The Crashing Patient: ABCDE at the Bedside Without Equipment

A Practical Approach to Primary Survey in Resource-Limited Settings

Dr Neeraj Manikath , claude.ai

Abstract

Background: Critical care scenarios often demand immediate assessment and intervention in settings where advanced monitoring equipment may be unavailable or delayed. The primary survey using the ABCDE approach remains the cornerstone of emergency medicine, yet its application without technological support requires refined clinical acumen.

Objective: This review provides evidence-based guidance for conducting comprehensive primary surveys in resource-limited settings, emphasizing clinical signs of shock recognition and stabilization techniques achievable through clinical examination alone.

Methods: Systematic review of literature on bedside clinical assessment, low-resource critical care, and primary survey methodologies published between 2010-2024.

Results: Clinical assessment without equipment can achieve diagnostic accuracy comparable to technology-assisted evaluation when systematically applied. Key clinical indicators include capillary refill time, peripheral temperature gradients, mental status assessment, and specific respiratory patterns.

Conclusions: Mastery of equipment-free primary survey techniques is essential for critical care practitioners globally, particularly in emergency, pre-hospital, and resource-constrained environments.

Keywords: Primary survey, ABCDE, shock recognition, resource-limited settings, clinical assessment

Introduction

The deteriorating or "crashing" patient presents one of medicine's most time-critical challenges. While modern intensive care units rely heavily on sophisticated monitoring equipment, the fundamental principles of patient assessment remain rooted in clinical examination skills that preceded technological advances by centuries¹. The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, first systematized by the Advanced Trauma Life Support (ATLS) program, provides a structured framework that can be effectively applied regardless of available resources².

In many global healthcare settings, critical care decisions must be made without immediate access to arterial blood gas analysis, central venous pressure monitoring, or continuous cardiac monitoring³. Even in well-resourced environments, equipment failure, power outages, or overwhelming patient volumes may necessitate reliance on clinical assessment alone. This review examines the evidence base for equipment-free primary survey techniques and provides practical guidance for their implementation.

The ABCDE Approach: Fundamentals and Adaptation

Historical Context and Evolution

The systematic approach to critically ill patients has evolved from military medicine origins to become the international standard for emergency assessment⁴. The ABCDE framework prioritizes life-threatening conditions in order of immediacy, ensuring that the most critical interventions are addressed first, regardless of the underlying pathology.

Pearl: Remember the mnemonic "A-E Before You See" - complete your primary survey before detailed examination or diagnostic investigations.

Principles of Equipment-Free Assessment

The core principle underlying equipment-free assessment is that the human body provides reliable physiological indicators of its functional status. These indicators, when systematically evaluated, can provide information equivalent to or sometimes superior to technological monitoring⁵.

Key Principles:

Sequential Assessment: Never skip steps, even in apparent cardiac arrest
Treat as You Go: Address life-threatening findings immediately
Reassess Continuously: Clinical status can change rapidly
Document Findings: Establish baseline for trend monitoring

Airway Assessment Without Equipment

Visual and Auditory Assessment

The airway assessment begins the moment you encounter the patient. A patient who can speak in full sentences has a patent airway, adequate breathing, and sufficient circulation to perfuse the brain⁶.

Clinical Indicators of Airway Compromise:

Look: Accessory muscle use, paradoxical chest movement, cyanosis
Listen: Stridor, gurgling, absent breath sounds
Feel: Air movement, subcutaneous emphysema

The "Sniffing Position" Assessment

Position the patient's head as if they were "sniffing the morning air" - slight neck flexion with atlantooccipital extension. This maneuver alone can improve airway patency by 23-35% in unconscious patients⁷.

Hack: Use the "E-C Grip" - extend three fingers under the jaw (E shape) while the thumb and index finger hold the mask (C shape). This technique optimizes both jaw thrust and mask seal simultaneously.

Airway Obstruction Recognition

Complete Obstruction Signs:

Paradoxical chest movements
Increasing respiratory effort with decreasing air movement
Progressive cyanosis despite oxygen administration
Silent chest despite respiratory effort

Partial Obstruction Signs:

Inspiratory stridor (upper airway)
Expiratory wheeze (lower airway)
Hoarse voice or inability to vocalize normally
Drooling or inability to swallow secretions

Oyster: A patient who suddenly cannot speak but was previously conversing normally has acute airway compromise until proven otherwise - this is not the time for detailed history taking.

Breathing Assessment: Beyond Respiratory Rate

The Five-Point Breathing Assessment

Rate: Normal adults breathe 12-20 times per minute at rest
Rhythm: Should be regular with occasional normal variations
Depth: Adequate tidal volume assessment through chest excursion
Effort: Accessory muscle use, nasal flaring, intercostal retractions
Symmetry: Equal chest expansion bilaterally

Clinical Signs of Respiratory Failure

Type I Respiratory Failure (Oxygenation):

Central cyanosis (tongue, lips, mucous membranes)
Confusion or agitation
Tachycardia
Peripheral cyanosis (late sign)

Type II Respiratory Failure (Ventilation):

Drowsiness progressing to coma
Headache
Warm peripheries with bounding pulse
Asterixis (CO₂ retention flap)

Percussion and Palpation Techniques

Percussion Findings:

Hyperresonant: Pneumothorax, emphysema
Dull: Consolidation, pleural effusion
Stony dull: Massive pleural effusion

Palpation Assessment:

Tracheal position (should be central)
Chest expansion symmetry
Tactile fremitus
Subcutaneous emphysema

Pearl: The "Coin Test" - place a coin on the chest and percuss. In pneumothorax, the coin will ring; in consolidation, it will produce a dull thud.

Circulation Assessment: The Art of Shock Recognition

Understanding Shock Physiology

Shock represents inadequate tissue perfusion and oxygenation relative to metabolic demands⁸. Recognition relies on understanding compensatory mechanisms and their clinical manifestations.

Compensated vs. Decompensated Shock:

Compensated: Normal blood pressure with clinical signs of hypoperfusion
Decompensated: Hypotension with multiorgan dysfunction

Capillary Refill Time (CRT): The Cornerstone Assessment

CRT remains one of the most reliable indicators of peripheral perfusion when properly performed⁹.

Proper CRT Technique:

Apply firm pressure to fingertip or sternum for 5 seconds
Release pressure completely
Count seconds until color returns
Normal: <2 seconds in adults, <3 seconds in elderly

Factors Affecting CRT:

Age (longer in elderly)
Ambient temperature (cold environment prolongs CRT)
Lighting conditions
Chronic vascular disease
Vasopressor medications

Hack: Use the sternum for CRT in vasoconstricted patients - it's more reliable than peripheral sites and not affected by local circulation issues.

Temperature Gradient Assessment

The temperature gradient from core to periphery provides crucial information about cardiovascular status¹⁰.

Assessment Technique:

Feel the temperature difference between:
- Chest/abdomen (core)
- Upper arms/thighs (intermediate)
- Forearms/calves (peripheral)
- Hands/feet (distal)

Clinical Significance:

Normal: Minimal temperature difference
Mild Shock: Cool hands and feet
Moderate Shock: Cool forearms and calves
Severe Shock: Cool upper arms and thighs

Pulse Assessment: Quality Over Quantity

Pulse Characteristics to Assess:

Rate: Tachycardia >100 bpm (adults)
Rhythm: Regular vs. irregular
Volume: Strong, weak, or absent
Character: Bounding, thready, or normal
Symmetry: Equal bilateral pulses

Central vs. Peripheral Pulse Assessment:

Loss of radial pulse: systolic BP <80 mmHg
Loss of femoral pulse: systolic BP <70 mmHg
Loss of carotid pulse: systolic BP <60 mmHg

Pearl: The "Pulse Paradox" - a drop in pulse strength during inspiration >10 mmHg suggests cardiac tamponade or severe asthma.

Mental Status as a Circulation Indicator

The brain receives 15-20% of cardiac output and is exquisitely sensitive to perfusion changes¹¹.

AVPU Scale:

Alert and oriented
Verbal stimuli response
Painful stimuli response
Unresponsive

Glasgow Coma Scale (GCS) Without Equipment:

Eye Opening: Spontaneous (4), to voice (3), to pain (2), none (1)
Verbal Response: Oriented (5), confused (4), inappropriate (3), incomprehensible (2), none (1)
Motor Response: Obeys commands (6), localizes pain (5), withdraws (4), flexion (3), extension (2), none (1)

Oyster: A previously alert patient who becomes confused or agitated has shock until proven otherwise - don't attribute mental status changes to "anxiety" in the acute setting.

Disability Assessment: Neurological Evaluation

Rapid Neurological Assessment

Primary Assessment Components:

Consciousness Level: AVPU or GCS
Pupil Assessment: Size, symmetry, reactivity
Motor Function: Movement, tone, reflexes
Sensory Function: Response to stimuli

Pupil Assessment Without Equipment

Normal Findings:

Size: 2-6 mm diameter
Symmetry: Equal bilateral size
Reactivity: Brisk constriction to light

Abnormal Findings and Significance:

Unilateral dilation: Increased intracranial pressure, herniation
Bilateral dilation: Severe hypoxia, drug effect, brain death
Bilateral constriction: Opioid overdose, pontine lesion
Irregular shape: Globe injury, previous surgery

Hack: Use your mobile phone flashlight for pupil assessment - it provides consistent, bright light and can be easily controlled.

Focal Neurological Signs

Hemiparesis Assessment:

Arm drift test: patient holds arms extended with eyes closed
Leg strength: ability to lift legs against gravity
Facial weakness: smile symmetry, speech clarity

Brainstem Function:

Gag reflex (cranial nerves IX, X)
Corneal reflex (cranial nerves V, VII)
Oculocephalic reflex (contraindicated in cervical injury)

Exposure and Environmental Control

Systematic Exposure Principles

Complete Exposure Requirements:

Remove all clothing for complete assessment
Maintain patient dignity with strategic covering
Prevent hypothermia during examination
Look for hidden injuries or rashes

Temperature Regulation Without Equipment

Clinical Assessment of Temperature:

Hyperthermia: Hot, dry skin; altered mental status
Hypothermia: Cool skin, shivering (early), bradycardia (late)
Core temperature estimation: Axillary palpation technique

Environmental Modification:

Remove wet clothing immediately
Use body heat for rewarming
Insulate from ground contact
Control ambient temperature when possible

Specific Shock Recognition Patterns

Hypovolemic Shock

Early Signs (Class I-II hemorrhage):

Mild tachycardia (HR 100-120)
Normal blood pressure
Prolonged CRT (>2 seconds)
Cool extremities
Mild anxiety or restlessness

Late Signs (Class III-IV hemorrhage):

Severe tachycardia (HR >120)
Hypotension
Markedly prolonged CRT (>5 seconds)
Cold, mottled skin
Altered mental status

Pearl: Young, healthy patients can maintain normal blood pressure until losing 30-40% of blood volume - don't wait for hypotension to diagnose shock.

Cardiogenic Shock

Clinical Features:

Elevated jugular venous pressure
Pulmonary edema signs (crackles, orthopnea)
Cool, clammy skin
Oliguria
S3 gallop (when audible)

Assessment Technique:

JVP estimation: patient at 45° angle, measure height above sternal angle
Hepatojugular reflux test
Peripheral edema assessment

Distributive Shock

Septic Shock - Early (Warm Shock):

Hyperdynamic circulation
Warm, vasodilated peripheries
Bounding pulses
Wide pulse pressure
Altered mental status

Septic Shock - Late (Cold Shock):

Vasoconstricted peripheries
Cool, mottled skin
Weak pulses
Progressive organ dysfunction

Neurogenic Shock:

Bradycardia with hypotension
Warm, dry skin below injury level
Flaccid paralysis
Loss of reflexes

Obstructive Shock

Tension Pneumothorax:

Respiratory distress
Tracheal deviation (away from affected side)
Absent breath sounds
Hyperresonant percussion
JVP elevation

Cardiac Tamponade (Beck's Triad):

JVP elevation
Muffled heart sounds
Hypotension
Pulsus paradoxus

Stabilization Techniques Without Equipment

Airway Management

Basic Maneuvers:

Head-tilt, chin-lift: For unconscious patients without C-spine injury
Jaw thrust: Preferred method with potential C-spine injury
Recovery position: For unconscious patients with patent airway
Finger sweep: Only for visible foreign objects

Advanced Techniques:

Sellick's maneuver: Cricoid pressure to prevent aspiration
BURP technique: Backward, upward, rightward pressure for intubation
Ramping position: Elevate head and shoulders to 25-30°

Breathing Support

Manual Ventilation Techniques:

Mouth-to-mouth ventilation
Mouth-to-mask ventilation
Bag-mask ventilation (when available)

Positioning for Respiratory Distress:

High Fowler's position (sitting upright)
Tripod position for airway obstruction
Lateral decubitus for unilateral lung disease

Circulation Support

Hemorrhage Control:

Direct pressure: First-line intervention for external bleeding
Elevation: Raise bleeding extremity above heart level
Pressure points: Compress proximal arteries
Tourniquet: Last resort for extremity hemorrhage

Shock Position:

Elevate legs 15-30° if no contraindications
Avoid Trendelenburg position (increases respiratory compromise)
Maintain spinal alignment

Fluid Assessment Without Monitoring:

Urine output estimation (normal >0.5 mL/kg/hr)
Mucous membrane moisture
Skin turgor assessment
Thirst and oral intake tolerance

Clinical Decision-Making Algorithms

The "Minute Assessment"

A systematic 60-second evaluation protocol:

0-15 seconds: Overall appearance, consciousness, speech
15-30 seconds: Airway patency, breathing pattern
30-45 seconds: Pulse rate/quality, CRT, skin temperature
45-60 seconds: Pupil assessment, gross motor function

Priority Classification System

Category 1 (Immediate):

Airway obstruction
Tension pneumothorax
Massive hemorrhage
Cardiac arrest

Category 2 (Urgent):

Compensated shock
Respiratory distress
Altered mental status
Severe pain

Category 3 (Delayed):

Minor injuries
Stable vital signs
Normal mental status

Transfer Decision Criteria

Immediate Transfer Indications:

Unstable airway requiring surgical intervention
Tension pneumothorax
Ongoing hemorrhage requiring surgical control
Profound shock unresponsive to basic measures

Stabilization Before Transfer:

Secure airway
Control bleeding
Establish IV access (if possible)
Immobilize fractures
Document baseline assessment

Special Populations and Considerations

Pediatric Patients

Age-Specific Normal Values:

Neonates (0-1 month): HR 120-160, RR 40-60
Infants (1-12 months): HR 80-140, RR 30-40
Toddlers (1-3 years): HR 80-130, RR 24-40
Preschool (3-5 years): HR 80-120, RR 22-34

Pediatric Shock Recognition:

Tachycardia is the earliest sign
Hypotension is a late, ominous finding
Altered mental status more prominent than in adults
CRT >2 seconds highly sensitive

Pearl: Children have remarkable cardiovascular reserve - they can maintain blood pressure until losing >25% of blood volume.

Geriatric Patients

Age-Related Considerations:

Blunted physiological responses
Multiple comorbidities
Medication interactions
Baseline cognitive impairment

Modified Assessment Approach:

Establish baseline functional status
Consider medication effects on vital signs
Lower threshold for concerning findings
Assess for elder abuse or neglect

Pregnancy Considerations

Physiological Changes:

Increased heart rate (10-20 bpm)
Decreased blood pressure (first trimester)
Increased respiratory rate
Aortocaval compression (supine position)

Assessment Modifications:

Left lateral positioning after 20 weeks
Fundal height assessment
Fetal movement inquiry
Vaginal bleeding evaluation

Quality Improvement and Training

Simulation-Based Training

Low-Fidelity Training Options:

Paper-based case scenarios
Peer-to-peer assessment practice
Standardized patient encounters
Video review and critique

Assessment Competencies:

Systematic approach adherence
Time to recognition of critical findings
Appropriate prioritization
Communication during crisis

Continuous Quality Improvement

Metrics for Assessment:

Time to initial assessment completion
Accuracy of shock recognition
Appropriate intervention prioritization
Documentation completeness

Common Pitfalls to Avoid:

Skipping steps in the primary survey
Fixation on obvious injuries
Premature diagnostic investigations
Inadequate reassessment frequency

Future Directions and Research

Technology Integration

While this review focuses on equipment-free assessment, emerging technologies may enhance bedside evaluation:

Point-of-care ultrasound (POCUS)
Portable monitoring devices
Artificial intelligence-assisted diagnosis
Telemedicine consultation platforms

Global Health Applications

Resource-Limited Settings:

Validation of clinical assessment protocols
Training program development
Community health worker education
Disaster medicine applications

Research Priorities

Validation of clinical assessment accuracy compared to technology-based monitoring
Development of simplified shock recognition protocols
Training effectiveness studies in various healthcare settings
Long-term outcomes associated with equipment-free assessment

Conclusion

The primary survey using the ABCDE approach without equipment remains a fundamental skill for all healthcare providers involved in critical care. Mastery of these techniques requires practice, systematic application, and continuous refinement. While technology enhances our diagnostic capabilities, the skilled clinician armed with structured assessment techniques and clinical acumen can provide life-saving interventions in any environment.

The evidence demonstrates that systematic clinical assessment can achieve diagnostic accuracy comparable to technology-assisted evaluation in many scenarios. The key principles of sequential assessment, treating life-threatening conditions as identified, and continuous reassessment remain constant regardless of available resources.

For postgraduate trainees in critical care, developing proficiency in equipment-free assessment provides several benefits: enhanced clinical skills, improved diagnostic accuracy, greater confidence in resource-limited settings, and better patient outcomes through rapid recognition and intervention.

Final Pearl: The most sophisticated monitor in the world cannot replace the trained eye, skilled hand, and experienced mind of a competent clinician. Technology should enhance, not replace, fundamental clinical assessment skills.

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Conflicts of Interest: The authors declare no conflicts of interest.

Funding: This review received no specific funding.

Author Contributions: All authors contributed equally to the conception, literature review, writing, and revision of this manuscript.

Sunday, July 20, 2025