ABCDE Assessment

The airway, breathing, and circulation, disability and exposure (ABCDE) assessment is the mainstay management approach used in managing critically ill patients. The ABCDEs are the essential 1st steps to perform in many situations including unresponsive patients, cardiac arrests, and critical medical or trauma patients. For the trauma patient, ABCDE is included in the primary survey, the initial evaluation, and management of injuries.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Primary Survey

A primary survey is the initial evaluation used to identify and manage life-threatening injuries in a trauma patient.

The components of the primary survey are:

  • Airway
  • Breathing
  • Circulation
  • Disability
  • Exposure

Airway

Purpose

  • Establish airway patency.
  • Assess the patient’s ability to protect the airway.
  • Manage the airway.
  • Spinal immobilization: using a backboard and rigid cervical collar

Causes of airway compromise

  • Traumatic injury
  • Patient’s tongue Tongue The tongue, on the other hand, is a complex muscular structure that permits tasting and facilitates the process of mastication and communication. The blood supply of the tongue originates from the external carotid artery, and the innervation is through cranial nerves. Oral Cavity: Lips and Tongue
  • Foreign body 
  • Vomit, blood, and secretions
  • Localized swelling due to infection or anaphylaxis

Airway assessment

  • If the patient can speak normally → airway is intact.
  • Signs of an unprotected airway:
    • Paradoxical chest and abdominal movements
    • Cyanosis
    • Abnormal breathing sounds:
      • Snoring
      • Stridor
      • Expiratory wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing
      • Gurgling
    • Presence of an expanding hematoma
    • Presence of subcutaneous emphysema
    • Glasgow Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma Scale (GCS) < 9

Airway management

  • Adequate ventilation with 100% oxygen using a bag and mask
  • Pulse oximetry to monitor oxygen levels
  • Special maneuvers:
    • Chin lift, jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint thrust
    • Oral (oropharyngeal tube) or nasal (nasopharyngeal tube) airways can be used to temporarily maintain the airway 
  • If maneuvers fail, establish a definitive airway:
    • Endotracheal (orotracheal) intubation 
      • Insertion of a tube into the trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea through the mouth (less commonly the nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose)
      • 1st-line procedure
    • Cricothyrotomy
      • Incision of the membrane between the thyroid cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage and cricoid cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage
      • Used if endotracheal in severe traumatic injuries, if intubation fails, or if airway is severely swollen (anaphylaxis!) 
      • Easier to perform than tracheostomy
      • Temporary procedure
    • Tracheotomy 
      • Incision to the trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea with insertion of a tracheal tube
      • Preferred in pediatric patients (age < 8) as the cricoid is much smaller

Breathing

Breathing is the next step after the airway has been deemed adequate.

Purpose

  • Detect signs of respiratory distress.
  • Maintain sufficient oxygenation and ventilation.
  • At this step, if breathing problems are found, it may be necessary to perform procedures (i.e., thoracostomy) to correct breathing issues found.

Breathing assessment

  • Listen to breath sounds.
  • Count respiratory rate:
    • 12–20/min is normal.
    • If respiratory rate is ↓ or ↑, consider airway assistance.
  • 40% of cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest patients may have agonal breathing (series of noisy gasps).

Signs of respiratory distress

  • Inspection: 
    • Central cyanosis
    • Jugular venous distention
    • ↑ effort needed to breathe
      • Use of accessory muscles
      • Abdominal breathing
  • Percussion: hyperresonance ( pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax) or dullness ( hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax)
  • Palpation: tracheal shift, subcutaneous emphysema, flail segments
  • Auscultation: ↓ air entry during auscultation
  • Oxygen saturation < 88%
  • ↓ end-tidal CO₂ (capnography)

Breathing management

  • Depends on the cause
  • Return to A (airway) to establish definitive airway if there is respiratory distress.
  • Procedures for management of life-threatening breathing conditions:
    • Tube thoracostomy (small incision of the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall is made and a chest tube is inserted) is needed in:
      • Tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax, open pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
      • Flail chest Flail chest Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Flail Chest
      • Massive hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
    • Pericardiocentesis (a needle and small catheter are inserted into the pericardial sac to drain excess fluid) is needed in cardiac tamponade Cardiac tamponade Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade.

Circulation

Performed after the airway and breathing have been judged as normal and adequate.

Purpose

  • Determine the effectiveness of the cardiac output.
  • Secure adequate tissue perfusion.
  • Treatment of external bleeding

Causes of poor circulation

  • Shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock (including hypovolemia, septic, or anaphylactic shock)
  • Traumatic injury to arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries ( compartment syndrome Compartment Syndrome Compartment syndrome is a surgical emergency usually occurring secondary to trauma. The condition is marked by increased pressure within a compartment that compromises the circulation and function of the tissues within that space. Compartment Syndrome, arterial lacerations, crush injury)
  • Cardiac arrhythmias 
  • Heart failure 
  • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism

Circulation assessment

  • Non-breathing (apneic) patients:
    • CPR (cardiopulmonary resuscitation) (function as artificial circulation)
    • Protect the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord with cervical collar
  • Breathing patients:
    • Blood pressure assessment: indication of the effectiveness of the cardiac output, considered ↓ if systolic < 90 mm Hg
    • Measure heart rate by palpating the following arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries:
      • If carotid pulse is palpable → systolic pressure likely ≥ 60 mm Hg
      • If femoral pulse is palpable → systolic pressure likely ≥ 70 mm Hg
      • If radial pulse is palpable → systolic pressure likely ≥ 80 mm Hg
      • If dorsalis pedis pulse is palpable → systolic pressure likely ≥ 90 mm Hg
    • Check skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin (cold, clammy skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is an indication of hypovolemia).
    • Check capillary refill time (abnormal greater than 2 seconds).
    • Check urinary output (< 0.5 ml/kg/h considered low).

Circulation management

  • Direct pressure to control any external hemorrhage
  • 2 large-bore IV lines to be placed in all patients; if not possible, alternatives include:
    • Central access into femoral, jugular, subclavian veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Intraosseous access
    • Percutaneous and cutdown catheters in the lower limb saphenous vein (less common)
  • Consider mass transfusion blood protocol.

Disability and Exposure

Disability assessment

The goal of disability assessment is to determine and manage the presence of neurologic injury.

  • Examine pupils → pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil dilation suggests ipsilateral brain mass or blood collection, causing compression on the 3rd cranial nerve 
  • Motor and sensory examination
  • Assess level of consciousness and mental status through GCS:
    • Patient receives score for best response in each area.
    • Scores in each area are combined to reach a total score of 3–15.
    • ↑ the number → the better the prognosis
    • Score ≤ 9 indicates coma and patient needs endotracheal intubation.
  • Life-threatening neurological injuries include:
    • Penetrating cranial injury
    • Intracranial hemorrhage:
      • Subdural hematomas
      • Epidural hematomas
      • Traumatic subarachnoid hemorrhage Subarachnoid Hemorrhage Subarachnoid hemorrhage (SAH) is a type of cerebrovascular accident (stroke) resulting from intracranial hemorrhage into the subarachnoid space between the arachnoid and the pia mater layers of the meninges surrounding the brain. Most SAHs originate from a saccular aneurysm in the circle of Willis but may also occur as a result of trauma, uncontrolled hypertension, vasculitis, anticoagulant use, or stimulant use. Subarachnoid Hemorrhage (SAH)
      • Intraparenchymal or intraventricular bleeding
    • Diffuse axonal injury
    • High spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord injury
Table: Glasgow Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma Scale
Feature Response Score
Eye opening Open spontaneously 4
Open to verbal command 3
Open to pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 2
No eye opening 1
Verbal response Oriented and appropriate 5
Disoriented but conversant 4
Nonsensical words 3
Moaning 2
Silent 1
Motor response Follows commands 6
Localizes pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 5
Withdraws to pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 4
Flexor posturing 3
Extensor posturing 2
Flaccid 1

Exposure

The goal of this step is to evaluate and manage negative environmental effects:

  • Completely undress the patient and carry out a full physical exam.
  • Keep the patient in a warm environment ( hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia can trigger coagulopathies).

Secondary Survey

The goal of the secondary survey is to rapidly and thoroughly examine the patient from head to toe to identify all potentially significant injuries.

  • Performed after the primary survey and initial stabilization are completed
  • Examine patient from head to toe, including all orifices (ears, nose Nose The nose is the human body's primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Anatomy of the Nose, mouth, vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor, rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal).
  • Order imaging as needed.
  • Go back to primary survey for reassessment frequently!

Clinical Relevance

The following are conditions that can cause acutely and severely impaired cardiovascular function in a patient:

  • Cardiac arrest: the loss of cardiac function in a person with or without known cardiac disease. The 4 cardiac rhythms that are known to produce a pulseless cardiac arrest Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. Cardiac Arrest are ventricular fibrillation Ventricular fibrillation Ventricular fibrillation (VF or V-fib) is a type of ventricular tachyarrhythmia (> 300/min) often preceded by ventricular tachycardia. In this arrhythmia, the ventricle beats rapidly and sporadically. The ventricular contraction is uncoordinated, leading to a decrease in cardiac output and immediate hemodynamic collapse. Ventricular Fibrillation, rapid ventricular tachycardia Ventricular tachycardia Ventricular tachycardia is any heart rhythm faster than 100 beats/min, with 3 or more irregular beats in a row, arising distal to the bundle of His. Ventricular tachycardia is the most common form of wide-complex tachycardia, and it is associated with a high mortality rate. Ventricular Tachycardia, pulseless electrical activity, and asystole. Treatment is with advanced cardiac life support (ACLS), which includes CPR and giving epinephrine. 
  • Flail chest Flail chest Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Flail Chest: a condition that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Marked by chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, tachypnea, hypoxemia, and paradoxical thoracic wall movement. Often, tube thoracostomy is needed, as the condition is associated with pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax. Management includes oxygen supplementation, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control, and positive pressure ventilation if respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure presents.
  • Hemothorax: a collection of blood in the pleural cavity. The condition usually occurs following chest trauma, which leads to lung laceration or damage to intercostal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries. Symptoms include shortness of breath and chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain. Signs include hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, tachycardia, decreased air entry, tracheal deviation, and dullness on percussion. Management is by chest tube insertion.
  • Pulmonary contusion: a traumatic parenchymal lung injury. Patients present with tachypnea, tachycardia, and hypoxemia. Computed tomography scan shows patchy alveolar infiltrates not restricted by anatomical borders (non-lobar opacification). Management involves oxygen administration, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control, chest physiotherapy, and mechanical ventilation in severe cases.
  • Pneumothorax: an abnormal collection of air in the pleural space. Physical exam findings include decreased breath sounds, hyperresonance on percussion, tracheal deviation, mediastinal shift (away from tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax), decreased tactile vocal fremitus, and distended jugular veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins. Chest X-ray, ultrasound of chest, and CT all can identify pneumothoraces. Treatment includes emergent needle decompression and thoracotomy.
  • Cardiac tamponade: an accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Cardiac tamponade is a severe form of pericardial effusion Pericardial effusion Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade. In the setting of trauma, the effusion is blood. Physical examination findings include Beck’s triad ( hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, jugular venous distention, and muffled heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). Heart Sounds). Treatment is emergent pericardiocentesis.

References

  1. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA. 0b013e31828b82f5.
  2. Sivilotti, M. Initial management of the critically ill adult with an unknown overdose. (2019). UpToDate. Retrieved November 22, 2020 from: https://www.uptodate.com/contents/initial-management-of-the-critically-ill-adult-with-an-unknown-overdose
  3. Thim, T., Krarup, N. H., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117–121. https://doi.org/10.2147/IJGM.S28478

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