ABCDE Assessment Practice Cases for Students

Almost every student can recite the ABCDE sequence before they can run it. Airway, Breathing, Circulation, Disability, Exposure — five letters, memorised in an afternoon. Then the first genuinely sick patient arrives, and the sequence collapses into whatever seems most alarming at that moment.

The gap is not knowledge. It is the set of decisions that sit between the letters: when to stop and treat, when to move on, when to go back to the beginning, and when to ask for help you are not sure you need yet. Those decisions are what this article practises.

If you would rather practise than read, work through an evolving ABCDE case in the app.

What the sequence is actually for

ABCDE is not a checklist to be completed. It is a priority ordering, built on a simple physiological argument: an obstructed airway kills faster than inadequate breathing, which kills faster than circulatory failure, which kills faster than a falling conscious level. Working in that order means you spend your first minutes on the thing most likely to end the encounter.

Two consequences follow, and both are frequently missed in early training.

First, the sequence is interruptible by design. You do not finish A before you touch anything. You find a problem, you treat it, and only then do you continue. A student who completes a full survey before applying oxygen to a hypoxic patient has followed the letters and missed the point.

Second, the sequence is circular. One pass is a snapshot. The patient in front of you is a moving target, so the survey has to be re-run — after every intervention, after any change in the patient, and at intervals you decide in advance rather than whenever you happen to remember.

When to interrupt the sequence and treat

The practical rule taught in most resuscitation courses is that you treat what you find before moving on. What that means in practice is worth spelling out, because "treat as you go" is vague enough to be unhelpful at the bedside.

Interrupt and act when a finding is immediately life-threatening and there is an intervention available to you now. Those two conditions together are the trigger. A partially obstructed airway with an audible snore and an available airway manoeuvre meets both. A suspicion of an intra-abdominal injury that will require surgery meets the first but not the second, so it changes your urgency and your escalation, not your next thirty seconds.

Applied across the sequence, that gives a short list of the findings most likely to stop you mid-survey:

• A — noisy or absent air movement, an obvious obstruction, a patient who cannot maintain their own airway. Position, suction, simple manoeuvres and adjuncts come before anything further down the alphabet.
• B — inadequate oxygenation or ventilation. Oxygen and assisted ventilation are applied at the point of discovery, not at the end of the survey.
• C — visible major external haemorrhage, or shock with a treatable cause. Direct pressure on a bleeding wound outranks a full set of observations.
• D — a documented low glucose, or a seizure in progress. Both have immediate interventions and both cause harm while you deliberate.
• E — a temperature extreme, or a rash and history that reframe the whole presentation. Exposure is where the missed diagnosis usually hides.

Everything else is recorded, escalated and reassessed — not treated on the spot. Learning to tell those two categories apart is most of what separates a fluent primary survey from a frantic one.

How reassessment changes the decision

A single set of observations tells you where the patient is. Two sets tell you where they are going, and the direction matters more than the absolute numbers in almost every borderline case.

Consider two patients with identical figures on your first pass: respiratory rate 24, heart rate 104, blood pressure 112/70, oxygen saturation 94% on air. One has been at those numbers for six hours and is unchanged. The other was 16, 78 and 128/82 forty minutes ago. The observations are the same; the clinical problems are not remotely comparable.

This is why early-warning scores are calculated repeatedly rather than once, and why the interval you choose is itself a clinical decision. Two useful habits:

• State the interval out loud and write it down. "Repeat full observations in fifteen minutes, or sooner if anything changes" is a plan. "Keep an eye on them" is not.
• Say what would change your mind. Naming the trigger in advance — a further rise in respiratory rate, a fall in conscious level, a lactate that has not improved after your first intervention — converts a vague worry into a decision you have already made.

Scores such as NEWS2 are a shared language for escalation, not a substitute for the judgement above. They are also less reliable where the baseline is unusual, where a single parameter is driving the total, or where the resources implied by the escalation protocol simply are not present. Treat the number as a prompt to think, not as the conclusion.

Three practice prompts

These are deliberately underspecified. There is no model answer, because the useful part is the reasoning you produce and the questions you notice you cannot answer. Work through each one out loud, ideally with someone else listening, and write down your first three actions before you read the second paragraph.

Prompt 1 — the quiet one

A 28-year-old is brought to you after a collapse at work. They are sitting up, answering in short sentences, and apologising for the fuss. Respiratory rate 26. Saturation 95% on air. Heart rate 118. Blood pressure 104/64. Skin cool. They tell you they feel much better now.

What do you do in the first minute, and what are you deliberately not doing yet? What would make you escalate before you have completed the survey? Which single additional piece of information would change your plan most?

Prompt 2 — the one that changes while you work

A 61-year-old with two days of vomiting is drowsy but rousable. On your first pass: airway patent, respiratory rate 30 and deep, saturation 98% on air, heart rate 122, blood pressure 96/52, capillary glucose high, temperature 36.4°C. You begin your first intervention. Eight minutes later they are harder to rouse and the respiratory rate has fallen to 22.

Is the falling respiratory rate reassuring or alarming, and how do you decide? What do you re-examine first, and why that rather than a new test? At what point does this stop being something you manage alone?

Prompt 3 — the one where help is far away

You are the only clinician on site. A 45-year-old has a deep forearm laceration with brisk bleeding, controlled for now by direct pressure that someone else is maintaining. They are pale, anxious, and talking. Transport to definitive care is at least three hours away. You have basic equipment and no blood products.

How does the three-hour figure change your primary survey, if at all? What do you document now that you would not bother with if help were ten minutes away? What is your reassessment interval, and what specific finding would make you change your transport plan?

What a good debrief looks like

A case you have run and not discussed is largely wasted. The debrief is where a sequence of actions turns into a rule you can apply next time, and it works best when it examines decisions rather than testing recall.

Debriefing methods vary, but the useful ones share a structure: describe what happened, explore why decisions were made, then generalise into something transferable. Two practical points for students running peer debriefs:

• Ask about the reasoning, not the outcome. "What made you go back to Breathing?" produces more learning than "was that the right call?"
• Separate the decision from the information available. A reasonable decision made on incomplete information is not an error, and treating it as one teaches people to hide uncertainty.

If you want a fuller structure, the five-question framework in the companion article is designed to be run in under ten minutes by people who are not trained facilitators.

Where to go next

The primary survey rewards volume. Doing five cases badly and discussing them properly beats reading the sequence again. Build the reps into something small and repeatable rather than waiting for a formal simulation session, and vary the cases enough that you are not pattern-matching on presentation.

Two specific next steps: pair the survey with a deterioration-recognition habit, and practise the debrief as a skill in its own right. Both compound faster than memorising the letters ever will.