the appropriate urgency level.
