xABCDE on the mountain #1: What is xABCDE and why does it make sense in an alpine accident?

The ABCDE scheme is a standardized method used by the emergency services to assess and treat an emergency patient. It is also taught in adapted versions to laypersons and first aiders so that they can take the first relevant first aid measures until professional help arrives on the scene. This algorithm is also being trained by more and more organizations in the Alpine region. One of the reasons for this development in German-speaking countries is Philipp Dahlmann. In 2017, he and his team of authors began publishing a 13-part (!) first aid series in the magazine bergundsteigen, making a plea for the use of this scheme for female mountaineers. The scheme was well received by these potential first aiders – at last they had a comprehensible algorithm that they could work through – but less so in professional circles at first: it was too complicated, too complex and in some cases recommended things that had not been decided on by the specialist committees. That’s true, because for us mountaineers and mountain guides there are no expert committees that think about how we should deal with an injured person in the terrain. In the meantime, everyone has – almost – become friends again and is working together constructively. However, there is still no xABCDE scheme that has been created specifically for female mountaineers and their requirements. So we asked Philipp, who is also an ÖKAS expert member, to formulate and justify such a tailor-made scheme. This was long overdue and the team of authors Katharina Helm and Philipp Dahlmann will be addressing the individual points in the next issues of analyse:berg. But first, let’s start with an overview of xABCDE.

Katharina Helm
NotSan HEMS and practical instructor (Germany),
B.Sc. student rescue pedagogy, PHTLS instructor,
trainer at the ADAC HEMS Academy

Philipp Dahlmann
Certified paramedic (Switzerland),
Post-doc in the field of rescue sciences

First of all: This article is aimed at ÖKAS members and analyse:berg readers.
We assume that they have already received alpine first aid training and are curious to understand the background and develop things further. In line with the ÖKAS motto: “Those who know nothing must believe everything” (Marie von Ebner-Eschenbach).

To answer this question, we briefly present the most relevant publications and their key messages:

xABCDE is a scheme in acronym form that enables structured and standardized examination and care. It is equally suitable for simple and complex events or emergencies so that nothing is forgotten or overlooked. It is already prioritized.
👉 Schmid, B., Sauer, F. & Busch, HJ. Preclinical initial assessment at the scene. Bundesgesundheitsblatt. 65, 979-986 (2022), https://doi.org/10.1007/s00103-022-03582-3

xABCDE is an aid to structured diagnostics and therapy for patients.
👉 Peran, D., Kodet, J., Pekara, J. et al. ABCDE cognitive aid tool in patient assessment – development and validation in a multicenter pilot simulation study. BMC Emergency Medicine 20, 95 (2020), https://doi.org/10.1186/s12873-020-00390-3

xABCDE is the foundation or basis for efficient patient care. It simplifies interdisciplinary communication because it is used both pre/post-hospital and in-hospital.
👉 Müller, HJ, König, H. & Prescher, T. Work process orientation in the vocational training of emergency paramedics. Emergency Rescue Medicine 23, 1-15 (2020), https://doi.org/10.1007/s10049-019-0612-2

The xABCDE scheme has been empirically confirmed and is therefore evidence-based.
👉 Thim T., Krarup, Grove, Rohde, Løfgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine, Vol. 5 (2012), https://doi.org/10.2147/IJGM.S28478

Why does xABCDE make sense?

Emergency situations in alpine areas pose complex challenges for private individuals, rescue teams and medical personnel. The terrain, general conditions and current weather conditions make access to the injured person difficult and the available resources are often limited.
Stress and uncertainty in emergency situations can also lead to important measures in patient care being overlooked. A structured and simple framework for action, such as the xABCDE acronym, helps to proceed in a standardized manner and to retain free cognitive resources in action while being able to concentrate on the essentials.
The scheme offers the possibility of working through both simple and complex situations in a targeted manner, as it already prioritizes the individual body regions according to their urgency. This structure also ensures that no essential aspects are overlooked or neglected (Peran, et al. 2020 and Schmid, Sauer, Busch 2022).
With the help of the xABCDE scheme, you can simply start from A again if the situation changes. This provides certainty of action, particularly in the case of a patient who collapses during treatment (ERC guidelines).
At the same time, the standardized procedure promotes interdisciplinary communication between pre/outside clinical and clinical actors, as the scheme is universally applied (Müller, König and Prescher 2020). There is also a common language for first responders (companion rescuers, BLS personnel such as piste or mountain rescuers) and ALS personnel, which is particularly important for handover.
This article examines the use of the scheme in the context of alpine accidents and its usefulness as an intuitive guide to action.

What does xABCDE stand for?

x (exsanguination) critical bleeding
The letter x refers to critical arterial or venous bleeding that must be stopped immediately. Such bleeding, for example from large arteries in the extremities, can be fatal within a very short time. The focus is on direct measures such as pressure bandages or the use of a tourniquet to stop the blood loss immediately.

A (Airways) Airways
Assessing and securing the airways is the next step in the scheme. This includes inspecting the mouth, nose and throat for foreign bodies or blood, assessing the mucous membranes (e.g. pink, pale, moist or dry) and detecting potential mouth odors (e.g. alcohol). In the case of severe injuries, the cervical spine is stabilized by holding it firmly (MILS) to prevent further damage.

B (Breathing) Breathing
The letter B is used to assess breathing through a detailed inspection of the chest (looking for hematomas, one-sided thoracic movements or retractions between the ribs).
The stability of the chest is also checked manually. Respiratory rate, depth of breathing and possible signs of a tension pneumothorax (e.g. respiratory and cardio-circulatory insufficiency) or other ventilatory problems are evaluated in order to be able to intervene promptly.

C (Circulation) Circulation
To assess the circulation, both the skin condition (pale, rosy, dry, moist, warmed) and the pulse rate and quality are evaluated.
The recapillarization time (which is usually less than two seconds in healthy people) shows how quickly blood flows back into the skin. It helps to assess the condition of the circulatory system – quickly and without equipment. Other large bleeding areas such as the abdomen, pelvis and thigh are palpated and inspected to detect internal bleeding.

D (Disability) Neurological condition
The neurological evaluation in letter D includes testing of consciousness (e.g. Glasgow Coma Scale or AVPU scheme), pupil control and assessment of pDMS (peripheral blood flow, motor function and sensitivity of the extremities).
These parameters provide indications of possible craniocerebral injuries, neurological deficits or systemic causes such as hypoxia.

E (Exposure/Environment) Extend/Environment
The last letter E in the scheme includes an extended (full body) examination and the environmental factors. Here, the medical history, visible injuries and potential sources of danger are assessed. Heat management is particularly crucial in the alpine environment, as hypothermia is a common and potentially life-threatening complication. Other injuries such as bruises, abrasions, etc. can also be treated “at rest”. By working through the scheme in a structured manner, there is hardly any risk of overlooking life-threatening injuries/illnesses. This means that if the patient is stable in ABCD, then I can take care of E.

The xABCDE scheme thus guarantees a tried-and-tested, systematic procedure for quick and effective assessment – even without fancy equipment.

In Fig. 1 we have summarized the scheme and designed the table in such a way that alpine-relevant examinations, red flags and key interventions are also mentioned in particular. Mountaineers trained in first aid as first aiders should be familiar with these contents, as should all alpine qualifications above them (mountain guides, tour leaders) and, of course, the rescue services from mountain rescuers upwards.
The contents of this table will not be broken down in more detail here, but will be discussed in the next issues of analyse:berg in articles on each “letter” of the scheme.

Conclusion

The principle of “treat first what kills first” illustrates the prioritization in the care of life-threatening patient conditions. A structured approach, such as that made possible by the xABCDE scheme, should be trained so intensively that it can be applied intuitively and without error even in highly stressful situations.
While the application of the scheme may subjectively appear simple, working according to it requires continuous and targeted practice in order to ensure the necessary safety and efficiency in emergency care.

Bibliography

Müller, H.-J., H. König, and T. Prescher. 2020. “Work process orientation in the vocational training of emergency paramedics.” Emergency and Rescue Medicine 1-15. https://doi.org/10.1007/s10049-019-0612-2

Peran, David, Jiri Kodet, Jaroslav Pekara, Lucie Mala, Anatolij Truhlar, Patrik Cmorej, Kasper Lauridsen, Ferenc Sari, and Roman Sykora. 2020. “ABCDE cognitive aid tool in patient assessment – development and validation in a multicenter pilot simulation study.” BMC Emergency Medicine 20, 95. https://doi.org/10.1186/s12873-020-00390-3

Schmid, Bonaventura, Florian Sauer, and Hans-Jörg Busch. 2022. “Preclinical initial assessment at the scene.” Federal Health Gazette Volume 65 979-986. https://doi.org/10.1007/s00103-022-03582-3

ERC Guidelines 2021, 2025