What is the initial step in the general examination of a patient in the emergency department?

Initial Assessment of a Patient in the Emergency Department

The initial step in the general examination of a patient in the emergency department should be a rapid assessment of airway, breathing, and circulation (ABC) within the first 10 minutes of arrival. 1, 2

Primary Survey: The ABCDE Approach

• Airway: Assess patency and provide immediate intervention if compromised 2, 1
• Breathing: Check respiratory rate, oxygen saturation via pulse oximetry, and administer supplemental oxygen to hypoxemic patients 2
• Circulation: Assess pulse rate, rhythm, quality, and blood pressure; apply cardiac monitoring for suspected cardiac or neurological issues 2, 1
• Disability: Perform rapid neurological assessment including level of consciousness 2
• Exposure: Conduct a brief head-to-toe examination to identify other potential injuries or issues 2, 3

Vital Signs Assessment

• Record baseline vital signs including temperature, pulse, respiratory rate, blood pressure, and oxygen saturation within the first minutes of arrival 2
• Monitor vital signs frequently as clinically indicated, but not less than every 30 minutes while the patient is in the ED 2
• Treat hyperthermia promptly as temperatures >99.6°F are associated with poor outcomes in stroke patients 2

Initial Diagnostic Measures

• Obtain a 12-lead ECG for patients with suspected cardiac issues or stroke within 10 minutes of arrival 2, 1
• Measure blood glucose immediately, especially in patients with altered mental status or suspected stroke 2, 1
• Establish intravenous access for medication administration and blood sampling 2
• Collect blood samples for initial laboratory tests including electrolytes, complete blood count, coagulation studies, and renal function 2

Neurological Assessment for Suspected Stroke

• For patients with suspected stroke, use a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) 2
• Document the exact time of symptom onset or last known well time 2, 1
• Order emergent brain imaging (CT or MRI) to be completed within 25 minutes for potential thrombolysis candidates 2

Common Pitfalls to Avoid

• Delaying the initial assessment beyond the recommended 10-minute window 1, 2
• Failing to identify time-sensitive conditions requiring immediate intervention 1, 3
• Neglecting to check blood glucose in patients with altered mental status 1, 2
• Waiting for laboratory results before initiating appropriate emergency care 2

Special Considerations

• For agitated patients, prioritize safety while still completing the initial assessment; consider verbal de-escalation techniques before pharmacologic interventions 4
• For pediatric patients, use age-appropriate assessment tools and equipment 1, 3
• For suspected cardiac issues, consider administering aspirin 160-325mg orally and sublingual nitroglycerin unless contraindicated 2

The systematic ABCDE approach ensures that life-threatening conditions are identified and addressed promptly, establishing the foundation for subsequent diagnostic workup and treatment planning 5, 3.