# ABC's not always so clear cut



## Sandog (Feb 8, 2011)

I recall asking a question in one of my EMT classes about the ABC's. Specifically I asked the following; "Now say we come upon a patient who is not breathing and has a major arterial bleed, say the femoral, would we still follow ABC?"

Answer I got was "Most definitely yes" Explanation was, No air, dead patient.

No air, dead patient, true; but, let us consider this, the brain can last 5 minutes or so without O2 but the body will bleed out in 2 minutes from an arterial bleed and the point of breathing will be moot. So I ask ya, does the ABC's really apply here? In my thinking, controlling the arterial bleed would be priority one. Of course one would think EMT #2 would begin airway procedures but for sake of this discussion assume one rescuer. 

Your thoughts?


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## MrBrown (Feb 8, 2011)

Common sense should prevail; if you are fully crewed there is no reason why one Officer cannot stop bleeding while the other looks after the airway at the same time.

On a macro-level the primary survey (ABCDE) looks at major systemic or multisystemic threats to life and from there you fix them.  

Nothing is ever set in stone and may require significant clinical judgement, something Brown wonders if is taught anymore .....


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## Akulahawk (Feb 8, 2011)

Sandog said:


> I recall asking a question in one of my EMT classes about the ABC's. Specifically I asked the following; "Now say we come upon a patient who is not breathing and has a major arterial bleed, say the femoral, would we still follow ABC?"
> 
> Answer I got was "Most definitely yes" Explanation was, No air, dead patient.
> 
> ...


With that kind of damage, I'd be thinking the patient's likely going to be dead anyway. Work fast. Very, Very fast. Improvise, adapt. Yes, the ABC's apply here. Airway/Breathing is a single entity. No airway or no breathing = bad for patient. You can control bleeding most awesomely but if your patient can't breathe, that's one dead patient. Work on the two problems as simultaneously as possible.

Come to the realization that some injuries may be so great that they're not survivable or that while it may be survivable under one circumstance, it wouldn't be in _that_ one.

And as Mr. Brown does say... clinical judgment is very important. If you know what needs to be done, you can prioritize the sequence for addressing them. Bleeding may take precedence..

But with a fully staffed ambulance or with bystanders, you should be able to address some issues rather quickly and simultaneously with others.


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## 281mustang (Feb 8, 2011)

If you theoretically had to choose one over the other a major arterial bleed should take presedence over airway, especially if this is a therodical BLS crew.


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## MSDeltaFlt (Feb 8, 2011)

My mentor, the late great Gene "Geno" Childress, told me a long time ago.  He said, "TA-TA (that's what they call me because I stutter), if you're hung up on airway, you're just hung up on airway.


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## usalsfyre (Feb 8, 2011)

MrBrown said:


> Nothing is ever set in stone and may require significant clinical judgement, something Brown wonders if is taught anymore .....



Clinical judgment requires thinking, and thinking means liability. Much easier just to write a set in stone protocol....

Control the arterial bleed, then take care of the airway. "Control" not "stop" being the key here. All you need to do is get it slowed down to the point you can move on and come back. 

In a single rescuer situation with a patient who has a airway issues/breathing issues with a concurrent major bleed in an area that can't be easily controlled is probably going to die. Do the best you can, sometimes it's not enough. No reason to not start preparing yourself for that fact now.


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## abckidsmom (Feb 8, 2011)

usalsfyre said:


> Clinical judgment requires thinking, and thinking means liability. Much easier just to write a set in stone protocol....
> 
> Control the arterial bleed, then take care of the airway. "Control" not "stop" being the key here. All you need to do is get it slowed down to the point you can move on and come back.
> 
> In a single rescuer situation with a patient who has a airway issues/breathing issues with a concurrent major bleed in an area that can't be easily controlled is probably going to die. Do the best you can, sometimes it's not enough. No reason to not start preparing yourself for that fact now.



I will just agree with you.  Who's to know he hasn't already bled out and that's why he stopped breathing?  Dead is sometimes just dead, and apneic with a femoral artery bleed outside the OR is a lot like dead.


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## mgr22 (Feb 8, 2011)

I think the big picture of ABCs (now CABs) is to treat the first independent, life-threatening condition found, before looking for others. An arterial bleed would qualify -- I can't imagine ignoring it to check for a patent airway.


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## mc400 (Feb 8, 2011)

CAB here. Also we always respond with engine co. and an RA, so you can accomplish pretty much all needed tasks quickly. Training and crew cohesiveness goes a long way.


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## Handsome Robb (Feb 8, 2011)

If the pt truly was apneic and needed airway support as well as had a life threatening bleed, that bleed would get a CAT then a BLS airway and ventilation. Problem solved in under a minute.

I would say with CAB instead of ABC that circulation coming before airway would indicate controlling the bleed first if you were in a single rescuer situation.


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## Veneficus (Feb 8, 2011)

Sandog said:


> I recall asking a question in one of my EMT classes about the ABC's. Specifically I asked the following; "Now say we come upon a patient who is not breathing and has a major arterial bleed, say the femoral, would we still follow ABC?"
> 
> Answer I got was "Most definitely yes" Explanation was, No air, dead patient.
> 
> ...



The textbook vs. the real world.

My thoughts are that the EMT texts state in the bleeding chapter to perform ABCs and control hemorrhage as part of C and if you see that question on the test, you shold reply accordingly.

I will point out that all of the medical texts state to control life threatening hemorrhage first. 

I agree with and would control bleeding first because I know far more about the pathophysiology of shock than what is presented in the EMT text.


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## firetender (Feb 8, 2011)

*Here's some imagery to work with*

Great example, the femoral artery!

I had a patient with a couple GSW's to the legs. Seeing the pt. was going downhill real fast, I slapped some bandages over the bleeding and got ready to do CPR.

Sure enough, the pt. went into arrest. What a smart guy I was, I thought!

So, according to protocol of the times, I focused on the ABC's. And guess what happened?

You got it; as soon as I started compressions, an 8 inch stream of blood pulsed out of a bullet wound on my patient's thigh, _*in precise rhythm with my compressions!*_

Does that answer your question?


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## wadford (Feb 8, 2011)

On the third or fourth night of my EMT-B class, our instructor asked us if we knew what ABC was. We said Airway, Breathing and Circulation. He shook his head ( at the time I was mentally going over everything I had read and thinking what the hell), then he said that it's AIRWAY, AIRWAY, AIRWAY, Breathing, Circulation. So A3BC. I'm just guessing here with the arterial bleed (still a student), but two rescuers, one controling the bleed with pressure and a tourniquet (?) and the other establishing a patent airway.


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## Sandog (Feb 9, 2011)

Thanks for the input everyone, good feedback, I think I got my answer


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## byoung57 (Feb 20, 2011)

The joys of critical thinking!  One of the most difficult skills new EMS personell will ever master.

Bill


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## VFlutter (Mar 13, 2011)

firetender said:


> Great example, the femoral artery!
> 
> I had a patient with a couple GSW's to the legs. Seeing the pt. was going downhill real fast, I slapped some bandages over the bleeding and got ready to do CPR.
> 
> ...




The new AHA BLS for health care providers 2010 teaches CAB for cardiac arrest


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## Sandog (Mar 13, 2011)

ChaseZ33 said:


> The new AHA BLS for health care providers 2010 teaches CAB for cardiac arrest



Firetender is well aware of the 2010 guidelines. He has worked in emergency medicine since Moby **** was a minnow. This post was more about trauma where ABC's are still the practice.


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## MrBrown (Mar 13, 2011)

ChaseZ33 said:


> The new AHA BLS for health care providers 2010 teaches CAB for cardiac arrest



American ambos complain they feel like taxi drivers, well with the introduction of CAB now its official 

Chest compressions and early defibrillation are the most important aspects of cardiac arrest management and that has been shown extensively in the literature over the past five or so years.

Now life threatening bleeding on the other hand gets controlled first, because even tho you might decide airway is most important and cram 15 LPM NRB down the patients gob let us remember, oxygen binds to haemoglobin which is present in the blood, so if he bleeds out guess what, all that oxygen aint gonne be carried nowhere!


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## usafmedic45 (Mar 13, 2011)

Tourniquet and deal with the airway.  If it's too high to put a tourniquet on, pack the wound and put your body weight down on to it using your knee while you deal with the airway.


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## usafmedic45 (Mar 13, 2011)

> One of the most difficult skills new EMS personell will ever master.



One that most never master.


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## MrBrown (Mar 13, 2011)

usafmedic45 said:


> One that most never master.



Like basic English?


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## usafmedic45 (Mar 13, 2011)

MrBrown said:


> Like basic English?


Yup.  Just like that.  LOL


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## mycrofft (Mar 13, 2011)

*Roger Ak,ula, Brown and USAF...and nice compressions, Firetender!*

It's like the old math thing about two trains going different speeds.

A = Time element to dispatch (time of insult + minutes to activating EMS+minutes to dispatch) plus time elements to arrival (minutes from dispatch to receipt and departure + minutes or hours to arrival on scene + time to find and make contact with pt).

B = Time from instant of insult to onset of irretrievable shock for this individual and insult.

B-A = Likelihood of your needing to worry about this classic question. Often expressed as a negative number.

When asked, give them their answer. If it happens, somehow plug or TK the wound if possible FAST, open airway,  QUICKLY look for anything else killing them _*right now*_ (turn em over!*) and address it FAST. If not breathing again spontaneously, give a couple breaths, but likelihood is by now they are also pulseless.

This is the EMS equivalent of Star Trek's "Kobyashi Maru" test.

PS: the higher the survival likelihood as above for your scenarios means a higher likelihood the shooter is still around. "Take five and stay alive".

* Nothing like doing CPR on a pt with a fist-sized exit wound on their back or upper thigh.


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