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It is generally accepted that the priorities, when resuscitating an ill patient are ABC, to which one can add D and E for the injured patient. I have been practising emergency medicine for over 20 years both in hospital and, occasionally, out of hospital and I am sure that I am not alone in still finding it helpful to say to myself “A.... B.... C....” etc, as I assess and treat a severely ill or injured patient.
A few years ago I was asked to give a guest lecture on a first aid course and made the above two points. The lecture seemed to be well received but at question time one of the participants commented that whereas everyone seemed to agree that the priorities were ABC, nobody could agree on what ABC stood for. It turned out that I had been teaching the Advanced Trauma Life Support (ATLS) system of Airway with cervical spine protection, Breathing, Circulation, Disability and Exposure and Environment1 whereas they, on an officially recognised first aid course, were being taught Assess and Airway, Breathing, Circulation, Deformities and Emotions and Ensure (that is, recheck all that you have previously done). Since then I have also discovered Assess, Breathing and Bleeding, Consciousness; Airway, Bleeding, Circulation; Airway, Breathing, Cervical spine; Airway, Breathing, Circulation, Drugs (for neonatal resuscitation)2 and Airway, Breathing, Circulation, Decompression (of the stomach—that is, gastric tube), Elimination (catheterisation) and Fluids.3E seems a particular problem: in the original ATLS protocol4E stood for Exposure (expose the patient) but this was of no relevance and was possibly even wrong advice for prehospital care and E now stands for Exposure and Environment.1 In the APLS protocol5E still stands for Exposure. I have also seen E standing for Examine (that is, to start the secondary survey) and, more than once, Evaluate and Environment.
Many of these ABCs have not been in published documents but have rather been in handouts or aide memoires given out at first aid lectures though one was a draft document that I was asked to review with a view to it becoming a national protocol for the ambulance service.
When dealing when special situations you may need to add additional priorities. The TOXALS system for advanced life support for contaminated patients recommends Assess and Airway, Breathing, Circulation, Decontaminate and Disability but E stands for Evacuation6 or Evacuation and Evaluation.7
No guideline should be set in stone, as treatment may change with advancing medical knowledge but just as in cardiac arrest, any cardiopulmonary resuscitation (CPR) is better than no CPR,8 so in trauma, any system of assessing and treating patients is better than no system. There is a value to simplicity in helping people to learn and retain knowledge and a system based on a simple ABCDE mnemonic has much to commend it.8 However, for different people to use the same mnemonic but with the letters standing for different things is confusing, particularly for lay people. Prehospital and inhospital staff should speak the same “language”.1
I do not wish to stifle novel alphabetical mnemonics and I particularly like the advice of an experienced mountain rescue leader that casualties should try to Ambulate Before Carry and the recommendation for sick children that after ABC, Don’t Ever Forget Glucose. It is also sensible to Anticipate Before Complications. However, when teaching the assessment and resuscitation of ill and injured patients, particularly to lay people, we should stick to one ABCDE (with additions, if necessary, for special circumstances). Different organisations involved with teaching resuscitation and first aid should agree a common use of ABCDE. To do otherwise causes confusion that may lead to error and it should never be forgotten that the results of error are often Accusation, Blame and Complaint with demand for Compensation.
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