LOC or ABC first?

[Caffeinated RN]

I feel like this is a silly question, but it is a topic that recently came up in class (I am just about to finish nursing school), and it is driving me off-the-wall CRAZY!

We all know that our ABCs are paramount to our practice as healthcare professionals. My instructor, who is a wonderful, very knowledgable ICU/recovery room nurse, recently insisted, in a nutshell, that the ABCs come before establishing the level of consciousness.

Now, as an EMT, I have always been trained to think that LOC comes before ABCs in major part because this can help dictate the airway adjunct. Are they semi-conscious? Well, then, they likely have a gag reflex, so drop an NPA. Are they unconscious? Drop an OPA. That sort of thing....And of course, if they are unconscious, we may very well not have any breathing or circulation, and we need to initiate CPR.

In real life, healthcare professionals can multitask, and we are not sitting there going, "OK - I just evaluated his airway. Now, let me assess his breathing and circulation. Hmm..." In other words, we make several assessments at once regarding LOC, ABCs, what have you.

So, why is this whole thing driving me crazy??? Well, in addition to not feeling like a dummy, I'd like to one day become a Certified ER nurse. And I suppose the NCLEX is important, too ;p

I feel as though my teacher has a slightly different perspective as an ICU nurse, which is why she states this is the correct answer. She, after all, usually receives the patient with an airway in place, etc.

Feedback would be great! Thanks so much!!

[JessiekRN]

Airway is the priority. A patient's LOC will not kill them. So if to maintain airway patency you need to assess LOC to determine how to maintain patency, that's fine. But that's the sole reason LOC would need to be assessed in that situation. I think you're over complicating this for yourself. Think of it this way- what difference does LOC make if your patient is about to die?

[CodeteamB]

Think of your primary survey... A for airway. Your LOC is going to land in D for disability. You will probably be aware of the LOC earlier in the survey, however it really isn't the priority.

[Larry77, RN]

One thing you'll find is that you will learn almost nothing about Emergency Nursing in nursing school. Basically you will be taught how to think like a nurse and how to perform on a med/surg floor. My point being, don't expect to be prepared to step in the ED with all your knowledge about primary and secondary assessment, and problem focused assessment. You probably have learned just as much about ED nursing from your previous job as an EMT...he he.

In the real world it is ABC...then in TNCC it's ABCDEFGHI.

The instructor may have been eluding to the fact that we do like to know the LOC before EMS (or the ED) has intubated the patient and we will ask but please don't think that we believe intubation should be stalled to assess LOC...all at once please :-)

[KnitWitch, ASN, RN]

If you're missing the A, B or C, the LOC won't matter because your patient will be done for in a matter of minutes. Whereas a patient with a decreased or fluctuating LOC can still maintain their own ABCs.

[SummitRN, BSN, RN]

On the test, ABC first. In real life, you often assess LOC as you do your ABC.

[skylark, BSN, RN]

Unless the airway is clear they aren't going to regain consciousness, so assessing LOC is rather like counting deckchairs on the Titanic.

[FlyingScot, RN]

Unless the airway is clear they aren't going to regain consciousness, so assessing LOC is rather like counting deckchairs on the Titanic.

Except to the person you start chest compressions on who was really just asleep.

Is your instructor confusing the term "LOC" with establishing unresponsiveness? Related but not really the same conept.

[FlorenceNtheMachine]

Except to the person you start chest compressions on who was really just asleep.

Is your instructor confusing the term "LOC" with establishing unresponsiveness? Related but not really the same conept.

^+1

No sane person is going to see asystole on the monitor and start popping ribs without further assessment. I'm guessing most will establish unresponsiveness by a loud HAY YOU! and noxious tactile stimuli before their other ABC interventions.

[skylark, BSN, RN]

Where did the talk of chest compressions come from?

Airway first, breathing second, PULSE THIRD, and then think about LOC.

My point was that there was no point wasting time calculating GCS or even AVPU without ensuring the airway is patent.

Because the ensuing hypoxia is going to mess with their LOC anyway : )

[FlyingScot, RN]

The point is it depends on the situation. Routine assessment yes it is ABC then LOC. Person dumped out of a car at the ED door then it's responsiveness/LOC first.

[bjaeram]

In reality you do it all at the same time in about 15 seconds. It's not a long process you think through and do in order.

If you are choosing an order for BLS everyone saying ABC is not correct. The newest version of CPR is actually CAB CHEST COMPRESSIONS come before breathing! In bystander CPR they don't even recommend breathing anymore.

I think it depends on what setting you are in and who your resources are. In the ER a tech does compressions and respiratory does airway and and the RN assesses. they happen at the same time.

You have to establish nonresponsiveness before doing CPR or you will get punched in the face by an angry patient. To the person that says you would never do CPR until the monitor showed asystole is very incorrect. They are rarely on the monitor yet when CPR starts in the ER. You don't take the time to put a monitor on a look at the rhythm. No signs of life....go directly to CPR. Then you worry about the monitor and iv's and airways.