What are the initial steps in acute management of a patient?

Initial Steps in Acute Patient Management

The initial evaluation of an acutely ill patient should focus on immediate stabilization of the airway, breathing, and circulation (ABCs), followed by a rapid assessment of neurological deficits and possible comorbidities. 1

Airway, Breathing, Circulation (ABC) Assessment

Airway

• Assess patency and protect the airway
• Provide airway support and ventilatory assistance for patients with depressed consciousness or airway compromise 1
• Position patient appropriately to maximize airway patency
• Consider advanced airway management if needed (endotracheal intubation)

Breathing

• Assess respiratory rate, effort, and oxygen saturation
• Provide supplemental oxygen to hypoxic patients only 1
• Non-hypoxic patients with acute conditions do not need supplemental oxygen 1
• Monitor for signs of respiratory distress or failure

Circulation

• Assess pulse, blood pressure, and perfusion
• Establish IV access
• Implement cardiac monitoring to detect arrhythmias 1
• Treat hypotension cautiously with volume replacement using normal saline 1
• For patients with suspected stroke, avoid lowering blood pressure unless systolic BP >220 mmHg or diastolic BP >120 mmHg 1

Rapid Initial Assessment

Vital Signs

• Temperature: Treat sources of fever with antipyretics 1
• Heart rate: Monitor for tachycardia/bradycardia
• Blood pressure: Take cautious approach to hypertension in acute settings 1
• Respiratory rate: Assess for tachypnea/bradypnea
• Oxygen saturation: Maintain appropriate levels

Blood Glucose

• Immediately check blood glucose levels (finger stick) 1
• Promptly correct hypoglycemia if present
• Manage hyperglycemia cautiously

Neurological Assessment

• Assess level of consciousness
• Evaluate for focal neurological deficits
• Rule out stroke mimics (see table below) 1

Common Stroke Mimics to Consider

Condition	Key Features
Psychogenic	Lack of objective cranial nerve findings, neurological findings in non-vascular distribution
Seizures	History of seizures, witnessed seizure activity, postictal period
Hypoglycemia	History of diabetes, low serum glucose, decreased consciousness
Migraine with aura	History of similar events, preceding aura, headache
Hypertensive encephalopathy	Headache, delirium, significant hypertension, cortical blindness
Wernicke's encephalopathy	History of alcohol abuse, ataxia, ophthalmoplegia, confusion
CNS abscess	History of drug abuse, endocarditis, medical device implant with fever
CNS tumor	Gradual progression of symptoms, other primary malignancy, seizure at onset
Drug toxicity	Lithium, phenytoin, carbamazepine

Critical Time-Sensitive Interventions

For Suspected Stroke

• Obtain 12-lead ECG within 10 minutes of arrival 2
• Establish time of symptom onset (when patient was last known normal) 1
• Implement stroke pathways and notify stroke team early 1
• Triage with same priority as acute myocardial infarction 1

For Suspected Myocardial Infarction

• Administer aspirin 160-325 mg (chew and swallow) 2
• Consider sublingual nitroglycerin for chest pain (one tablet dissolved under tongue, may repeat every 5 minutes up to 3 doses in 15 minutes) 3
• Obtain 12-lead ECG immediately 2
• Establish IV access and cardiac monitoring 2

Establishing Efficient Processes

• Create efficient pathways to manage critically ill patients 1
• Develop clear protocols for rapid assessment and treatment 2
• Ensure capability to receive, identify, evaluate, and treat or refer patients appropriately 1
• Establish access to specialty expertise when needed 1

Common Pitfalls to Avoid

• Delaying airway management in patients with decreased consciousness
• Administering oxygen to non-hypoxic patients 1
• Using sublingual nifedipine or other agents causing precipitous blood pressure reduction 1
• Overlooking hypoglycemia as a cause of altered mental status 1
• Missing time-sensitive interventions for stroke or myocardial infarction
• Failing to recognize stroke mimics 1
• Excessive use of nitroglycerin leading to tolerance or severe hypotension 3

The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) provides a systematic framework for immediate assessment and treatment in all clinical emergencies 4. This structured approach helps healthcare professionals focus on the most life-threatening problems first, potentially improving outcomes in acute settings.