2.3 Primary Assessment: ABCDE

From doorway impression to hands-on ABCDE

After the Pediatric Assessment Triangle sets urgency, the primary assessment is the systematic hands-on evaluation. PALS teaches the sequence:

A — Airway
B — Breathing
C — Circulation
D — Disability
E — Exposure

You still interrupt the sequence whenever a life-threatening problem appears. Opening an obstructed airway or starting CPR is not "skipping steps"; it is correct primary assessment behavior.

A — Airway

Ask: Is the airway open? Can the child maintain it? Does it need intervention?

Airway assessment actions:

• Look for chest rise, listen for stridor/snoring/gurgling, feel for air movement.
• Use head-tilt–chin-lift if no trauma concern; use jaw-thrust if cervical spine injury is possible.
• Suction obvious secretions; remove visible foreign body only with appropriate techniques (do not perform blind finger sweeps).
• In a conscious child with suspected severe upper-airway obstruction (e.g., epiglottitis picture), do not force inspection or procedures that agitate the child and convert partial to complete obstruction.

B — Breathing

Once the airway is open enough to assess ventilation, evaluate breathing:

1. Respiratory rate — count carefully; compare with age-typical ranges (detailed in section 2.4).
2. Respiratory effort — retractions, nasal flaring, grunting, head bobbing, accessory muscle use (links back to PAT work of breathing, now quantified hands-on).
3. Chest expansion / air entry — bilateral rise; auscultate for wheezes, crackles, unequal sounds, silent chest.
4. Pulse oximetry (SpO2) — continuous when available; interpret with work of breathing (a "normal" SpO2 on high FiO2 does not mean the child is fine if effort is extreme).
5. Skin color — ongoing check for cyanosis.

Oxygen and ventilation priorities during B:

• Provide oxygen for hypoxia or significant distress per clinical need.
• If breathing is inadequate (slow, irregular, only gasping, or ineffective effort), begin assisted ventilation with bag-mask.
• Recognize the transition from distress (increased effort) to failure (inadequate gas exchange ± fatigue with decreasing effort).

C — Circulation

Circulation assessment answers: Is cardiac output delivering oxygenated blood to vital organs?

Critical CPR decision point (memorize exactly):

Start high-quality CPR if the infant or child is:

• Unresponsive, and
• Not breathing or only gasping, and
• No pulse (or you are uncertain after a pulse check of ≤10 seconds),

OR if heart rate is <60/min with signs of poor perfusion despite adequate oxygenation and ventilation support in the infant/child.

Do not spend longer than about 10 seconds trying to confirm a pulse. If there is any doubt in a lifeless-appearing child, begin compressions.

D — Disability (neurologic status)

Disability is a rapid neurologic check—not a full neurology consult.

AVPU scale (fast and exam-friendly):

Alternatively use an age-adjusted Glasgow Coma Scale (GCS) when time and training allow. Also check:

• Pupils — size, equality, reactivity (asymmetric/fixed pupils raise concern for intracranial process or drug effects).
• Blood glucose — hypoglycemia is a common, reversible cause of altered mental status in infants and children; check early when disability is abnormal.
• Seizure activity / posturing — treat ABCs first; note findings for the secondary assessment and post-stabilization care.

A sudden decline in AVPU/GCS during resuscitation is a re-evaluate trigger: hypoxia, hypoperfusion, rising CO2, or intracranial catastrophe may be evolving.

E — Exposure

Exposure means fully examining the child while protecting against hypothermia:

• Remove clothing to look for rash (purpura/petechiae raise concern for meningococcemia/sepsis), trauma, bleeding, abdominal distention, and other clues.
• Measure temperature when feasible (fever or hypothermia both matter).
• Keep the child warm with blankets, radiant warmer, or controlled environment—especially infants, who lose heat rapidly.

Exposure completes the primary survey so that obvious reversible findings (massive hemorrhage, tension physiology clues, petechial rash with shock) are not missed because the child remained covered.

Life threats first: how ABCDE interacts with interventions

Primary assessment scenario walk-through

Case: 3-year-old found unresponsive at home.

1. PAT (already done by first rescuer): unresponsive appearance, slow/irregular breathing, pale-mottled skin → sick / near-arrest.
2. A: snoring respirations → jaw-thrust/airway open; suction.
3. B: only occasional gasps → inadequate breathing → bag-mask ventilation with oxygen.
4. C: pulse check ≤10 s → brachial/carotid pulse absent → start CPR, monitor pads on, rhythm check as soon as possible.
5. D/E: deferred details until CPR is ongoing and roles assigned; glucose and full exposure follow once circulation support is underway or ROSC occurs.

If instead the same child had a pulse of 50/min with poor perfusion while gasps continued, you would still start CPR based on HR <60 with poor perfusion, while ensuring oxygenation and ventilation are optimized—because hypoxia-driven bradycardia is a classic pediatric pathway to arrest.

Documentation and team communication cues

High-performing teams verbalize primary findings in a compact format:

"Airway maintainable with jaw-thrust. Breathing inadequate—bagging. Heart rate 40 with weak central pulses—starting CPR. AVPU is U. Exposing now—no rash, cool mottled skin."

That language maps directly onto evaluate–identify–intervene and hands the next provider a clear physiologic picture.

Master ABCDE so thoroughly that you can perform it under stress, interrupt it for CPR without hesitation, and resume it after each major intervention. The written exam tests the criteria and order; the skills test grades whether you actually do them.