The Basic Principles of the A-E Assessment
Created by sudiksha devendra kumar
Welcome to this self study session on the basic principles of the A-E Assessment! The session is split into 2 parts: Part 1 will teach you the A-E Assessment Part 2 will test what you have learnt with an interactive simulation!
continue
Intended Learning Outcomes
By the end of this session you should be able to:
- Describe the A-E assessment- Perform an A-E assessment - Feel confident performing the A-E assessment - Respond appropriately to A-E assessment findings
continue
Already completed the teaching component? Click here to skip to the simulation component!
Pre-Session Confidence
Before we get started with the teaching...
How confident do you feel performing the A-E Assessment on a scale of 1 to 5?
1 = not confident at all5 = very confident
continue
Why do we do an A-E Assessment?
In an emergency scenario, it allows us to identify and address the most life-threatening issues first before moving on to more specific assessments.
continue
Click on each letter to reveal the answer!
What does A-E stand for?
Airway
Breathing
Circulation
Disability
Exposure
continue
Before we start, we always want to check our patient details.
If the patient is conscious, we will ask for their name and date of birth.However if they are unable to tell us this (e.g. they are unconscious, have dementia) then we can look at the patient wristband to check their name, date of birth, and NHS number.
continue
Brief history before A-E assessment
Before we proceed with the assessment, it is good practice to take a brief history so we know what symptoms the patient is experiencing. Can you think of what we may want to ask in the emergency setting?
continue
Brief history before A-E assessment
Before we proceed with the assessment, it is good practice to take a brief history so we know what symptoms the patient is experiencing. Can you think of what we may want to ask in the emergency setting?
We want to ask about:- Presenting complaint and history of presenting complaint (brief) - Current medical conditions - Current medications - Allergies
There is no correct history format so you may see variations of this in practice - just make sure to keep your history brief to around 2-3 minutes.
continue
Now let's move on to assessing the patient!
A - Airway Assessment
If the patient is able to talk to you and give you a history - the airway is open and no intervention is required.If they are unconscious or unresponsive, shake them by the shoulders and say their name to see if you can rouse them. If they still do not respond then apply a pain stimulus, such as a trapezius squeeze. If unarousable, you need to formally assess the airway.
continue
A - Airway Assessment
If unconscious/unresponsive:- Do a head tilt chin lift - Place the side of your face by the patient's mouth to feel for breath and look at their chest for rise and fall (except in suspected COVID) - If there is no pulse or chest movement - this is a cardiac arrest, you need to call for help and start chest compressions
continue
A - Airway Assessment
If you suspect airway obstruction, look in the mouth:- If you can see any obstructing material → remove material with suction - If you cannot see any obstruction → open up the airway with a oropharyngeal or nasopharyngeal airway - If they are not tolerating this or difficulties arise, call the anaesthetists
continue
Airway adjuncts
There are different airway adjuncts you can use, and different sizes are used depending on the patient.These are found in the top drawer of the crash trolley.
continue
Airway adjuncts
Nasopharyngeal airways tend to be better tolerated, here is how to measure size from the tip of the nose to the earlobe:
Insert the airway through the nostril with the inner curve facing towards the patient, advance until in position
Use the oropharyngeal airway if there is an absent gag reflex, here is how to measure the size from the midpoint of the incisors to the angle of the mandible:
Insert with the inner curve initially towards the roof of the mouth (to prevent further pushing back the tongue) then once you advance it further, rotate the airway 180 degrees so it sits above the tongue
continue
Airway Adjuncts
Watch these videos to observe the technique used to insert different airway adjuncts
Nasopharyngeal:
Oropharyngeal:
continue
B - Breathing Assessment - Inspection
When assessing breathing we want to inspect, then touch/palpate and then listen
On inspection:- Look for central cyanosis, use of accessory muscles of respiration, chest wall deformities and abdominal breathing - Count the respiratory rate over 1 minute (the normal range is 12-20)
Here you can see a patient using their accessory muscles of respiration:
continue
B- Breathing Assessment - Touch / Palpation
- Measure oxygen saturations using a pulse oximeter: if it is below 94% then give 15 litres of high flow oxygen through a non-rebreathe mask, aiming for saturations of 94-98% (or aim for 88-92% for patients with COPD due to the risk of respiratory depression)- If the patient is not ventilating well themselves, a bag-valve-mask can be used to aid ventilation, or consider Non-Invasive Ventilation (NIV)
continue
B- Breathing Assessment - Touch / Palpation
- Feel the trachea - is it central or deviated? If deviated... you should be worried about a tension pneumothorax - Examine chest expansion - is it equal or is it reduced on one or both sides?- Percuss the chest (see below for percussion points)Hyperresonance could indicate pneumothorax Dullness could indicate consolidation e.g. due to pneumonia Stony dullness could indicate pleural effusion
Chest percussion points:
continue
B - Breathing Assessment - Auscultation
- Auscultate the chest (in the same spots you percussed) and listen to the breathing sounds- If reduced or absent this could indicate a pneumothorax - If you hear coarse crackles this could indicate an infection
Chest auscultation points:
continue
Breathing Assessment - Next Steps
Use your findings to come up with potential differential diagnoses. You can order a chest X-ray and/or an arterial blood gas to help with diagnosis and management. If a clinical diagnosis is made, e.g. of tension pneumothorax, prioritise managing and treating this before continuing with the assessment.
continue
C - Circulation Assessment
To assess circulation work in a C motion - start peripherally at the hands and then work your way up!
continue
C - Circulation Assessment
- Look at the colour of the hands: are there any signs of peripheral cyanosis or are they cold to touch? - Measure capillary refill time by pressing for 5 seconds and looking at the nail; circulation should spontaneously return in 2 secondsIf prolonged this is a sign of poor peripheral perfusion - Feel the pulse to measure the pulse rate, rhythm and character (normal heart rate is 60-100 beats per minute)
continue
C - Circulation Assessment
- Measure the blood pressureIf this is below 90mmHg systolic or 60mmHg diastolic, you need to insert a large bore cannula (14 or 16 guage, usually orange or grey) to take bloods and give a rapid bolus of 500ml 0.9% sodium chloride over 15 minutes (reassess the BP once the fluids have run through) - In the neck look for the Jugular Venous Pressure (JVP): is it raised or normal?If raised this could indicate many different pathlogies
Click here for some causes of raised JVP
Measurement of JVP:
continue
45°
Circulation Assessment
- Finish the circulation assessment by auscultating the heart to listen for any murmurs or a pericardial rub (which could indicate pathologies such as pericarditis) If there are any abnormalities in the circulation assessment or if you are suspecting a cardiac cause for their presentation, perform an ECG and check the troponin levels in the blood.
continue
Disability Assessment
Here you assess the other things that did not fit in ABC, but are still important!- Assess consciousness level using AVPU (or GCS can also be used especially if you are suspecting a head injury)
Alert Voice Pain Unresponsive
Alert and responsive without any stimuli
Responding to voice
Only responding to painful stimuli
Not responding at all
continue
Disability Assessment
- Examine the pupils with a pen torch to see if the pupillary reflexes are normal, also known as PEARL (Pupils Equal And Reactive to Light); the pupil should normally constrict with the light from the pen torch- If the pupillary reflexes are abnormal then you should be worried about intracranial pathology
continue
Disability Assessment
- Measure the blood glucose: if this is below 4mmol/L the patient is hypoglycaemic → if the patient is conscious then give them a source of glucose from the Hypo Box or if they are unconscious give them 50ml of 10% glucose solution IV. Keep re-assessing the glucose levels until they reach normal levels.- Measure the temperature - the normal is 36.5 to 37.5°C
continue
Exposure
- Here you want to expose the patient to look for anything that could be causing the presentation. You have to look top to toe and front to back!- Always maintain dignity and minimise heat loss to keep the patient comfortable- draw the curtains and only make sure the people you need are there
continue
Exposure
- The best way to do this is expose the top half then the bottom half looking for wounds, injuries, signs of infection (potentially causing sepsis), bleeding etc.- At this point you can also examine any relevant systems that have not yet been examined e.g. abdominal exam
continue
What do I do after completing the A-E Assessment?
- Put out any alerts that need to be done for your patient e.g. peri-arrest call, activating the major haemorrhage protocol- Escalate your patient to a senior doctor - Refer your patient to the relevant specialities (using a SBAR handover) - Repeat your A-E to keep assessing your patient until further help arrives or a management plan is created - You can also take any further history required if relevant (e.g. social history), perform further examinations and order any other investigations
continue
Part 1 Complete!
Well Done - you have now completed the teaching component of this resource!
Or click here to return to the start of Part 1!
Click here to move on to the simulation!
Simulation briefing
Welcome to the A&E department! You are the FY1 on shift today - this will involve you carrying out initial assessments for patients before they are seen by a senior or speciality doctor. You will be presented with an unwell patient, and you will be able to choose your next steps by clicking on items/areas on the screen (like you would do in real life) - but remember your actions have consequences!
Start
Additionally you can click on the patient to interact e.g. check patient wristband by clicking on it
Symbol Keys
The icons mean the following:
Speak to the patient
Take a history
Inspection
Call a senior/speciality doctor
Examination
Order investigations e.g. bloods
Carry out A-E assessment (you can also interact with each drawer as part of your assessment)
continue
Remember you can click on the patient to interact with him!
Introduction to patient
Here is your patient - he is looking quite unwell!What do you want to do first?
Checking patient identification
That's correct!We first need to check patient identification to make sure we have the right patient (we do!) What do you want to do next?
Not quite...
Before we start there's something we need to do first!
Back
Patient history
Yes we want to take a history!Luckily the senior nurse took a history during the initial clerking, here it is:
continue
Not quite...
What do we want to do before we start to assess the patient?
Back
Next steps after history
Now we have taken a history, what do you want to do next?
Telephone call with senior
You have called for senior help, however your registrar is busy with another patient and will be another 20 minutes. He tells you to start the A-E Assessment.Click on the crash trolley to start your A-E Assessment!
Starting the A-E Assessment
How would you like to start your assessment?Click on the corresponding part of the trolley.
That's not quite right, try again!
Back
Starting the Airway Assessment
What would you like to do to start your assessment?
Hi my name is Reece. I am really breathless, please can you help me?
The patient is talking to us so we know the airway is open.
continue
Doctor, what are you doing?!
The patient is talking to us so we know the airway is open!
continue
Continuing the A-E Assessment
Which part of the assessment would you like to move on to next?
That's not quite right, try again!
Back
Starting the Breathing Assessment
How would you like to start?
Not quite...
We would want to do this but let's start by inspecting the patient.Click on the eye to inspect the patient.
Breathing Inspection
On inspection you can see that Reece is using his accessory muscles of respiration however he is not cyanotic. His respiratory rate is 32. What would you like to do next?
As the patient is putting a lot of effort into his breathing, is there something you want to check first?
Back
The pulse oximeter shows oxygen saturations of 85%.What would you like to do next?
What would you like to do to complete your examination?
On examination you find:- Trachea is central - Chest expansion is reduced on the right side - On percussion there is hyperresonance on the right side
On auscultation you find the breath sounds are reduced on the right side.The senior nurse comes along to see how you are getting along and alerts you he is becoming cyanotic now. The pulse oximeter shows he now has oxygen saturations of 75%.
What would you like to do now?
The patient has oxygen saturations below 94% so we need to start him on 15L of oxygen through a non-rebreathe mask.Go back to give him oxygen.
Back
Auscultation usually takes place towards the end of the breathing assessment - what should you do before that?Go back to try again.
Back
Oxygen is now being given - what is your next step now?
Before auscultating, what do you want to do first?Go back to try again.
Back
What would you like to do to complete your examination?
On examination you find:- Trachea is central - Chest expansion is reduced on the right side - On percussion there is hyperresonance on the right side
On auscultation you find the breath sounds are reduced on the right side.
continue
Breathing Assessment Complete!
We have now finished assessing breathing, so far you have started Reece on 15L of oxygen through a non-rebreathe mask.What do you want to do now?
Starting the Circulation Assessment
What would you like to do first?
Not quite...
Before we do anything, what do we want to look at and feel?
Back
Looking at the hands they do not look cyanotic, however they are cold to touch, with a capillary refill time of 4 seconds.As you do this your senior doctor arrives:
A) Pneumonia
B) Lung cancer
What do you think is going on?
C) pleural effusion
D) Traumatic pneumothorax
e) tension pneumothorax
If you were thinking this why did you not order any investigations? You need to order an arterial blood gas and chest x-ray now!
Click on the lab and radiology icon to order this!
You have just ordered an arterial blood gas and a chest x-ray.As you do this, your senior colleague arrives to help.
continue
The senior nurse has gone to run the arterial blood gas but in the meantime the chest x-ray is carried out.The oncall radiologist has not yet reviewed the x-ray but you have access to the images.
Click here for a reminder of the patient history!
What do you think is going on?
Source: Wikimedia
A) Pneumonia
B) Lung cancer
C) pleural effusion
D) Traumatic pneumothorax
e) tension pneumothorax
NB: The chest x-ray for Reece also shows a right sided clavicular fracture
I don't agree with that, try again!
Back
Source: Wikimedia
NB: The chest x-ray for Reece also shows a right sided clavicular fracture
I agree, I think this patient has a pneumothorax secondary to a clavicular fracture. I'll insert a chest drain into Reece. Whilst I am preparing everything, please can you continue with the A-E Assessment, starting at the beginning of circulation.
Click on the circulation drawer to continue with the assessment.
Starting the Circulation Assessment
How would you like to start the circulation assessment?
Whilst we want to do this at some point, what do we tend to look at first?
Back
Looking at the hands there are no signs of peripheral cyanosis however Reece's hands are cold to touch.The capillary refill time is 4 seconds and the pulse is 120 beats per minute with a regular rhythm and character. What do you want to do next?
You don't want to do this yet, there's one thing you need to measure first.
Back
The blood pressure reads 89/54.What would you like to do now?
As you turn around to carry out your next step, your senior peers in:
That's a low blood pressure! You need to put in a large bore cannula and start a fluid challenge!
Click on the cannula to insert.
A large bore cannula has been inserted, what do you want to do now?
The fluids have been set up and are now being given to the patient.
Don't forget we need some bloods too, please can you take a FBC, LFTs, U&Es and a blood culture
That cannula really hurt... can't believe I have to be pricked again!
From the cannula you have taken a FBC, LFTs, U&Es and a blood culture. What would you like to do next?
Your cannula currently does not have anything going through it - do you want to give anything through the cannula?
Back
Excellent job - you have now taken bloods and the patient has been started on fluids. Let's continue assessing circulation! What would you like to do next?
Before this, what should we check first?
Back
Reece's JVP is normal. What is the final step in the circulation assessment?
On auscultation the heart sounds are normal. Would you like to do anything else before moving onto the next part of the assessment?
Before we move on, the patient was tachycardic so let's do an ECG to be on the safe side.
The ECG performed shows this:
Source:LITFL
The ECG shows sinus tachycardia, the senior doctor agrees with you no further action needs to be taken and you can continue the assessment.
continue
Moving on...
Which part of the assessment would you like to move onto next?
Not quite...
Think about which assessment step we do after assessing circulation.
Back
Disability Assessment
Pupils: Equal and reactive to light
Reece is alert and talking to you. Complete the disability assessment by clicking on the items in the drawer.
Temperature: 37.0°C
Blood glucose: 6.0 mmol/L
continue
Click here for a reminder of the patient history!
Exposure Assessment
You close the curtains to expose your patient top to toe and front to back.All you see is this:
Source: Musculoskeletal Key
continue
End of A-E Assessment
You have completed your A-E Assessment and the registrar successfully inserted a chest drain into Reece.The patient now needs to be admitted to hospital under the relevant speciality.
Telephone calls with specialities
You call the respiratory doctors with an SBAR handover to admit Reece to a respiratory ward- they say their team will be down soon to review the patient but in the meantime you need to keep repeating the A-E assessment and inform them if Reece deteriorates.You also call the orthopaedic doctors who will come down to review the clavicular fracture and decide a management plan.
It's now the end of your shift and the registrar takes over the patient care until speciality review.
end
End of simulation!
Well done- you have now completed the simulation component of the session!Take a minute to reflect on your performance: - How did you find the simulation? - What did you do well? - What do you think you can improve on? - What will you do differently next time and in practice?
continue
Post-Session Confidence
Now that you have completed this session on the A-E Assessment...
How confident do you feel performing the A-E Assessment on a scale of 1 to 5?
1 = not confident at all5 = very confident
continue
Thank you!
Please do fill in this feedback form on your experience and thoughts about the session so I can improve this for future students! The next slide has some further resources to continue your learning!
Feedback
continue
Further Resources (click to access)
Resuscitation Council
Geeky Medics
Oxford Medical Education
A-E Assessment Demonstration (by the Resuscitation Council)
UHL HELM e-Learning - The A-E Approach
Feedback
Basic Principles of the A-E Assessment
Sudiksha Devendra Kumar
Created on January 24, 2023
This resource will teach you the basic principles of the A-E Assessment followed by an interactive simulation to apply what you've learnt!
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Transcript
The Basic Principles of the A-E Assessment
Created by sudiksha devendra kumar
Welcome to this self study session on the basic principles of the A-E Assessment! The session is split into 2 parts: Part 1 will teach you the A-E Assessment Part 2 will test what you have learnt with an interactive simulation!
continue
Intended Learning Outcomes
By the end of this session you should be able to:
- Describe the A-E assessment- Perform an A-E assessment - Feel confident performing the A-E assessment - Respond appropriately to A-E assessment findings
continue
Already completed the teaching component? Click here to skip to the simulation component!
Pre-Session Confidence
Before we get started with the teaching...
How confident do you feel performing the A-E Assessment on a scale of 1 to 5?
1 = not confident at all5 = very confident
continue
Why do we do an A-E Assessment?
In an emergency scenario, it allows us to identify and address the most life-threatening issues first before moving on to more specific assessments.
continue
Click on each letter to reveal the answer!
What does A-E stand for?
Airway
Breathing
Circulation
Disability
Exposure
continue
Before we start, we always want to check our patient details.
If the patient is conscious, we will ask for their name and date of birth.However if they are unable to tell us this (e.g. they are unconscious, have dementia) then we can look at the patient wristband to check their name, date of birth, and NHS number.
continue
Brief history before A-E assessment
Before we proceed with the assessment, it is good practice to take a brief history so we know what symptoms the patient is experiencing. Can you think of what we may want to ask in the emergency setting?
continue
Brief history before A-E assessment
Before we proceed with the assessment, it is good practice to take a brief history so we know what symptoms the patient is experiencing. Can you think of what we may want to ask in the emergency setting?
We want to ask about:- Presenting complaint and history of presenting complaint (brief) - Current medical conditions - Current medications - Allergies
There is no correct history format so you may see variations of this in practice - just make sure to keep your history brief to around 2-3 minutes.
continue
Now let's move on to assessing the patient!
A - Airway Assessment
If the patient is able to talk to you and give you a history - the airway is open and no intervention is required.If they are unconscious or unresponsive, shake them by the shoulders and say their name to see if you can rouse them. If they still do not respond then apply a pain stimulus, such as a trapezius squeeze. If unarousable, you need to formally assess the airway.
continue
A - Airway Assessment
If unconscious/unresponsive:- Do a head tilt chin lift - Place the side of your face by the patient's mouth to feel for breath and look at their chest for rise and fall (except in suspected COVID) - If there is no pulse or chest movement - this is a cardiac arrest, you need to call for help and start chest compressions
continue
A - Airway Assessment
If you suspect airway obstruction, look in the mouth:- If you can see any obstructing material → remove material with suction - If you cannot see any obstruction → open up the airway with a oropharyngeal or nasopharyngeal airway - If they are not tolerating this or difficulties arise, call the anaesthetists
continue
Airway adjuncts
There are different airway adjuncts you can use, and different sizes are used depending on the patient.These are found in the top drawer of the crash trolley.
continue
Airway adjuncts
Nasopharyngeal airways tend to be better tolerated, here is how to measure size from the tip of the nose to the earlobe:
Insert the airway through the nostril with the inner curve facing towards the patient, advance until in position
Use the oropharyngeal airway if there is an absent gag reflex, here is how to measure the size from the midpoint of the incisors to the angle of the mandible:
Insert with the inner curve initially towards the roof of the mouth (to prevent further pushing back the tongue) then once you advance it further, rotate the airway 180 degrees so it sits above the tongue
continue
Airway Adjuncts
Watch these videos to observe the technique used to insert different airway adjuncts
Nasopharyngeal:
Oropharyngeal:
continue
B - Breathing Assessment - Inspection
When assessing breathing we want to inspect, then touch/palpate and then listen
On inspection:- Look for central cyanosis, use of accessory muscles of respiration, chest wall deformities and abdominal breathing - Count the respiratory rate over 1 minute (the normal range is 12-20)
Here you can see a patient using their accessory muscles of respiration:
continue
B- Breathing Assessment - Touch / Palpation
- Measure oxygen saturations using a pulse oximeter: if it is below 94% then give 15 litres of high flow oxygen through a non-rebreathe mask, aiming for saturations of 94-98% (or aim for 88-92% for patients with COPD due to the risk of respiratory depression)- If the patient is not ventilating well themselves, a bag-valve-mask can be used to aid ventilation, or consider Non-Invasive Ventilation (NIV)
continue
B- Breathing Assessment - Touch / Palpation
- Feel the trachea - is it central or deviated? If deviated... you should be worried about a tension pneumothorax - Examine chest expansion - is it equal or is it reduced on one or both sides?- Percuss the chest (see below for percussion points)Hyperresonance could indicate pneumothorax Dullness could indicate consolidation e.g. due to pneumonia Stony dullness could indicate pleural effusion
Chest percussion points:
continue
B - Breathing Assessment - Auscultation
- Auscultate the chest (in the same spots you percussed) and listen to the breathing sounds- If reduced or absent this could indicate a pneumothorax - If you hear coarse crackles this could indicate an infection
Chest auscultation points:
continue
Breathing Assessment - Next Steps
Use your findings to come up with potential differential diagnoses. You can order a chest X-ray and/or an arterial blood gas to help with diagnosis and management. If a clinical diagnosis is made, e.g. of tension pneumothorax, prioritise managing and treating this before continuing with the assessment.
continue
C - Circulation Assessment
To assess circulation work in a C motion - start peripherally at the hands and then work your way up!
continue
C - Circulation Assessment
- Look at the colour of the hands: are there any signs of peripheral cyanosis or are they cold to touch? - Measure capillary refill time by pressing for 5 seconds and looking at the nail; circulation should spontaneously return in 2 secondsIf prolonged this is a sign of poor peripheral perfusion - Feel the pulse to measure the pulse rate, rhythm and character (normal heart rate is 60-100 beats per minute)
continue
C - Circulation Assessment
- Measure the blood pressureIf this is below 90mmHg systolic or 60mmHg diastolic, you need to insert a large bore cannula (14 or 16 guage, usually orange or grey) to take bloods and give a rapid bolus of 500ml 0.9% sodium chloride over 15 minutes (reassess the BP once the fluids have run through) - In the neck look for the Jugular Venous Pressure (JVP): is it raised or normal?If raised this could indicate many different pathlogies
Click here for some causes of raised JVP
Measurement of JVP:
continue
45°
Circulation Assessment
- Finish the circulation assessment by auscultating the heart to listen for any murmurs or a pericardial rub (which could indicate pathologies such as pericarditis) If there are any abnormalities in the circulation assessment or if you are suspecting a cardiac cause for their presentation, perform an ECG and check the troponin levels in the blood.
continue
Disability Assessment
Here you assess the other things that did not fit in ABC, but are still important!- Assess consciousness level using AVPU (or GCS can also be used especially if you are suspecting a head injury)
Alert Voice Pain Unresponsive
Alert and responsive without any stimuli
Responding to voice
Only responding to painful stimuli
Not responding at all
continue
Disability Assessment
- Examine the pupils with a pen torch to see if the pupillary reflexes are normal, also known as PEARL (Pupils Equal And Reactive to Light); the pupil should normally constrict with the light from the pen torch- If the pupillary reflexes are abnormal then you should be worried about intracranial pathology
continue
Disability Assessment
- Measure the blood glucose: if this is below 4mmol/L the patient is hypoglycaemic → if the patient is conscious then give them a source of glucose from the Hypo Box or if they are unconscious give them 50ml of 10% glucose solution IV. Keep re-assessing the glucose levels until they reach normal levels.- Measure the temperature - the normal is 36.5 to 37.5°C
continue
Exposure
- Here you want to expose the patient to look for anything that could be causing the presentation. You have to look top to toe and front to back!- Always maintain dignity and minimise heat loss to keep the patient comfortable- draw the curtains and only make sure the people you need are there
continue
Exposure
- The best way to do this is expose the top half then the bottom half looking for wounds, injuries, signs of infection (potentially causing sepsis), bleeding etc.- At this point you can also examine any relevant systems that have not yet been examined e.g. abdominal exam
continue
What do I do after completing the A-E Assessment?
- Put out any alerts that need to be done for your patient e.g. peri-arrest call, activating the major haemorrhage protocol- Escalate your patient to a senior doctor - Refer your patient to the relevant specialities (using a SBAR handover) - Repeat your A-E to keep assessing your patient until further help arrives or a management plan is created - You can also take any further history required if relevant (e.g. social history), perform further examinations and order any other investigations
continue
Part 1 Complete!
Well Done - you have now completed the teaching component of this resource!
Or click here to return to the start of Part 1!
Click here to move on to the simulation!
Simulation briefing
Welcome to the A&E department! You are the FY1 on shift today - this will involve you carrying out initial assessments for patients before they are seen by a senior or speciality doctor. You will be presented with an unwell patient, and you will be able to choose your next steps by clicking on items/areas on the screen (like you would do in real life) - but remember your actions have consequences!
Start
Additionally you can click on the patient to interact e.g. check patient wristband by clicking on it
Symbol Keys
The icons mean the following:
Speak to the patient
Take a history
Inspection
Call a senior/speciality doctor
Examination
Order investigations e.g. bloods
Carry out A-E assessment (you can also interact with each drawer as part of your assessment)
continue
Remember you can click on the patient to interact with him!
Introduction to patient
Here is your patient - he is looking quite unwell!What do you want to do first?
Checking patient identification
That's correct!We first need to check patient identification to make sure we have the right patient (we do!) What do you want to do next?
Not quite...
Before we start there's something we need to do first!
Back
Patient history
Yes we want to take a history!Luckily the senior nurse took a history during the initial clerking, here it is:
continue
Not quite...
What do we want to do before we start to assess the patient?
Back
Next steps after history
Now we have taken a history, what do you want to do next?
Telephone call with senior
You have called for senior help, however your registrar is busy with another patient and will be another 20 minutes. He tells you to start the A-E Assessment.Click on the crash trolley to start your A-E Assessment!
Starting the A-E Assessment
How would you like to start your assessment?Click on the corresponding part of the trolley.
That's not quite right, try again!
Back
Starting the Airway Assessment
What would you like to do to start your assessment?
Hi my name is Reece. I am really breathless, please can you help me?
The patient is talking to us so we know the airway is open.
continue
Doctor, what are you doing?!
The patient is talking to us so we know the airway is open!
continue
Continuing the A-E Assessment
Which part of the assessment would you like to move on to next?
That's not quite right, try again!
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Starting the Breathing Assessment
How would you like to start?
Not quite...
We would want to do this but let's start by inspecting the patient.Click on the eye to inspect the patient.
Breathing Inspection
On inspection you can see that Reece is using his accessory muscles of respiration however he is not cyanotic. His respiratory rate is 32. What would you like to do next?
As the patient is putting a lot of effort into his breathing, is there something you want to check first?
Back
The pulse oximeter shows oxygen saturations of 85%.What would you like to do next?
What would you like to do to complete your examination?
On examination you find:- Trachea is central - Chest expansion is reduced on the right side - On percussion there is hyperresonance on the right side
On auscultation you find the breath sounds are reduced on the right side.The senior nurse comes along to see how you are getting along and alerts you he is becoming cyanotic now. The pulse oximeter shows he now has oxygen saturations of 75%.
What would you like to do now?
The patient has oxygen saturations below 94% so we need to start him on 15L of oxygen through a non-rebreathe mask.Go back to give him oxygen.
Back
Auscultation usually takes place towards the end of the breathing assessment - what should you do before that?Go back to try again.
Back
Oxygen is now being given - what is your next step now?
Before auscultating, what do you want to do first?Go back to try again.
Back
What would you like to do to complete your examination?
On examination you find:- Trachea is central - Chest expansion is reduced on the right side - On percussion there is hyperresonance on the right side
On auscultation you find the breath sounds are reduced on the right side.
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Breathing Assessment Complete!
We have now finished assessing breathing, so far you have started Reece on 15L of oxygen through a non-rebreathe mask.What do you want to do now?
Starting the Circulation Assessment
What would you like to do first?
Not quite...
Before we do anything, what do we want to look at and feel?
Back
Looking at the hands they do not look cyanotic, however they are cold to touch, with a capillary refill time of 4 seconds.As you do this your senior doctor arrives:
A) Pneumonia
B) Lung cancer
What do you think is going on?
C) pleural effusion
D) Traumatic pneumothorax
e) tension pneumothorax
If you were thinking this why did you not order any investigations? You need to order an arterial blood gas and chest x-ray now!
Click on the lab and radiology icon to order this!
You have just ordered an arterial blood gas and a chest x-ray.As you do this, your senior colleague arrives to help.
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The senior nurse has gone to run the arterial blood gas but in the meantime the chest x-ray is carried out.The oncall radiologist has not yet reviewed the x-ray but you have access to the images.
Click here for a reminder of the patient history!
What do you think is going on?
Source: Wikimedia
A) Pneumonia
B) Lung cancer
C) pleural effusion
D) Traumatic pneumothorax
e) tension pneumothorax
NB: The chest x-ray for Reece also shows a right sided clavicular fracture
I don't agree with that, try again!
Back
Source: Wikimedia
NB: The chest x-ray for Reece also shows a right sided clavicular fracture
I agree, I think this patient has a pneumothorax secondary to a clavicular fracture. I'll insert a chest drain into Reece. Whilst I am preparing everything, please can you continue with the A-E Assessment, starting at the beginning of circulation.
Click on the circulation drawer to continue with the assessment.
Starting the Circulation Assessment
How would you like to start the circulation assessment?
Whilst we want to do this at some point, what do we tend to look at first?
Back
Looking at the hands there are no signs of peripheral cyanosis however Reece's hands are cold to touch.The capillary refill time is 4 seconds and the pulse is 120 beats per minute with a regular rhythm and character. What do you want to do next?
You don't want to do this yet, there's one thing you need to measure first.
Back
The blood pressure reads 89/54.What would you like to do now?
As you turn around to carry out your next step, your senior peers in:
That's a low blood pressure! You need to put in a large bore cannula and start a fluid challenge!
Click on the cannula to insert.
A large bore cannula has been inserted, what do you want to do now?
The fluids have been set up and are now being given to the patient.
Don't forget we need some bloods too, please can you take a FBC, LFTs, U&Es and a blood culture
That cannula really hurt... can't believe I have to be pricked again!
From the cannula you have taken a FBC, LFTs, U&Es and a blood culture. What would you like to do next?
Your cannula currently does not have anything going through it - do you want to give anything through the cannula?
Back
Excellent job - you have now taken bloods and the patient has been started on fluids. Let's continue assessing circulation! What would you like to do next?
Before this, what should we check first?
Back
Reece's JVP is normal. What is the final step in the circulation assessment?
On auscultation the heart sounds are normal. Would you like to do anything else before moving onto the next part of the assessment?
Before we move on, the patient was tachycardic so let's do an ECG to be on the safe side.
The ECG performed shows this:
Source:LITFL
The ECG shows sinus tachycardia, the senior doctor agrees with you no further action needs to be taken and you can continue the assessment.
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Moving on...
Which part of the assessment would you like to move onto next?
Not quite...
Think about which assessment step we do after assessing circulation.
Back
Disability Assessment
Pupils: Equal and reactive to light
Reece is alert and talking to you. Complete the disability assessment by clicking on the items in the drawer.
Temperature: 37.0°C
Blood glucose: 6.0 mmol/L
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Click here for a reminder of the patient history!
Exposure Assessment
You close the curtains to expose your patient top to toe and front to back.All you see is this:
Source: Musculoskeletal Key
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End of A-E Assessment
You have completed your A-E Assessment and the registrar successfully inserted a chest drain into Reece.The patient now needs to be admitted to hospital under the relevant speciality.
Telephone calls with specialities
You call the respiratory doctors with an SBAR handover to admit Reece to a respiratory ward- they say their team will be down soon to review the patient but in the meantime you need to keep repeating the A-E assessment and inform them if Reece deteriorates.You also call the orthopaedic doctors who will come down to review the clavicular fracture and decide a management plan.
It's now the end of your shift and the registrar takes over the patient care until speciality review.
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End of simulation!
Well done- you have now completed the simulation component of the session!Take a minute to reflect on your performance: - How did you find the simulation? - What did you do well? - What do you think you can improve on? - What will you do differently next time and in practice?
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Post-Session Confidence
Now that you have completed this session on the A-E Assessment...
How confident do you feel performing the A-E Assessment on a scale of 1 to 5?
1 = not confident at all5 = very confident
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Thank you!
Please do fill in this feedback form on your experience and thoughts about the session so I can improve this for future students! The next slide has some further resources to continue your learning!
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Further Resources (click to access)
Resuscitation Council
Geeky Medics
Oxford Medical Education
A-E Assessment Demonstration (by the Resuscitation Council)
UHL HELM e-Learning - The A-E Approach
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