What are the initial steps in emergency medicine for a critically ill or injured patient?

Initial Steps in Emergency Medicine for Critically Ill or Injured Patients

The initial management of critically ill or injured patients should follow the ABCDE approach, focusing first on airway, breathing, and circulation to maintain vital functions and prevent further deterioration. 1, 2, 3

Primary Assessment and Stabilization

Airway Management

• Assess airway patency as the first priority; open the airway using appropriate maneuvers 1
• Maintain an unobstructed airway; equipment to maintain airway patency should be immediately available 1, 4
• For patients with suspected opioid overdose in respiratory arrest, airway management takes highest priority before other interventions 1

Breathing Assessment and Support

• Evaluate breathing pattern and provide rescue breathing or bag-mask ventilation for patients in respiratory arrest until spontaneous breathing returns 1
• Administer supplemental oxygen to hypoxemic patients (oxygen saturation <94%) 1, 3
• Monitor respiratory status continuously during resuscitation efforts 1, 4

Circulation Assessment and Support

• Check for pulse; if no definite pulse is felt within 10 seconds, start chest compressions 1
• For cardiac arrest, focus on high-quality CPR with proper compression depth (at least 2 inches/5 cm) and rate (at least 100/min) 1
• Minimize interruptions in chest compressions and avoid excessive ventilation 1
• Establish IV access promptly for medication administration and fluid resuscitation 1

Disability Assessment

• Perform rapid neurological assessment to determine level of consciousness 1, 5
• Check blood glucose levels and treat hypoglycemia if present 1
• For patients with seizures, consider appropriate anticonvulsant therapy while maintaining airway and breathing 1, 4

Exposure and Environmental Control

• Fully expose the patient as needed to complete assessment while maintaining dignity and preventing hypothermia 5
• Obtain baseline vital signs and monitor continuously 1, 5

Special Considerations

Cardiac Arrest Management

• Early activation of emergency response system is critical 1
• For witnessed collapse, retrieve AED/defibrillator immediately if available 1
• Follow the defibrillation sequence: turn on AED, follow AED prompts, resume chest compressions immediately after shock 1
• Standard resuscitative measures should take priority over specific antidotes (like naloxone in suspected opioid overdose) 1

Opioid Overdose Management

• For respiratory arrest due to suspected opioid overdose, focus first on airway and ventilation 1
• For patients with suspected opioid overdose who have a pulse but no normal breathing, it is reasonable to administer naloxone in addition to standard care 1
• After return of spontaneous breathing, observe patients in a healthcare setting until risk of recurrent toxicity is low 1

Stroke Management

• For suspected stroke, assess the patient within 10 minutes of arrival 1
• Establish time of symptom onset by interviewing witnesses or family members 1
• Perform neurological screening assessment and arrange for emergent CT scan 1
• Avoid treating hypertension in the prehospital environment unless systolic blood pressure is <90 mmHg 1

Pitfalls to Avoid

• Delaying activation of emergency response system while awaiting response to initial interventions 1
• Prioritizing specific treatments (like naloxone administration) over basic life support measures in cardiac arrest 1
• Spending too much time checking for pulse (>10 seconds) which delays chest compressions 1
• Failing to recognize respiratory arrest versus cardiac arrest, which require different initial approaches 1
• Neglecting continuous monitoring of vital signs during resuscitation efforts 1, 4

Recent Evidence on Resuscitation Approaches

• Some recent research suggests a circulation-first (CAB) approach may be beneficial for trauma patients with hemorrhagic shock, as early intubation before volume resuscitation may increase mortality in hypotensive patients 6, 7
• However, the traditional ABC approach remains standard for most critically ill patients, with the ABCDE framework being widely accepted for systematic assessment 2, 5