University of Bristol at Gloucestershire Academy
Number 126
1st May 2014
Monthly News
Learning your ABC,
Dr Philip Davies, Deputy Dean, Gloucestershire Academy
When asked how they would deal with a medical emergency,
medical students and junior doctors will often respond with the
statement “I would use the ABC approach”. Depending on their
depth of knowledge of the subject, the response tends to stop
there, go on to describe a generic ABC assessment or with the
best candidates explain how this approach can be best adapted
to the situation that they are dealing with.
The use of ABC as a mnemonic to guide health professionals
and the lay public in helping to remember priorities when dealing
with acutely ill or traumatised patients has its roots in the 1950s.
Peter Safar, now known as the godfather of resuscitation (he
also developed the first intensive care unit and ambulance
service in the United States), was the one of the first doctors to
publish research into cardiac arrest and described methods to
safeguard the airway and deliver rescue breaths in this group of
patients. Along with James Elam he established a practice called
"mouth-to-mouth resuscitation" after finding that artificial
circulation of oxygen in expired air could revive a victim. Jude,
Knickerbocker and Kouwenhouen were undertaking parallel
research at this time and developed the method of external chest
compression. Safar published “the ABC of resuscitation” in 1957
and started to promote his ideas on the lecture circuit. In 1962 he
collaborated with Jude and Knickerbocker to produce a training
video called “the pulse of life”, which they managed to show to
millions of American students with the aim of improving their
response to dealing with emergencies. By effectively linking their
research Safar, Jude and Knickerbocker were able to promote
the ABC (airway, breathing, circulation) principle, which is so
widely known today. The ABC system for cardiorespiratory
(CPR) training was adopted by the American Heart Association
in 1973 and has now become a worldwide common language in
approach to resuscitation.
Further development of the ABC approach to encompass
patients with emergency conditions other than those in cardiac
arrest (and the addition of the next two letters of the alphabet to
form the ABCDE structure) can be credited to an American
orthopaedic surgeon. In 1976 Doctor Jim Styner was flying home
from Los Angeles to his home in Nebraska in his six seater
private light aircraft (as perhaps only an orthopaedic surgeon can
do). After hitting bad weather, the plane crashed into a bank of
trees. Doctor Steiner’s wife was killed immediately and three out
of his four children sustained significant head injuries. Despite an
open facial fracture and significant chest injury Doctor Styner
managed to evacuate his family to a local primary care hospital.
DATES FOR YOUR
DIARY:-
EXAMINERS
REQUIRED: Year 4 COMP 2 OSCEs
10th June 2014 @
Sandford Education
Centre, CGH
eVoting Workshop
Showcase, explore and
encourage uptake of
educational practices
facilitated through the
use of TurningPoint.
9.30-1pm, 16th June
2014 @ Redwood
Education Centre, GRH
If you are interested in
examining for any of the
above dates please email
Emily.L.Matthews@glos.nhs.uk
USEFUL LINKS:Gloucestershire Academy
Website – Click Here
Gloucestershire Academy
Contacts – Click Here
On arrival at the hospital, the emergency room
door was locked and two local General
Practitioners had to be called in to deal with the
casualties. It became evident to Doctor Styner
that the doctors and staff at the hospital had little
preparation or training for dealing with trauma
victims and he personally had to arrange for his
family to be evacuated to a large hospital to
receive appropriate care. Styner stated that
“when I can provide better care in the field with
limited resources for my children than I received
at a primary care facility there is something wrong
with the system and the system has to be
changed”. Styner was astute enough to realise
that he needed to “train rather than blame” the
doctors involved. He recognized that effecting this
change would require the development of a
training programme that could teach doctors to
deal with the rare but potentially life-threatening
events related to trauma and injury. He drew
heavily on the Advanced Cardiac Life Support
course that had been developed by the American
Heart Association and became an instructor on
this course himself so that he could better
understand the medical and educational concepts
he thought he would need to set up a successful
trauma course. Whilst developing his course,
Styner developed the idea that rather than
assessing every system involved, attempting to
make a diagnosis and then finally providing
treatment the assessment and treatment should
be combined in a task orientated way so that
problems such as hypoxia or haemorrhage were
dealt immediately, often without a definitive
diagnosis and not left until completely sorted out.
This concept, which now seems so obvious and
practical, was controversial at the time, as it
deviated significantly from the classical teaching
of medicine that involved history taking,
examination and investigation before reaching a
definitive diagnosis and starting treatment. It has
now become a cornerstone of all emergency
care. The original trauma course developed by
Styner was taught locally before being adopted
by the American College of Surgeons. It has
become the Advanced Trauma Life Support
Course (ATLS). From its origins in Nebraska,
ATLS has now been taught to 500,000 doctors in
46 countries across the world. The concept of
ABCDE assessment it pioneered has been
adopted into many other resuscitation courses
such as Advanced Paediatric Life Support (APLS)
and Acute Life-threatening Events Recognition
and Treatment (ALERT).
Whilst it has become common parlance to talk of
ABC in the emergency setting, is perhaps wise to
also understand and remember the concepts
behind this technique. Remembering what ABC
stands can be a useful starter. In ATLS it stands
for airway, breathing, circulation, disability (i.e.
global brain function) and exposure/environment.
Most of the resuscitation courses and teaching
tend to also use this airway breathing circulation
structure, although it is wise to check that
everyone is indeed using the same language or
mnemonic. On first aid courses for instance it is
used to describe Assessment, Breathing,
Circulation, Deformities and Emotions. Mountain
rescue leadership courses talk about Ambulate
Before Carry as a method of evacuation from the
mountain. Certain doctors have also been known
to Arrive, Blame and Criticise when attending
emergency situations.
It is also important to question the perceived
dogma that has evolved around the ABC
principles. We must remember that although ABC
provides a common language it is not necessarily
rooted in evidence based medicine. The ABC
system continues to evolve. For instance, in
major haemorrhagic trauma there is now good
evidence that attention to massive haemorrhage
is more important than assessment of the airway
and breathing. ABC has now become CABC in
military and major trauma centres as personnel
deal with catastrophic haemorrhage (“big C”)
before the airway. Forty years after initially
promoting the ABC system for cardiac arrest, the
American Heart Association has recently
refocused
priorities
in
cardiopulmonary
resuscitation as evidence suggests that reducing
interruptions to external cardiac compressions
improves outcomes. Safars’ groundbreaking
advice of ABC has now given way to circulation
airway breathing – CAB.
So the next time you tell someone that you plan
to use an ABC (DE) approach to a medical
emergency you can congratulate yourself that
you are using a tried and tested method, but
prepare to explain your choice of approach,
remember what the mnemonic stands for, be able
to justify the evidence behind its use ….. and
perhaps impress your examiner with your
knowledge of the history of the development of
this now universally accepted technique.