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As seasoned and new providers, we are flooded with acronyms, codes and “cheats” to help us calm the chaos and manage emergencies to the best of our abilities. None is so widely used across the profession as Airway-Breathing-Circulation (ABCs.)
No matter how many days, months, or years a provider has put into the business, the ability to regurgitate the ABCs continues to be a standard of practice. Is this a check-the-box moment, or does it have a deeper meaning for experienced providers at all levels?
The pediatric assessment triangle (PAT) is a common and standardized assessment tool used by many providers at various levels, both prehospital and in-hospital. The American Academy of Pediatrics (AAP) introduced it in pediatric education for paramedics in 2000 and became widely adopted in almost all pediatric life support programs in 2005.
More Opportunities?
While the ABC or CAB or some other combination of letters that providers are using in their specific jurisdictions are intended to be the foundation for providers to remember critical steps in any emergency, is there an opportunity for them to be more?
While each step of the process has its place in the crucial steps to save a life, these articles will be focusing on the “B’s” (breathing or work of breathing) of the ABCs and, more so, the provider’s assessment of what is impacting the breathing and how best to assess it in the initial and secondary assessment of our patients.
For many providers, three main areas are assessed and considered key in evaluating patients experiencing respiratory issues or complaints. While these assessments are critical for specific patients, the standard patient with a non-respiratory complaint can still provide information as to the patient’s general status.
Respiratory rate, rhythm and quality (RRQ) is another staple providers use to evaluate their patients in the health care profession.
The interesting and, at times, confusing part of this assessment, especially for new providers, is that examples and defining when and how these items are assessed range widely from provider to provider.
To shed more light on the assessment opportunities and how best to implement the foundational items of ABC and RRQ that many providers are taught in their initial education and reinforced in their practical application in the field.
Appearance
This assessment begins with the provider first seeing the patient and determining what many will use, such as the Sick/Not Sick, Stable/Unstable, or Load and Go/Stay and Play criteria. What are your first impressions of the patient? Is the patient alert? Are they interacting with those in the area or their surroundings?
Do you see anything that would cause you concern or prompt you into quick and decisive action? As a provider who is just gaining experience or has years of experience, there will be things that trigger us into action based on only what we see. This can quickly change as we engage with the patient or continue along our original care path, but it will not dictate our care plans alone.
Work of Breathing
The next item a provider should assess is the patient’s work of breathing. While many will think this is when you begin a detailed assessment, this is not the intent at this time. Remember that at this point, you have just laid eyes on the patient and are not necessarily at the patient’s side.
This is another across-the-room assessment where you are trying to determine the situation’s severity level. The provider is not focusing on numbers or values but on the appearance of being outside of the norms or something that would require immediate intervention. This is also where the initial RRQ comes into play. Is the patient breathing?
Does the respiratory rate (R-1 of the RRQ) appear to be too fast or too slow? Do the patient’s respirations appear to have a pattern (R-2 of RRQ) that is other than regular? And lastly, the across-the-room assessment of respiratory quality. Can you hear them breathing, or do they have audible adventitious breath sounds, wheezing, stridor, etc.?
Does the patient appear to be struggling to breathe? Any of these initial findings would prompt the provider to assist with ventilator management once at the patient’s side.
Color
The last part of this patient assessment triangle would be the patient’s general color of their exposed skin. While the patient may not have much-exposed skin, their face, neck and hands may provide some clues as to their general circulation.
Is the patient pale or flushed? Do they have a grey, bluish or yellowish hue to their skin? Any of these give the responder a clue about their general medical condition or degree of stability.
While this assessment does not provide the definitive diagnosis or by any means provide all the answers needed to best care for the patient, the patient assessment triangle does provide a good initial presentation for providers to determine priorities in their primary assessment.
No matter what level of certification or years of experience, there are always helpful clues as to the patient’s condition during these first critical moments in the patient interaction, and they can assist you with the decision process of treatment and transport priorities.
JEMS Editor-in-Chief for Clarion Events Fire & Rescue Group. Servant Leader, Professional Educator, Author, and Textbook Contributor. Critical Care EMT- Paramedic and Nationally Registered Paramedic, with an Associate Degree in Emergency Medical Science, a Bachelor’s in Health Science and EMS Management, a Master’s Degree in Education and a Doctor of Education Degree in higher education leadership. Background includes EMS educator with over 20 years of experience in both on site and online programs, EMS shift supervisor, field training officer and team leader, over 20 years of field paramedic and six years of critical care transport experience along with seven years of military experience in a leadership position with rapid-deployments units.
