xABCDE: Priority list for emergencies
The story of the ABCDE scheme begins with Peter Safar, who established several fundamental principles of cardiopulmonary resuscitation (CPR) in the 1950s. Among other things, he demonstrated on unconscious individuals (i.e., people who, thanks to medication, could no longer move a single muscle) that mouth-to-mouth resuscitation is effective and that tilting the head back on an unconscious person saves their life because tilting the tongue away from the beginning of the trachea (1). His book "ABC of Resuscitation" laid the foundation for all resuscitation guidelines and led to CPR being taught nationwide. Before this book, you were simply considered dead, Hollywood-style, if you had no pulse. Over time, the scheme was refined into ABCDE and placed under the umbrella of what is probably the most famous phrase in trauma care:
“Treat first, what kills first!”
The letters referred not only to the time it took to die, but also to organ systems: A – Airways, B – Breathing, C – Circulation, D – Disability (Nervous System), E – Exposure. There are few things that cause instantaneous death. Absence of oxygen is one of them. And the ABCDE approach was about getting oxygen into the body using A and B. Because after about four minutes without air, the brain suffers and reacts with rapid intellectual decline and the death of nerve cells.
Almost 60 years later, TJ Hodgetts summarized the medical efforts of the British military:
where rapid hemostasis has increasingly become the focus of immediate treatment (2).
Even if we get oxygen all the way to the lungs, we still need blood to transport it to the end organs. This was already known, which is why the "C" was in the scheme. But it took some time to numerically prove that the survival rate demonstrably increases when severe bleeding is stopped immediately. Thus, the cABCDE scheme was born, which was renamed xABCDE shortly afterward. Firstly, because an "X" simply makes everything more awesome (ask Elon Musk), secondly, to avoid confusion with two different "C"s, and thirdly, to adequately address internal bleeding with eXsanguation (excess bleeding). While we can't stop this externally, it always leads to the decision to get to the hospital as quickly as possible.
This system has been around for over 50 years. I'd bet that everyone who's had any kind of training in emergency medicine has heard of it. And that's worldwide. So it seems to be important and to solve problems. And in keeping with our educational mission, let's now go through each letter individually.
x ABCDE
The "x" in eXsanguation stands for the mother of all bleeding. Whether you're faced with arterial fountains or venous bleeding that could fill the Red Sea, the priority is to stop the bleeding quickly. In the worst-case scenario of a brutal thigh injury, you only have a few minutes to stop the bleeding before the affected person dies. With very few exceptions, bleeding should always be stopped with manual pressure and pressure bandages. Manual pressure is the technical term for applying firm pressure to the wound with a pat of the hand. And for all our self-proclaimed, tourniquet-wielding super-medics: manual pressure is sufficient in the vast majority of cases. You don't always have to apply a tourniquet to the entire limb.
x A BCDE
The letter A stands for airways and often leads to confusion with the next letter. In very simple terms, A refers only to the mouth and trachea, not the lungs themselves. It comes second in our diagram because, as mentioned above, our brain feels neglected after four minutes without oxygen and reacts defiantly with cell death. Besides throat swelling of various causes, we are also interested here in classic cases like loss of consciousness or the "Bockwurst death" (a type of death caused by a foreign object lodged in the trachea). This occurs when a foreign object is lodged in the trachea, which should first be removed by firmly tapping between the shoulder blades, and if this is unsuccessful, by applying abdominal compressions.
xA B CDE
From B onwards, things get a bit more complicated. Ventilation generally revolves around all the processes that occur within the lungs. These can be disrupted by anything from an asthma attack to pneumonia to a (multiple) rib fracture. However, initial clues to an existing B-problem can be obtained by observing how the affected person breathes. Asking, "Are you getting enough air?" is a rarely considered trick that doesn't require a medical degree. If the answer is a sentence interrupted at least once by a pause, we can be fairly certain that there's a problem within the lungs. At that point, you can help the affected person sit upright and then consider the underlying cause and how to address it.
xAB C DE
C stands for circulatory system, representing the heart and blood volume. Is the heartbeat too fast, too slow, or are all parts of the body still receiving adequate blood flow? These are the questions to be answered in this section. Here, in addition to measuring pulse rate and blood flow, questioning proves to be a helpful tool. Whether the person is experiencing dizziness or feeling cold are often indicators of a C-related problem. It's also a good idea to ask about the cause. Besides the usual traumatic issues, where the person is bleeding where they shouldn't, a heart attack or explosive vomiting and diarrhea could also be the underlying cause of a circulatory problem.
xABC D E
When I think about disability, I always laugh about a situation from my training. We were simulating case studies, and I was supposed to play an elderly, confused stroke patient. My colleague came into the room, and when he asked what had happened, I snapped at him that I was Homer Simpson and he should get me a beer. To this day, I don't know which of us looked more like we had an acute neurological problem at that moment.
But D generally refers to the brain and neural pathways. Classic indicators to watch for include the aforementioned stroke, but also personality changes due to hypoglycemia or after a fall on the head. When assessing someone's state of consciousness, it's crucial to examine both the quantity and quality of their awareness. Quantity refers to how much consciousness the person currently possesses. Are they fully present, or merely reacting to being spoken to or experiencing pain? The quality is well illustrated by the Homer Simpson anecdote. While I was quantitatively fully present, the quality left much to be desired. If people are disoriented, losing track of where they are, when they are (a month is sufficient; otherwise, half of all students would have a D problem), and who they are, then a visit to the hospital is advisable to address the underlying cause.
xABCD E
The final stage of our scheme, called Exposure (or Extra), covers all the issues that don't fall into the problem categories already presented. A more thorough examination of the preceding points should also be conducted, and consideration should be given to further treatment or evacuation. The most important medical considerations would be thermal disorders such as heatstroke and hypothermia. And a crucial point for all helpers: remember to maintain body temperature. Our patients are almost always cold! The exception is heat-related disorders, but otherwise, maintaining body temperature is always a good idea!
Once you've worked through this scheme, you'll have identified the most critical medical problems and, if necessary, taken initial measures. Now it's crucial to reassess the individual at regular intervals. Emergency situations are always dynamic and change over time. The brilliant thing is, we simply use the xABCDE scheme again for this assessment. And if you'd like to learn how to do this yourself, feel free to check out... our courses over!